Gynaecology - Fertility and contraception Flashcards
Contraception for under 16s
Fraser criteria
- Understands doctor’s advice
- Attempted to persuade her to tell her parents
- Believe she will continue intercourse without contraception
- Physical or mental health is at risk
- It is in her best interests
Short-acting methods of contraception
COCP
POCP
Diaphragm/cap
COCP method of action
Inhibits ovulation
TAKES 7 DAYS!!
COCP advantages
Reversible
Decreases dysmenorrhoea
Decreases menorrhagia
Decreases acne
Protective for…
- Endometrial cancer
- Ovarian cancer
- Colon cancer
COCP disadvantages and contraindications
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
POCP method of action
Thickens cervical mucus
Decreases tubal motility - ECTOPIC RISK!!
TAKES 2 DAYS!!
POCP advantages / disadvantages
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
Long-acting methods of contraception
Implant
Depo injection
IUD - Copper
IUS - Mirena - Levonogestrel
Implant MOA
Advantages vs disadvantages
Progesterone - Negative feedback - Prevents ovulation
Thickens cervical mucus
TAKES 7 DAYS
Advantages
- Long-acting
- Decreases menorrhagia
- Decreases dysmenorrhoea
Disadvantages
- Irregular bleeding
- Minor-op
Depo-provera MOA
Advantages vs disadvantages
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
IUD MOA
Advantages vs disadvantages
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
IUS method of action
Advantages vs disadvantages
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
Emergency contraception methods
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
Post-partum contraception
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
Female sterilisation methods
Tubal ligation
Essure - Coil blockage in tubes
Tubal ligation
Advantages vs disadvantages
Advantages - No hormonal side effects
Disadvantages
- Non-reversible on the NHS
- Ectopic risk
- Surgical procedure
Essure - Coil blockage
Advantages vs disadvantages
Advantages
- Quick
- Permanent
Disadvantages
- Irreversible
- Surgical procedure
Menstrual cycle days 1-4
Low hormone level
Endometrium shedding
HPA - Producing some FSH and LH
Menstrual cycle days 5-14
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
Menstrual cycle days 15-28
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
Roles of progesterone
Spiral artery formation
Stromal cell enlargement
Endometrium thickening
Negative feedback on HPA
Subfertility definition / aetiology
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
Subfertility investigations
FSH / LH Anti-Mullerian hormone - Marked of ovarian reserve Oestradiol Testosterone Prolactin
TFTs
Triple swab
USS - Check for abnormalities
Subfertility management
Treat cause!
Low FSH/LH
- Gonadotrophins
- Weight loss
PCOS
- Clomiphene
- Metformin
- Gonadotrophins
Menopause - Egg donor required
Endometriosis - Ablation of ectopic tissue
Amenorrhoea types
Primary
- Not started by 16 - With secondary characteristics
- Not started by 14
Secondary - Stopped for 6 months
Amenorrhoea hypothalamic causes and investigations
Primary
- Anorexia
- Stress
- Exercise
- Kallmann’s
Investigations - FSH/LH
Amenorrhoea anterior pituitary causes and investigations
Primary - Prolactinoma
Investigations - Prolactin ^^^
Amenorrhoea thyroid causes and investigations
Primary - Thyroid disease
Investigations
- TSH
- T3
- T4
Amenorrhoea adrenal causes and investigations
Primary
- Adrenal tumour
- Cushing’s
- CAH
Secondary - Adrenal tumour
Investigations
- Adrenal tumour - CT
- Cushing’s - Dexamethasone suppression test
- CAH - Testosterone ^^^
Amenorrhoea ovarian causes and investigations
Primary
- Androgen insensitivity
- PCOS
- Primary ovarian failure
- Turner’s syndrome
