Contraception/HRT Flashcards
Describe the physiology of the monophasic COCP?
Releases high amounts of progesterone and oestrogen throughout the monthly cycle. These act as negative feedback on the pituitary gland, to reduce levels of FSH and LH, thus preventing stimulation of a follicle to mature. This overall prevents an egg from being released, thus causing contraceptive effects.
The low level of oestrogen also has local effects on the endometrial lining in order to maintain a constant thin endometrial lining. Progesterone works synergistically with oestrogen to do this.
what are the benefits of a monophasic COCP?
Highly effective contraceptive rates (> 99%)
Regular bleeding - predictable
Constant hormone levels - simple and easy to use, rather than remembering different doses and levels
Improvement in acne
Improvement in menorrhagia
reduced rates of ovarian and uterine cancer
what are the negatives of monophasic COCP?
Can have higher level of side effects than the multiphasic COCP
Does not follow natural fluctuations in hormones
what are some examples of the monophasic COCP?
Microgynan 30
Microgynan 20
what are some examples of multiphasic COCP?
Qlaira
Yaz
How do multiphasic COCP work?
Release varying levels of oestrogen and progesterone throughout the cycle, to mimic natural fluctuations more closely.
These can be biphasic or triphasic depending on the type. They typically have 2 pills which are placebo, to again mimic the natural fall in hormone levels towards the end of the cycle.
what are the benefits of multiphasic COCP?
reduced side effects
tolerated better
reduced uterine and ovarian cancer rates
what is the benefit of the Yaz pill specifically?
It is taken over 24 days, with 4 pill free days.
This reduces the amount of pre-menstrual symptoms, by reducing the amount of time without progestin/oestrogen. This stability reduces the risk of premenstrual symptoms.
Additionally, the Yaz pill contains drospirenone, a progestin that has anti-androgenic and mild diuretic properties similar to spironolactone. This can help reduce water retention, bloating, and symptoms related to excess androgens, such as oily skin and hair growth.
which is better for PMDD - the COCP continuous dosing or the Yaz pill?
Continuous Regimen: Ideal for those who want to completely avoid periods and associated symptoms, or those with severe PMS/PMDD.
Yaz 24/4 Regimen: Better suited for those who prefer to have some regularity in their cycle while still managing premenstrual symptoms.
what are the negatives of continuous dosing of the COCP?
Breakthrough bleeding
psychological discomfort due to the absence of periods
potential delays in detecting pregnancy
concerns about long-term effects
how long can you use the COCP continuously for?
3 months (12 weeks) followed by a 4- or 7-day break to allow for withdrawal bleeding
although many healthcare providers suggest 6, 9 or even 12 months. There is no specific rule.
what are the rules if you miss one COCP?
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
what are the rules if you miss 2 or more pills in week 1 of COCP?
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1.
what are the rules if you miss 2 or more pills in week 2 of COCP?
After seven consecutive days of taking the COC there is no need for emergency contraception.
what are the rules if you miss 2 or more pills in week 3 of COCP?
she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
what are the contraindications to the COCP?
< 6 wks postpartum
smoker over the age of 35 (>15 cigarettes per day)
hypertension (systolic > 160mmHg or diastolic > 100mmHg)
current of past histroy of venous thromboembolism (VTE)
ischemic heart disease
history of cerebrovascular accident
complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis)
migraine headache with focal neurological symptoms
breast cancer (current)
diabetes with retinopathy/nephropathy/neuropathy
severe cirrhosis
liver tumour (adenoma or hepatoma)
how do you start the COCP in a woman that is amenorrheic?
Start the combined oral contraceptive (COC) at any time, if it is reasonably certain that the woman is not pregnant.
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days.
Additional contraception is required for 7 days (9 days for Qlaira®).
how do you start the COCP in a woman that is postpartum and not breastfeeding?
Start the COC on day 21 postpartum if there are no additional risk factors for venous thromboembolism.
Additional contraception is required for 7 days.
how do you start the COCP in a woman that is postpartum and is breastfeeding?
Do not start a COC if the woman is less than 6 weeks postpartum.
After 6 weeks and before 6 months postpartum, start the COC as for postpartum women who are not breastfeeding.
what are the negatives of the COCP?
people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be seen
what form do combined contraceptives come in?
transdermal patch
oral contraceptives
vaginal ring
how does the transdermal combined patch work?
