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3A > Gynaecology - Fertility and contraception > Flashcards

Gynaecology - Fertility and contraception Flashcards

1
Q

Contraception for under 16s

A

Fraser criteria

  1. Understands doctor’s advice
  2. Attempted to persuade her to tell her parents
  3. Believe she will continue intercourse without contraception
  4. Physical or mental health is at risk
  5. It is in her best interests
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2
Q

Short-acting methods of contraception

A

COCP
POCP

Diaphragm/cap

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3
Q

COCP method of action

A

Inhibits ovulation

TAKES 7 DAYS!!

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4
Q

COCP advantages

A

Reversible

Decreases dysmenorrhoea
Decreases menorrhagia
Decreases acne

Protective for…

  • Endometrial cancer
  • Ovarian cancer
  • Colon cancer
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5
Q

COCP disadvantages and contraindications

A

Risks…

  • VTE
  • Breast cancer
  • Cervical cancer

Contraindications…

  • Aged > 35 + 15 cigs/day
  • BMI > 35
  • Migraine with aura
  • Previous VTE, stroke or IHD
  • Breast-feeding < 6 weeks
  • Uncontrolled HTN
  • Breast cancer or BRCA1/2
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6
Q

POCP method of action

A

Thickens cervical mucus

Decreases tubal motility - ECTOPIC RISK!!

TAKES 2 DAYS!!

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7
Q

POCP advantages / disadvantages

A

Reversible

Useful in difficult populations

  • Obese
  • Migraines
  • HTN
  • Aged > 35

Decreased oestrogen side effects

  • Nausea
  • Breast tenderness
  • Headaches

Disadvantages

  • Irregular bleeding
  • Ectropion risk
  • Ovarian cyst risk
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8
Q

Long-acting methods of contraception

A

Implant
Depo injection
IUD - Copper
IUS - Mirena - Levonogestrel

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9
Q

Implant MOA

Advantages vs disadvantages

A

Progesterone - Negative feedback - Prevents ovulation
Thickens cervical mucus

TAKES 7 DAYS

Advantages

  • Long-acting
  • Decreases menorrhagia
  • Decreases dysmenorrhoea

Disadvantages

  • Irregular bleeding
  • Minor-op
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10
Q

Depo-provera MOA

Advantages vs disadvantages

A

Progesterone - Negative feedback - Inhibits ovulation
Thickens mucus

TAKES 7 DAYS
Lasts 3 months

Advantages - 55% amenorrhoea after first year

Disadvantages

  • Not immediately reversible - Up to one year!
  • Decreased bone mineral density
  • Irregular bleeding
  • Weight gain
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11
Q

IUD MOA

Advantages vs disadvantages

A

Hostile environment for sperm
Decreases sperm motility and survival

INSTANT

Advantages

  • Long-acting
  • No need to remember to take it
  • Non-hormonal
  • Works immediately after insertion

Disadvantages

  • Menorrhagia
  • Dysmenorrhoea
  • Uterine perforation
  • Expulsion
  • Ectopic risk
  • PID in first 20 days
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12
Q

IUS method of action

Advantages vs disadvantages

A

Levonogestrel
Thickens cervical mucus
Thins endometrium

TAKES 7 DAYS

Advantages

  • Long-acting
  • Reduces menorrhagia
  • Reduces dysmenorrhoea
  • Can lead to amenorrhoea

Disadvantages

  • Irregular bleeding
  • Painful fitting
  • Ectopic
  • Expulsion
  • Perforation
  • PID in first 20 days
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13
Q

Emergency contraception methods

A

Progesterone - Within 72 hours
Levonelle - Within 72 hours

Ellaone - Ullipristal acetate - 5 days

IUD
- 5 days after intercourse
OR
- 5 days after likely ovulation date

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14
Q

Post-partum contraception

A

Required from day 21

POCP - Safe if breastfeeding

COCP

  • CI if breastfeeding < 6 weeks
  • Safe if breastfeeding - 6 weeks - 6 months

IUD - Best option!
- 48 hours PP
OR
- 4 weeks PP

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15
Q

Female sterilisation methods

A

Tubal ligation

Essure - Coil blockage in tubes

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16
Q

Tubal ligation

Advantages vs disadvantages

A

Advantages - No hormonal side effects

Disadvantages

  • Non-reversible on the NHS
  • Ectopic risk
  • Surgical procedure
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17
Q

