Contraception, HRT and the Menopause Flashcards
emergency contraception available in the UK?
- levonorgestrel-progestogen, PO single dose 1.5mg
- ulipristal acetate-selective progesterone receptor modulator, PO single dose 30mg
- Cu-IUD
association of breast cancer with HRT?
risk of breast Ca is higher with combined HRT compared to oestrogen only
risk increases with duration of exposure
risk begins to decline once HRT stopped and returns to same level as in women who have never taken HRT by 5 years after stopping.
guidelines for HRT in women with premature or early menopause?
HRT recommended until the age of 51 for treatment of vasomotor symptoms, and for bone and CVS protection-oestrogen raises HDLs and lowers LDLs.
what route for HRT should be used for those at higher risk of VTE?
transdermal
as not being given orally means avoidance of 1st pass metabolism by the liver so can give the patient a smaller dose of HRT and hence there is less risk of its ADRs e.g. VTE.
role of tibolone in the menopause?
this is a SERM which can be used in women with an intact uterus who have had no bleeding for more than 1 year, without the need for a cyclical progestogen.
may improve sexual function and vasomotor symptoms
may be small increased risk of stroke, endometrial and breast cancers.
less effective than combined HRT for relieving menopausal symptoms.
effects of HRT on PV bleeding?
monthly sequential preps should produce regular, predictable and acceptable bleeds towards the end, or soon after, the progestogen phase
breakthrough bleeding is common in the 1st 3-6mnths of continuous combined and long cycle regimens.
when is IUD expulsion most likely to occur?
within the 1st 3mnths after insertion, 1/20 risk
advice with regards to use of levonorgestrel for emergency contraception?
- must be taken within 72hr of unprotected sexual intercourse, single dose
- acts both to inhibit ovulation and inhibit implantation
- 84% effectiveness
- may cause vomiting, if vomit within 1st 2hrs after dose must repeat the dose
- can be used more than once in the same menstrual cycle.
advice with regards to use of ulipristal for emergency contraception?
- acts to inhibit ovulation
- selective progesterone receptor modulator, single 30mg PO dose
- can be taken up to 5 days post unprotected intercourse
- may reduce the effectiveness of hormonal contraception-pill, patch or ring should be started/restarted 5 days after having ulipristal, barrier methods should be used during this period.
- caution in pts with severe asthma
- breastfeeding should be delayed for 1wk after taking it
- not recommended to use more than once in same menstrual cycle
advice regarding IUD (copper coil) use for emergency contraception?
- most effective form, 99% effective regardless of when used in the cycle
- must be inserted within 5 days of UPSI, or if presents after 5 days then may be fitted up to 5 days after likely ovulation date
- acts to prevent fertilisation, inhibit implantation
- if pt doesn’t want to keep it for LT contraception then should at least be kept in until next period.
why is the COCP often preferred by most women vs the POP for contraception?
taking the COCP for 21 days and then having a 7 day off period allows a controlled bleed at the end of each month, which is usually lighter than a woman’s normal periods, whereas the POP, although it can mean that a woman has no periods, it is often associated with irregular bleeding.
COCP-inhibits ovulation
POP-thickens cervical mucus, desogestrel-also inhibits ovulation
options for long acting reversible methods of contraception?
- progesterone implant (works for up to 3 years before it requires changing) e.g. nexplanon-etonogestrel, inhibits ovulation and thickens cervical mucus, irregular bleeding is a common side effect.
- injectable progestogen (3 monthly)-medroxyprogesterone acetate-acts to inhibit ovulation aswell as thickening cervical mucus. note potential delay in return to fertility (maybe up to 12mnths). may potentially increase risk of osteoporosis.
- IUS (progesterone releasing coil)-Mirena-prevents endometrial proliferation and thickens cervical mucus. effective for 5 years. effective from 7 days after insertion.
- IUD (copper coil)-inhibits fertilisation-CU-toxic to sperm-reduces motility and survival. effective straight away, up to 10 years. complications-expulsion, PID, uterine perforation, higher risk of EP if fails.
a/v regarding 1 missed pill when taking the COCP?
- take the last pill when remember, and then continue taking pills daily as normal
- no need for additional contracpetion
missed pill=patient is more than 24hrs late
a/v regarding 2 or more missed pills when taking the COCP?
- take the last pill, leave any earlier missed pills, carry on taking pills daily.
- use barrier contraception or abstinence till has taken pills for 7 days in a row
- if pills missed in week 1 (days 1-7)-emergency contraception should be considered if had UPSI in pill-free interval or in week 1
- if pills missed in week 2 (days 8-14)-after 7 consecutive days of pill taking there is no need for emergency contraception.
- if pills missed in week 3 (days 15-21)-should finish pills in current pack then start a new pack the next day, omitting pill free interval.
potential harms and benefits of the COCP?
- more than 99% effective if taken correctly
- can have a controlled bleed at end of 21 days of pill taking
- risks-small risk of blood clots, very small risk of heart attacks and strokes, and increased risk of breast and cervical cancer.
-side effects-breast tenderness, low mood, headache, nausea, abdo cramps.