Inhibition of Ovulation: The primary way the patch prevents pregnancy is by inhibiting ovulation. The hormones suppress the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland, preventing the ovary from releasing an egg each month.
Thickening of Cervical Mucus: The progestin in the patch also thickens the cervical mucus, making it difficult for sperm to travel through the cervix and reach an egg.
Thinning of the Endometrial Lining: The patch causes changes to the endometrium (the lining of the uterus), making it less suitable for implantation if an egg were to be fertilized.
how long do you wear the transdermal combined patch?
Each patch is worn for one week, and it is replaced with a new patch on the same day of the week for three consecutive weeks. After three weeks (21 days), no patch is worn during the fourth week, allowing for a withdrawal bleed similar to a menstrual period.
what is oestrogens role in maintaining bone density?
Estrogen plays a crucial role in maintaining bone density by inhibiting bone resorption (the process where bone is broken down) and promoting bone formation. A reduction in estrogen levels can lead to increased bone loss and a higher risk of osteoporosis.
what are some common side effects in general of the COCP?
Nausea
breast tenderness
bloating and fluid retention
headache
dysmenorrhoea
decreased libido
breakthrough bleeding
If on a COCP and experiencing nausea, how should the COCP be adjusted?
reduce oestrogen dose
exclude pregnancy
take pills at night
consider switching to progesterone only
if on COCP and experiencing breast tenderness, how should the COCP be adjusted?
reduce ostrogen and/or progesterone dose
change to different type of progesterone
consider using pill containing drospirenone
if on COCP and experiencing bloating and fluid retention, how should COCP be adjusted?
reduce oestrogen dose
change to progesterone with mild diuretic effect such as drospirenone
if on COCP and experiencing headaches, how should COCP be adjusted
reduce oestrogen and/or change progesteron
if on COCP and experiencing dysmenorrhea, how should COCP be adjusted?
extended pill regimen to reduce frequency of bleeding
if on COCP and having breakthrough bleeding, how should COCP be adjusted?
if taking an ethinyloestradiol 20 microgram pill, increase oestrogen dose to a maximum of 35 micrograms
change progesterone already
try another form of contraception
what is the hormone content of microgynan 30?
ethinylestradiol 30
levonorgestrel 150
what are some specific side effects of COCP’s such as microgynan and rigevidon?
oily hair or skin
loss of libido
bloating
what are some gynaecological red flags?
post menopausal bleeding
abnormal discharge
feeling of bloating/fullness
pelvic masses
ascites
post-coital bleeding
dyspaerunia
lump/skin changes of vulva
vulval itching
vulval pain/soreness
what are some red flags of endometrial cancer?
post-menopausal bleeding
heavier periods
vaginal discharge
weight loss
what are the risk factors for endometrial cancer?
Prolonged periods of unopposed oestrogen are the main risk factor. When oestrogen is not modified by the effects of progesterone, this is termed ‘unopposed oestrogen’.
PCOS - persistently high oestrogen causes proliferation of the endometrium
family history of endometrial cancer
Nulliparity
Obesity - raises levels of oestrogen
Tamoxifen use
hereditary nonpolyposis colon cancer (HNPCC) - 30-60% lifetime risk of endometrial cancer
Menopause past the age of 52
what are the types of endometrial cancer?
80% adenocarincoma
20% squamous cell carcinoma
Endometrial cancers can also be subclassified into: oestrogen-dependent endometrioid (type 1) and oestrogen-independent non-endometrioid carcinomas (type 2).
what is the management of a woman who presents to the practice with first episode of post-menopausal bleeding?
referral via 2ww
what investigations are done to investigate a possible endometrial cancer? (these are typically done by the gynaecology team via 2ww)
TVUSS - measure the endometrial thickness
Hysteroscopy + endometrial biopsy
most women will also have bloods as routine + CXR.
test for lynch syndrome.
what are the stages of endometrial cancer?
stage 1- confined to the corpus uteri
stage 2- This involves the corpus and there is invasion into the cervical stroma but it has not extended outside the uterus
stage 3- This has local or regional spread outside the uterus but still confined to the reproductive organs.
stage 4 - This is involvement of the bladder or bowel mucosa, or distant metastasis
Management of stage 1 endometrial cancer?
