Gynaecology

Question 1

What is the efficacy of the Copper IUD for emergency contraception if inserted within 5 days of UPSI or ovulation ?

Answer 1

99.9%

Question 2

What is the mechanism of action of the LNG-IUS?

Answer 2

Progestogenic effect = cervical mucus thickening (hence reducing sperm access) and endometrial suppression (hence preventing implantation)

Also general foreign body effect

> 75% of women with Mirena IUS continue to ovulate

Question 3

What are the different brands of LNG-IUS licensed for use in the UK?

Answer 3

Mirena - 52mg LNG - licensed for 5 yrs - licensed for contraception, HMB & endometrial protection in HRT (licensed for 4 yrs for endometrial protection but FSRH supports the off-license use for 5 yrs for endometrial protection)
Other unlicensed benefits - dysmenorrhoea, endometriosis, symptomatic management of fibroids

Levosert - 52mg LNG - licensed for 6 yrs - licensed for contraception, HMB

Kyleena - 19.5mg LNG - licensed for 5 years - only licensed for contraception

Jaydess - 13.5mg LNG - licensed for 3 years - only licensed for contraception

Question 4

What is the risk of perforation associated with IUD/IUS insertion?

Answer 4

1-2 in 1,000

6x higher if breast feeding

Slightly higher risk if < 36 wks postpartum

Question 5

True or false - Cu-IUD has been linked to increased incidence of bacterial vaginosis?

Answer 5

TRUE
Indivuduals who suffer from recurrent BV may wish to switch contraception

Note - the association between LNG-IUS and BV is less clear
Both LNG-IUS and Cu-IUD may be assoicated with increased risk of recurrent vuvlovaginal candidiasis although the evidence is less clear.

Question 6

What is the risk of expulsion associated with IUD/IUS

Answer 6

1 in 20

Risk is highest in the first 3 months

Slightly higher risk of menstrual cup user!

Question 7

What is the ectopic pregnancy risk associated with IUD/IUS

Answer 7

Risk of ectopic pregnancy is lower than if not on any contraception but if pregnancy does occur while in-situ then risk between 18-50% of it being ectopic.

If viable intrauterine pregancy, IUD/IUS should be removed if possible to improve the risk of successful ongoing pregnancy

Question 8

What are the UKMEC 4 criteria for Cu-IUD / LNG-IUS?

Answer 8

UKMEC 4 CRITERIA FOR BOTH COPPER & MIRENA COIL:
- Insertion with known pelvic TB, PID, purulent cervicitis, gonorrhoea or symptomatic chlamydia infection
- Insertion OR Continuation in post-partum or post-abortion sepsis
- Insertion with unexplained vaginal bleeding
- Insertion with cervical or endometrial cancer awaiting treatment (continuation is UKMEC 2 for both)
- Insertion OR continuation with gestational trophoblastic neoplasia with persistently elevated hcg levels

AN ADDITIONAL UKMEC FOR LNG-IUS ONLY IS:
- Current breast Ca

Question 9

What are the UKMEC 3 criteria for for Cu-IUD / LNG-IUS ?

Answer 9

UKMEC 3 CRITERIA FOR BOTH COPPER & MIRENA COIL:

Insertion if
* Known long QT syndrome
* Post organ transplant with complications
* Asymptomatic chlamydia infection
* HIV with CD4 < 200

Continuation if
* pelvic TB

Insertion OR continuation if:
* Fibroids that distort the uterine cavity
* Gestational trophoblastic neoplasia with decreasing HCG levels
* Post radical trachelectomy
* Between 48 hrs - 4 wks post partum

LNG-IUS SPECIFIC:
- Continuation if develops IHD or stroke while in-situ
- Previous breast cancer
- insertion / continuation if severe / decompensated liver cirrhosis, hepatocellular carcinoma or adenoma

Question 10

What are the recommendations for STI screening prior to intrauterine contraception insertion?

Answer 10

If known PID, purulent cervicitis, gonorrhoea or symptomatic chlamydia infection then insertion is UKMEC 4

If asymptomatic for STI, screen for chlamydia if risk factors (age < 25, new partner in the last 3 months or more than 1x partner in the past 12 months) screen for gonorrhoea depending on individual / local area prevalence.

DO NOT NEED TO DELAY INSERTION WHILE AWAITING STI RESULTS IF THE PT IS ASYMPTOMATIC

NO EVIDENCE FOR PROPHYLACTIC ABX TO COVER INSERTION WHILE AWAITING STI RESULTS

Question 11

If someone develops PID after an intrauterine coil is already in place, when should removal be considered?

Answer 11

If no clinical improvement after 72 hrs of abx

Question 12

What is the guidance on Copper and LNG intrauterine contraception in the approach to menopause?

