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The Patient > Contraception > Flashcards

Contraception Flashcards

1
Q

What are monophasic pills?

A

Same hormone concentration throughout all pills

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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

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3
Q

What is in COC?

A

Ethinylestradiol (EE) and progestogen

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4
Q

What are phasic COCs?

A

Varying hormone concentrations throughout cycle
biphasic - 2 concs
triphasic - 3 concs

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5
Q

Examples of phasic COCs?

A

21 day phasic cycle

28 day phasic cycle - Qlaira 26+2, logynon

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6
Q

What is POP?

A

Progestrone only Pill

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7
Q

Characteristic of POP cycles?

A

no pill free period - taken for 28 days

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8
Q

Examples of POP?

A

traditional - norethisterone 350mcg (higher doses are therapeutic)
newer - desogestrel

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9
Q

What is CHC?

A

Combined hormonal contraception - non oral

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10
Q

What is POC?

A

Progestrogen only contraception - non oral

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11
Q

Examples of CHC?

A

contraceptive patch, vaginal ring

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12
Q

How contraceptive patch is used?

A

1 patch per week for 21 days, then 7 days patch free

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13
Q

How vaginal ring is used?

A

1 ring for three weeks, then 7 days free

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14
Q

Examples of POC?

A

Depo injection, contraceptive implant, IUS

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15
Q

Frequency of contraceptive injection?

A

150mg IM every 8-12 weeks

104mg subcut every 13 weeks (more common)

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16
Q

What hormone is in the injection?

A

Medroxyprogesterone

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17
Q

What hormone is in the contraceptive implant?

A

etonogestrel

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18
Q

What hormone is in the IUS?

A

levonorgestrel

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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

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20
Q

How to POCs prevent pregnancy?

A

Suppression of ovulation, thickened cervical mucus, delayed ovum transport, hostility of endometrium,

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21
Q

Efficacy of CHC and POC?

A

99.7% with perfect use, 92% with typical use

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22
Q

Efficacy of contraceptive pills?

A

99% perfect use, 91% typical use

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23
Q

Efficacy of vaginal ring, patch etc?

A

99% perfectuse, 91% typical use

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24
Q

Efficacy or LARC?

A

All 99% - expect typical use of injection 94%

less user dependent

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25
Q

Efficacy of non-hormonal methods?

A

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

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26
Q

What is lactational amenorrhoea?

A

breastfeeding can be used as contraception, up to 98% effective

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27
Q

Criteria for LAM to be effective?

A
  • fully breastfeeding (or nearly)
  • baby is under 6 months
  • amenohrrhoeic

risk of pregnancy increases once any of these changes, regardless of other factors

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28
Q

What determines contraceptive choice?

A

UKMEC categories for contraindications/DDIs, other than that patient choice

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29
Q

Things for patients to consider when choosing contraception?

A

efficacy, risks, pros and cons, advice on missed doses (user dependence and adherence)

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30
Q

What is quick starting contraception?

A

Started on any day, not the first day of the cycle. Additional precautions required

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31
Q

Advantages of COC?

A
  • Periods lighter, more regular, less painful
  • reduced acne, functional ovarian cysts, benign ovarian tumours
  • decreased risk of uterine, ovarian and colon cancer
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32
Q

Disadvantages of CHC?

A
  • 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
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33
Q

Advantages of POC?

A
  • high efficacy
  • suitable when CHC isn’t
  • reduced risk of endometrial cancer, benign breast disease, uterine fibroids, anaemia
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34
Q

Definition of a missed pill for COC?

A

> 24 hours late

Zoely/Qlaira - >12 hours

critical at start and end of cycle as extends pill free period

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35
Q

When is EHC indicated for COC users?

A

2 or more pills missed within 7 days and UPSI

Zoely and Qlaira: 1 pill missed

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36
Q

Definition of a missed pill for POP?

A

> 3 hours late for norethisterone, 12 hours for desogestrel

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37
Q

When is EHC indicated for POP users?

A

1 missed pill and UPSI occurring before 2 pills taken correctly

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38
Q

Counselling for POP users regarding missed pills

A

If one pill missed, use precautions for 2 days

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39
Q

UKMEC category 1 definition?

A

No restriction of use on the method

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40
Q

UKMEC category 2 definition?

A

Advantages of using the method generally outweight the risks

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41
Q

UKMEC category 3 definition?

A

Theoretical or proven risks usually outweight the benefits. Requires expert/specialist judgement. not recommended unless no suitable alternative

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42
Q

UKMEC category 4 definition?

A

Unacceptable health risk if the method is used

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43
Q

UKMEC category conditions

A
  • 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
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44
Q

Who has increased risk of MI with contraception?

A

current COC users who smoke

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45
Q

Stroke risk and contraception?

