Gynecology CIS 1: intro and contraception (Dunn) Flashcards
Menorrhagia
heavy menstruation >80cc
Metrorrhagia-
bleeding in between periods
Menometrorrhagia
heavy bleeding and bleeding in between menses
EGBUS:
External Genitalia
Bartholins Gland
Urethra
Skene’s Gland
Uterus:
physical exam
AVAF-anteverted,anteflexed
RVRF-retroverted,retroflexed
Axial-
Size-
Unintended Pregnancy
Sexually active young adult women are at high risk for unintended pregnancy
Highest rate among young adult women & older teens
107 / 1,000 women age 20-24 / year
103 / 1,000 women age 18-19 / year
That’s 10% per year!
CDC Medical Eligibility Criteria for contraception by category
1 - No restriction for use of the method
2- Advantages of using the method generally outweigh the theoretical or proven risks
3- Theoretical or proven risks usually outweigh the advantages of using the method
4- An unacceptable health risk if the contraceptive method is used
least effective–> most effective family planning methods
least effective-- withdrawal, spermicide fertility awareness condoms/ diaphragm patch pill lactational amenorrhea injectables vasectomy implants, IUD, female sterilization - most effective
LARC
Long-acting Reversible Contraception
Etonogestrel Implant
Single 40-mm 2-mm rod Rod is made of ethylene vinyl acetate copolymer Contains 68 mg of etonogestrel active metabolite of desogestrel releases 60 mcg daily Effective for 3 years
Etonogestrel Implant Efficacy
More effective than permanent sterilization
0.05% typical (and perfect-use) failure
No pregnancies during 1200 woman-years of exposure (Pearl Index, 0; 95% CI 0.0-0.2)
American study of 330 women aged 18-40
no pregnancies in 2 years
Etonogestrel ImplantBleeding Patterns
Total number of bleeding/spotting days decreased or similar for majority of users Key difference: irregularity and unpredictability ~20% amenorrhea in 1st year Increases to 30-40% after 1st year
Other Side Effects of etonogestrel
acne (17%)
weight gain
not contraindicated in obese women/ girls
Bone Mineral Density & Etonogestrel Implant
Implanon does not suppress estrogen levels to extent that Depo-Provera® does
Randomized trial of Implanon and copper IUD
No differences in BMD changes between the two groups during one year of use
Etonogestrel implant continuation
Bleeding irregularity is the most common reason for discontinuation
U.S. studies: 13-14%
Overall U.S. continuation rate: 75%-84%
contraindications for etonogestrel
very few SLE with anti-phospholipid antibodies Hepatocellular adenoma Discontinue if develops during use: Migraines with aura Unexplained vaginal bleeding suspicious for serious condition, before evaluation
Appropriate patients for etonogestrel
Women desiring highly effective,
confidential, “forgettable” contraception
Women who cannot use estrogen
Tolerant of irregular bleeding
The importance of counseling
Intrauterine contraception: paragard
Copper IUD
use up to 10 years
heavier periods
no hormonal side effects
don’t use on young women
Mirena
IUD- local progestin
use up to 5 years
lighter periods- irreular for 3-6 months
some systemic effects
Copper-releasing IUDs:Mechanism
Mass effect, like plastic IUDs Copper alters uterine and tubal fluid - Hinders spermatozoa function / motility Inhibits fertilization - Not an abortifacient
Progestin-releasing IUDs:Mechanism
Impairs spermatozoa motility / function Inhibits conception - Unable to recover fertilized ova - Not an abortifacient Thickens cervical mucus Atrophy of endometrium Impairs tubal motility 85% of women are ovulatory
Levonorgestrel-releasing IUS
Releases 20 mcg per day of Levonorgestrel
Hormonal side effects are rare
Endometrial concentrations 200-800x higher than in blood
Increasing IUD use among young women
ACOG Committee Opinion December 2007
IUDs should be offered as a “first-line choice” for contraception in both nulliparous and parous adolescents
> 99% effective
IUD Risks – younger patients
Insertion may be more difficult in nulliparous women
Higher expulsion in adolescents
May have higher rates of copper IUD removals due to bleeding and pain
No evidence this occurs with the LNG-IUS
Copper IUDs – menstrual changes
Increased menstrual flow
- Increased amount and duration
- Usually no change in hemoglobin
Increased dysmenorrhea
Management
- Patience and reassurance
- NSAIDS around clock, start 1 day before menses
Progestin IUDs – side effects
Hormonal side effects are rare & not more common than in general population
Nonetheless, they are reasons given for discontinuation
No weight gain
Dalkon Shield
1970 Introduced
1973 High incidence of PID recognized
1975 Removed from market
1983-1988 No IUDs sold in U.S.