Stage I requires total abdominal hysterectomy with bilateral salpingo-oophorectomy. The role of lymphadenectomy is debated.
The use of progestogen in the treatment of stage IA endometrioid endometrial cancer without myometrial invasion is an option for those women who want to preserve their fertility.
Management of stage 2 endometrial cancer?
In stage II there should be radical hysterectomy with systematic pelvic node clearance.
Management of stage 3 and stage 4 endometrial cancer?
Stage III and IV are best treated with maximal de-bulking surgery in those women with good performance status and resectable tumour
what is the prognosis of endometrial cancer?
Those women who are diagnosed early have a far better prognosis. Most recurrences will occur within the first three years after treatment.
The majority of women (80% in stage I) will be diagnosed with early-stage disease and are cured with surgery.
For this group of women five-year survival rates are over 95%; however, five-year survival rates are much lower if there is regional spread or distant disease (68% and 17%, respectively)
what are some causes of endometrial thickening?
PCOS
obesity
adhesions
fibroid with degeneration
ovarian tumours
endometrial hyperplasia
how should suspected endometrial thickening be investigated?
TVUSS on day 5-12 of the cycle
Management of endometrial thickening on USS?
refer via 2ww
Management of confirmed endometrial hyperplasia?
Usually using contraceptive methods containing progesterone to regulate the endometrial lining growth - i.e. IUS
If pre-menopausal:
Hormonal contraceptives - can have POP, COCP, implant, injections and IUS
If menopausal:
Progestin-only birth control pills
Progestin injections
Vaginal cream containing progestin
An IUD that gradually releases progestin
what are the indications for considering HRT?
perimenopausal women with vasomotor symptoms
perimenopausal women with low CVD risk
women who have a high FRAX score (who have a high risk of osteoporosis fractures)
what type of HRT would you recommend to a perimenopausal woman who has vasomotor symptoms, who is 49 years old?
cyclical HRT - in order to avoid breakthrough bleeding
what type of HRT would you recommend for a woman who has vasomotor symptoms who has been postmenopausal for 2 years?
continuous HRT - less risk if unscheduled bleeding
what are the benefits of HRT?
improves hot flushing (77%); improves headaches (30%) and insomnia (55%)
reverses genital tract atrophy
improves psychological symptoms e.g. confidence improved in about 30%
reduces osteoporosis and thus, fracture rate
how does HRT impact risk of stroke?
Explain to women that taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke
in which forms can you prescribe sequential HRT?
oral
transdermal
when does the perimenopause state usually happen?
Perimenopause usually occurs between the ages of 40 and 50. The average age of onset is 47 and can last between 4-8 years
what are the risks with oral HRT?
increased risk of VTE - highest risk during the first 12 months
increased risk of CHD - using combined oral HRT started past the age of 60 years
slight increase in breast Ca incidence - particularly when using HRT for more than 5 years
what are common SE of oestrogen component of HRT and COCP?
fluid retention
breast tenderness
bloating
nausea
headaches
what are common SE of progesterone in HRT or POP?
- Fluid retention
- Breast tenderness
- Headaches
- Mood swings
- PMT-like symptoms
in which patients with menorrhagia should a LNG-IUS be considered first line?
no identified pathology
fibroids < 3cm in diameter
suspected adenomyosis
what are some non-hormonal options for management of heavy menstrual bleeding?
tranexamic acid
NSAID’s
what are some hormonal options for heavy menstrual bleeding?
COCP
cyclical POP
symptoms of fibroids?
bowel/urinary symptoms - if pressing on the abdomen
bulky uterus
heavy and painful periods
what are absolute contraindications to the COCP?
current breast Ca
breastfeeding and < 6 weeks postpartum
age > 35 years and > 15 cigarettes/day
elevated BP
history of DVT/PE
IHD or stroke
migraines with aura (at any age)
diabetes for > 20 years
what are some relative contraindications to COCP?
history of breast ca > 5 years
breastfeeding and 6 weeks to <6 months post partum
age 35 years and smokes < 15 per day
elevated BP (systolic 140-159, or diastolic 90)
known hyperlipidaemia
management of bartholins abscess?
flucloxacillin 500mg QDS or erythromycin 500mg QDS
Review - if persistent , not responding to abx, worsening - referral for I+D
what are some conservative management fir bartholin cyst?