A

normotensive, non-smoking COC users:

  • no increased risk of hemorrhagic stroke
  • 1.5x higher risk of ischaemic stroke
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46
Q

VTE risk and contraception?

A

non pregnant women - 2 cases per 10,000 / year

pregnant women - 6 cases per 10,000 pregnancies / year

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47
Q

When should CHC be stopped immediately?

A
  • 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
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48
Q

When can COC be started and what precautions are necessary?

A

Day 1 of cycle is ideal
Day 1-5 no precautions needed
Day 6 onwards (quick starting), precautions for 7 days

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49
Q

When can traditional POPs be started and what precautions are needed?

A

Start at any time, no precautions needed

50
Q

When can newer POPs be started and what precautions are needed?

A

Day 1-5, no precautions needed

Day 6 onwards (quick starting), precautions for 2 days

51
Q

How to change from COC (21 day) to POP?

A

exclude pregnancy

if pill free period has happened, use precautions for 2 days. or omit pill free period for immediate cover

52
Q

How to change from COC (ED) to POP?

A

if placebo taken, use precautions for 2 days, or omit placebo for immediate cover

53
Q

How to change from POP to COC?

A

Use precautions for 7 days (9 days for Qlaira)

54
Q

Vomiting and diarrhoea with oral contraception?

A

Vomiting within 2 hours or persistent diarrhoea over 24 hours equates to missed pill (use relevant precautions)

55
Q

What EHC is available?

A

Hormonal - ellaOne (ulipristal acetate) and Levonelle (levonorgestrel)
Non-hormonal - Copper IUD

56
Q

Which drugs interact with contraception?

A 
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
Q

Which contraception methods are not affected by any drugs?

A

Parenteral POC, IUS

58
Q

For how long does the contraception and drug interaction last?

A

28 days after cessation

59
Q

What is precocious puberty?

A

puberty before age 8 or 9 for girls and boys respectively

60
Q

What is defined as delayed puberty?

A

girls - no period after 15

boys - no testicular development at 14

61
Q

What is dysmenorrhoea?

A

Pain during menstruation

subdivided into primary and secondary

62
Q

Incidence of dysmenorrhoea?

A

50-80% of women will experience it at some point

10% are severely debilitated

63
Q

What is primary dysmenorrhoea?

A

No underlying cause

64
Q

Characteristics of primary dysmenorrhoea?

A
  • peak incidence teens to 20s
  • cramping, may radiate to thighs and back
  • GI symptoms
  • headaches, fatigue, faintness
65
Q

Characteristics of secondary dysmenorrhoea?

A
  • peak incidence 30-40s
  • pain may begin before menstruation
  • consequence of underlying pelvic pathology
66
Q

Aetiology of dysmenorrhoea

A
  • higher PG concentrations (mostly E and F) in fluid
  • increased myometrial contractility
  • potential: endothelins, vasopressin
67
Q

Effect of endothelins on dysmenorrhoea

A

role in local regulation of prostaglandin synthesis

68
Q

Effect of vasopressin on dysmenorrhoea

A

stimulates uterine motility, decreased blood flow (vasoconstriction causes ischaemia)

69
Q

What converts membrane bound phospholipids to arachidonic acid?

A

Phospholipase

70
Q

What can inhibit conversion of membrane-bound phospholipids to arachidonic acid?

A

corticosteroids

71
Q

What triggers the production of arachidonic acid?

A

progesterone withdrawal

72
Q

What does COX-1 do relating to arachidonic acid?

A

converts AA to prostaglandins (involved in physiological processes like cytoprotection)

73
Q

What form of cyclooxygenase is COX-1

A

constitutive form of the enzyme

74
Q

What form of cylo-oxygenase is COX-2?

A

inducible form of the enzyme

75
Q

What is arachidonic a prescursor of ?

A

Prostaglandins - mostly PGE and PGF

76
Q

What does COX-2 do relating to arachidonic acid?

A

converts AA to prostaglandins (involvwd in physiological processes like labour and inflammation)

77
Q

What can inhibit COX-1?

A

NSAIDs

78
Q

What can inhibit COX-2?

A

newer compounds like meloxicam

79
Q

What convers arachidonic acid to leukotrienes?

A

lipoxygenases

80
Q

Effect of PGs on uterine tissue

A

vasoconstriction, myometrial ishaemia and contractility - leads to pain

81
Q

What can be used for pharmacological management of primary dysmenorrhoea?

A

NSAIDs, oral contraceptives, antispasmodics

82
Q

How does oral contraception help with primary dysmenorrhoea?

A

progesterone so doesn’t trigger PG production in luteal phase, decreased uterine contractility

83
Q

Limitations of antispasmodics for primary dysmenorrhoea?

A

poor oral bioavailability. not licensed OTC

84
Q

What can be the underlying causes of secondary dysmenorrhoea?

A

Pelvic inflammatory disease, endometriosis, menorrhagia, fibroiads, uterine polyps

85
Q

Management options for secondary dysmenorrhoea?