Secondary
- PCOS
- Primary ovarian failure
Amenorrhoea genital causes and investigations
Primary
- Imperforate hymen
- Transverse vaginal septum
Secondary
- Cervical stenosis
- Asherman’s - Intrauterine adhesions
Investigations
- USS
- MRI
PCOS aetiology / diagnostic criteria
Genetics - Family history
Smoking
Insulin resistance
LH ^^^
Ovarian androgens ^^^
Adrenal androgens ^^^
- Multiple cysts on USS
- Androgen excess
- Irregular periods
PCOS presentation
Gynae…
- Subfertility
- Amenorrhoea
- Intermenstrual bleeding
- Oliguria
Other…
- Acne
- Hirsutism
- Acanthosis nigricans
- Insulin resistance - Weight gain
PCOS investigations
Testosterone ^^^ LH/FSH ratio ^^^ Prolactin ^^^ TSH Pelvic USS Insulin ^^^
PCOS management
Lifestyle advice - Weight loss
Hirsutism and acne…
- COCP
- Spirnonlactone
- Eflornithine
Infertility
- Clomiphene
- Metformin
- GnRH
Kallmann’s syndrome
X-linked
Failure of GnRH secreting neurons to migrate to hypothalamus
Presentation
- Anosmia
- Amenorrhoea
- Hypogonadism
Investigations
- FSH/LH - LOW
Angroden insensitivity aetiology and presentation
X-linked
Testosterone resistance
Undescended testes Normal female genitalia Primary amenorrhoea Absent uterus / vagina Testosterone ^^^
Androgen insensitivity investigations and management
Investigations
- Buccal smear
- Karyotype
Management
- Orchidectomy - Increased Ca risk
- HRT
IVF indications / procedure
Male infertility
Unexplained infertility
Tubular disease
Endometriosis
- GnRH agonist + FSH every day until follicle is 18-20mm
- hCG administration
- Egg and sperm collection
- Culture
- Transfer
IVF risks
Ovarian hyperstimulation syndrome
Ovarian cancer
Multiple pregnancy
Ectopic
Ovarian hyperstimulation syndrome aetiology
Cause - IVF
RFs
- Low BMI
- PCOS
- Young
- bHCG ^^^ + Oestrogen ^^^ + Progesterone ^^^
- Increased vascular permeability
- Fluid moves from vascular compartment into tissues
Ovarian hyperstimulation syndrome presentation / management
Vascular
- Hypovolaemia - Thrombosis risk
- Hypotension - Shock
- Hypoalbuminaemia - Oliguria
Tissues
- Ascites
- Hydrothorax
- Ovarian cysts
- Weight gain
Management
- Fluid correction
- TED compression stockings
- LMWH
Menopause definition and diagnosis
Permanent cessation of menstruation
Due to loss of ovarian follicle activity
12 consecutive months of amenorrhoea
Mean age - 51
Menopause presentation
Vasovagal
- Sleep disturbance
- Night sweats
- Hot flushes
Periods - Dysfunctional menstrual bleeding
Urogynae
- Vaginal dryness
- Vaginal atrophy
- Dyspareunia
- Itching
- Prolapse
- Incontinence
- UTI
- Urinary frequency ^^^
Menopause long-term risks
Osteoporosis
CVD
Psychological effects
- Dementia
- Depression
- Anxiety
Perimenopause
From the onset of symptoms
TO
12 months after last period
Menopause investigations
Only if < 40
OR
Atypical symptoms
Less follicles…
- FSH ^^^ - 2 measurements 4 weeks apart - Day 2-5
- AMH ^^^
Others…
- TFT
- LH
- Oestradiol
- Progesterone
- DEXA
Menopause management
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
HRT - ROA
Advantages vs disadvantages
Oral
Transdermal
MIRENA COIL
Advantages
- Reduces symptoms
- Reduces osteoporosis risk
Disadvantages
- Breast cancer
- VTE
- CVD
- Oestrogen only - Endometrial and ovarian cancer
HRT contraindications
Oestrogen responsive cancer
- Breast
- Endometrial
- Ovarian
Undiagnosed PV bleed
Untreated endometrial hyperplasia
Premature menopause definition and causes
Menopause < 40 - A CRISIC
Causes
- AI disease
- Chromosomal
- Radiotherapy
- Idiopathic
- Surgery
- Infection
- Chemotherapy
Premature menopause management
- FSH > 25 UI/L
- 4 months amenorrhoea
Oestrogen replacement - COCP
Androgen replacement - Testosterone gel
