Fertility and contraception Flashcards
What forms of projestin only contraceptives are there?
Injectables: FU every 3 months
Progestin only pills
What needs to be councelled in usage of progesterone injectables?
- Irregular cycles (occurs for 2 years before amenorrhea)
- 99% ovulation suppression as well as hormone production producing a hypoestrogenic effect so prone to decreased BMD (osteoporosis) –> requires bone protection with advise on calcium rich food and vit D (sunlight exposure)
- Weight gain (due to increased progesterone so increased appetite. But also kid doesn’t each much so mum compensates to not waste food. Adivise on diet)
- Low mood
- Need to plan ahead for future pregnancy: as excess hormones in blood (only form of contraception that takes time for menstrual cycle to return)
Adv and disadv of COC
What myths can you dispell to the patient?
- No evidence that it will cause weight gain. There is just water retention and increased appetite due to progestogen (lifestyle changes)
- Conflicting results: no definitive cause of CA breast
- Will not effect fertility: 99% of women will resume normal cycles after stopping COC for 6m
Mechanism of COC pills vs POP pills
COC pills: mimic normal menstruation as the withdrawal 7 day placebo causes a decrease in estrogen + progesterone which allows for shedding of endometrium. Reassures the patient that the contraception is effective. The menstrual flow is less and more regular cycles.
POP pills just cause thickening of the cervical mucus and thinning of the endometrium which inhibits implantation of the embyro. But without any break there is no menstrual flow which can be convenient for women who do not desire menstrual flow.
Absolute C/I of IUD
- Known or suspected pregnancy
- Current genital tract infection
- Undiagnosed vaginal bleeding
- Uterine abnormalities with endometrial cavity distortion
- Current trophoblastic neoplasia
- CA breast for Mirena
What is the timing for insertion of IUD?
- Done during 1st day of menses as it rules out pregnancy (saves doing a pregnancy test). Cervical os is dilated so easier insertion. Insertion always causes bleeding and pain (so it is masked by the menses)
- Don’t have sex after menses (exclude pregnancy before insertion)
Complications of IUD insertion?
- Uterine perforation (doctors fault). If there is severe persistent pain (suspicious of perforatin) –> will normally come back within first week.
- Infection (cannot wash away the cervical bacteria as the endocervical canal is too deep. Cervical bacteria include neisseria gonorhea, chlamydia trachomatis –> hence must ask in Hx about PID). Normal people will not get infection after insertion of intrauterine device. Chlamydia is a intracellular bacterium: when there is insertion (there is abrasions) which brings out chlamydia. Infection will occur within 20 days after insertion. If more than 20 days than not related to insertion.
Compare Mirena to POP effect
- Will have half a year of irregular bleeding (in comparison to POPs which take around 2 years as it is systemic progestin) –> more localized effect –> local atrophic effect.
- Everyone will have amenorrhea in comparison to have POP (50% regular menstrual cycles, 30% irregular cycles, 20% amenorrhea)
- Mirena and POP inhibits implantation of fertilized embryo (will not cause ectopic pregnancy)
- If IUD user is pregnant it has to be ectopic pregnancy (rare) (IUD can only prevent intrauterine pregnancy)
In lady more than 50 years old previously on OCP what other contraceptive options can she use?
- There is CVS risk with OCP (estrogen: but now have microdose 20mg (previous age limit was 40))
- Can use POP instead (just progestin so no cardiovascular risk): has irregular bleeding (50% have normal period, 30% irregular spotting, 20% takes 2 years before amenorrhea). In comparison to mirena (convience patient: irregular patient will happen either ways as perimenopausal)
- Spermicide is second best option after POP pills as patient has already has decreased fertility. Assess the history of STI (increased risk of HIV/STD transmission), previous PID. Can be used in the form of suppository or sponge.
- Injectable POPs is not advised as there is osteoporosis without estrogen replacement
OCP pills what to do if missed 1 pill?
Take it immediately <24 hrs and then continue cycle.
Does not affect the contraceptive effect
If OCP pills what to do if missed 2 pills?
Any sex during the missed pill days? Need of emergency?
How to resume pills?
Any additional abstinence/protection for next 7 days?
Answers based on which week
First week: Yes, continue with cycle, yes
Second Week: No, continue with cycle, no (first week suppressed ovulation)
Third Week: No, throws current pills and start new pills (re-establish contraceptive effect)
