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gynaecology > Contraception > Flashcards

Contraception Flashcards

1
Q

what are the different types of contraception?

A

barrier
medical - oral, implant, depo
IUS/IUD
sterilisation

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2
Q

what are the different types of barrier contraception?

A

male condom
female condom
cervical cap
diaphragm

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3
Q

what are the advantages of male and female condoms?

what are the disadvantages?

A

both reduce transmission of STIs (especially the male condom)
both have few side effects and can be used when needed. both have no contraindications (other than latex allergy)
The female condom can be inserted up to 8 hours before sex

however the female condom is difficult to insert and the penis can sometimes slip between vagina and condom 
both can reduce the sensitivity/ comfort of sex 
Can tear (more likely in the male condom, esp if oil based lubricant being used e.g. baby oil)
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4
Q

how does a female condom work?

A

2 rings - one sits deep into vagina and one sits superficially outside the vulvula. there is then a tube that runs along vagina

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5
Q

how does a diaphragm work?

A

rubber ring which sits across anterior and posterior cervix to cover the cervix.
held in place by the rigid frame, pubic symphysis and vaginal tone

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6
Q

how does a cervical cap work?

A

small cap that fits across the cervix

held in place by suction and vaginal tone

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7
Q

how can the efficacy of diaphragms and cervical caps be reinforced?

A

can be combined with spermicide

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8
Q

what are the advantages and disadvantages of using diaphragms/ caps?

A

advantages: no side effects
disadvantages: difficulty inserting, needs to be planned i.e. inserted in time before sex (up to 3 hours before - good things about this and bad), difficult to get perfect use, increases UTIs, spermicide can irritate vaginal mucosa (increases STI transmission). still can have STI transmission

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9
Q

what are the overall advantages and disadvantages of barrier contraception?

A

almost no side effects
easy use when needed

poor compliance because require planning before sex
requires good application technique

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10
Q

how does the COCP work?

A

O and P together inhibit the HPG axis to prevent ovulation

P also inhibits proliferation of endometrium and thickens mucus to prevent fertilisation and implantation

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11
Q

what are the different types of COCP?

A

monophasic - equal amounts of O + P taken for 21 days and then break for 7 days. Can also have options where there is a low dose of O

biphasic - O+P where dose of P is increased in second half
triphasic : same as above but P increased in 3 separate parts

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12
Q

give examples of monophasic COCP

A

microgynon
levest
Brevinor

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13
Q

give the names of oestrogens and progesterone’s used in COCP

A

progesterone: levonorgestrel, norethisterone
oestrogen: ethinylestradiol

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14
Q

what advice should be given to girls taking the pill?

A

how to take: take on day 1 to 5 of cycle otherwise need to use condoms for 7 days. if one is missed take ASAP if 2 missed then need to use condoms for 7 days

vomiting and diarrhoea can reduce the efficacy
some Abx e.g. rifampicin can reduce efficacy

BP checked and weight every 3-6 months
check for contraindications

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15
Q

what are the advantages of taking the COCP?

A

non invasive
works well (better than barrier) if used correctly i.e. good compliance
sex doesn’t need to be interrupted for use
less painful, more regular and lighter periods
reduces risk of ovarian, endometrial and colon cancer
reduces risk of functional ovarian cysts
normal fertility remains after stopping

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16
Q

what are the disadvantages of using COCP?

A 
user dependant 
no protection against STIs
increased risk of cervical and breast cancer
increased risk of stroke, MI and DVT
weight gain and increased BP
other side effects
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17
Q

what are the contraindications against using COCP?

A 
BMI >35
smoker and >35 yrs
HTN 
migraines with auras
DVT risk - e.g. family history or thrombotic disease, surgery
breast cancer/ primary liver tumours 
breast feeding 
diabetes with complications
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18
Q

what are the methods of delivering COCP?

A 
oral
transdermal patch - via skin absorption, patch changed every 7 days for 3 weeks and 1 week rest (better compliance) 
vaginal ring (NuvaRing) - plastic ring in vagina that delivers O + P. sits in vagina for 21 days then 7 day break and new ring.
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19
Q

when are transdermal patches used?

