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Question 1

What is contraception?

Answer 1

• any method to prevent pregnancy
• blocking transport of sperm to avoid fertilization of oocyte
• Disrupting the HPG axis to interfere with ovulation
• Inhibiting implantation of the conceptus into endometrium

Question 2

Broadly, what are the methods of contraception?

Answer 2

1. Natural
2. Barrier
3. Hormonal Control
4. Prevention of implantation
5. Sterilisation
6. Emergency contraception

Question 3

What are the different types of natural contraception?

Answer 3

• abstinence
• withdrawal method
• fertility awareness method
• lactation always amenorrhoea

Question 4

What is abstinence? Explain the advantages and disadvantages

Answer 4

-only reliable method of contraception, just dont have sex

Advantage
-only 100% reliable method of contraception

Disadvantage
-nothing

Question 5

What is the withdrawal method? Explain the advantages and disadvantages

Answer 5

-withdrawing before ejaculation

Advantage
-no device/hormones

Disadvantage

• not reliable
• will male have “will power” to withdraw on time?
• some sperm may be released in the pre-ejaculate
• no protection for STI’s

Question 6

What is the fertility awareness method? Explain the advantages and disadvantages?

Answer 6

• use of fertility indicators to identify fertile and infertile points of the menstrual cycle
• monitor basal body temperature, avoid intercourse around the time of ovulation, monitoring cervical mucus, length of menstrual cycle

Advantage
-no hormones/contraindications

Disadvantages

• unreliable
• no protection from STI’s

Question 7

What is lactational amenorrhoea? What are the advantages and disadvanatages?

Answer 7

-breastfeeding delays the return of ovulation after childbirth
-hypothalamus is “switched off” because of sucking response and high levels of prolactin
-disrupts release of GnRH
-relies exclusively on breast feeding
Only effective up to 6 months after giving birth
-female must be amenorrheic

Advantage
-no hormones/contraindications

Disadvantages

• unreliable
• no STI prevention

Question 8

What is barrier contraception? What are the advantages and disadvantages?

Answer 8

• barrier to sperm entering the cervix
• physical barriers: male/female condoms, diaphragm/cap
• chemical barrier: spermicide

Advantage

• reliable: 98% effective (if used correctly)
• protection from STIs
• male condom is widely available

Disadvantage

• “disrupts romantic nature of sexual intercourse”
• “reduce sexual pleasure”
• danger of expiring!
• allergy/sensitivity to latex/spermicide

Question 9

What is hormonal contraception?

Answer 9

• can be divided into short acting and long acting reversible hormonal contraception
• aim is to disrupt HPG axis to prevent ovulation
• may have additional effects on endometrial lining

Question 10

What are two common short acting reversible contraception?

Answer 10

• progesterone only pill (POP)

- combined oral contraceptive pill (COCP)

Question 11

What is the progesterone only pill? What are the advances and disadvantages?

Answer 11

• low dose of progesterone which is not enough to inhibit ovulation
• taken every day, w/o break
• principal action: thicken cervical mucus
• can be more than 99% effective if taken correctly

Advantage

• quickly reversible
• doesn’t interrupt sexual intercourse
• can be used where the COCP is contraindicated

Disadvantage

• user dependant!
• menstrual problems are common
• interacts with other medication
• risk of ectopic pregnancy
• doesn’t protect from STI’s
• missed pill rules

Question 12

What is the combined oral contraceptive pill? What are the advantages/disadvantages?

Answer 12

-contains synthetic oestrogen and progestogen
-various types in varying strengths
-principal action: prevents ovulation
By tricking the hypothalamus in thinking it is in luteal phase
-secondary action: reduce endometrial receptivity to inhibit implantation, thicken cervical mucus to inhibit penetration of sperm
-taken for either 21 days followed by 7 day break or 21 days with 7 day placebo pill

Advantage

• 98% effective
• can relieve menstrual disorders
• reduces risk of ovarian cysts
• reduces risk of ovarian cancer and endometrial cancer

Disadvantage

• no protection from STIs
• contraindications: ex. BMI, migraine, breast cancer
• side effects: breakthrough bleeding, breast tenderness, mood disturbance
• increased risk of: breast and cervical cancer, VTE, MI/stroke

Question 13

What are two long acting reversible contraceptives?

Answer 13

• progesterone injection

- progesterone implant

Question 14

What is progestogen?

Answer 14

Synthetic progesterone

Question 15

What is the progestogen injection?

Answer 15

• Intramuscular injection of high progestogen given in intervals
• principal action: prevent ovulation
• secondary action: thickens cervical mucus, prevents endometrial proliferation

Advantage:

• reliable: eliminates risk of user failure
• doesn’t disrupt sexual intercourse
• can be useful for women who cant have oestrogen contraceptives

Disadvantage

• appointment needed every 12 weeks
• contraindications and side effects
• delay in fertility returning
• no STI protection

Question 16

What is progestogen implant? What are the advantages/disadvantages?

Answer 16

• small flexible tube about 40mm in length inserted subcutaneously in arm
• releases high dose progestogen
• lasts for 3 years
• principal action: inhibits ovulation
• secondary action: thickens cervical mucus, prevents endometrial proliferation

Advantages

• 99% effective
• reliable: eliminates risk of user failure
• can be useful for women who cant use oestrogen
• natural fertility returns quickly when removed

Disadvantage

• minor procedure to insert
• side effects
• no STI protection

Question 17

What are the two coils that can inhibit implantation?

Answer 17

• intrauterine system (IUS)

- intrauterine device (IUD)

Question 18

What is the intrauterine system?

