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Gynae (Owen) > Contraception > Flashcards

Contraception Flashcards

1
Q

What happens to temperature across menstrual cycle

A

Increased after ovulation by about 1^C due to progestogen production

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2
Q

What is an oestrogen versus a progestogen

A

Oestrogen- substance which induces proliferation of the endometrium
Progestogen- substance which induces secretory changes in the endometrium

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3
Q

What are 3 main oestrogens

A

17-b oestradiol- main oestrogen of menstrual cycle
Oestrone- precursor
Oestriol- main oestrogen of pregnancy

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4
Q

Pathway for production of oestrogens

A

Androstenedione -> Oestrone-> 17 beta oestradiol
Androstenedione -> testosterone -> Oestrone

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5
Q

What are the 2 FSH and LH sensitive cells

A

Theca cells respond to LH producing androgens
Granulosa cells FSH producing aromatase which convert androgens
FSG

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6
Q

How do oestogen levels increase so much in the follicular phase

A

FSH binds to granulosa cells which produce aromatase converting androgens to 17beta oestradiol which binds to oestrogen receptors on same granulosa cells causing even more conversion
Auto positive feedback

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7
Q

What happens in ovulation

A

Oestrogen causes surge in LH and some FSH which releases graaffian follicle, remaining follicle becomes corpus luteum producing oestrogen and progesterone

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8
Q

What happens in luteal phase

A

Corpus luteum produces oestrogen and progestogens which thicken endometrium and induce secretory changes
Oestrogen and progestogens inhibit FSH and LH preventing another follicle being released

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9
Q

What does corpus luteum become

A

Corpus albicans

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10
Q

What causes start of menstruation

A

After about 2 weeks the corpus luteum degenerates into corpus albicans which stops oestrogen and progesterone release- this prevents maintenance of endometrium so is sloughed away

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11
Q

What are the 3 emergency contraception methods available

A

Copper intrauterine device
Oral ulipristal acetate
Oral levonorgestrel

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12
Q

Copper IUD MOA, advantages and disadvantages

A

MOA- toxic effects on sperm and sterile inflammation on uterus which prevents implantation
Advantages- most effective regardless of time in ovulation
Disadvantages- none everyone should be offered if meet criteria

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13
Q

How does ulipristal acetate work

A

Progesterone receptor modulator which inhibits ovulation

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14
Q

Criteria for using copper IUD as emergency contraception

A

Within 5 days of UPSI or 5 days after ovulation

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15
Q

Risks of using copper IUD

A

Can be expelled especially in first 3 months
Risk of PID soon after insertion
Pain on doing so and then can get pelvic pain longer term too
Can perforate the wall of uterus on insertion

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16
Q

What happens if vomit within 3 hours of taking emergency contraception pill

A

For both retake them ASAP

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17
Q

Side effects of ulipristal and levonorgesterol as morning after pill

A

Vomiting
Menstrual irregularities- mild bleeding and can have later or earlier
Ectopic pregnancy
Standard headace, tummy pain or diarrhoea etc

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18
Q

How does levonorgestel work as emergency contraception

A

Progestogen which stops ovulation and inhibits implantation

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19
Q

When can contraceptive pills be restarted after levonorgestel and ulipristal

A

Levonorgestel straight away
Ulipristal wait 5 days

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20
Q

When need to double the dose of levonorgestel

A

BMI over 26
Weight over 70kg
On liver induces such as carbamezapine and rifampicin

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21
Q

How long after UPSI can you use each oral emergency contraceptive

A

Ulipristal- 120 hours
Levonorgestel- 72 hours

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22
Q

What condition should ulipristal not be used in

A

Severe asthma

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23
Q

Can you breastfeed after taking levonorgestel or ulitpristal

A

Levonorgestel- yes
Ulipristal- no wait 1 week

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24
Q

Can you use ulipristal or levonorgestel more than once in same menstrual pregnancy

A

Yes can use more than once

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25
Q

What are methods of contraception offered in the UK

A

Combined hormonal contraception
Progestogen only
Intrauterine contraception
Barrier method
Sterilisation

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26
Q

What are options for combined hormonal contraception

A

Oral pill
Transdermal patch
Combined vaginal ring

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27
Q

What are options for progestogen only contraception

A

Progestogen only pill
Progestogen implant
Progestogen injectable

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28
Q

What are intrauterine contraception methods

A

Copper IUD
Levonorgestel intrauterine system

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29
Q

What are the sterilisation methods for men and women

A

Men- vasectomy
Women- tubal occlusion

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30
Q

What factors need to be assessed in contraception

A

Preferred method
Future plans for children
Personal views and beliefs
Attitudes of partner and family

