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Flashcards in Contraception Deck (58):
1

Choose all of the correct answers:
a) copper IUD is more effective than Plan B for emergency contraception
b) copper IUD can be used up to 4 days after intercourse for emergency contraception provided pregnancy ruled out
c) levonorgestrel IUD is effective as emergency contraception up to 5 days after though efficacy drops with time
d) fibristal is effective as emergency contraception if used on the day of ovulation
e) you should wait a week before starting hormone-containing contraception after emergency used

a) correct
b) 7 days
c) correct
d) false -not effective if used at time of ovulation
e) false -can start same day + use backup method

2

Choose all correct answers:
a) contraceptive efficacy = "perfect use"
b) contraceptive effectiveness = "perfect use"
c) discussion re: choice of contraceptive should include: effectiveness, safety, accessibility, affordability, acceptability

a) true
b) false - number of pregnancies prevented with "typical use"
c) true

3

What factors influence a woman's contraceptive choice and ability to adhere over time?

knowledge about choices
motivation to stick to choice
ability to stick to choice
(cost, supportive partner/family, access to care)

4

What is the medication and dose in Plan B? What is the window of effective use?

levonorgestrel 750mcg x 2 tabs taken together within 72 hours of intercourse (evidence of efficacy up to 5 days) no rx needed

5

What are the medications and dose involved in the Yuzpe method? What is the window of effective use?

Two doses of ethanol estradiol 100mcg and levonorgestrel 500mcg (5 alesse pills) taken 12 hours apart
requires rx, less effective and more S/E than Plan B or UPA-EC

6

What are the medications and doses involved in the UPA-EC method of emergency contraception? What is the window of effective use?

Fibristal 30mg up to 5 days after unprotected intercourse (6 tabs)

7

What risk factor may make emergency contraception with UPA more effective than LNG?

BMI > 30 UPA more effective, no difference in pregnancy rates for BMI 25-29

8

When in the cycle are LNG-EC and UPA-EC not effective methods of emergency contraception?

On the day of or the day just prior to ovulation. Studies suggest it is not effective if given after ovulation.

9

When is the fertile window in the cycle?

5 days before ovulation until 1 day after (based on 5 day lifespan of sperm and 12-24 hour lifespan of unfertilized oocyte)

10

What is the mechanism of action for LNG in emergency contraception?

Prevents ovulation if given before LH surge (therefore not an abortafacient -works pre-implantation to prevent pregnancy) can use up to 5 days post

11

What is the mechanism of action of Ulipristal-acetate as an emergency contraceptive?

selective progesterone receptor modulator -direct inhibitory effect on follicular rupture (can use up to 5 days post)

12

What is the mechanism of action of mifepristone as an emergency contraceptive?

Blocks or Delays ovulation in a dose-dependent fashion

13

What is the mechanism of action of Cu-IUD as an emergency contraceptive?

Induces a sterile inflammatory reaction in the endometrium that inhibits implantation (confirm no existing IUP before inserting for EC) can use up to 7 days post

14

Which method of emergency contraception has the most favourable side effect profile?

LNG-EC and UPA-EC cause less N/V, dizziness, and fatigue than the Yuzpe method.

15

What follow-up would you recommend for a woman on whom you are consulted for emergency contraception?

Urine beta 21 days after EC
Can start "quick start" method of backup contraception right away for LNG-EC or Yuzpe or 5 days after UPA-EC. Recommend backup x 14 days with Cu-IUD or UPA insertion.

16

In whom is lactational amenorrhea considered an effective method of contraception.

