Contraception and HRT Flashcards
Define contraception
How is this accomplished?
- the prevention of pregnancy
- this is accomplished by preventing ovulation, preventing fertilisation, or by preventing implantation of the pre-embryo in the uterus, thus preventing the initiation of pregnancy
What are the features of the ideal contracteptive?
100% safe and effective independent of intercourse reversible acceptable, simple and painless cheap independent of medical profession acceptable to every culture, religion and political view used by or obviously visible to women
The ideal contraceptive does not exist so what factors must be taken into account when choosing one?
- patient preferences
- hormonal (age, weight, smoking)
- compliance
- problems related to menstrual cycle (periods, PMS)
- fertility options
How is effectiveness measured in contraceptives?
Measure of failure
- failure rates / 100 woman years of exposure
- PEARL index
- If PEARL INDEX = 4, then of 100 women using the contraception for a year, 4 will be pregnant by the end of the year
What is the average fertility at the following ages in 100 women years?
- no method, young women
- no method, age 40
- no method, age 45
- no method, age 50
- 80-90/100 woman years
- 40-50/100 woman years
- 10-20/100 woman years
- 0-5/100 woman years
What features of human intercourse favour fertility?
- pleasure
- instinct
- drive
- timing (maximal female desire coincides with most fertile phase)
- outpouring of vaginal transudate (raises pH = favourable to sperm)
- orgasm - negative pressure,
What is the fertility window in humans?
5 days before ovulation
and 1 day after
What are the main types of contraception?
Hormonal - CHC, POP, DMPA, implants/injectables
Intrauterine devices - cooper, Mirena
Barrier - condoms, femidom, diaphragm, cap, sponge +/- spermicides
Natural methods - coitus interrupts, fertility awareness
Sterilisation
What are some examples of natural family planning methods?
- rhythm method, avoiding intercourse around ovulation
- Billing’s method, changes in cervical mucus
- Changes in the cervix, high and soft at ovulation
- Basal body temperature
- Coitus interruptus/withdrawal
- Lactational amenorrhoea
What are the advantages and disadvantages of natural family planning?
Advantages - no side effects - in the couple's control Disadvantages - not a very reliable or of contraception - messy and 'clinical'
What are the 3 barrier methods?
condoms male/female
diaphragm and cap
spermicides
- these are reliable if properly used, user dependent
What are the 3 main classes of hormonal contraceptives?
Combined Hormonal Contraceptives
Progesterone Only
Long Acting Reversible Contraceptives
What is the mode of action of CHC’s?
What is their efficacy?
What is their efficacy affected by?
- prevent ovulation via negative feedback on HPG axis
- unfavourable changes to cervical mucus, endometrium, myometrium and fallopian tubes
- 0.2-3/100 woman years
- efficacy affected by enzyme inducers, diarrhoea, vomiting
What are the benefits, side effects and disadvantages of CHC?
Benefits
- highly effective, convenient, reversible
- bleeding/anaemia, dusmenorrhea, prevents ovarian cysts, reduces risk of ovarian and endometrial carcinoma
Side effects
- headaches, weight gain, breast tenderness, bloatedness. leg cramps, post pill amenorrhea
Disadvantages
- small increase in breast cancer risk
- circulatory disease
- venous thromboembolic, and arterial wall disease
What are the Evra patch and NUVA ring
Evra patch - transdermal CHC - once weekly - more than 99% effective - bypasses 1st pass metabolism NUVA ring - vaginal ring CHC - in situ for 21 days, removed for 7 days and new ring inserted - 98% effective
What is the mode of action of the POP?
What is its efficacy?
Changes in cervical mucus
Anovulation
Changes in endometrium
- 0.3-4/100 woman years
What are the benefits and disadvantages/side effects of POP’s?
Benefits
- effective, well tolerated, reversible
- no evidence of increase risk of circulatory or malignant disease
- can be prescribed to lactating mother, smokers, over 35s, those who cannot take CHC, hypertensives, antibiotics
Disadvantages/side effects
- must take regularly
- menstrual irregularities, functional ovarian cysts, ectopic pregnancy
- hormonal (headaches, mood swings, depression, weight gain, belatedness, breast tenderness)
What are contraindications for POP?
pregnancy
undiagnosed genital tract bleeding
Caution: severe migraine, circulatory disease, lipid disorders, enzymes inducing drugs
What are injectables?
What is their mode of action?
What is their efficacy?
- DMPA, or norethisterone enantate
- Mode of action same as POP
- Efficacy = 0.1-1/100 woman years
What are the disadvantages and advantages of injectables?
