Contraception Flashcards
1
Q
What are monophasic pills?
A
Same hormone concentration throughout all pills
2
Q
Types of monophasic pills? (COC)
A
21 day cycle 1 OD for 21 days, 7 day break
ED pills: 21 hormonal pills then 7 placebo
Zoely 24+4
3
Q
What is in COC?
A
Ethinylestradiol (EE) and progestogen
4
Q
What are phasic COCs?
A
Varying hormone concentrations throughout cycle
biphasic - 2 concs
triphasic - 3 concs
5
Q
Examples of phasic COCs?
A
21 day phasic cycle
28 day phasic cycle - Qlaira 26+2, logynon
6
Q
What is POP?
A
Progestrone only Pill
7
Q
Characteristic of POP cycles?
A
no pill free period - taken for 28 days
8
Q
Examples of POP?
A
traditional - norethisterone 350mcg (higher doses are therapeutic)
newer - desogestrel
9
Q
What is CHC?
A
Combined hormonal contraception - non oral
10
Q
What is POC?
A
Progestrogen only contraception - non oral
11
Q
Examples of CHC?
A
contraceptive patch, vaginal ring
12
Q
How contraceptive patch is used?
A
1 patch per week for 21 days, then 7 days patch free
13
Q
How vaginal ring is used?
A
1 ring for three weeks, then 7 days free
14
Q
Examples of POC?
A
Depo injection, contraceptive implant, IUS
15
Q
Frequency of contraceptive injection?
A
150mg IM every 8-12 weeks
104mg subcut every 13 weeks (more common)
16
Q
What hormone is in the injection?
A
Medroxyprogesterone
17
Q
What hormone is in the contraceptive implant?
A
etonogestrel
18
Q
What hormone is in the IUS?
A
levonorgestrel
19
Q
How do CHCs prevent pregnancy?
A
synthetic oestrogens inhibit FSH by negative feedback no follicular development
inhibit ovulation
thickened cervical mucus and altered endometrium
20
Q
How to POCs prevent pregnancy?
A
Suppression of ovulation, thickened cervical mucus, delayed ovum transport, hostility of endometrium,
21
Q
Efficacy of CHC and POC?
A
99.7% with perfect use, 92% with typical use
22
Q
Efficacy of contraceptive pills?
A
99% perfect use, 91% typical use
23
Q
Efficacy of vaginal ring, patch etc?
A
99% perfectuse, 91% typical use
24
Q
Efficacy or LARC?
A
All 99% - expect typical use of injection 94%
less user dependent
25
Efficacy of non-hormonal methods?
male condom - up to 98% (82% typical)
female condom - up to 95% (79% typical)
Natural family planning - up to 98%
Diaphragm: 92-96% perfect (71-88% typical)
Sterilisation: male - 1/2000, female - 1/2-500
26
What is lactational amenorrhoea?
breastfeeding can be used as contraception, up to 98% effective
27
Criteria for LAM to be effective?
- fully breastfeeding (or nearly)
- baby is under 6 months
- amenohrrhoeic
risk of pregnancy increases once any of these changes, regardless of other factors
28
What determines contraceptive choice?
UKMEC categories for contraindications/DDIs, other than that patient choice
29
Things for patients to consider when choosing contraception?
efficacy, risks, pros and cons, advice on missed doses (user dependence and adherence)
30
What is quick starting contraception?
Started on any day, not the first day of the cycle. Additional precautions required
31
Advantages of COC?
- Periods lighter, more regular, less painful
- reduced acne, functional ovarian cysts, benign ovarian tumours
- decreased risk of uterine, ovarian and colon cancer
32
Disadvantages of CHC?
- minor ADRs (nausea, breast tenderness, loss of libido, breakthrough bleeding)
- EE increases angiotensin (BP)
- EE increases HDL and decreases LDL - progesterone does opposite
- EE decreases antithrombin but increases some other clotting factors (VTE, MI, stroke)
- breast and cervical cancer risk
33
Advantages of POC?