A

Determine underlying cause and treat that. may involve:

  • surgery (ablation of tissue)
  • pharmacological treatments (non-analgesic)
  • symptomatic relief (pain)
86
Q

What is endometriosis?

A

Endometrial tissue found outside of the uterus (e.g. GI tract, urinary tract)

87
Q

What is the embryological theory of endometriosis?

A

cells de-differentiate to their primitive endometrial form

88
Q

What is the retrograde menstruation theory of endometriosis?

A

reflux of mestrual loss, increased prevalence with outflow obstruction

89
Q

Symptoms of endometriosis?

A

Pain, subfertility, fatigue

dyspareunia, dyschezia, dysuria, chronic pelvic pain and mestrual irregularities

90
Q

rarer symptoms of endometriosis?

A
  • 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
Q

How to diagnose endometriosis?

A

Pelvic exam/ultrasound to identify masses, diagnostic laparoscopy

bloods and MRI not recommended

92
Q

What determines the stage of endometriosis?

A

visualisation of sites, degree and location of invasion

93
Q

What is endometriosis stage not indicative of?

A

levels of pain, subfertility and prognosis. this is highly variable between individuals

94
Q

Defintion of stage 1-2 endometriosis?

A

minimal to mild, poorly visualised

implantation at common sites - uterine and ovarian

95
Q

Definition of stage 3-4 endometriosis?

A

moderate to severe, commonly associated with adhesions

rectovaginal, bowel invasion (adenomyosis)

96
Q

NICE quality standard for endometriosis?

A
  • 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
Q

Management options for endometriosis?

A

Surgery or medical treatment

98
Q

Aims of surgical treatment for endometriosis

A

restore normal pelvic anatomy, divide adhesions, ablate endometrial tissue

99
Q

Aims of medical treatment for endometriosis?

A

symptomatic releif (pain management) and improve fertility if desired

100
Q

What is a last resort option for endometriosis treatment?

A

hysterectomy for women who do not plan any further children

101
Q

First line for pharmacological management of endometriosis?

A

Pain relief - NSAIDs with or without paracetamol

102
Q

Second line pharmacological management of endometriosis?

A

utilise fact that endometrial tissue is oestrogen dependent (inhibits growth)

contraceptives, progestogens, GnRH analogues, anti-progestogens (last resort)

103
Q

Examples of GnRH analogues?

A

buserelin, goserelin, nafarelin, Leuprorelin

104
Q

Examples of antiprogestogens?

A

danazol and gestrinone

105
Q

Why are antiprogestogens last resort?

A

Unpleasant side effects

106
Q

What are SARMs?

A

Selective androgen receptor modulators - immunomudulators, target biosynthetic steroid pathways

107
Q

What is menorrhagia?

A

Menstrual blood loss >80mL per month

108
Q

Risks of menorrhagia?

A

Fe deficiency anaemia

109
Q

Subjective criteria for menorrhagia?

A

Clots, flooding, double protection, frequent sanitary changes

110
Q

Effect of menorrhagia on quality of life?

A

3 days of heavy bleeding = 1 month per year reduced QOL

111
Q

Epidemiology of menorrhagia?

A

30% of women complain of heavy bleeding

112
Q

Aetiology of menorrhagia?

A

unknown, prostanoids could be implicated

60% of sufferers have no underlying pathology

113
Q

Causes of dysmenorrhagia?

A
  • 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
Q

What is adenomyosis?

A

inner lining of uterus breaks through myometrium

115
Q

what symptoms of dysmenorrhoea indicate underlying pathology?

A

irregular bleeding, sudden change, intermenstrual bleeding, post coital bleeding, painful intercourse, pelvic pain, premenstrual pain

116
Q

Ways to diagnose menorrhagia?

A 
Blood tests (FBC, Iron, Ferritin)
Cervical smear 
Endometrial biopsy 
Ultrasound  (uterus, ovaries and pelvis)
Sonohysterography 
Hysteroscopy
117
Q

Pharmacological management options for menorrhagia?

A

CHC/POC (IUS most effective)

if contraception not required:

  • tranexamic acid
  • GnRH analogues
  • oral progestogen (5mg norethisterone)
  • antiprogestogen
118
Q

What is amenorrhoea?

A

absence of periods

119
Q

What is oligomenorrhoea?

A

infrequent periods - often diagnosed if 35 days without a period

120
Q

What is polymenorrhoea?

A

a cycle shorter than 21 days

121
Q

What is metrorrhagia?

A

bleeding between periods

122
Q

Disadvantages of POCs?

A
  • ADRs (acne, depression, weight gain, vaginal dryness, loss of libido)
  • menstrual irregularities
  • increased risk of breast cancer, functional ovarian cyst, ectopic pregnancy

The Patient (8 decks)

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