Disadvantages
- once given cannot be reomveed
- menstrual irregularities
- delay in return of fertility
- hormonal side effects - same as POP
- decrease bone mineral density over longterm
Advantages
- highly effective, convenient, non-intercourse related, reversible
- reduces bleeding, treats anaemia, pain, pelvic infection, PMT
What are implants?
What is they mode of action?
What is their efficacy?
- subdermal implant e.g. nexplanon (barium coated)
- Mode of action, inhibition of ovulation, increased viscosity of cervical mucus
- Efficacy = 0-0.07/100
What are the advantages and disadvantages of implants?
advantages
- highly effective, independent of intercourse, reversible
disadvantages
- surgical procedure, removal can be difficult
- hormonal side effects (same as POP)
What is the mirena coil?
How long is it licensed for?
What is its mode of action?
What is its efficacy?
- Levorgestrel releasing device, T shaped
- licensed for 5 years
Mode of action - renders endometrium insensitive to endogenous oestrogen
- cervical mucus scanty and viscid
- inhibits ovulation
- foreign body reaction
Efficacy = 0.1-0.2/100
What are the advantages, disadvantages and contraindications of mirena?
Advantages
- reduces menstrual bleeding, pain, pelvic infection, ectopic pregnancy, to treat endometrial hyperplasia, endometriosis
Disadvantages
- hormonal, irregular bleeding that can last up to 9 months
Contraindications
- pregnancy, hormone dependent tumours, liver tumours, undiagnosed vaginal bleeding, active pelvic infections, artificial heart valves
What is IUD?
What is its mode of action?
What is its efficacy?
- Copper coil
Mode of action - foreign body type reaction n the uterus, copper is spermicidal
Efficacy = 0.2-1/100
What are the advantages, disadvantages and contraindications of the IUD?
Advantages = highly effective, no unwanted side effects, reversible, independent of intercourse, cheap
Disadvantages = intrauterine pregnancy, ectopic pregnancy, expussion, uterine perforation, malposition, pelvic infection, pain, abnormal bleeding
Contraindications
- pregnancy, undiagnosed genital tract bleeding, current pelvic infection, uterine abnormality, allergy to copper, valvular heart disease, Wilson’s disease
What are the options for male and female sterilisation?
Male = vasectomy Female = dual clips, rings, diathermy
What do couples undergoing sterilisation need to be counselled on?
- failure rates, early and late
- irreversibility
- occasional need for laparotomy
- ectopic pregnancy
What are the two categories of emergancy/post-coital contraception
Hormonal e.g progesterone only, ellaOne
Cooper IUD
When can Levonelle be used?
What is its efficacy?
within 72 hours, sooner the better
efficacy = 75-80%
When can ellaOne be used?
What is its mode of action?
What is efficacy?
- licensed for up to 5 days
- synthetic progesterone receptor modulator, inhibition or delay of ovulation, changes in endometrium too
- prevents about 60% of pregancies
When can copper IUD be used as emergancy contraception?
What its efficacy?
What are the risks?
5 days
99.9%
pain, bleeding, infection
What has the greatest effect on pearl index?
where it is user dependent/independent
termination of pregnancy slides?
not gone over in lecture
What is menopause?
the cessation of menses
average age = 51 years
What is climacteric?
transition from reproductive to non-reproductive phase of life
What are the menopausal symptoms and what are they due to?
Menopausal symptoms due to reduced oestrogens and progesterones:
- hot flushes and night sweats
- loss of libido
- skin dryness
- frequency of micturition, urgency, noctuira
- lethargy/depression
What can be used in the diagnosis of measure
Gonadotrophins rise in response to ovarian failure
FSH measured
What are the treatment options for women with and without a uterus?
Why is their a difference?
With - combined HRT
Without - unopposed oetrogens
- if not combined –> endometrial hyperplasia and cancers
What are the long term effects of oestrogen deficiency?
osteoporotic fractures
Alzheimers disease
increased insulin resistance/diabetes
?CVS disease
What are some impacts of osteoporosis over time?
kyphosis height loss neck become weak and head falls forward pain in back breathing difficulties tummy bulges due to loss of space under ribs indigestion and reflux stress incontinence
What was the million women study and women health initiative study?
What were the conclusions from both?
WHI = RCT, Oestrogen and progesterone RCT
Million Women Study - breast screening
Conclusions:
- oestrogen and progesterone users = increased risks of BC, coronary artery disease, dementia, stroke, decreased risk colorectal cancer, fractures
- oestrogen only = no increased risk of BC, benefits of CVS debated, may prevent or delay onset and enhance treatment of Alzheimer’s disease