Less than 6/12 PP and fully or nearly exclusively breastfeeding with no resumption of menses postpartum (98% effective if all 3 criteria are met)

17

Choose the false options:
a) lambskin condoms protect against STIs
b) non-latex condoms are as effective as latex condoms at preventing STIs
c) the contraceptive sponge/spermicide options are not highly effective when used on their own
d) contraceptives containing nonoxynyl-9 may cause vaginal epithelial damage and inc risk of HIV transmission

a
b

18

Choose all correct answers:
a) a substitute-decision maker cannot consent to a non-therapeutic permanent sterilization procedure for a mentally incompetent patient
b) the absolute risk of ectopic pregnancy is lower in women post TL than in women who have not had the procedure
c) the 10-year failure rate of TL is 2%
d) the greatest side effect of TL is regret, with young age being the greatest risk factor

a
b
c
d

19

Choose the correct answers:
a) tubal sterilization is more effective than vasectomy
b) tubal sterilization is more invasive than vasectomy
c) vasectomy is effective immediately after surgery
d) vasectomy does not increase the risk of prostate/testicular cancer

b
c -false only after semen analysis shows azoospermia (<1x10^6)
d

20

What factors should be discussed with a pt prior to performing a permanent tubal sterilization?

risks of procedure
alternatives (LARC and male vasectomy)
risk of regret

21

Post tubal sterilization, how long should patients use a backup method of contraception for (laparoscopic and hysteroscopic)?

laparoscopic - one week
hysteroscopic - 3 months (until imaging shows bilateral occlusion)

22

Name 4 types of "natural family planning"

1. fertility awareness
2. lactational amenorrhea
3. coitus interruptus
4. abstinence

23

What methods might women use for the "fertility awareness" method?

1 standard days (no ic days 8-19 of cycle)
2 calendar days (calculate window based on shortest and longest cycle in a calendar year)
3 symptothermal method
4 cervical mucus (Billing's) method
5 basal body temperature

24

What is the mechanism of action of lactational amenorrhea

Disruption of HPO axis.. GnRH pulsatility is disrupted resulting in reduced LH production and amenorrhea

25

Lactational amenorrhea contra-indications:

1. Inability to fulfill 3 criteria (<6/12 PP, exclusively BF, amenorrheic)
2. BF difficulties that cannot be overcome w/ pumping
3. medical contraindication to another pregnancy
4. contraindication to BF (e.g. HIV, TB, drugs/meds)
5. newborn has condition/prematurity that makes BF difficult

26

Choose all correct answers:
a) a diaphragm/cervical cap can be placed up to 8 hours before intercourse
b) diaphragm/cervical cap should be replaced once yearly
c) diaphragm/cervical cap should be used in conjunction with a spermicidal jelly or lubricant
d) devices can be removed after intercourse
e) diaphragms protect against HIV exposure

a -false -2hrs for these, female condom up to 8 hrs
b -true
c -true
d -false -should be left in for 6hrs post-intercourse
e -false only male condoms

27

What is the contraindication to spermicide and sponge use?

high risk for HIV infection as nonoxyl-9 increases susceptibility to virus

28

Name one risk associated with vaginal forms of contraception (sponge/diaphragm/cap/female condom)

Toxic shock syndrome

29

Choose all correct answers:
a) post-partum (at time of C/S) filshie clip application is not as effective as salpingectomy
b) in the presence of abnormal Fallopian tubes, complete or partial salpingectomy is preferable to filshie
c) salpingectomy has been shown to decrease the lifetime risk of epithelial ovarian cancer in RCTs
d) laparoscopic/mini-lap tubal can be done at the time of TA

a
b
c -false -theoretical decreased risk, 40% risk reduction for serous/endometriod cancers demonstrated in observational studies (decr risk also with filshie)
d

30

Where should a filshie clip be placed?

Tube placed on stretch and fimbria identified so that you know you have the right structure. Clip placed 3cm distal to uterotubal junction at 90 degrees to the tube

31

What options exist for patient wanting pregnancy post-tubal ligation?

