Mental Health + Contraception Flashcards
Define generalised anxiety disorder
Disproportionate, pervasive, uncontrollable and widespread worry and range of somatic, cognitive and behavioural symptoms that occur on a continuum of severity
ICD-10 criteria for generalised anxiety disorder
Symptoms of anxiety to be present for most days for several months
- apprehension
- motor tension
- autonomic overactivity
Risk factors for generalised anxiety disorder
Female sex FH of psychiatric disorders Childhood adversity - maltreatment - parental problems - exposure to overprotective or overly harsh parenting style - bullying or peer victimisation Environmental stressors - physical or emotional trauma - domestic violence - unemployment - low socioeconomic status Substance dependence Chronic/painful illnesses
Complications of anxiety
Serious disability and impaired quality of life Impaired social and occupational functioning Comorbidities - depression - social anxiety disorder - alcohol and drug misuse - chronic pain - asthma - COPD - IBD Suicidal ideation and attempts
Differential diagnosis of GAD
Situational anxiety Adjustment disorder Depression Panic disorder Social phobia OCD PTSD Medication induced anxiety Cardiac disease Pulmonary disease Hyperthyroidism Anaemia Infection IBS Pheochromocytoma
Stages of suicide risk assessment
Do you ever think about suicide
Have you made plans for ending your life
Do you have the means for doing this available
What has kept you from acting on these thoughts
Protective factors
- what keeps you
- anything that makes your life worth living
Risk factors for suicide risk
Previous attempts at suicide or self-harm Feelings of hopelessness Male gender Age < 30 Advanced age Single/living alone History of substance or alcohol abuse FH of suicide Recent initiation of antidepressant treatment Psychosis Anxiety, agitation, panic attacks Severe depression
Management of GAD
Individual non-facilitated or guided self-help
Psychoeducational groups
Psychological intervention - CBT or applied relaxation
Drug treatment
- SSRI - sertraline or pregabalin
Define depression
Persistent low mood and/or loss of pleasure in most activities and range of associated emotional, cognitive, physical and behavioural symptoms
Risk factors for depression
Chronic comorbidities Medicines Female Older age Recent childbirth Psychosocial issues - divorce, unemployment, poverty, homelessness PMH Genetic and FH Adverse childhood experiences Past head injury
Complications of depression
Exacerbation of pain, disability or distress Reduced QoL Increased morbidity and mortality Impaired ability to function normally Increased risk of substance abuse
Complications of antidepressants
Risk of self-injurious behaviour Sexual adverse effects Undesired weight gain Hyponatraemia Agitation or excessive activation Risk of suicide
Diagnosis of depression
At least one of the two core symptoms present most days, most of the days for at least 2 weeks
- bothered by feeling down, depressed or hopeless
- little interest/pleasure in doing things
Associated symptoms of depression
Disturbed sleep
Decreased or increased appetite and/or weight
Fatigue/loss of energy
Agitation or slowing of movements
Poor concentration or indecisiveness
Feelings of worthlessness or excessive/inappropriate guilt
Suicidal thoughts/acts
Stages of depression
Subthreshold - 2-5 symptoms
Mild - more than 5 but minor functional impairment
Moderate - symptoms or functional impairment are mild-severe
Severe - most symptoms and marked interference with functioning
Differential diagnosis of depression
Grief reaction Anxiety disorders Bipolar disorder Premenstrual dysphoric disorder Neurological conditions - Parkinson's - MS - dementia Substance and adverse drug effects - CO poisoning - substance misuse Hypothyroidism Obstructive sleep apnoea syndrome
Management of depression
Low-intensity psychosocial intervention
Group based CBT
Antidepressant
High-intensity psychosocial intervention
Consider starting an anti-depressent if
History of moderate or severe depression
Subthreshold depressive symptoms that have persisted for a long period - 2 years