A

poor compliance to oral pill

poor absorption e.g. crohns / coeliacs

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20
Q

how does the progesterone only pill work?

A

mainly works by inhibiting proliferation of the endometrium and thickening the cervical mucus
has some effect on inhibiting ovulation

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21
Q

name the brands for POP?

A

micronor
cerazette - very good at inhibiting ovulation
noriday

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22
Q

what are the advantages of POP?

A

better than barrier - safer
less risks compared to COCP so can be taken when COCP contraindicated
sex doesn’t need to be interrupted
less risk of endometrial cancer

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23
Q

what are the disadvantages of POP?

A

user dependant
some risk of breast cancer and overian cysts
side effects of progesterone
break through bleeding

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24
Q

what are the contraindications of POP?

A

active/ past breast cancer or liver cirrhosis/ tumours
less effective in those >70kg
stroke/ coronary artery disease
pregnancy

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25
Q

what is the progesterone only implant?

A

small metal device that sits in upper arm and slowly releases etonogestrel over 3 years
works by thickening endometrium and inhibiting ovulation but also thickens mucus

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26
Q

what are the advantages of the progesterone implant?

A 
used when COCP contraindicated
can be used in breast feeding
used for any BMI 
very effective 
no compliance issues 
fertility returns as soon as it is removed
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27
Q

what are the disadvantages of the progesterone implant?

A

break through bleeding
small risk of breast cancer
fitting and removing can cause irritation and pain
the device can sometimes break in situ

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28
Q

what are the contraindications of progesterone implant?

A

contraindicated in pregnancy
unexplained vaginal bleeding
previous breast cancer/ liver cirrhosis
stroke

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29
Q

How are progesterone only injections given?

A

IM or SC injection

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30
Q

name an example of a progesterone only injection

A

Depo-Provera (Depo),

- contains medroxyprogesterone acetate (MPA)

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31
Q

how often is the Depo injection given?

A

every 12 months IM to buttock

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32
Q

what are the advantages of Depo injection

A

no need to worry about compliance, very effective and non user dependant
can be given when COCP contraindicated
no known DDI
may reduce risk of endometrial cancer

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33
Q

what are the disadvantages of the Depo injection?

A

break through bleeding
non rapidly reversible - can take up to a year for fertility to return
increased weight gain
slight increased breast cancer risk
loss of bone mineral density with long term use

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34
Q

what are the contraindications of the depo injection

A 
current breast cancer (within 5 years)
history of arterial disease or risk factors for this
pregnancy 
diabetes with vascular disease 
people who want fertility in near future
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35
Q

what happens if you miss one of the COCP pills

A

one missed >24hours but <48 hours late:

  • take the pill ASAP and take the rest of the pack as normal
  • no additional contraception needed
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36
Q

what happens if you miss two of the COCP pills?

A

if pill missed >48 hours
take the last pill missed (but not both) and continue the rest of the pack
use contraception for 7 days
if the pill missed was within first week of the pack - take emergency contraceptions

37
Q

what happens if you miss the POP?

A

if >3 hours late, need additional contraception
however new brand Cervazette gives a window of 12 hours
emergency contraception is required if sexual intercourse 2-3 days prior to missed pill.

38
Q

what is the difference between and IUD and IUS?

A 
Intrauterine device (IUD) = copper coil that is inserted into the endometrium 
Intrauterine system = device that sits in endometrium and releases progesterone
39
Q

how does an IUD work?

A

copper thickens mucus (to stop sperm), is toxic to sperm and prevents the fertilised egg from implanting

can be used for up to 5-10 years depending on the type

40
Q

what are the advantages of IUD?

A

no hormones needed
can be used as emergency contraception
no compliance issues

41
Q

what are the disadvantages of IUD?

A

periods can become heavier and more painful
not safe from STIs
can cause infection when inserted
increased risk of ectopic pregnancy if you do become pregnant

42
Q

how does an IUS work?

A

sits in endometrium and releases progesterone which prevents endometrial proliferation

43
Q

What is the Mirena ?

A

levonorgestrel releasing intrauterine system (LNG - IUS)

44
Q

can the IUS be used for emergency contraception?