Essure - Coil blockage

Advantages vs disadvantages

A

Advantages

  • Quick
  • Permanent

Disadvantages

  • Irreversible
  • Surgical procedure
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18
Q

Menstrual cycle days 1-4

A

Low hormone level
Endometrium shedding
HPA - Producing some FSH and LH

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19
Q

Menstrual cycle days 5-14

A

Proliferative phase
FSH and LH acting on the ovary - Follicular growth
Follicle produces oestrogen and inhibit - Negative feedback on HPA
HPA stops producing FSH and LH - Prevents further follicular growth
Oestradiol level increases - Positive feedback on HPA
HPA releases FSH and LH - Egg is released

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20
Q

Menstrual cycle days 15-28

A

Follicle releases egg and becomes corpus luteum
Corpus luteum maintained by LH - Secretes oestrogen and progesterone

No fertilisation…

  • Corpus luteum degenerates
  • No further progesterone secretion
  • No negative feedback on HPA
  • Back to square 1
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21
Q

Roles of progesterone

A

Spiral artery formation
Stromal cell enlargement
Endometrium thickening
Negative feedback on HPA

22
Q

Subfertility definition / aetiology

A

Failure to conceive after 1 year of trying

Hormonal - Amenorrhoea

Uterine

  • Congenital abnormalities
  • Polyps
  • Fibroids
  • Endometriosis
  • Infection / PID
  • Asherman’s - Intrauterine adhesions

Lifestyle - Obesity and smoking

Metabolic - Thyroid dysfunction

23
Q

Subfertility investigations

A 
FSH / LH 
Anti-Mullerian hormone - Marked of ovarian reserve 
Oestradiol
Testosterone 
Prolactin

TFTs

Triple swab

USS - Check for abnormalities

24
Q

Subfertility management

A

Treat cause!

Low FSH/LH

  • Gonadotrophins
  • Weight loss

PCOS

  • Clomiphene
  • Metformin
  • Gonadotrophins

Menopause - Egg donor required

Endometriosis - Ablation of ectopic tissue

25
Q

Amenorrhoea types

A

Primary

  • Not started by 16 - With secondary characteristics
  • Not started by 14

Secondary - Stopped for 6 months

26
Q

Amenorrhoea hypothalamic causes and investigations

A

Primary

  • Anorexia
  • Stress
  • Exercise
  • Kallmann’s

Investigations - FSH/LH

27
Q

Amenorrhoea anterior pituitary causes and investigations

A

Primary - Prolactinoma

Investigations - Prolactin ^^^

28
Q

Amenorrhoea thyroid causes and investigations

A

Primary - Thyroid disease

Investigations

  • TSH
  • T3
  • T4
29
Q

Amenorrhoea adrenal causes and investigations

A

Primary

  • Adrenal tumour
  • Cushing’s
  • CAH

Secondary - Adrenal tumour

Investigations

  • Adrenal tumour - CT
  • Cushing’s - Dexamethasone suppression test
  • CAH - Testosterone ^^^
30
Q

Amenorrhoea ovarian causes and investigations

A

Primary

  • Androgen insensitivity
  • PCOS
  • Primary ovarian failure
  • Turner’s syndrome

Secondary

  • PCOS
  • Primary ovarian failure
31
Q

Amenorrhoea genital causes and investigations

A

Primary

  • Imperforate hymen
  • Transverse vaginal septum

Secondary

  • Cervical stenosis
  • Asherman’s - Intrauterine adhesions

Investigations

  • USS
  • MRI
32
Q

PCOS aetiology / diagnostic criteria

A

Genetics - Family history
Smoking
Insulin resistance

LH ^^^
Ovarian androgens ^^^
Adrenal androgens ^^^

  1. Multiple cysts on USS
  2. Androgen excess
  3. Irregular periods
33
Q

PCOS presentation

A

Gynae…

  • Subfertility
  • Amenorrhoea
  • Intermenstrual bleeding
  • Oliguria

Other…

  • Acne
  • Hirsutism
  • Acanthosis nigricans
  • Insulin resistance - Weight gain
34
Q

PCOS investigations

A 
Testosterone ^^^ 
LH/FSH ratio ^^^ 
Prolactin ^^^ 
TSH 
Pelvic USS 
Insulin ^^^
35
Q