Answer 12

A Cu-IUD inserted at age 40+ can be used as contraception until menopause achieved (1 yr after last period if >50 or 2 yrs after last period if <50)

A 52mg LNG-IUS inserted at age 45+ can be used as contraception until menopause achieved.

All contraception can be stopped at age 55 regardless if not amenorrheic as spont conception v unlikely

Question 13

which methods of contraception are unaffected by and therefore safe to use alongside enzyme inducing medications?

Answer 13

Copper IUD
LNG-IUS
Depot injection
Barrier methods

Question 14

How long after ullipristal acetate emergency contraception should progestogen-based medications / contraceptions be avoided?

Answer 14

5 days!
This includes starting POP, inserting implant or giving Depot medication

Patients should also be advised that taking progestogens in the days leading upto UA use may also reduce UA’s effectiveness at delaying ovulation.

Question 15

What should women who have had UPSI in the 4th year of an implant being in-situ be advised?

Answer 15

That although the implant is only licensed for 3 years, the risk of pregnancy in the 4th year is extremely low.
EC is likely not required.

Question 16

What is the relationship between progestogen implant and cancers of the reproductive organs

Answer 16

There is some evidence of a very small increased risk of breast Ca with current or recent hormonal contraception and breast cancer risk although absolute risk remains low

There is insufficient evidence to establish an association between implant use and ovarian, endometrial or cervical cancer.

Question 17

For how many days after Implant insertion are additional contraception precautions required?

Answer 17

If inserted upto day 5 of a natural menstrual cycle or post-abortion or upto day 21 postpartum then no added precautions needed.

At any other time can quickstart if reasonably certain not pregnant - need extra precautions for 7 days

Question 17

What treatment options can be considered in a women having ongoing problematic bleeding with the implant after the first few months?

Answer 17

Exclude pregnancy, STI, cervical cancer

Offer 3 month trial of COC or 5 days of mefanamic acid during bleeding

Question 18

What are the failure rates of the depot injection in the first year of use with perfect use and typical use?

Answer 18

Perfect use 0.2%
Typical use 6%

Question 19

True or false - the depot injection is a safe contraception in sickle cell disease and may reduce the severity of sickle cell crises?

Answer 19

TRUE!!

Question 20

How frequently should women on DPMA injection be reviewed ?

Answer 20

Every 2 years - to consider bone mineral density risk and other pros/cons

Question 21

What is the association between DPMA use and reproductive cancer risks?

Answer 21

Slight increased risk of breast cancer with current and recent depot use (as with other hormonal contraceptives) but absolute risk remains low

No evidence of increased risk of ovarian or endometrial cancers, infact depot may be protective

Weak evidence that there is an increased risk of cervical cancer associated with use of depot injection beyond 5 years.

Question 22

The depot injection can cause weight gain - which individuals are most at risk of depot-associated weight gain?

Answer 22

Those < 18 years of age
and
Those with a BMI of 30+

Note - women that gain 5% of more in the first 6 months of use are most likely to continue to gain weight !!

Question 23

What is the best mode of administration of the depot injection?

Answer 23

IM is associated with fewer injection site problems

But can also be given SC, especially if lots of adipose tissue and hard to get to muscle

Question 24

When is a depot considered ‘late’ and extra contraceptive precautions required?

Answer 24

Depot is licensed for administration every 13 wks, can be given upto 7 days late (upto 14 wks) without any additional precautions or EC needed.

If injection is delayed > 14 wks, then EC is needed if UPSI has happended > 14 wks and extra precautions are needed for 7 days after administering the depot.

Question 25

True or false - higher body weight does not affect the efficiacy of the depot injection?

Answer 25

True

Although there is limited evidence in women with BMI > 40

Question 26

True or false - smoking is associated with a reduced risk of hyperemesis gravidarum?

Answer 26

TRUE

Smoking is actually protective from hyperemesis

Question 27

Which SSRIs are considered the safest / recommended for use in breast-feeding women?

Answer 27

Sertraline or Paroxetine

( Small amounts ssecreted in breast milk but considered safe)

Question 28

What are the lower threshold target ‘normal’ haemoglobin levels for women during pregnancy and postpartum?

Answer 28

115 - non-pregnant women
110 - early pregnancy
105 - late pregnancy
100 - in the postpartum period

Question 29

How should you manage a newly pregnant women with essential hypertension who is currently on an ACEi ?

Answer 29

ACEi are teratogenic - should be stopped immediately on uncovering pregnancy, switched to a safe alternative (labetalol 1st line) and referred to a specialist for review

Question 30

When is a POP considered missed ?