Answer 18

• coil that releases progesterone locally but not into systemic circulation
• principal action: prevents implantation and reduces endometrial proliferation
• secondary action: thickens cervical mucus

Question 19

What is an intrauterine device?

Answer 19

• coil is made of copper
• makes it a physical barrier and is toxic to sperm and ova
• works for 5-10 years
• secondary action: endometrial inflammatory reaction preventing implantation and changes consistency of cervical mucus

Question 20

What are the advantages and disadvantages of using a coil?

Answer 20

Advantages

• convenient
• long duration of action
• 99% effective

Disadvantages

• insertion may be unpleasant
• risk of uterine perforation (2/1000)
• menstrual irregularity
• dont prevent STI
• displacement/expulsion may occur

Question 21

What are the two types of sterilization?

Answer 21

• vasectomy

- tubular ligation

Question 22

What is a vasectomy?

Answer 22

• vas deferens cut or tied to prevent sperm entering ejaculate
• performed under local anaesthetic
• must confirm success by post-op semen analysis to confirm o sperm in ejaculation
• failure rate: 1 in 2000

Question 23

What is tubal ligation?

Answer 23

• Fallopian tubes cut or blocked to stop ovum travelling from the ovary to the uterus
• can be done under local or general anaesthetic
• failure rate 1 in 205

Question 24

What is emergency contraception?

Answer 24

• for women who get pregnant unintentionally
• can be done with an IUD up to 5 days after the event
• can also be done with hormonal pills that can be taken within 3-5 days
• ex: emergency IUD, emergency pill with ulipristal acetate, emergency pill with levonorgestrel

Question 25

What is subfertility?

Answer 25

• a couple who has regular, unprotected sex (every 2-3 days) but cannot conceive within a year
• primary infertility: never been pregnant
• secondary infertility: has been pregnant in the past (including ectopic pregnancy and termination of pregnancy) and are struggling to conceive again

Question 26

What are the main causes of subfertility?

Answer 26

• factors in male 30%
• unexplained infertility 25%
• Ovulatory disorders 25%
• tubal damage 20%
• uterine or peritoneal disorders 10%
• other: coital problems, concurrent health problems
• 40% of cases are from problems due to men and women

Question 27

What are the male causes of subfertility?

Answer 27

Pre-testicular
-generally issues that affect HPG axis

Testicular

• due to sperm production or storage
• chromosomal or congenital abnormalities meaning sperm production is reduced
• STIs
• vascular causes such as testicular torsion
• drugs such as chemotherapy

Post-testicular

• may include obstructive causes (ex. Vasectomy)
• ejaculatory problems
• erectile dysfunction

Question 28

What are the female causes of subfertility?

Answer 28

Ovulatory disorders

• can be divided into 3 groups
  1. Failure of GnRH to act on the pituitary (hypothalmic-pituitary failure)
  2. Failure of the axis to respond appropriately to stimulation (hypothalamic-pituitary-ovarian dysfunction) such as PCOS or high levels of prolactin
  3. Failure of ovary to respond appropriately (ovarian failure) such as Turner’s syndrome or early menopause

Uterine/Peritoneal disorders

• uterine fibroids
• conditions where scarring/adhesions have occurred (i.e. PID, asherman’s syndrome, endometriosis, abd surgery)
• abnormal structure of uterus from issues of the Müllerian duct developing incorrectly (eg. Septae)

Tubal damage

• endometriosis
• iatrogenic from pelvic surgery
• infection (ex. Chlamydia)
• ectopic pregnancy

Question 29

What investigations would you do for male for subfertility?

Answer 29

• general health
• are you a father already
• alcohol/smoking
• surgical history
• drug history
• sexual health history
• sexual dysfunction
• semen analysis
• hormone levels: LH, FSH, testosterone
• ultrasound scan of testes
• karyotyping

Question 30

What investigations would you do for females for subfertility?

Answer 30

• age
• general health
• drug history
• smoking/alcohol history
• on/gyn history
• menstrual cycle
• surgical history
• sexual health history
• hormone levels: LH, FSH, progesterone, androgens
• systemic blood tests: prolactin, thyroid function
• pelvic USS
• test to check tubal patency

Question 31

What other management would you do for subfertility?

Answer 31

• refer to special clinic
• surgical or medical management
• IVF

Question 32

A baby is reviewed on the postnatal ward the day after delivery. All examination findings are normal other than ambiguous external genitalia.
The baby is booked in for a follow up appointment. Before they are seen by the specialist, the parents bring the baby to A&E because they have become more lethargic and have lost a lot of weight.
What is the most likely diagnosis?

Answer 32

Congenital adrenal hyperplasia because excessive androgen

Question 33

A 17 year old girl sees the GP because she has not had a period for 4 months.
The history reveals that the patient has previously had regular periods, with an average cycle length of 28 days. She is sexually active and uses barrier contraception. She is revising for A Levels.
On examination her BMI is 21, and secondary sexual characteristics are present. Observations are normal.
The GP suspects secondary amenorrhoea. What is the first investigation you would order?

Answer 33

-B-HCG to rule out pregnancy

Question 34

A 16 year old girl is referred to the gynaecology department with primary amenorrhoea. She has no history of tremors or palpitations, and no significant changes in weight.
On examination, secondary sexual characteristics are present, however no cervix can be palpated on bimanual examination of the vagina. What is the most likely diagnosis?

Answer 34

Androgen insensitivity

-testes in body producing androgens but tissues not responding to it