- high efficacy
- suitable when CHC isn't
- reduced risk of endometrial cancer, benign breast disease, uterine fibroids, anaemia
34
Definition of a missed pill for COC?
>24 hours late
Zoely/Qlaira - >12 hours
critical at start and end of cycle as extends pill free period
35
When is EHC indicated for COC users?
2 or more pills missed within 7 days and UPSI
Zoely and Qlaira: 1 pill missed
36
Definition of a missed pill for POP?
>3 hours late for norethisterone, 12 hours for desogestrel
37
When is EHC indicated for POP users?
1 missed pill and UPSI occurring before 2 pills taken correctly
38
Counselling for POP users regarding missed pills
If one pill missed, use precautions for 2 days
39
UKMEC category 1 definition?
No restriction of use on the method
40
UKMEC category 2 definition?
Advantages of using the method generally outweight the risks
41
UKMEC category 3 definition?
Theoretical or proven risks usually outweight the benefits. Requires expert/specialist judgement. not recommended unless no suitable alternative
42
UKMEC category 4 definition?
Unacceptable health risk if the method is used
43
UKMEC category conditions
- breastfeeding women <6 weeks pp
- >35y + 15 cigs a day
- multiple CVS risks
- consistently elevated BP
- vascular disease & history of VTE, IHD, stroke
- migraine with aura
- current breast cancer
- Diabetes with nephropathy, retinopathy or neuropathy
- Benign hepatocellular adenoma and malignant hepatoma
- Systemic lupus erythematosus
44
Who has increased risk of MI with contraception?
current COC users who smoke
45
Stroke risk and contraception?
normotensive, non-smoking COC users:
- no increased risk of hemorrhagic stroke
- 1.5x higher risk of ischaemic stroke
46
VTE risk and contraception?
non pregnant women - 2 cases per 10,000 / year
| pregnant women - 6 cases per 10,000 pregnancies / year
47
When should CHC be stopped immediately?
- sudden severe chest pain (even if not radiating to left arm)
- sudden breathlessness (or cough with blood-stained sputum)
- unexplained swelling or severe pain in calf of one leg
- severe stomach pain
- serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body
- hepatitis, jaundice, liver enlargement;
- blood pressure above systolic 160 mmHg or diastolic 95 mmHg; (in adolescents stop if blood pressure very high)
- prolonged immobility after surgery or leg injury
48
When can COC be started and what precautions are necessary?
Day 1 of cycle is ideal
Day 1-5 no precautions needed
Day 6 onwards (quick starting), precautions for 7 days
49
When can traditional POPs be started and what precautions are needed?
Start at any time, no precautions needed
50
When can newer POPs be started and what precautions are needed?
Day 1-5, no precautions needed
| Day 6 onwards (quick starting), precautions for 2 days
51
How to change from COC (21 day) to POP?
exclude pregnancy
if pill free period has happened, use precautions for 2 days. or omit pill free period for immediate cover
52
How to change from COC (ED) to POP?
if placebo taken, use precautions for 2 days, or omit placebo for immediate cover
53
How to change from POP to COC?
Use precautions for 7 days (9 days for Qlaira)
54
Vomiting and diarrhoea with oral contraception?
Vomiting within 2 hours or persistent diarrhoea over 24 hours equates to missed pill (use relevant precautions)
55
What EHC is available?
Hormonal - ellaOne (ulipristal acetate) and Levonelle (levonorgestrel)
Non-hormonal - Copper IUD
56
Which drugs interact with contraception?
```
Enzyme inducers and griseofulvin
Antiepileptics: Carbamazepine, oxcarbazepine, phenytoin, phenobarbital, primidone, topiramate
Antiretrovirals: Nevirapine, ritonavir
Antibiotics: Rifabutin, rifampicin
Other: St John’s Wort and griseofulvin
```
57
Which contraception methods are not affected by any drugs?
Parenteral POC, IUS
58
For how long does the contraception and drug interaction last?