Answer 30

Traditional POP - if > 3 hrs late
Desogestrel POP - if > 12 hours late
Drosperinone POP - if > 24 hrs late

Question 31

What is the typical and perfect use efficacy of POP

Answer 31

Perfect use 99% effective
Typical use 91% effective

No evidence that significant difference in effiacy between traditional and desogestrel pOP

Question 32

What is the expected bleeding pattern on the POP?

Answer 32

Tradiational POP - 8/10 will have normal freq bleeding, ~ 1 in 10 will have infrequent or no bleeding and ~ 1 in 10 will have increased freq or prolonged bleeding

Desogestrel POP - ~ Half will either have no or infrequent bleeding, 4/10 will have normal freq bleeding and ~ 1/10 will have increased freq/prolonged bleeding

Question 33

For how long after starting the POP are extra precautions needed?

Answer 33

FOR TRADITIONAL AND DESOGESTREL POP: If started upto day 5 of normal menstrual cycle or post abortion or upto day 21 postpartum then effective immediately
If not, then extra precautions needed for 2 DAYS

FOR DROSPERINONE POP
Effective immediately only if taken on day 1 of natrual menstrual cycle or post abortion or upto day 21 postpartum
Otherwise extra precautions needed for 7 days

Question 34

Which route of COC may be affected by high body weight

Answer 34

The transdermal COC patch may be reduced in body weight > 90kg

Ring or pill recommended instead

Bariatric surgery MAY reduce the efficacy of any oral form of contraception due to impaired absorption

Question 35

Which contraceptive options should not be used with lamotrigine?

Answer 35

Bidirectional relationship whereby certain contraceptives reduce the efficacy of lamotrigine and lamotrigine reduces the efficacy of the contraceptives.

COC (ring,patch,pill) may reduce the efficacy of Lamotrigine

POP may actually increase Lamotrigine levels, risking toxicity

Lamotrigine may reduce the efficacy of COC, POP, implant and hormonal EC.

Copper coil, mirena coil, depot and barrier contraception all safe to use with lamotrigine

Question 36

What are the risks associated with COC and various cancers?

Answer 36

Reduced risk of ovarian, endometrial and colorectal cancer, this protective effect persists even after stopping

Slight increased risk of breast cancer with current and recent COC use

Slight increased risk of cervical cancer with COC use > 5 yrs - this risk reduces after stopping and is back to baseline 10 yrs after stopping

Question 37

How long before major surgery / period of prolonged immobility should women be advised to stop the COC?

Answer 37

Should be stopped AT LEAST 4 WEEKS BEFORE major surgery / period of prolonged immobility and another contraceptive method used then instead

Question 38

How should you advise women on COC who are trekking to high altitudes (4,500M or 14,500 ft) for more than a week?

Answer 38

To stop COC and switch to another form of contraception

Question 39

What methods can be used to either induce a withdrawal bleed or prevent endometrial proliferation in women with PCOS who have fewer than 4 bleeds a year ?

Answer 39

COCP
Cyclical oral progestogen for at least 12 days a month (does not provide contraceptive cover!)
LNG-IUS

Question 40

What treatment options can be considered in primary care to help with hirsutism associated with PCOS?

Answer 40

COCP - may want to consider 3rd generation with anti-androgenic components or with Co-Cyprindiol (note these carry higher VTE risk)

If COCP doesn’t work, can try Topical Eflornithine

Other things that can be tried by secondary care include spironolactone and finasteride

Question 41

How do you calculate the earliest expected date of ovulation e.g in the context of planning emergency contraception?

Answer 41

Find out the shortest cycle length (e.g if cycles range from 28 - 32 days then take day 28) and subtract 14
Hence = day 14 earliest date of ovulation

Question 42

What are the diagnostic criteria for gestational diabetes?

Answer 42

OGTT is the preferred diagnostic test for GDM

Can diagnose GDM if
- Fasting blood glucose 5.6 or above
- 2 hour post OGT glucose 7.8 or above

Not to use HbA1C to diagnose GDM in pregnancy

Question 43

True or false - severe asthma is a contraindication for the ullipristal acetate EC pill?

Answer 43

True

Question 44

What the risk factors for increased risk of intrauterine device expulsion?

Answer 44

• Adolescence
• Menstrual cup use
• IUD/IUS insertion after 2nd / late trimester abortion
• Fibroids / uterine cavity distortion
• Those with a previous expulsion

Question 45

For how many days prior to IUD/IUS removal / replacement should patient’s be advised to either abstain from sex or use other methods?

Answer 45

7 days prior to removal (or replacement, in case repalcement in unsuccessful)

Question 46

How does VIN (vulval intraepithelial carcinoma in situ) usually present?

Answer 46

Usually presents with burning, itching and flat/slightly vulval lesions

Question 47

When should insulin be started straight away in Gestational Diabetes Mellitus?