A

no (only the copper IUD can)

45
Q

what are side effects of the levonorgestrel releasing intrauterine system?

A

irregular bleeding may last for up to 6 months
breast tenderness
acne
headache

46
Q

what are the two types of delivering emergency contraception?

A

oral tablet = levonorgestrel or Ulipristal acetate

IUD

47
Q

how does levonorgestrel work as an emergency contraception?

A 
high dose (1.5mg) progesterone given which delays ovulation by 5-7 days by which point sperm will be dead
can be used for up to 72 hours after intercourse
48
Q

How does Ulipristal acetate work as an emergency contraception?

A

progesterone receptor modulator
works to delay ovulation
can be used up to 120 hours after intercourse

49
Q

what are the contraindications to using levonorgestrel as an emergency contraception?

A

malabsorption e.g. crohns

use of rifampicin - inducing effect and wont work

50
Q

what are the contraindications to using Ulipristal acetate as an emergency contraception?

A

malabsorption e.g. crohns
use of rifampicin - inducing effect and wont work
hypersensitivity to ulipristal acetate
severe hepatic dysfunction
drugs increasing gastric pH
asthma insufficiently controlled with steroids
avoid breast feeding for 7 days after

51
Q

if a patient is on rifampicin which emergency contraception should be indicated and are there altneratives?

A

IUD is recommended due to inducing effects of rifampicin on progesterone and ulipristal acetate

however if refused can offer a higher dose of levonorgestrel (3mg) (but ulipristal acetate is contraindicated)

52
Q

what are the adverse effects of emergency hormonal contraception?

A

vomiting - if it occurs within 2 hours of levonorgestrel or 3 hours of ulipristal acetate, then may not have been absorbed and they need to seek advice

nausea, dizziness, menstrual disturbance, abdo pain , headache

53
Q

when are hormonal methods of contraception ineffective?

A

if taken ovulated <5days ago

in this case IUD needed

54
Q

what is levonelle? ElleOne?

A

levonorgestrel as a type of emergency contraception

ElleOne = ulipristal acetate

55
Q

when can emergency IUD be inserted to work as emergency contraception?

A

IUD can be inserted within 5 days of intercourse and be used as emergency contraception
it can then be kept in for 5-10 years as contraception

56
Q

what are the contraindications of IUD?

A

uterine fibroids or distorted uterine cavity

documented / suspected PID/ STI

57
Q

other than prescribing emergency contraception what other things should be covered in a consultation with a women seeking emergency contraception?

A
  • assess relationship - could it be non-consensual, child abuse etc
  • advice on safe sex and screening for STIs
  • warn of side effects and what to do if vomited
58
Q

what factors should be considered when prescribing contraception?

A

BMI, BP, smoking, cormorbidities (menorrhagia, fibroids, migraines, CVD, previous DVT), breast feeding, STIs/PID
current medication
age (capacity)
different methods and side effects discussed
reason for contraception
exclude pregnancy

59
Q

what is frasers criteria?

A

A way of assessing capacity and right to consent for contraception without parental consent (this law is specifically used for contraception)

understands doctors advice
cant be persuaded to tell parents
likely to begin/continue intercourse regardless
it is in the persons best interest to have contraception without parental consent

60
Q

what does female sterilisation involve?

A

involves blocking fallopian tubes with clips/ rings

can be done under general anaesthetic laparoscopically

61
Q

what are the advantages of female sterilisation?

A

permanent
no hormones needed
periods unaffected

62
Q

what are the disadvantages of female sterilisation?

A

cannot be reversed so need to ensure correct decision made with both partners involved
if it fails and pregnancy occurs, more likely to be ectopic.
problems of surgery - pain, bleeding, infection, anaesthetic risk

63
Q

what is male sterilisation?

A

small operation in which vas deferens is cut = vasectomy

64
Q

what are the advantages of male sterilisation?

A

very reliable
usually under local anaesthetic
permanent
usually more effective than female sterilisation

65
Q

what are the problems with male sterilisation / vasectomy?

A

infection
bruising / haematoma
aching of scrotum (settles in 3 months)
risk of anaesthesia

66
Q

is a vasectomy reversible?

