Contraception

Question 1

Name the contraindications to COCs.

Answer 1

Migraine with aura
Age > 35 smoking 15 cig/day
Hx of VTE
Less than 6 weeks postpartum
Uncontrolled htn
Vascular dx or stroke
Major sx with prolonged immobility
Ischemic heart disease, cardiomyopathy or A. Fib
Liver cirrhosis and liver tumours
SLE & antiphospholipid syndrome

Question 2

Testing for female infertility

Answer 2

Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea

High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.

High LH may suggest polycystic ovarian syndrome (PCOS).

A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.

Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

Further investigations, often performed in secondary care:

Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
Hysterosalpingogram to look at the patency of the fallopian tubes
Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

Question 3

Name 2 types of progesterone found in COCs.

Answer 3

Levonorgestrel (Alesse): less breakthrough bleeding
Drospirenone (Yasmin, Yas): spironolactone analogue and has a mild diuretic effect
- Yasmin = 30 mcg of ethinyl estradiol; Yas = 20 mcg

Question 4

List the 2 key side effects of Depo-Provera (Medroxyprogesterone).

Answer 4

Weight gain
Decrease in bone mineral density

Question 5

How is a COC initiated?

Answer 5

Start on the 1st day of menstrual cycle (no additional contraception is needed if started up to day 5 of menstrual cycle)
If starting after day 5, extra protection for first seven days