warm baths
hot compress
analgesia
symptoms of BV?
fishy smelling discharge
thin discharge
can be grey in colour
can cause local irritation , no pruritis
may be asymptomatic
what is the cause of BV?
gardnerella vaginallis
what are the investigations for BV?
microscopy - “clue cells” seen epithelial cells densely covered with bacilli
positive amine test - a fishy ammoniacal smell when the discharge is mixed with 10% potassium hydroxide
what is the 1st line treatment for BV?
metronidazole 400mg BD for 7 days
management of pelvic organ prolapse?
pelvic floor muscle training
pessary
lifestyle advise - re weight loss, minimising straining or constipation, avoidance of heavy lifting / coughing or high impact exercise
surgical management
what are the different types of incontinence?
overactive bladder
stress incontinence
urge incontinence
mixed incontinence
what is overactive bladder/urge incontinence?
overactivity of the detrusor muscle, whereby the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
what is stress incontinence?
leaking small amounts when coughing or laughing
what different types of contraception are there?
barrier - condoms , femidoms
hormonal pills - cocp, POP
hormonal patch - combined transdermal patch
hormonal injection - progesterone
hormonal implant - progesterone implant
IUS - progesterone
IUD - copper
what are the different types of long act reversible contraceptives?
implantable contraceptives
injectable contraceptives - although these are not considered to the LARCs
intrauterine system (IUS): progesterone releasing coil
intrauterine device (IUD): copper coil
what is the UKMEC guidance for combined contraceptives in obesity?
if BMI 30-34 - UKMEC 2
if BMI > 35 - UKMEC 3 due to risk of thromboembolism
which type of contraceptive causes weight gain?
depo-provera
what is the main injectable contraception in the UK?
depo-provera
what is contained in the depo-provera?
medroxyprogesterone acetate 150mg
how does the depo-provera work?
releases high dose progesterone which acts to inhibit ovulation and thicken the cervical mucous to prevent sperm entering.
how is the depo-provera given?
IM injection every 12 weeks
what are the negative effects of the depo-provera?
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
which contraceptive increases the risk of osteoporosis?
depo-provera
what are the contraindications for depo-provera?
current breast Ca
how quickly does fertility return after stopping the depo-provera?
can have delayed fertility return of up to 12 months
why is migraine with aura an absolute contraindication for COCP?
migraine with aura is an absolute contraindication to combined oral contraceptive pill use due to the increased risk of stroke.
how late can a depo-provera been taken?
latest 14 weeks
how does the mirena coil work?
progesterone effect on the endometrium to thin the lining over time, and stimulates production of a cervix mucous plug
what is the failure rate of IUS?
1-2% in 1000 over 5 years
why is it important to ensure a woman is not pregnant prior to fitting IUS?
increased risk of ectopic pregnancy
benefits of the mirena coil?
improves dysmenorrhoea and menorrhagia (licensed for this)
how long can mirena coil be used for HRT purposes?
5 years - very strict!
how long can a mirena remain in situ for contraceptive purposes in woman over the age of 45 years?
licensed until enters the menopause
what are the negatives of copper IUD?
can make periods heavier and more painful
continue to have regular bleeds
what is the equivalent progesterone that is absorbed into the blood when having a mirena coil compared to the POP?
2 progesterone only pills a week
negatives or side effects of mirena coil?
increases risk of ectopic (but overall is lower than general population)
can have irregular bleeding
can have progestognenic side effects.- breast tenderness, acne, weight gain
what are the different types of IUS?
mirena
jaydess
Kyleena - less progesterone, equivalent of 1 POP per week, however failure rate higher of 61 in 1000 of contraception
what is the expulsion rate of mirena coil?
1 in 20 within the first 3 months , after that significantly less likely
what is the risk of perforation when fitting the IUS/IUD?
2 in 1000
what would make the risk of perforation higher when fitting IUS/IUD?
6 fold higher risk in women who are breastfeeding and have a baby < 6 months
when can you not fit a coil in a woman who has had a baby?
cannot fit it between 48 hours to 6 weeks post delivery
which is the only contraceptive causes a delay in fertility return
depo-provera
when is the risk of infection highest after coil fitting?
first 8 weeks
highest in women who are high risk for STI’s
contraindications to the combined pill?
personal preference
liver cirrhosis
breast cancer
migraine with aura
previous DVT or at risk of DVT
HTN systolic > 160, diastolic > 100
age 35 or older and smokes > 15 / day
BMI > 35
history of stroke / IHD or risk of these
age > 50
contraindications to POP?
active liver disease - i.e.e decompensated liver cirrhosis or liver tumour
active breast cancer
what is the failure rate of nexplanon?
