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Repro Exam II > Gynecology CIS 1: intro and contraception (Dunn) > Flashcards

Gynecology CIS 1: intro and contraception (Dunn) Flashcards

1
Q

Menorrhagia

A

heavy menstruation >80cc

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2
Q

Metrorrhagia-

A

bleeding in between periods

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3
Q

Menometrorrhagia

A

heavy bleeding and bleeding in between menses

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4
Q

EGBUS:

A

External Genitalia
Bartholins Gland
Urethra
Skene’s Gland

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5
Q

Uterus:

physical exam

A

AVAF-anteverted,anteflexed
RVRF-retroverted,retroflexed
Axial-
Size-

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6
Q

Unintended Pregnancy

A

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!

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7
Q

CDC Medical Eligibility Criteria for contraception by category

A

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

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8
Q

least effective–> most effective family planning methods

A 
least effective--
withdrawal, spermicide
fertility awareness
condoms/ diaphragm
patch
pill
lactational amenorrhea
injectables
vasectomy
implants, IUD, female sterilization
- most effective
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9
Q

LARC

A

Long-acting Reversible Contraception

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10
Q

Etonogestrel Implant

A 
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
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11
Q

Etonogestrel Implant Efficacy

A

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

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12
Q

Etonogestrel ImplantBleeding Patterns

A 
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
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13
Q

Other Side Effects of etonogestrel

A

acne (17%)
weight gain
not contraindicated in obese women/ girls

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14
Q

Bone Mineral Density & Etonogestrel Implant

A

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

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15
Q

Etonogestrel implant continuation

A

Bleeding irregularity is the most common reason for discontinuation
U.S. studies: 13-14%

Overall U.S. continuation rate: 75%-84%

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16
Q

contraindications for etonogestrel

A 
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
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17
Q

Appropriate patients for etonogestrel

A

Women desiring highly effective,
confidential, “forgettable” contraception

Women who cannot use estrogen

Tolerant of irregular bleeding
The importance of counseling

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18
Q

Intrauterine contraception: paragard

A

Copper IUD
use up to 10 years
heavier periods
no hormonal side effects

don’t use on young women

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19
Q

Mirena

A

IUD- local progestin
use up to 5 years
lighter periods- irreular for 3-6 months
some systemic effects

20
Q

Copper-releasing IUDs:Mechanism

A 
Mass effect, like plastic IUDs
Copper alters uterine and tubal fluid 
- Hinders spermatozoa function / motility
Inhibits fertilization
- Not an abortifacient
21
Q

Progestin-releasing IUDs:Mechanism

A 
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
22
Q

Levonorgestrel-releasing IUS

A

Releases 20 mcg per day of Levonorgestrel
Hormonal side effects are rare
Endometrial concentrations 200-800x higher than in blood

23
Q

Increasing IUD use among young women

A

ACOG Committee Opinion December 2007
IUDs should be offered as a “first-line choice” for contraception in both nulliparous and parous adolescents

> 99% effective

24
Q

IUD Risks – younger patients

A

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

25
Q

Copper IUDs – menstrual changes

A

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
26
Q

Progestin IUDs – side effects

A

Hormonal side effects are rare & not more common than in general population
Nonetheless, they are reasons given for discontinuation
No weight gain

27
Q

Dalkon Shield

A

1970 Introduced
1973 High incidence of PID recognized
1975 Removed from market
1983-1988 No IUDs sold in U.S.

28
Q

IUD and Pelvic Inflammatory Disease RiskEvidence-Based?

A

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
29
Q

infertility in nulliparous women and IUD?

A

NO association with past use of Copper IUD

30
Q

IUD candidates

A

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

31
Q

Depo-Provera

A

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

32
Q

DMPA (depo-provera) benefits and risks/ side effects

A 
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
33
Q

DMPA – bleeding patterns

A

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

34
Q

DMPA and Weight Gain

A

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

35
Q

DMPA & Bone Mineral Density (BMD)

A

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

36
Q

Depo-Provera contraindications

A 
Similar to progestin implant
Severe hypertension (>160/>100)
Diabetes with 
vascular disease and / or 
> 20 years disease
37
Q

depo-provera appropriate patients

A 
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
38
Q

Combined Hormonal Contraceptives

A

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

39
Q

Contraceptive patch

A

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

40
Q

The vaginal ring

A 
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
41
Q

Potential advantages of new delivery systems

A

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

42
Q

Weight andCombined Hormonal Contraceptives

A

no link to weight gain

43
Q

Breakthrough bleeding and CHC

A 
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
44
Q

acne and CHC

A

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 (!)
45
Q

Combined Hormonal Contraception:Contraindications

A 
History of a venous thromboembolism
Known thrombogenic mutations
Migraines with aura* 
Hypertension, esp. if poorly controlled
Lupus with antiphospholipid antibodies
46
Q

Condoms

A 
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 &amp; STIs
47
Q

Summary of contraception

A

Unplanned pregnancy is common
The implant and IUDs provide greater:
- Convenience
- Efficacy

Discontinuation of all methods is high
Counseling in advance is vital

Repro Exam II (18 decks)

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