28 days after cessation
59
What is precocious puberty?
puberty before age 8 or 9 for girls and boys respectively
60
What is defined as delayed puberty?
girls - no period after 15
| boys - no testicular development at 14
61
What is dysmenorrhoea?
Pain during menstruation
subdivided into primary and secondary
62
Incidence of dysmenorrhoea?
50-80% of women will experience it at some point
10% are severely debilitated
63
What is primary dysmenorrhoea?
No underlying cause
64
Characteristics of primary dysmenorrhoea?
- peak incidence teens to 20s
- cramping, may radiate to thighs and back
- GI symptoms
- headaches, fatigue, faintness
65
Characteristics of secondary dysmenorrhoea?
- peak incidence 30-40s
- pain may begin before menstruation
- consequence of underlying pelvic pathology
66
Aetiology of dysmenorrhoea
- higher PG concentrations (mostly E and F) in fluid
- increased myometrial contractility
- potential: endothelins, vasopressin
67
Effect of endothelins on dysmenorrhoea
role in local regulation of prostaglandin synthesis
68
Effect of vasopressin on dysmenorrhoea
stimulates uterine motility, decreased blood flow (vasoconstriction causes ischaemia)
69
What converts membrane bound phospholipids to arachidonic acid?
Phospholipase
70
What can inhibit conversion of membrane-bound phospholipids to arachidonic acid?
corticosteroids
71
What triggers the production of arachidonic acid?
progesterone withdrawal
72
What does COX-1 do relating to arachidonic acid?
converts AA to prostaglandins (involved in physiological processes like cytoprotection)
73
What form of cyclooxygenase is COX-1
constitutive form of the enzyme
74
What form of cylo-oxygenase is COX-2?
inducible form of the enzyme
75
What is arachidonic a prescursor of ?
Prostaglandins - mostly PGE and PGF
76
What does COX-2 do relating to arachidonic acid?
converts AA to prostaglandins (involvwd in physiological processes like labour and inflammation)
77
What can inhibit COX-1?
NSAIDs
78
What can inhibit COX-2?
newer compounds like meloxicam
79
What convers arachidonic acid to leukotrienes?
lipoxygenases
80
Effect of PGs on uterine tissue
vasoconstriction, myometrial ishaemia and contractility - leads to pain
81
What can be used for pharmacological management of primary dysmenorrhoea?
NSAIDs, oral contraceptives, antispasmodics
82
How does oral contraception help with primary dysmenorrhoea?
progesterone so doesn't trigger PG production in luteal phase, decreased uterine contractility
83
Limitations of antispasmodics for primary dysmenorrhoea?
poor oral bioavailability. not licensed OTC
84
What can be the underlying causes of secondary dysmenorrhoea?
Pelvic inflammatory disease, endometriosis, menorrhagia, fibroiads, uterine polyps
85
Management options for secondary dysmenorrhoea?
Determine underlying cause and treat that. may involve:
- surgery (ablation of tissue)
- pharmacological treatments (non-analgesic)
- symptomatic relief (pain)
86
What is endometriosis?
Endometrial tissue found outside of the uterus (e.g. GI tract, urinary tract)
87
What is the embryological theory of endometriosis?
cells de-differentiate to their primitive endometrial form
88
What is the retrograde menstruation theory of endometriosis?
reflux of mestrual loss, increased prevalence with outflow obstruction
89
Symptoms of endometriosis?
Pain, subfertility, fatigue
dyspareunia, dyschezia, dysuria, chronic pelvic pain and mestrual irregularities
90
rarer symptoms of endometriosis?
- Cyclical haematuria (endometrial tissue in the bladder bleeds in response to hormonal variation)
- Cyclical haemoptysis (endometrial tissue in the lungs bleeds in response to hormonal variation)
- Cyclical tenesmus (constant need to open bowels)
Others: ureteric obstruction, rectal bleeding or rectal obstruction
91
How to diagnose endometriosis?