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31
Q

In contraception assessment history what need to do

A

Exclude pregnancy
Take history
- PMH
- allergies
- reproductive history
Risk of STI
- sexual circumstances
- partners
- activity
- use of substances
Risk assess for sexual assault

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32
Q

How can pregnancy be excluded

A

Not had intercourse since last period
Currently correctly using contraception
Within 7 days of onset of period
Within 4 weeks of giving birth and not breastfeeding
Within 6 months of giving birth and breastfeeding
Within 7 days of termination or miscarriage
Negative pregnancy test sooner than 3 weeks of last UPSI

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33
Q

If person under age of 16 requesting contraception what need to do

A

Assess fraser competent
- understands practitioners advice
- cannot persuade to tell parents or allow doctor to tell tem
- going to continue having sex with or without the contraception
- physical or mental health will deteriorate unless receives the treatment
- best interests require practitioner to give contraception without telling parents

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34
Q

What do if someone with learning disabilities asks for contraception

A

Support her own decisions
Assess competence to consent

If cant take responsibility then other carers/parties should be involved

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35
Q

What drugs need to look out for when giving contraception

A

Teratogenic- sodium valproate, lithium
Liver inducing enzymes
Lamotrigine
Griseofulvin
Vomiting inducing

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36
Q

What do for contraception if taking a teratogenic drug

A

Use a highly efficient method like Cu-IUD, LNG-IUS or progestogen injection
+
Advise to use barrier protection
OR
If want to use other method like combined hormone contraception or progestogen MUST use barrier protection

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37
Q

What are liver enzyme inducing drugs

A

Rifamycins
Anti-epileptics
- carbamezapine
- pheytoin
- topiramate
Anti-virals
- protease inhibitors (tenofovir etc)
- non-nucleoside reverse transcriptase inhibitors

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38
Q

What do with contraception if taking a liver enzyme inducing drug

A

Warn that they affect the efficacy of combined hormonal contraception plus oral and implantable progesterone
Recommend Cu-IUD, LNG-IUS and progestogen injections

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39
Q

What do with contraception if taking lamotrigine

A

Recomend that with CHC and POP it will reduce seizure protection and increase toxicity of the drug

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40
Q

What do with contraception if taking griseofulvin

A

Do not use any hormonal therapy as reduces the efficacy

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41
Q

What do with contraception if taking a drug that causes vomiting

A

Recommend against oral options however if do take then advise if vomits within 3 hours of taking then must treat as if is a missed pill

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42
Q

Does a previous pelvic inflammatory disease influence contraception choice

A

NO can use any

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43
Q

Does a current PID affect contraception choice

A

Yes you would not insert an intrauterine device
Hormonal methods can be used

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44
Q

What do if current chlamydia or gonorrhoea/prurulent cervicitis

A

Do not initiate Cu-IUD or LNG-IUS
Use hormonal methods fine

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45
Q

What do with contraception if have BV or trichomonas

A

Any method can be used

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46
Q

What do with contraception if idiopathic menorrhagia that has been investigated

A

Any method can be used
1st line- LNG-IUS as can help with symptoms
2nd line- COCP
3rd line- POP or progestogen injectable

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47
Q

What do for contraception if unexplained vaginal bleeding

A

Can leave in implantable devices but DO NOT apply
Progestogen only implant and injectable are contraindicated but all other hormonal methods are fine

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48
Q

What do for contraception if history of ectopic pregnancy

A

All methods are fine

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49
Q

What do for conrtaception if uterine fibroids present

A

Depends on if distortion of uterine cavity
- if is not then any is fine
- implantable not acceptable but can use hormonal

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50
Q

What do with contraception if DM

A

No vascular disease
- any method is fine
Vascular disease or complication like nephropathy etc
- combined hormal therapy contraindicated

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51
Q

What do with contraception if history of gestational DM

A

Any method is fine

52
Q

What do with contraception if migraine

A

If aura dont use CHC
If no aura is fine but then if develops one then not recommended