IUD and Pelvic Inflammatory Disease RiskEvidence-Based?
Re-analysis excluding the Dalkon Shield and addressing bias = no increased risk
3 types of bias in observational studies:
- Inappropriate comparison groups
- Over diagnosis of PID among IUD users
- Inability to control for confounding factors
WHO analysis of 22,900 women over 8 yrs
- Increased risk in first 20 days after insertion
- No increased risk with continued use
infertility in nulliparous women and IUD?
NO association with past use of Copper IUD
IUD candidates
Prior STI or PID: NOT a contraindication
- Contraindicated: current PID or within the past 3 months / Current cervicitis
High risk women: screen for infection with GC or CT prior to insertion
Adolescence and nulliparity are not contraindications
CDC category 2 for age < 20 years & nulliparity
Depo-Provera
150 mg of depot medroxyprogesterone acetate; administered deep intramuscular
or
104 mg subcutaneous
Q 3 months
Initiate anytime in cycle; rule out pregnancy
Back up method for 7 days if injection is not within 5 days of start of menses
DMPA (depo-provera) benefits and risks/ side effects
Benefits: Highly effective: 96% Little compliance required Easily concealed No decreases in efficacy in overweight women
Risks and Side Effects: Bleeding irregularities Delayed return of fertility Weight gain Decrease in bone mineral density
DMPA – bleeding patterns
Irregular bleeding
70% in the first year; 10% thereafter
Usually light; hemoglobin levels rise
Most common reason for discontinuation
Up to 25% in the first year of use
Management
Similar to management with Implanon
Bleeding and spotting decrease progressively with each reinjection
Amenorrhea:
55% at one year
70% at 2 years
80% at 5 years
DMPA and Weight Gain
Adult women: 4.3 kg increase over 5 years
Compared to 1.8 kg increase in copper IUD users
Early weight gain may predict excessive gain
Weight gain greater in adolescents who are overweight (BMI >30) when initiating DMPA
20 lb weight gain over 18 months in obese teens
DMPA & Bone Mineral Density (BMD)
Use of DMPA is associated with loss of BMD
After stopping, recovery of BMD is seen
return to baseline in 1-4 years
No data on fracture risk in women who have used DMPA in the past
Depo-Provera contraindications
Similar to progestin implant Severe hypertension (>160/>100) Diabetes with vascular disease and / or > 20 years disease
depo-provera appropriate patients
Women desiring effective, confidential, method and who can return for injections Women who cannot use estrogen Tolerant of irregular bleeding Special populations - Sickle cell disease - Epilepsy
Combined Hormonal Contraceptives
Safe for most young women
Added benefit of regulation of menses
“Typical-use” effectiveness ~ 92%
(Do not quote perfect use ~ 99%)
Commonly reported as most effective method
Poor continuation
Contraceptive patch
Weekly transdermal patch
20 mcg EE + 150 mcg norelgestromin daily
Continuous delivery
Area “under the curve” is 60% > in a 35 mcg pill
Possible increase in estrogen side effects such as VTE
Less effective if body weight > 90 kg
The vaginal ring
3 weeks with 1 week ring-free interval or 24-4, or continuous Lowest ethinyl estradiol dose (15 mcg EE, 120 mcg etonorgestrel daily) Continuous dosing Use back-up method if out for > 3 hours
Potential advantages of new delivery systems
Compliance
-Patch > pill in some studies…but not in others
Satisfaction
-No consistent differences
Side effects
-Ring with some improvement in nausea and cycle control
Continuation and efficacy
Weight andCombined Hormonal Contraceptives
no link to weight gain
Breakthrough bleeding and CHC
Common reason for discontinuation With time, improved with extended regimens Higher rates in women - who smoke - with cervical infections
Management:
- If near end of cycle, discontinue early
- If severe, consider exogenous estrogen
acne and CHC
All pills studied reduced acne compared to placebo
No consistent results regarding different types of progestins
- Cyproterone (pregnane) may be better than LNG
- LNG may be better than desogestrel (!)
Combined Hormonal Contraception:Contraindications
History of a venous thromboembolism Known thrombogenic mutations Migraines with aura* Hypertension, esp. if poorly controlled Lupus with antiphospholipid antibodies
Condoms
Safe for all young women Only method that offers PROTECTION FROM STIs Not effective enough for contraception Typical-use failure is 15% Counsel for dual protection from pregnancy & STIs
Summary of contraception
Unplanned pregnancy is common
The implant and IUDs provide greater:
- Convenience
- Efficacy
Discontinuation of all methods is high
Counseling in advance is vital