Pelvic exam/ultrasound to identify masses, diagnostic laparoscopy
bloods and MRI not recommended
92
What determines the stage of endometriosis?
visualisation of sites, degree and location of invasion
93
What is endometriosis stage not indicative of?
levels of pain, subfertility and prognosis. this is highly variable between individuals
94
Defintion of stage 1-2 endometriosis?
minimal to mild, poorly visualised
implantation at common sites - uterine and ovarian
95
Definition of stage 3-4 endometriosis?
moderate to severe, commonly associated with adhesions
rectovaginal, bowel invasion (adenomyosis)
96
NICE quality standard for endometriosis?
- anyone presenting with suspected endometriosis should receive an abdo/pelvic exam
- if hormonal treatment not effective/tolerated or contraindicated, refer to gynaecologist
- suspected or confirmed deep endometriosis (with bowel/bladder/ureter invasion) should be referred to specialist endometriosis service
97
Management options for endometriosis?
Surgery or medical treatment
98
Aims of surgical treatment for endometriosis
restore normal pelvic anatomy, divide adhesions, ablate endometrial tissue
99
Aims of medical treatment for endometriosis?
symptomatic releif (pain management) and improve fertility if desired
100
What is a last resort option for endometriosis treatment?
hysterectomy for women who do not plan any further children
101
First line for pharmacological management of endometriosis?
Pain relief - NSAIDs with or without paracetamol
102
Second line pharmacological management of endometriosis?
utilise fact that endometrial tissue is oestrogen dependent (inhibits growth)
contraceptives, progestogens, GnRH analogues, anti-progestogens (last resort)
103
Examples of GnRH analogues?
buserelin, goserelin, nafarelin, Leuprorelin
104
Examples of antiprogestogens?
danazol and gestrinone
105
Why are antiprogestogens last resort?
Unpleasant side effects
106
What are SARMs?
Selective androgen receptor modulators - immunomudulators, target biosynthetic steroid pathways
107
What is menorrhagia?
Menstrual blood loss >80mL per month
108
Risks of menorrhagia?
Fe deficiency anaemia
109
Subjective criteria for menorrhagia?
Clots, flooding, double protection, frequent sanitary changes
110
Effect of menorrhagia on quality of life?
3 days of heavy bleeding = 1 month per year reduced QOL
111
Epidemiology of menorrhagia?
30% of women complain of heavy bleeding
112
Aetiology of menorrhagia?
unknown, prostanoids could be implicated
| 60% of sufferers have no underlying pathology
113
Causes of dysmenorrhagia?
- Dysfunctional uterine bleeding (60%). absence of other pelvic pathology
- other gynae causes (35%)- e.g. fibroids, menopause, ectopic pregnancy/miscarriage, PID, IUD, adenomyosis
- endocrine & haematological (5%) - hepatic/renal/thyroid disease, PCOS, blood thinning condition or medication
114
What is adenomyosis?
inner lining of uterus breaks through myometrium
115
what symptoms of dysmenorrhoea indicate underlying pathology?
irregular bleeding, sudden change, intermenstrual bleeding, post coital bleeding, painful intercourse, pelvic pain, premenstrual pain
116
Ways to diagnose menorrhagia?
```
Blood tests (FBC, Iron, Ferritin)
Cervical smear
Endometrial biopsy
Ultrasound (uterus, ovaries and pelvis)
Sonohysterography
Hysteroscopy
```
117
Pharmacological management options for menorrhagia?
CHC/POC (IUS most effective)
if contraception not required:
- tranexamic acid
- GnRH analogues
- oral progestogen (5mg norethisterone)
- antiprogestogen
118
What is amenorrhoea?
absence of periods
119
What is oligomenorrhoea?
infrequent periods - often diagnosed if 35 days without a period
120
What is polymenorrhoea?
a cycle shorter than 21 days
121
What is metrorrhagia?
bleeding between periods
122
Disadvantages of POCs?
- ADRs (acne, depression, weight gain, vaginal dryness, loss of libido)
- menstrual irregularities
- increased risk of breast cancer, functional ovarian cyst, ectopic pregnancy