Mild depression that persists despite other interventions
Mild depression complicating care of chronic physical health problem
Causes of fatigue
Physiological - pregnancy - breastfeeding - inadequate rest/sleep - excessive exercise Physical - anemia - DM - glandular fever - malignancy Psychological - depression - anxiety - loss - stress Chronic fatigue
Risk factors for chronic fatigue
Female
Higher BMI
Lower educational attainment
Clinical features of chronic fatigue syndrome
Fatigue - persistent (4 months) or recurrent - new or specific onset - unexplained by other conditions - resulted in substantial reduction in activity level - characterised by post-exertional malaise / fatigue Other features - difficulty sleeping - muscle or joint pain without inflammation - headaches - painful lymph nodes without enlargement - sore throat - cognitive dysfunction - worsening symptoms on exertion - general malaise/flu-like symptoms - dizziness/nausea - palpitations
Investigations for fatigue
FBC - anaemia - polycythaemia - haematological malignancy ESR and CRP - infection - inflammation - autoimmunity LFTs U&Es - kidney disease - electrolyte imbalance Thyroid function tests - hypo - hyper HbA1c - DM IgA tissue transglutaminase - coeliac
Method of action of COCP
Inhibit ovulation
- no LH and FSH surge
Oestrogen - endometrium proliferation and growth
Progesterone - prevents hyperplasia of endometrium
When to start COCP
Postpartum - breastfeeding = 6 weeks to 6 months - not breastfeeding = 21 days No regular contraception - day 1 of menstrual cycle
Advantages of COCP
More effective than barrier methods
Sexual intercourse not interrupted
Menstrual bleeding usually regular, lighter and less painful
Reduced risk (50%) of ovarian and endometrial cancer
Reduced risk of colorectal cancer
Reduced severity of acne
Normal fertility returns immediately after stopping
Disadvantages of COCP
Temporary adverse effects when start
Does not protect against STIs
Less effective than long-acting reversible methods
Risks/adverse effects of COCP
Nausea and abdo pain Headache Breast pain/tenderness Menstrual irregularities Hypertension Changes in lipid metabolism MI and stroke VTE Breast cancer Cervical cancer Mood changes
Drug interactions to be aware of with COCP
Liver enzyme-inducing drugs
- antibiotic - rifampicin
- antiepileptics - carbamazepine, phenytoin
- antiretrovirals - ritonavir
- St John’s wort
Missed pill rules
Take missed pill asap
Emergency/barrier contraception required if
- 9 or more days since last pill over break
- 2-7 pills missed
Advantages of combined transdermal patch
Applied weekly - more convenient than daily pill
Do not become less effective if user vomits/diarrhoea
As effective as COCP
Disadvantages of combined transdermal patch
Can be seen May become detached from skin - compromises efficacy Less effective if > 90kg Skin irritation, N+V Delay in return to normal fertility
Mechanism of action of intrauterine system
Progestogenic effect on endometrium
- prevents implantation of fertilised ovum
- changes in mucus inhibit sperm penetration
Advantages of an intrauterine system
Very safe and effective
Long-term - replaced every 3-5 years
Sex not interrupted
Periods usually lighter, shorter and less painful
Normal fertility returns as soon as device removed
Disadvantages of an intrauterine system
Internal pelvic exam needed to check suitable and insert device
- pain/discomfort for few hours after insertion
Trained healthcare provider must remove device
Does not protect against STIs
May be expelled without women knowing
Adverse effects of intrauterine system
Pain on insertion Perforation of wall of uterus Expulsion PID Ectopic pregnancy Ovarian cysts Acne, breast tenderness, headache Unscheduled bleeding Hypersensitivity Depression
What is natural family planning
Method of birth control where a woman monitors and records different fertility indicators during her menstrual cycle to determine when she is least/most fertile
- Fertility Awareness Methods (FAM)
- Lactational Amenorrhoea Method (LAM)
What do fertility awareness methods of contraception involve?