53
Q

What do with contraception if history of migraine with aura

A

If history over 5 years then do not use CHC

54
Q

In women with multiple CVD risk factors what do with contraception

A

Any CHC or progestogen injectables are contraindicated

55
Q

What do with contraception if obese

A

BMI under 35 anything is acceptable
BMI over 35 do not used CHC

56
Q

What do with contraception if HTN

A

Never use Combined
If vascular disease too do not use progestogen injectable

57
Q

What do if someone has a gastric sleeve for contraception

A

Can not use oral

58
Q

In patients considering taking progestogen contraception what must always check

A

Cervical screening history

59
Q

With the progestogen oral pill, what are important considerations

A

Cervical screening
Anything causing hyperkalaemia
- renal failure
- K+ losing drugs
- hypoaldosteronism

60
Q

If going to take progestogen only injectable what are considerations

A

Cervical screening
Osteoporosis risk

61
Q

Risks of combined hormonal contraceptive

A

Risk of VTE
Breast and endometrial cancer risk

62
Q

How should assess someone for LNG-IUS and Cu-IUD

A

Perform Bimanual before insertion
If at high risk of STI then offer testing
Exclude unexplained bleeding

63
Q

What is MOA of CHC

A

Inhibits ovulation

64
Q

What is MOA of injectable contraceptive

A

Inhibits ovulation
Thickens cervical mucous

65
Q

What is MOA of Cu-IUD

A

Reduces sperm motility

66
Q

What is MOA of LNG-IUS

A

Prevents endometrial proliferation
Thickens cervical mucous

67
Q

What are family awareness methods

A

Methods of monitoring own body to plan pregnancy or avoid it
Monitor cycle length and dates, temperature and cervical mucous

68
Q

How long can sperm survive inside a womans body

A

7 days

69
Q

How long after ovulation can sperm successfully fertilise

A

2 days before graffian follicle becomes corpus luteum

70
Q

What are methods of barrier protection

A

Men- condoms
Women- caps and diaphragms

71
Q

Who are diaphragms and caps contraindicated in

A

Poor vaginal tones
Shallow pubic edge
Distorted anatomy
Cant touch vagina without discomfort

72
Q

How long after partum do you need to use contraception

A

21 days

73
Q

When after birth can Cu-IUD or intra uterine system be used

A

Within 48 hours or after 4 weeks

74
Q

What is nexplanon

A

Progestogen implantable device

75
Q

What is the difference between the UKMEC categories

A

1- no contraindication
2- advantages generally outweigh the disadvantages
3- disadvantages outweigh advantages
4- absolute contraindication

76
Q

What are some category 4 UKMEC

A

Migraine with aura
More than 35 smoking over 15 cigarettes a day
History of VTE
History of stroke or IHD
Uncontrolled HTN
Major surgery
Current breast cancer
Breastfeeding and under 6 weeks post partum

77
Q

What are some category 3 UKMEC

A

Less than 35 smoking over 15 cigarettes a day
Family history of thromboembolic disease under 45
Carriers of BRCA
Immobility- wheel chair use
Current gallbladder disease
Previous breast cancer

78
Q

Adverse effects of injectable contraceptives

A

Weight gain
Irregular bleeding
Osteoporosis risk and should only use in children if absolutely have to

79
Q

How long do injectable contraceptives work for

A

12 weeks

80
Q

What happens if miss a progestogen only pill

A

Typical ones
- less than 3 hours late is fine
- over 3 hours action needed
Desogestrel
- less than 12 hours late is fine
- over 12 hours action needed

81
Q

What is action needed for missed progestogen only pill

A

Take pill as soon as possible and if more than 1 is missed take only 1
Use condoms for 48 hours

82
Q

What are the progestogen only pills and how do they work

A

Typical- thicken cervical mucous
- include norgeston, noriday
Desogestrel- inhibit ovulation

83
Q

How long does it take contraceptives to work

A

IUD- immediately
2 days- POP
7 days- COC, implantable, injectable

84
Q

What is best post partum contraception

A

Can insert Cu-IUD 2 days post partum if not
Progestogen only pill
- good as will not suppress lactation
- good as also not increased VTE risk which post partum people at risk of for 28 days post partum

85
Q

What are typical side effects of progestogens

A

Nausea
Breast pain
Headache

86
Q

What do if miss 1 COCP

A

Take it even if means taking 2 in one day then continue 1 each day

87
Q

What do if miss 2 or more COCP

A

Take 2 on a day and discount other missed ones
Use condoms until taken pills for 7 days
If on week 1- consider emergency contraception if UPSI
If week 2- no need for emergency contraception
If week 3- finish the pack and then omit pill free period