Answer 47

If fasting blood glucose at diagnosis is 7 or greater

Question 48

Which oral emergency contraceptive is more suitable in breast feeding women?

Answer 48

Levenorgestrel

(Women must discard breast milk for 7 days after taking ulipristal acetate)

Question 49

How should you manage a missed progesterone only pill?

Answer 49

Traditional POP (LNG / NTN) - considered missed if > 3 hrs late
Desogestrel POP - considered missed if > 12 hrs late

For both:
Take the next pill even if means 2x in one day, use extra precautions until taken pill continuously for 2x days - need EC if UPSI between the time since first missed pill to when it had been taken consistently for 2 days.

Drosperinone POP slightly different
Considered missed if > 24 hrs late
Take the last missed pill even if means take 2x in one day, use extra precautions for 7 days, consider EC if UPSI between first missed pill and until when pills taken correctly for 7 consecutive days OR if missed pill in the 1st weeks after HFI and UPSI in the HFI or 1st wk.

Question 50

What are the missed pill rules for COCP pill?

Answer 50

Considered missed if > 24 hrs since last active pill taken (or 9 or completed days since last active pill if after the HFI eg if last active pill of pack taken at 9am on Monday, pill considerered missed if taken at or after 9am on the following Wed)

If 1x pill missed anywhere in the pack - take it even if means 2x in one day, EC not required and additional precautions not required so long as pills taken normally the 7 days leading upto it (or the HFI was not extended if in week 1)

If 2-7 pills missed in the 1st week - consider EC if UPSI in the HFI or wk 1 - extra precautions for 7 days

If 2-7 pills missed in wk 2 or 3 or subsequent - no need for EC, extra precautions needed for 7 days

If > 7 pills missed anywhere, pregnancy test, EC, consider like restarting contraception, extra precautions for 7 days

Question 51

Missed ‘pill’ rules for combined hormonal ring? (Stays in 3 weeks out for 1 wk HFI)

Answer 51

If late reinserting a new ring after the HFI (8 or more completed days since last ring removed) then need to consider EC if UPSI in the HFI and extra precautions for 7 days

If accidentally left the ring in during day 21-28 (what should be the HFI) - no extra precautions needed

If accidentally left the ring in day 21-35 then no EC needed but use extra precautions for next 7 days

If accidentally left the ring for > 35 days (over 5 completed weeks of use) then consider EC if UPSI during wk 5 or later and need extra precautions for 7 days

Question 52

‘Missed pill’ rules for the combined transdermal patch ?

Answer 52

if > 8 completed days since last patch was removed for HFI then consider EC and need extra precautions for 7 days

If patch accidentally removed OR extended use (ie not changed every 7days as planned) for < 48 hrs then no precautions needed

If accidental removal or extended use of patch > 48hrs - if in wk 1 then consider EC if sex in HFI or wk 1, if after wk 1 then EC not required but need additional precautions for 7 days

Question 53

Which contraceptive options are suitable in epilepsy?

Answer 53

If on enzyme-inducing agent (carbamazepine, phenytoin, topiramate etc) then UKMEC 1 is Depot Provera or IUS/IUD. UKMEC 2 is implant.

If on Lamotrigine, COCP reduces the efficacy of lamotrigine and lamotrigine may theoretically reduce the efficacy of the COCP.
The POP and implant may increase the risk of lamotrigine toxicity.

FSRH recommends that Depot injection and LNG and Copper coil unlikely to be effected and safe to co-use with Lamotrigine.

If cannot avoid being on COCP, POP or Implant with lamotrigine should liaise with their neurologist / psychiatrist - with COCP they may need a higher lamotrigine dose and they should avoid the HFI to reduce the risk of lamotrigine toxicity during this time. If on POP, may need closer monitoring of serum lamotrigine levels and looking out for signs of toxicity (dizziness, diplopia etc)

Question 54

According the BMS statement on unscheduled bleeding in HRT, women should first be assessed for any major or minor endometrial cancer risk factors. What are these major / minor risk factors?

Answer 54

MAJOR RISK FACTORS: BMI 40+, lynch or cowen syndrome, unopposed oestrogen HRT for > 6 months in woman with a uterus, prolonged sequential HRT for > 5 yrs if started 45+, 12 months or more of using less than 10 days/month norethisterone or medroxyprogesterone acetate or less than 12 days/month of micronised progesterone)

MINOR RISK FACTORS BMI 30-39, diabetes, PCOS (Anovulatory cycles), unopposed oestrogen in woman with uterus for 3-6 months, 6-12 months of inadequate progesterone cover (<10 days/mth norethisterone / medroxyprogsterone or < 12 days/mth of utrogestan, expired Mirena IUS)