Tubal reversal
IVF
adoption

32

Choose all correct answers:
a) progestin only contraception is not associated with increased risk of VTE, stroke, or MI
b) efficacy of DMPA decreases with increased BMI
c) DMPA is associated with a slower return to ovulation compared to other methods
d) DMPA is associated with long-term irreversible decreased bone mineral density

a
b - false
c
d -false -reversible

33

Choose all correct answers:
a) DMPA is associated with decreased breast milk production
b) DMPA is associated with decreased risk of endometrial and ovarian cancer
c) pts on DMPA should be counselled re: Ca, Vit D, smoking cessation, weight bearing exercise
d) side effects of progestin only contraceptives include amenorrhea

a) false
b
c
d

34

Choose the correct answers:
a) current breast cancer is not a contraindication to progestin-only contraception
b) relative contraindications to implanted progestin include previous breast cancer, liver cirrhosis, unexplained vaginal bleeding
c) implanted progestin can be used to treat endometriosis pain
d) implanted progestin is associated with increased risk of benign ovarian cysts

a) false
b) true
c) true
d) true

35

What is the mechanism of action of DMPA?

1. Inhibits HPO axis by inhibiting pituitary gonadotropins thereby suppressing ovulation
2. increases viscosity of cervical mucous
3. induces endometrial atrophy

36

What are indications for DMPA?

1. contraindication to estrogen containing methods
2. desire for discretion (injection in office q 3 months)
3. difficulty with adherence to daily forms
4. lactating
5. women wanting menstrual suppression
6. women taking anticonvulsant meds

37

List non-contraceptive benefits of progestin only contraception.

1. high rates of amenorrhea
2. endometriosis sx improvement
3. higher seizure threshold
4. decreased risk of PID
5. decreased sx PMS
6. reduced risk endometrial hyperplasia/cancer
7. decreased risk sickle cell crisis

38

Choose all correct answers:
a) 40% of patients will discontinue DMPA within one year because of excessive weight gain
b) weight gain is thought to be due to progestin effect on adipose cells
c) risk of weight gain with DMPA is related to BMI prior to starting
d) early weight gain with DMPA is predictive of ongoing weight gain

a) true
b) false - thought to be due to inc appetite
c) false - no relationship
d) true

39

Which of the following is associated with the longest period of time to return of ovulation on average following discontinuation?
a) Mirena IUS
b) DMPA
c) COCP
d) mini-pill

b (up to one year, six month conception rate only 25%)

40

Choose all correct answers:
a) DMPA has been shown to decrease bone mineral density in a majority of users
b) BMD loss with DMPA use is reversible and BMD returns to normal within months of discontinuation
c) The maximum recommended time that a patient should be on DMPA according to FDA/Health Canada is 5 years
d) RCTs have demonstrated an increased lifetime fracture risk in users of DMPA
e) There is good evidence that DMPA use causes osteoporosis

a
b -false -BMD returns to normal after 2 years
c false - 2 years although data suggest that drop in BMD levels off after 2 years
d false
e false

41

Choose all correct answers:
a) DMPA use is associated with increased risk of HIV acquisition in susceptible women
b) DMPA use is associated with increased risk of VTE
c) DMPA inadvertently administered in pregnancy has been shown to cause birth defects
d) DMPA given within the first six weeks postpartum has a negative effect on breastmilk production

a) false -data has not shown this convincingly
b) false
c) false
d) false -though it does potentially decrease PRL (PRL surge triggered by PP drop in progesterone) so giving it before milk comes in theoretically may limit supply in women at risk of breastfeeding difficulties

42

When in the cycle can DMPA be started?
Describe "Quick start method" and

Ideal if given in first 5 days of cycle as will block ovulation and be effective immediately.
If "Quick Start" or "Depo Now" method used (injection on day of consult) backup method should be used for at least 7 days and LNG-ES should be used if unprotected intercourse within the last 5 days

43

A woman presents for her DMPA injection 14 weeks after the last one. She had unprotected intercourse a week ago. What do you recommend?

preg test
if negative, give DMPA and advise backup contraception x 7 days.
If intercourse was within last 5 days, recommend LNG-EC + DMPA + backup x 7 days and repeat pregnancy test in 3-4 weeks

44

What are the formulations of the mini-pill and visanne?

