Gynaecology Flashcards
What is the efficacy of the Copper IUD for emergency contraception if inserted within 5 days of UPSI or ovulation ?
99.9%
What is the mechanism of action of the LNG-IUS?
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
What are the different brands of LNG-IUS licensed for use in the UK?
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
What is the risk of perforation associated with IUD/IUS insertion?
1-2 in 1,000
6x higher if breast feeding
Slightly higher risk if < 36 wks postpartum
True or false - Cu-IUD has been linked to increased incidence of bacterial vaginosis?
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.
What is the risk of expulsion associated with IUD/IUS
1 in 20
Risk is highest in the first 3 months
Slightly higher risk of menstrual cup user!
What is the ectopic pregnancy risk associated with IUD/IUS
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
What are the UKMEC 4 criteria for Cu-IUD / LNG-IUS?
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
What are the UKMEC 3 criteria for for Cu-IUD / LNG-IUS ?
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
What are the recommendations for STI screening prior to intrauterine contraception insertion?
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
If someone develops PID after an intrauterine coil is already in place, when should removal be considered?
If no clinical improvement after 72 hrs of abx
What is the guidance on Copper and LNG intrauterine contraception in the approach to menopause?
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
which methods of contraception are unaffected by and therefore safe to use alongside enzyme inducing medications?
Copper IUD
LNG-IUS
Depot injection
Barrier methods
How long after ullipristal acetate emergency contraception should progestogen-based medications / contraceptions be avoided?
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.
What should women who have had UPSI in the 4th year of an implant being in-situ be advised?
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.
What is the relationship between progestogen implant and cancers of the reproductive organs
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.
For how many days after Implant insertion are additional contraception precautions required?
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
What treatment options can be considered in a women having ongoing problematic bleeding with the implant after the first few months?
Exclude pregnancy, STI, cervical cancer
Offer 3 month trial of COC or 5 days of mefanamic acid during bleeding
What are the failure rates of the depot injection in the first year of use with perfect use and typical use?
Perfect use 0.2%
Typical use 6%
True or false - the depot injection is a safe contraception in sickle cell disease and may reduce the severity of sickle cell crises?
TRUE!!
How frequently should women on DPMA injection be reviewed ?
Every 2 years - to consider bone mineral density risk and other pros/cons
What is the association between DPMA use and reproductive cancer risks?
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.
The depot injection can cause weight gain - which individuals are most at risk of depot-associated weight gain?
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 !!
What is the best mode of administration of the depot injection?
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
When is a depot considered ‘late’ and extra contraceptive precautions required?
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.
True or false - higher body weight does not affect the efficiacy of the depot injection?
True
Although there is limited evidence in women with BMI > 40
True or false - smoking is associated with a reduced risk of hyperemesis gravidarum?
TRUE
Smoking is actually protective from hyperemesis
Which SSRIs are considered the safest / recommended for use in breast-feeding women?
Sertraline or Paroxetine
( Small amounts ssecreted in breast milk but considered safe)
What are the lower threshold target ‘normal’ haemoglobin levels for women during pregnancy and postpartum?
115 - non-pregnant women
110 - early pregnancy
105 - late pregnancy
100 - in the postpartum period
How should you manage a newly pregnant women with essential hypertension who is currently on an ACEi ?
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
When is a POP considered missed ?
Traditional POP - if > 3 hrs late
Desogestrel POP - if > 12 hours late
Drosperinone POP - if > 24 hrs late
What is the typical and perfect use efficacy of POP
Perfect use 99% effective
Typical use 91% effective
No evidence that significant difference in effiacy between traditional and desogestrel pOP
What is the expected bleeding pattern on the POP?
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
For how long after starting the POP are extra precautions needed?
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
Which route of COC may be affected by high body weight
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
Which contraceptive options should not be used with lamotrigine?
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
What are the risks associated with COC and various cancers?
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
How long before major surgery / period of prolonged immobility should women be advised to stop the COC?
Should be stopped AT LEAST 4 WEEKS BEFORE major surgery / period of prolonged immobility and another contraceptive method used then instead
How should you advise women on COC who are trekking to high altitudes (4,500M or 14,500 ft) for more than a week?
To stop COC and switch to another form of contraception
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 ?
COCP
Cyclical oral progestogen for at least 12 days a month (does not provide contraceptive cover!)
LNG-IUS
What treatment options can be considered in primary care to help with hirsutism associated with PCOS?
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
How do you calculate the earliest expected date of ovulation e.g in the context of planning emergency contraception?
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
What are the diagnostic criteria for gestational diabetes?
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
True or false - severe asthma is a contraindication for the ullipristal acetate EC pill?
True
What the risk factors for increased risk of intrauterine device expulsion?
- Adolescence
- Menstrual cup use
- IUD/IUS insertion after 2nd / late trimester abortion
- Fibroids / uterine cavity distortion
- Those with a previous expulsion
For how many days prior to IUD/IUS removal / replacement should patient’s be advised to either abstain from sex or use other methods?
7 days prior to removal (or replacement, in case repalcement in unsuccessful)
How does VIN (vulval intraepithelial carcinoma in situ) usually present?
Usually presents with burning, itching and flat/slightly vulval lesions
When should insulin be started straight away in Gestational Diabetes Mellitus?
If fasting blood glucose at diagnosis is 7 or greater
Which oral emergency contraceptive is more suitable in breast feeding women?
Levenorgestrel
(Women must discard breast milk for 7 days after taking ulipristal acetate)
How should you manage a missed progesterone only pill?
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.
What are the missed pill rules for COCP pill?
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
Missed ‘pill’ rules for combined hormonal ring? (Stays in 3 weeks out for 1 wk HFI)
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
‘Missed pill’ rules for the combined transdermal patch ?
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
Which contraceptive options are suitable in epilepsy?
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)
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?
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)