PCOS management

A

Lifestyle advice - Weight loss

Hirsutism and acne…

  • COCP
  • Spirnonlactone
  • Eflornithine

Infertility

  • Clomiphene
  • Metformin
  • GnRH
36
Q

Kallmann’s syndrome

A

X-linked

Failure of GnRH secreting neurons to migrate to hypothalamus

Presentation

  • Anosmia
  • Amenorrhoea
  • Hypogonadism

Investigations
- FSH/LH - LOW

37
Q

Angroden insensitivity aetiology and presentation

A

X-linked
Testosterone resistance

Undescended testes 
Normal female genitalia 
Primary amenorrhoea 
Absent uterus / vagina 
Testosterone ^^^
38
Q

Androgen insensitivity investigations and management

A

Investigations

  • Buccal smear
  • Karyotype

Management

  • Orchidectomy - Increased Ca risk
  • HRT
39
Q

IVF indications / procedure

A

Male infertility
Unexplained infertility
Tubular disease
Endometriosis

  1. GnRH agonist + FSH every day until follicle is 18-20mm
  2. hCG administration
  3. Egg and sperm collection
  4. Culture
  5. Transfer
40
Q

IVF risks

A

Ovarian hyperstimulation syndrome
Ovarian cancer

Multiple pregnancy
Ectopic

41
Q

Ovarian hyperstimulation syndrome aetiology

A

Cause - IVF

RFs

  • Low BMI
  • PCOS
  • Young
  1. bHCG ^^^ + Oestrogen ^^^ + Progesterone ^^^
  2. Increased vascular permeability
  3. Fluid moves from vascular compartment into tissues
42
Q

Ovarian hyperstimulation syndrome presentation / management

A

Vascular

  • Hypovolaemia - Thrombosis risk
  • Hypotension - Shock
  • Hypoalbuminaemia - Oliguria

Tissues

  • Ascites
  • Hydrothorax
  • Ovarian cysts
  • Weight gain

Management

  • Fluid correction
  • TED compression stockings
  • LMWH
43
Q

Menopause definition and diagnosis

A

Permanent cessation of menstruation
Due to loss of ovarian follicle activity

12 consecutive months of amenorrhoea

Mean age - 51

44
Q

Menopause presentation

A

Vasovagal

  • Sleep disturbance
  • Night sweats
  • Hot flushes

Periods - Dysfunctional menstrual bleeding

Urogynae

  • Vaginal dryness
  • Vaginal atrophy
  • Dyspareunia
  • Itching
  • Prolapse
  • Incontinence
  • UTI
  • Urinary frequency ^^^
45
Q

Menopause long-term risks

A

Osteoporosis
CVD

Psychological effects

  • Dementia
  • Depression
  • Anxiety
46
Q

Perimenopause

A

From the onset of symptoms
TO
12 months after last period

47
Q

Menopause investigations

A

Only if < 40
OR
Atypical symptoms

Less follicles…

  • FSH ^^^ - 2 measurements 4 weeks apart - Day 2-5
  • AMH ^^^

Others…

  • TFT
  • LH
  • Oestradiol
  • Progesterone
  • DEXA
48
Q

Menopause management

A

Lifestyle

  • Sleep hygiene
  • Weight loss

HRT

  • Hysterectomy - Oestrogen
  • No hysterectomy - Oestrogen + Progesterone

Non-HRT

  • Vasomotor - Fluoxetine and Citalopram
  • Psych - Antidepressants

Contraception
> 50 - Continue until 12 months after last period
< 50 - Continue until 24 months after last period

49
Q

HRT - ROA

Advantages vs disadvantages

A

Oral
Transdermal
MIRENA COIL

Advantages

  • Reduces symptoms
  • Reduces osteoporosis risk

Disadvantages

  • Breast cancer
  • VTE
  • CVD
  • Oestrogen only - Endometrial and ovarian cancer
50
Q

HRT contraindications

A

Oestrogen responsive cancer

  • Breast
  • Endometrial
  • Ovarian

Undiagnosed PV bleed
Untreated endometrial hyperplasia

51
Q

Premature menopause definition and causes

A

Menopause < 40 - A CRISIC

Causes

  • AI disease
  • Chromosomal
  • Radiotherapy
  • Idiopathic
  • Surgery
  • Infection
  • Chemotherapy
52
Q

Premature menopause management

A
  1. FSH > 25 UI/L
  2. 4 months amenorrhoea

Oestrogen replacement - COCP
Androgen replacement - Testosterone gel

3A (31 decks)

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