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Obstetrics & Gynaecology > Contraception and Fertility control > Flashcards

Contraception and Fertility control Flashcards

1
Q

Natural oestrogen

A

Estradiol valerate

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2
Q

Most common form of synthetic oestrogen used in contraception

A

Ethinyl estradiol

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3
Q

Normal starting dose of oestrogen in contraception for a healthy woman

A

15-30 micrograms

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4
Q

Effect of higher and lower than normal doses of oestrogen in contraceptive pills

A

Higher: much higher increased risk of arterial and venous thrombosis

Lower: poorer cycle control

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5
Q

What is cyproterone acetate and what are indications for its use?

A

An anti-androgen progestin
Indicated for treatment of acne and hisutism but not contracpetion
In a combined preparation: Dianette

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6
Q

Absolute contraindications for use of the COCP (13)

A 
Breastfeeding less than 6 weeks postpartum
Smoking over the age of 35
Multiple risk factors for CVD
HTN: SBP 160, DBP 100
History of DVT or PE
Major surgery with prolonged immobilisation
Known thrombogenic mutations
History of IHD or stroke
Complicated valvular heart disease
Migraine with aura, or without aura if over 35
Current breast cancer
Active viral hepatitis
Severe liver disease
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7
Q

Common side effects of COCP (13)

A 
CNS:
- depressed mood
- mood swings
- headaches
- loss of libido
GI:
- nausea
- perceived weight gain
- bloatedness
Reproductive system:
- breakthrough bleeding
- increased vaginal discharge
- breast pain and enlargement
Miscellaneous:
- chloasma
- fluid retention
- change in contact lens wearing
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8
Q

What is chloasma

A

AKA melasma or mask of pregnancy
Facial pigmentation which worsens with continued oestrogen exposure, and spontaneously resolved after exposure is ceased (e.g. COCP, HRT, pregnancy)

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9
Q

Benefits of COCP

A

Contraception
Light, pain-free, regular bleeds (thus suitable to treat heavy or painful periods)
Reduced risk of PID
improved premenstrual syndrome
Long-term protection against ovarian and endometrial cancers
Improvement of acne

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10
Q

Failure rate of contraception of the COCP

A

0.1-1 per 100 woman years (i.e. 1/100 women will become pregnant on the pill each year)

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11
Q

What to do if miss one pill (COCP)

A

Take most recent pills when remember and continue taking remaining pills daily at the usual time
Do not require any additional contraception or emergency contraception

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12
Q

What to do if miss 2 pills (COCP)

A

Take most recent pills as soon as remembers
Continue taking remaining pills at usual time
Use condoms or abstain from intercourse until have taken pills for 7 days in a row
IF MISSED IN WEEK 1: emergency contraception if unprotected sex in pill-free interval or week 1
IF MISSED IN WEEK 3:
continue pills as normal and then start neck pack, skipping pill-free interval

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13
Q

Failure rate of combined hormonal vaginal ring or patch

A

0.3% perfect use

9% typical use

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14
Q

How to use a contraceptive combined hormonal patch

A

Wear patch for 1 week for 3 weeks, followed by 1 week without patch

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15
Q

How to use a combined hormonal vaginal ring for contraception

A

Insert and leave in for 3 weeks, remove for 1 week before re-inserting a new ring
Additional contraception required for 7 days if ring removed for more than 3 hours outside of ring-free interval

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16
Q

How progestogen only contraceptives work

A

Local action on:
- Cervical mucus - makes cervical canal hostile to ascending sperm
- Endometrium - makes thin and atrophic preventing implantation and sperm transport
Higher doses of progestogen also act centrally and inhibit ovulation

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17
Q

Side effects of progestogen only contraceptives

A 
Erratic, or absent menstrual bleeding
Simple, functional ovarian cysts
breast tenderness
Acne
Weight gain
Loss of bone mineral density (due to drop in oestrogen)
Emotional lability
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18
Q

Failure rate of minipill (POP)

A

1-3%
+ slightly higher risk of ectopic pregnancy if does fail
Must be taken daily within 3 hour time frame

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19
Q

how long does Depo-provera (DPMA) last

A

12 weeks with 2 week grace period

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20
Q

Cons of depo-provera in relation to other progestogen only methods of contraception

A

Delay in return of fertility - can take up to 6 months longer to conceive compared to a woman who stops the COCP
If intolerable, cannot remove

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21
Q

How long does implanon last

A

Up to 3 years (re-insert around 2.5 years)

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22
Q

Failure rate of implanon

A

0.05-0.1% - equivalent to female sterilisation

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23
Q

Failure rate of Depo provera

A

0.2% with perfect use

6% with typical use

24
Q

Side effects of intrauterine contraceptive devices

A

Copper: periods can become heavier and painful with more days of spotting but nil hormonal side effects
Mirena: irregular but lighter periods (often become amenorrhoeic), erratic spotting initially often settles, greasier skin and acne, breast tenderness, mood swings (hormonal side effects often settle with time)
Slightly increased risk of ectopic pregnancy if failure

25
Q

failure rate of intrauterine devices

A

Copper: 0.8%
Mirena: 0.1%

26
Q

Contraindications to use of a intrauterine contraceptive device

A

Current STI or PID
Malignant trophoblastic disease
Unexplained vaginal bleeding
Endometrial or Cervical cancer (not yet treated)
Known malformation of the uterus or distortion of the cavity (e.g. fibroids)
Copper allergy (can still use mirena)

27
Q

How does a copper intrauterine contraceptive device work?

A

Toxic effect on both sperm and egg before fertilisation occurs

28
Q

How does a mirena work?