A

yes but not on NHS

success of this is better the shorter the time since the vasectomy

67
Q

is vasectomy instantly a method of contraception?

A

no sperm can survive for several weeks in vas deferens

after 12 weeks, the man can be tested to see if sperm are still viable.

68
Q

what are the indications of HRT?

A

menopause (if risk of HRT < benefits of HRT)
premature ovarian insufficiency (even if no symptoms)
endocrine deficiency e.g. Turners
for those <60yrs and at risk of osteoporosis fracture

69
Q

what are the different methods for giving HRT?

A

sequential combined - daily O and cyclical P

continuous combined - daily O +P

unopposed O

method of delivery - vaginal, transdermal patch, nasal, oral , oestrogen releasing vaginal ring and IUS

70
Q

when is sequential combined HRT used? how does it work?

A

if last menstrual period if <1yr ago (perimenopausal)

O for 25 days, O+P for 10 to 14 days , 3-5 days no hormones

71
Q

when is continuous combined HRT used?

A

if they have received sequential combined HRT for 1 year or 1 year since last menstrual period

72
Q

when is unopposed O recommended as HRT?

A

only for those with hysterectomies because of increased risk of endometrial hyperplasia/cancer

73
Q

when is testosterone supplements offered to women?

A

if they are complaining of loss of libido

74
Q

what are the advantages of the non-oral preparations of HRT?

A

less effect on clotting,
reduced Nausea
better if suffer from malabsorption
good for those with diabetes, risk of thrombosis, BMI >30 or migraines

75
Q

what are the benefits of HRT?

A 
reduced vasomotor symptoms
improves sleep, muscle aches and thus quality of life
improves mood
improves urogenital symptoms - vaginal dryness, incontinence, cystitis
reduces osteoporosis and fracture risk 
reduces CVS disease
reduced CRC risk
reduces long term Alzheimer's risk 
improves muscle mass
76
Q

what are the side effects of HRT?

A 
nausea and breast tenderness, 
weight gain and fluid retention 
headaches
mood swings (progesterone)
bloated sensation (progesterone)
legs cramping  (oestrogen)
abnormal bleeding (usually stops after first 3-6 months)

increased risk of gall stones, VTE, stroke, breast cancer

77
Q

when is HRT contraindicated?

A

history of breast cancer or active breast cancer
history of VTE, stroke, MI
uncontrolled HTN
some caution if: abnormal vaginal bleeding, abnormal LFTs (because HRT is metabolised by liver), migraine (transdermal patch can be offered), high risk gall bladder disease, Hx of endometrial/ovarian cancer

78
Q

what are the side effects of oestrogen?

A 
breast tenderness/ hyperplasia 
N, V, headache
increased blood coagulability 
reduced glucose tolerance
IHD/stroke 
leg cramps
bloating
79
Q

what are the side effects of progesterone?

A

mood changes, acne, weight gain, N, V and headaches

80
Q

what is Tibolone?

A

selective oestrogen receptor modulator (SERM)

not as effective as combined HRT but can be an alternative

81
Q

how should HRT be stopped?

A

gradually

82
Q

how can optimum level of HRT be determined?

A

by symptom control (not by level of FSH)

83
Q

how is premature ovarian insufficiency treated with HRT?

A

oestrogens used for 1st half and then progesterone added to second half of month (to prevent endometrial hyperplasia)
can also add low dose androgen to improve libido and fatigue
in young woman can just use COCP

84
Q

when is androgen replacement therapy indicated in men?

A

primary of secondary hypogonadism

85
Q

what are the advantages of androgen replacement therapy in men?

A

improves libido, strength, reduces osteoporosis risk and improves secondary sexual characteristics.

86
Q

how can androgen replacement therapy be given?

A

IM, implant, transdermal, oral

87
Q

what are the ADRs of androgen replacement therapy?

A

increased risk of prostate cancer
adverse lipid profile and increased risk of atherosclerotic disease
polycythemia

88
Q

what are the contraindications of androgen replacement therapy?

A

breast/ prostate cancer
benign prostatic hyperplasia
sleep apnoea

gynaecology (7 decks)

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