Mini-Pill aka Micronor = 35mcg norethindrone x 28 days (no pill free interval -approved for contraception)
Visanne = dienogest 2mg daily (not approved for contraception)

45

What is the mechanism of action of micronor?

alters cervical mucous -makes it more viscid and less hospitable to sperm

46

Does the use of progestin-only pill increase the risk of ectopic pregnancy?

overall absolute risk of ectopic decreased with POP use, but if pregnancy does occur, up to 10% risk of ectopic due to inhibitory effect on tubal cilia (if positive pregnancy test on POP must r/o ectopic)

47

How soon after starting the progestin-only pill is it considered a reliable method of contraception?

Effective right away if started during first 5 days of cycle, if after day 5 use backup for 48hrs (effect on cervical mucous takes 48 hrs)

48

Which of the following is required prior to prescribing a combined oral contraceptive?
a) BMI calculation
b) BP measurement
c) pap smear
d) STI testing

b

49

Name 4 things that can interfere with the efficacy of Combined Oral Contraceptive pill use.

1. adherence (missed doses)
2. Med interactions (i.e. anti-convulsants)
3. Vomiting/Diarrhea (decr absorption)
4. obesity (mixed evidence re increased risk of failure)

50

Describe the mechanisms of action for COC:

1. estrogen --> pituitary GNRH suppression --> suppressed ovulation
2. progestin increases cervical mucous viscosity
3. progestin suppresses LH surge and further suppresses ovulation

51

Name 10 contraindications COCs.

smoker>35, < 4 weeks postpartum (breastfeeding) or < 21 days postpartum (non-breastfeeding), acute VTE, prior VTE with high risk of recurrence on estrogen, hx stroke, vascular disease, HTN (SBP>160 or DBP>100), major surgery with prolonged immobilization, severe liver cirrhosis, hepatoma, thrombophilia, ischemic heart disease, current breast cancer, migraine with aura, SLE with antibodies, peripartum cardiomyopathy, complicated organ transplant

52

Name 10 non-contraceptive benefits of COCs.

decreased menstrual flow, cycle regulation with predictable bleeds, improved dysmenorrhea, decr acne, decr hirsutism, decr anemia, increased bone mineral density, decr perimenopausal sx, decr endometrial/ovarian/colorectal Ca, inc libido, decr fibroids, fewer functional ovarian cysts, decr benign breast disease, decr PMS/PMDD sx, decr recurrence of endometriomas with endometriosis

53

Choose all correct responses:
a) Side effects of the COC pill are most often self-limiting within the first 3 months of use.
b) The most common side effect of COCs is weight gain
c) unscheduled bleeding may occur in up to 30% of women within their first month of COC use
d) amenorrhea is more likely in pills that contain less estrogen and have a hormone free interval

a) true
b) false - most common side effect is abnormal uterine bleeding
c) true
d) true

54

Describe the increased risk of VTE in a woman starting on the COC pill.

Background risk of VTE 4/10,000 per year increases to 10/10,000 if started on COC (2.5x inc), but pregnancy increases risk to 11

55

Choose all correct responses:
a) COC pill use increases risk of MI
b) COC pill use increases risk of stroke
c) COC pill use increases the risk of breast cancer
d) COC pill use increases the risk of biliary colic

data does not support any of these

56

Which are true regarding the patch?
a) The patch is less effective in women > 90kg
b) The actual use failure rate of the patch is lower than the pill
c) The patch is contraindicated in women with a history of malabsorptive bariatric procedures
d) up to 20% of users experience a local skin reaction
e) the patch is associated with less breast pain but more breakthrough bleeding than the pill

a) true
b) false, both 9%
c) false - the pill is, the patch is indicated in these pts
d) true
e) the opposite is true (patch assoc with more breast tenderness in first few months but less breakthrough bleeding than pill)

57

List advantages of continuous use of combined contraceptives (pill, patch,ring with no hormone free interval).

less bleeding
less dysmenorrhea and associated time off work
less sanitary supplies
more convenient

58

Choose all true responses.
a) continuous COC pill use for more than three months is associated with increased failure rate
b) continuous COC use is associated with greater patient satisfaction
c) there is more breakthrough bleeding with continuous COC use compared with standard 24 or 28 day cycles
d) any pill, patch or ring can be used continously

a) false
b) true
c) false
d) true