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Obstetrics & Gynaecology > Fertility Control > Flashcards

Fertility Control Flashcards

1
Q

Contraception to avoid with breast cancer

A

Avoid any hormonal contraception

Copper coil or barrier methods

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2
Q

Contraception to avoid with cervical or endometrial cancer

A

Avoid the IUS (Mirena)

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3
Q

Contraception to avoid with Wilson’s disease

A

Copper coil

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4
Q

Which conditions should avoid COCP?

A

Uncontrolled hypertension (particularly ≥160 / ≥100)

Migraine with aura

History of VTE

Aged over 35 smoking more than 15 cigarettes per day

Major surgery with prolonged immobility

Vascular disease or stroke

Ischaemic heart disease, cardiomyopathy or atrial fibrillation

Liver cirrhosis and liver tumours

SLE and antiphospholipid syndrome

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5
Q

What are dental dams and what do they protect against?

A

Used during oral sex to provide barrier between the mouth and the vulva, vagina or anus.

Prevent infections that can be spread through oral sex, including:

Chlamydia
Gonorrhoea
Herpes simplex 1 and 2
HPV (human papillomavirus)
E. coli
Pubic lice
Syphilis
HIV
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6
Q

Examples of barrier methods

A

Condoms

Diaphragms

Cervical caps

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7
Q

Hormonal contraception mechanisms

A

Stop eggs being released (ovulation)

Thin womb lining

Thicken cervical mucus

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8
Q

COCP mechanism of action

A

Preventing ovulation (this is the primary mechanism of action)

Progesterone thickens the cervical mucus

Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation

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9
Q

Types of COCP

A

Monophasic pills contain the same amount of hormone in each pill

Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely

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10
Q

What COCPs are recommended in premenstrual syndrome?

A

Yasmin or other COCPs containing drospirenone

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11
Q

What COCPs are recommended in treatment of acne and hirsutism?

A

Dianette and other COCPs containing cyproterone acetate

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12
Q

COCP regime options

A

21 days on and 7 days off

63 days on (three packs) and 7 days off (“tricycling“)

Continuous use without a pill-free period

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13
Q

Side effects and risks of COCP

A

Unscheduled bleeding is common in the first three months and should then settle with time

Breast pain and tenderness

Mood changes and depression

Headaches

Hypertension

VTE (the risk is much lower for the pill than pregnancy)

Small increased risk of breast and cervical cancer, returning to normal ten years after stopping

Small increased risk of myocardial infarction and stroke

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14
Q

Benefits of COCP

A

Effective contraception

Rapid return of fertility after stopping

Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)

Reduced risk of endometrial, ovarian and colon cancer

Reduced risk of benign ovarian cysts

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15
Q

COCP contraindications

A

Uncontrolled hypertension (particularly ≥160 / ≥100)

Migraine with aura (risk of stroke)

History of VTE

Aged over 35 and smoking more than 15 cigarettes per day

Major surgery with prolonged immobility

Vascular disease or stroke

Ischaemic heart disease, cardiomyopathy or atrial fibrillation

Liver cirrhosis and liver tumours

SLE and antiphospholipid syndrome

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16
Q

What counts as missing a pill?

A

Missing a pill = more than 24hrs late (48hrs since last pill taken)

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17
Q

What to do after missing one pill (less than 72hrs since last pill taken)

A

Take the missed pill as soon as possible (even if this means taking two pills on the same day)

No extra protection is required provided other pills before and after are taken correctly

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18
Q

What to do after missing one pill (more than 72hrs since last pill taken)

A

Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)

Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight

If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex

If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required

If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed

They should go back-to-back with their next pack of pills and skip the pill-free period

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19
Q

How is the POP taken?

A

Continuously (unlike cyclical combined pills)

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20
Q

What are the two types of POP?

A

Traditional progestogen-only pill (e.g. Norgeston or Noriday)

Desogestrel-only pill (e.g. Cerazette)

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21
Q

Missed POP pills

A

Traditional POP - more than 3hrs late is missed pill

Desogestrel only pill - more than 12hrs late is missed pill

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22
Q

How do traditional POPs work?

A

Thickening the cervical mucus

Altering the endometrium and making it less accepting of implantation

Reducing ciliary action in the fallopian tubes

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23
Q

How do desogestrel only pills work?

A

Inhibiting ovulation

Thickening the cervical mucus

Altering the endometrium

Reducing ciliary action in the fallopian tubes

24
Q

How long does COCP take to work?

A

7 days before the woman is protected from pregnancy, as it works by inhibiting ovulation

25
Q

How long does POP take to work?

A

48 hours before it thickens the cervical mucus enough to prevent sperm entering the uterus

26
Q

Side effects and risks of POP

A

Unscheduled bleeding

Breast tenderness

Headaches

Acne

Ovarian cysts

Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes

Minimal increased risk of breast cancer, returning to normal ten years after stopping

27
Q

How is the progestrogen-only injection given?