1-2% in 1000
how does nexplanon work?
inhibits ovulation
what hormone is found in nexplanon?
desogestrel
what drugs should be avoided with the implant?
enzyme inducing drugs
at what age should contraception be stopped?
POP can continue until 55 years
after this age it can safely be stopped as chances of pregnancy are low, but if a woman wishes to continue for personal reasons, another option can be considered (even if she is still having some menstrual loss)
COCP - should be stopped at 50 years
or menopausal - i.e. no periods for 12 months
what is UKMEC 3?
the risks generally outweigh the benefits but the method can be considered for use with clinical judgement and/ or specialist referral if other methods are unacceptable.
what is UKMEC 4?
absolute contraindication - not allowed to be prescribed
what is UKMEC 2?
A condition where the advantages of using the method generally outweigh the theoretical or proven risks
when to take out IUS in woman with absent periods in menopause however unsure as has IUS in situ?
if on hormonal contraception - over 50 years and absent periods for 1 year -> do a spot FSH, if raised -> come back in 12 months and remove IUS
if on hormonal contraception - under age of 50 years and absent periods for 1 year -> do spot FSH and advise to come back in 24 months for removal
what should be done if a woman has stroke or heart attack whilst on POP?
this becomes a UKMEC 3 and should consider swapping to copper IUD
what is the rate of irregular bleeding with the implant?
18% of women will have irregular problematic bleeding with the implant - there is a chance this would settle after 6 months
what management plan can be made if a woman has had problematic bleeding a few weeks after implant fitting?
can trial 3 month additional COCP to reset the endometrium
usually bleeding improves after this, but if this does not, may need to have this implant removed
can women who have PCOS have the implant?
yes - can have the implant and they do not need to have 4 breakthrough bleeds per year, they can have as many bleeds as they have
what MEC is unexplained vaginal bleeding?
UKMEC 4 - should be investigated prior to commencing contraception/mirena , if happy this is a hormonal cause and not pathological then can be treated with contraceptive options
what monitoring should be done for women over age of 50 years who wish to continue depo provera?
review their decision every 2 years due to the risk of osteoporosis / effect on bone density
what is used for medical termination of pregnancy in the uk?
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
what monitoring is required after medical termination of pregnancy?
multi level pregnancy test 2 weeks after to detect level of hCG
what are the surgical management options for termination of pregnancy?
vacuum aspiration
electric vacuum aspiration
dilatation and evacuation
cervical priming with misoprostol +/- mifepristone is used before procedures
up until how many weeks can a woman decide to terminate her pregnancy?
23+6 weeks
what are fibroids?
benign smooth muscle tumours of the uterus that develop usually in response to oestrogen
how common are fibroids?
thought to occur in around 20% white and 50% afro-carribean women
symptoms of fibroids?
can be asymptomatic
menorrhagia
lower abdo pain
bloating
urinary symptoms
subfertility
can rarely cause polycythaemia due to autonomous production of EPO
how are fibroids diagnosed?
TVUSS
medical management of menorrhagia secondary to fibroids?
IUS - however cannot be inserted in GP if distorted uterine cavity
COCP
POP
LARC progesterone inj
mefanemic acid / tranexamic acid
surgical management of firboids?
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
what is a complication of firboids that can occur in pregnancy?
red degeneration - haemorrhage into tumour
When should a woman with fibroids be referred to secondary care?
An uncertain diagnosis.
Severe heavy menstrual bleeding or compressive symptoms.
Symptoms which cannot be successfully managed in primary care.
Confirmed fibroids measuring 3 cm or more in diameter or suspected submucosal fibroids (for example on pelvic ultrasound scan).
Suspected fertility or obstetric issues associated with fibroids.
Rapid or unexpected growth of fibroids after the menopause.
when should sperm sample be repeated if found to be abnormal when doing fertility investigations?
around 3 months after the first sperm sample - to allow sufficient time for the cycle of spermatozoa formation to be completed