A

Local release of levonorgestrel has local effect on cervical mucus (making cervix more hostile for ascending sperm) and on endometrium (atrophy - prevents implantation and sperm motility)

29
Q

Failure rates for condoms

A

Perfect use 2%

Typical use 18%

30
Q

failure rates for withdrawal method

A

Perfect use 4%

Typical use 22%

31
Q

Methods used to calculate fertile period in natural family planning

A

changes in basal body temperature
changes in cervical mucus
tracking cycle days
combined approaches

32
Q

Contraceptive protection of full breast feeding postpartum

A

Over 98%

AKA lactational amenorrhoea method

33
Q

failure rates of natural family planning

A

perfect use 0.4-5%

Typical use 24%

34
Q

When should emergency contraception be used?

A

After unprotected intercourse if there has either been failure of barrier method or a dose of hormonal contraception has been forgotten

35
Q

Options for emergency contraception

A

Hormonal: single dose levonorgestrel 1.5mg
OR
Copper IUD

36
Q

Use of hormonal emergency contraception

A

Must be used within 72 hours of unprotected intercourse
More effective if taken earlier
No contraindications to use (does not cause an abortion or harm an existing pregnancy)

37
Q

Mechanism of action of hormonal emergency contraception

A

Unknown, likely disruption of ovulation or corpus luteal function depending on time in cycle that it is taken
prevents approx 75% of pregnancies

38
Q

Use of copper IUD as emergency contraception

A

Can be inserted up to 5 days after single episode of unprotected intercourse at any stage in cycle OR 5 days after calculated earliest day of ovulation covering multiple episodes of intercourse
Give antibiotic cover if there is a risk of STI
Can remain in situ for ongoing contraception or removed once next menstrual period begins
same contraindications for general IUD contraception

39
Q

Mechanism of action of copper IUD as an emergency contraception

A

prevention of implantation + copper ions exert embryotoxic effect

40
Q

Failure rate of female sterilisation

A

Approx 0.1%

41
Q

Options of female sterilisation

A 
Tubal ligation (laparoscopic tube tying) - most common
OR
Tubal occlusion (Essure procedure - coiling)
42
Q

Procedure of laparoscopic tubal ligation

A

Requires general anaesthesia (usually a day case though)

Small cut near umbilicus to insert laparoscope, used to close clips over the uterine tubes

43
Q

Side effects of tubal ligation

A

+/- discomfort (often need a few days off work)

+/- pain under diaphragm or shoulder or abdomen immediately after procedure

44
Q

How soon does tubal ligation offer contraception

A

immediately

45
Q

Reversibility of tubal ligation

A

potentially reversible

50% chance of having a child after reversal but the high cost not covered by Medicare

46
Q

Procedure involved in tubal occlusion

A

Sedation of woman
Hysteroscope passed through cervix, through which tiny metal coils are passed into each uterine tube
Tissue grows into the coil over about 3 months to permanently block the tubes
x-ray 3 months later to confirm complete occlusion
Sometimes a hysterosalpingogram is required to confirm success

47
Q

Disadvantages of tubal occlusion

A
  • Takes 3 months to work (additional contraception required)
  • Unable to be performed successfully in 5% of cases
  • Irreversible
  • Cramping and pain after procedure
  • Some bleeding or spotting for a few days after procedure
48
Q

How long does it take for tubal occlusion to work as a successful contraceptive method

A

At least 3 months - additional contraception required until confirmed to be successful

49
Q

How common is a vasectomy

A

1/4 men over the age of 40 have had it performed

50
Q

Procedure of vasectomy

A

takes 15-20 minutes
Performed under general or local anaesthetic
Small cut made on each side of the scrotum - vas deferens is cut and small piece removed + ends of vas sealed with a stitch or diathermy
Semen analysis 12 weeks later to ensure no live sperm - re-check every 1-2 months until clear

51
Q

Expected side effects of vasectomy

A

small amount of bruising and mild discomfort for a few days, relieved by OTC analgesics, ice packs and supportive underwear

52
Q

Risks of vasectomy

A

Less than 1/20
- Infection
- Bleeding
- long-term scrotal pain (30% at 12 weeks, 6-8% at 12 months)
- Pain with ejaculation
(medications or [rarely] surgery can help with pain)
- Sperm antibodies (4/5 men) may affect sperm motility if reverse procedure
- Sperm granulomas - small lumps at cut end of vas due to local inflammation may need surgical excision

53
Q

Failure rates of vasectomy

A

1/500

recanalization can develop to bypass vasectomy site months-years later

54
Q

How long does it take for vasectomy to offer effective contraception

A

3 months - sperm needs to clear out of ducts - will be sped up with regular ejaculation
Other methods of contraception required until no live sperm are seen in semen

55
Q

Vasectomy reversal success rates

A

Succeeds technically in 60-90% (only 40-70% will result in pregnancy after 3 years though)
Lower rates of success if: long time between vasectomy and reversal (e.g. 10-15 years), large amount of vas deferens removed or cut near epididymis, other blockages have developed in the epididymis

56
Q

Suitable contraception for a woman with epilepsy

A

IF ON ENZYME INDUCING AGENTS
COCP - 50mcg AT LEAST of oestrogen (increase to 80-100 if breakthrough bleeding)
Depo Provera: suitable, but need to give 10-weekly rather than 12 weekly
IMPLANON IS NOT RELIABLE

If on lamotrigine with COCP, may need to increase lamotrigine dose as oestrogen reduces plasma concentration

Obstetrics & Gynaecology (22 decks)

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