A

12-13 week intervals

IM or subcut injection

28
Q

Contraindications for the progestogen-only injection

A

Active breast cancer

Ischaemic heart disease and stroke

Unexplained vaginal bleeding

Severe liver cirrhosis

Liver cancer

Can cause osteoporosis

29
Q

Mechanism of action of progestogen-only injection

A

Inhibits ovulation by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries

Thickens cervical mucus

Alters endometrium and makes it less accepting of implantation

30
Q

Timing the injection

A

Day 1-5 of cycle - immediate protection

After day 5 - extra contraception required

31
Q

Side effects of progestogen-only injection

A

Changes to bleeding schedule

Weight gain & osteoporosis (injection only!)

Acne

Reduced libido

Mood changes

Headaches

Flushes

Hair loss (alopecia)

Skin reactions at injection sites

32
Q

How does the progestogen-only implant work?

A

Slowly releases progestogen into the systemic circulation

Inhibits ovulation

Thickens cervical mucus

Alters endometrium and makes it less accepting of implantation

33
Q

When should the implant be inserted?

A

Day 1-5 of cycle - immediate protection

After day 5 - requires 7 days of contraception

34
Q

Benefits of the implant

A

Effective and reliable contraception

Can improve dysmenorrhoea (painful menstruation)

Can make periods lighter or stop all together

No need to remember to take pills

Does not cause weight gain (unlike the depo injection)

No effect on bone mineral density (unlike the depo injection)

No increase in thrombosis risk (unlike the COCP)

No restrictions for use in obese patients (unlike the COCP)

35
Q

Drawbacks to the implant

A

Requires a minor operation with a local anaesthetic to insert and remove the device

Can lead to worsening of acne

No protection against STIs

Can cause problematic bleeding

Can be bent or fractured

Can become impalpable or deeply implanted, leading to investigations and additional management

36
Q

Contraindications for coils

A

Pelvic inflammatory disease or infection

Immunosuppression

Pregnancy

Unexplained bleeding

Pelvic cancer

Uterine cavity distortion (e.g. by fibroids)

37
Q

Risks relating to coil insertion

A

Bleeding

Pain on insertion

Vasovagal reactions (dizziness, bradycardia and arrhythmias)

Uterine perforation (1 in 1000, higher in breastfeeding women)

PID (particularly in the first 20 days)

Expulsion rate highest in first three months

38
Q

What must women do before coil removal?

A

Avoid sex for 7 days

39
Q

What needs to be excluded when coil threads cannot be seen/palpated?

A

Expulsion

Pregnancy

Uterine perforation

40
Q

What LARC can also be used as emergency contraception?

A

Copper coil

41
Q

Mechanism of action of copper coil

A

Copper is toxic to the ovum and sperm

Also alters the endometrium and makes it less accepting of implantation

42
Q

Benefits of copper coil

A

Reliable contraception

Can be inserted at any time in the menstrual cycle and is effective immediately

Contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers

May reduce the risk of endometrial and cervical cancer

43
Q

Copper coil contraindication

A

Wilson’s disease

44
Q

Drawbacks to copper coil

A

Procedure is required to insert and remove the coil, with associated risks

Can cause heavy or intermenstrual bleeding (this often settles)

Some women experience pelvic pain

Does not protect against STIs

Increased risk of ectopic pregnancies

Can occasionally fall out (around 5%)

45
Q

What hormone do IUS contain?

A

Levonorgestrel

46
Q

Which IUS is licensed for contraception, menorrhagia and HRT?

A

Mirena

5 years for contraception & menorrhagia, 4 years for HRT

47
Q

Mechanism of action of IUS

A

Thickening cervical mucus

Altering the endometrium and making it less accepting of implantation

Inhibiting ovulation in a small number of women

48
Q

When can the IUS be inserted?

A

Up to day 7 of the menstrual cycle

If inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days

49
Q

Benefits of IUS

A

Can make periods lighter or stop altogether

May improve dysmenorrhoea or pelvic pain related to endometriosis

No effect on bone mineral density (unlike the depo injection)

No increase in thrombosis risk (unlike the COCP)

No restrictions for use in obese patients (unlike the COCP)

Mirena has additional uses (i.e. HRT and menorrhagia)

50
Q

Drawbacks to IUS

A

Procedure is required to insert and remove the coil, with associated risks

Can cause spotting or irregular bleeding

Some women experience pelvic pain

Does not protect against STIs

Increased risk of ectopic pregnancies

Increased incidence of ovarian cysts

Can be systemic absorption causing side effects of acne, headaches, or breast tenderness

Can occasionally fall out (around 5%)

51
Q

Options for emergency contraception

least to most effective

A

Levonorgestrel (within 72 hours of UPSI)

Ulipristal/EllaOne (within 120 hours of UPSI)

Copper coil (within 5 days of UPSI, or within 5 days of the estimated date of ovulation)

52
Q

Which emergency contraception should asthmatics avoid?

A

Ulipristal

53
Q

Outline female sterilisation

A

Tubal occlusion - laparoscopic - GA

Clip Fallopian tube

More than 99% effective

54
Q

Outline male sterilisation

A

Vasectomy - local

Cut vas deferens

55
Q

Outline Fraser guidelines

A

They are mature and intelligent enough to understand the treatment

They can’t be persuaded to discuss it with their parents or let the health professional discuss it

They are likely to have intercourse regardless of treatment

Their physical or mental health is likely to suffer without treatment

Treatment is in their best interest

Obstetrics & Gynaecology (13 decks)

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