Contraceptives and HRT

Question 1

COCP mode of action?

Answer 1

inhibits ovulation

Question 2

POP mode of action ( excluding desogestrel)?

Answer 2

thickens cervical mucus

Question 3

The desogestrel-only pill, injectable contraceptive (medroxyprogesterone acetate) and the implant (etonogestrel) all have the same mechanism of action. What is it?

Answer 3

Primary: Inhibits ovulation
Also: thickens cervical mucus

Question 4

IUD mode of action?

Answer 4

Decreases sperm motility and survival

Question 5

IUS (levonorgestrel) mode of action?

Answer 5

Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus

Question 6

How long does it take for the different types of contraceptive to become effective ? (if not first day of period)

Answer 6

instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

Question 7

Outline the 3 main types of emergency contraception

Answer 7

Levonorgestrel - up to 3 days (72 hrs) after UPSI, dose doubled if obese, does not interfere with hormonal contraceptives

Ulipristal acetate - up to 5 days (120hrs) after UPSI , be careful w severe asthma, wait 5 days before restarting hormonal contraceptives

IUD - up to 5 days after UPSI / ovulation, most effective

Question 8

Risks of coil insertion?

Answer 8

IUDs make periods heavier, longer and more painful

IUS is associated with initial irregular bleeding, later women typically have intermittent light menses and some women become amenorrhoeic

Both:
uterine perforation
ectopic pregnancies
PID
expulsion: most likely to occur in the first 3 months

Question 9

Missed pill rules for COCP?

Answer 9

1 pill missed : take ASAP and don’t worry

2 pills missed: week 1 = emergency contraception, week 3 = omit the break and no need for emergency contraception

Question 10

The decision of whether to start a women on the COCP is guided by the UK Medical Eligibility Criteria (UKMEC).

UKMEC 1: no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: unacceptable health risk

Give some examples of UKMEC 4 conditions

Answer 10

> 35 years old and smoking > 15 cigarettes/day
migraine with aura
history of thromboembolic disease, stroke or IHD
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
positive antiphospholipid antibodies (e.g. in SLE)

Question 11

Which contraceptive is most likely to cause weight gain?

Answer 11

depo-provera (injectable)

Question 12

How does COCP affect cancer risk?

Answer 12

increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer

Question 13

What are the options for postpartum contraception?

Answer 13

only required after 21 days

POP- can be started at any time, can still breastfeed
COCP- should not be used for 21 days due to VTE risk
Coils - can be inserted within 48 hours of childbirth or after 4 weeks
Lactational amenorrhea method - effective for 6 months if exclusively breastfeeding and no periods

Question 14

when can women using non-hormonal forms of contraception be advised to stop using contraception due to the menopause?

Answer 14

after 1 year of amenorrhoea if aged over 50 years,
after 2 years of amenorrhoea if aged under 50 years

Question 15

Menopause is defined as the permanent cessation of menstruation and is a clinical diagnosis usually made when a woman has not had a period for 12 months.

What lifestyle modifications can help to manage menopausal symptoms?

Answer 15

Hot flushes
regular exercise, weight loss and reduce stress

Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene

Mood
sleep, regular exercise and relaxation

Cognitive symptoms
regular exercise and good sleep hygiene

Question 16

Contraindications to HRT?

Answer 16

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

Question 17

Risks of HRT?

Answer 17

VTE: slight increase in risk with all forms of oral HRT, no increased risk with transdermal HRT

Stroke: inc risk w oral oestrogen HRT

Coronary heart disease: inc risk w combined HRT

Breast cancer: increased risk with all combined HRT

Ovarian cancer: increased risk with all HRT

Question 18

What non-HRT medical management is available for menopausal sxs?

Answer 18

Vasomotor symptoms
fluoxetine, citalopram or venlafaxine

Vaginal dryness
vaginal lubricant or moisturiser

Psychological symptoms
self-help groups, CBT or antidepressants

Urogenital symptoms
urogenital atrophy - vaginal oestrogen

Question 19

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen, combined with a progestogen (in women with a uterus), to help alleviate menopausal symptoms.

What are the indications?

Answer 19

vasomotor symptoms such as flushing, insomnia and headaches

premature menopause - should be continued until the age of 50 years to prevent the development of osteoporosis

Question 20

What types of HRT are available?

Answer 20

natural oestrogens, synthetic progestogens, tibolone
(synthetic compound with both oestrogenic, progestogenic, and androgenic activity)

HRT can be taken orally or transdermally (via a patch or gel) - transdermally better for high VTE risk