88
Q

How to manage severe irregular bleeding if on injectable or implantable

A

3 months of COCP

89
Q

How does it work with application of Evra combined hormonal patch

A

Change every week for 3 weeks then 1 patch free week where can get bleeding

90
Q

What happens if is delayed removal of Evra patch

A

If end of week 1 and 2
- fine if delayed less than 48 hours
- if delayed over then need barrier protection for 7 days however if has had UPSI in last 5 days need to use emergency contraception
If end of week 3
- remove and apply new one at start of next cycle
If delayed before start of new cycle use barrier protection for 7 days

91
Q

Ideal choice of contraception if under 18

A

Progesterone implant
IUD/IUS UKMEC 2

92
Q

When is the predicted ovulation date

A

14 days before start of next cycle
If 30 day cycle then day 16

93
Q

When can you share information about someones sexual relationship if under 18

A

Too immature to understand
Person in a position of trust
Big difference in maturity/age
Bribery/payment
Substances involved

94
Q

Where is implantable device put

A

Non-dominant arm

95
Q

What contraception is most associated with delayed return to fertility

A

Depo-provera

96
Q

How does pearl index work

A

Number of women in 100 women who would get pregnant over a year of exposure

97
Q

Which cancer is COCP protective against

A

Endometrial
Ovarian

98
Q

What drugs can be used for males wanting to transition

A

Oestradiol
GNRH analogs
Finasteride
Cytoperone

99
Q

What effect do drugs used to transition males have on fertility

A

Reduce sperm production but must still use condoms or vasectomy as not 100% effective

100
Q

What is seen as most appropraite contraception in a trans person

A

Either a vasectomy or a tube occlusion

101
Q

What contraception methods are appropriate in a trans man with a uterus

A
  • oestrogen not recommended as antagonises testosterone supplements
  • progestogen has no impact on testosterone
  • LNG-IUS good as would allow for menstrual cessation
  • Cu-IUD will not interact with hormones however can affect potentiate menstrual bleeding
102
Q

Side effects of progestogen only pill

A

Irregular bleeding- most common
Breast pain
Nausea
Headache

103
Q

What is done with regards to COCP around a surgery

A

Stop 4 weeks before and start 2 weeks after

104
Q

How does using the vaginal ring work

A

21 days of ring in, 7 days off then replace
OR
Can keep in for 28

105
Q

When does vaginal ring work from

A

If on menses straight away
If not then 7 days so use barrier

106
Q

Side effects of vaginal ring

A

Some discharge initially
Breast pain
Headache

107
Q

With what contraceptive can the COCP be used to treat bleeding

A

Implantable progestogen

108
Q

What effect do the intrauterine contraceptives have on periods

A

CuIUD- heavy and more painful
LNG-IUS- bleeding irregularly at start but then amenorrhoea or light menses

109
Q

How long can use patch or COCP without a break

A

Technically forever it depends if want withdrawal bleeds

110
Q

Why is COCP not given if breastfeeding

A

Reduced milk produced

111
Q

When can fully determine if someone is not pregnant

A

Do pregnancy test 3 weeks after last UPSI

112
Q

If someone has had UPSI in last 3 weeks what do before prescribing a long term contraception

A

Give pill or tell them to abstain

113
Q

Oestrogen SEs

A

Breast tenderness
Premenstrual syndrome
Nausea
CVD and breast cancer risk

114
Q

SEs of progesterone contraception

A

Acne
Abnormal bleeding

115
Q

If want to use lactational method what need to do

A

Exclusively breastfeed
Cant use anything else
Includes giving in the middle of night

116
Q

For family awareness method when take temp

A

As soon as wake up

117
Q

What is the investigation of choice for lost coil threads and if it is not seen in cervical or uterine cavity

A

Pelvic TVUSS
Abdo x-ray

118
Q

If coil is in abdomen what do

A

Laparoscopy and removal

119
Q

How long after IUS should abnormal bleeding be investigated

A

6 months

120
Q

When need to check threads of IUS/D

A

Every month post period

121
Q

How can intrauterine coils dislodging present

A

Discoloured discharge
Abdo pain

122
Q

How successful are condoms when use them properly

A

98%

123
Q

How long does spermatogenesis take

A

64 days

124
Q

If develop irregular bleeding on progesterone implant or injection what is management

A

Rule out other causes like STIs
Then can initiate COCP

125
Q

What do if on COCP and reach 50

A

Stop it as CI in over 50s

Gynae (Owen) (11 decks)

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