Monitoring and recording fertility signs
- cervical secretions - volume of cervical secretions which are wet, slippery and clear indicates ovulation is approaching
- changes in cervix - fertile window cervix changes from being low and firm to being high and soft
- basal body temperature - slight rise in temp that persists for 3 days indicates that fertile time has ended
- calculate menstrual cycle and fertile period - over minimum of 12 cycles
Computerised monitoring devices - urine dipsticks to follow changes of hormone concentrations
What does the lactational amenorrhea method of contraception involve
Breastfeeding after childbirth to prevent pregnancy
- delays the return of ovulation by disrupting gonadotrophin release
First 6 months after giving birth provided
- complete amenorrhoea
- fully or very nearly fully breastfeeding
- less than 6 months since birth
Advantages of fertility awareness methods
Can be used by most couples Do not involve use of chemicals or physical products No physical or hormonal adverse effects No contraindications for use Help women recognise normal and abnormal vaginal secretions Acceptable to all faiths and cultures Initial and continuing costs can be low Immediatley reversible
Disadvantages of fertility awareness methods
Only moderately effective
Require continuing cooperation and commitment by both partners
Must be taught by someone trained to teach natural family planning
Takes 2-3 menstrual cycles to learn how to identify fertile time accurately
Not suitable for women with irregular cycles
Does not protect against STIs
Advantages of lactational amenorrhea method
Can be effective up to 6 months Encourages exclusive breastfeeding Can be used immediately after childbirth No need to anything at the time of sexual intercourse No direct cost No hormonal adverse effects Encourages starting follow-up method at proper time Does not involve abstinence
Disadvantages of lactational amenorrhea
Does not protect against STIs
Becomes unreliable after 6 months and when other foods are introduced into baby’s diet
Frequent breastfeeding can be inconvenient
Method of action of progestogen-only pills (POPs)
Suppression of ovulation - suppression of mid-cycle of LH and FSH Production of hostile blocked mucus - poor sperm penetration Prevents implantation - reduction in number and size of endometrial glands and inhibition of progesterone receptor synthesis in endometrium Reduction in activity of cilia in the Fallopian tube Prevent conception
Advantages of POP
Very effective when taken correctly - better than barrier
Sex not interrupted
Used when COCP not suitable
Reduce risk of endometrial cancer
Desogestrel may be beneficial in managing dysmenorrhoea
Normal fertility returns when POP stopped
Disadvantages of POP
Pills must be taken at same time each day - within 3 hours
Adverse effects
Does not protect against STIs
Adverse effects of POP
Menstrual irregularities Breast tenderness Ovarian cysts Ectopic pregnancy Increased risk of breast cancer
Method of action of progesterone implant
Inhibit ovulation
Changes in cervial mucus - inhibit sperm
Advantages of progesterone implant
Very effective Users do not have to think about contraception for 3 years Sexual intercourse not interrupted Used when breastfeeding Normal fertility returns as soon as removed Used when COCP not suitable May help alleviate dysmenorrhoea May reduce risk of endometrial cancer Effective in women of all weights
Disadvantages of progesterone implant
50% will experience changes in menstrual bleeding
Bleeding patterns likely to remain irregular
Efficacy reduced with liver enzyme-inducing drugs
Does not protect against STIs
Adverse effects of progesterone implant
Menstrual irregularites Acne Complications of insertion and removal Increased breast cancer risk VTE
Advantages of progesterone injectables
Very effective
Do not have to think about contraception for 8-12 weeks
Used when breastfeeding
No know interactions with any medications
May reduce heavy periods and help with PMS
Used when COCP not suitable
Used by women with BMI over 35
May reduce risk of ovarian and endometrial cancer
Disadvantages of progesterone injectables
Not rapidly reversible
- delay up to 1 year until normal fertility returns
Does not protect against STIs
Adverse effects - unscheduled bleeding and weight changes
Adverse effects of progesterone injectables
Menstrual irregularities Weight gain Increased risk of breast cancer Small loss of body mass index Injection site reactions
Types of male sterilisation (vasectomy)
Scalpel method Minimally invasive vasectomy (MIV) Occlusion of vas deferens achieved by - coagulation/cauterisation - ligation with sutures/metal clips - insertion of intra-vas devices or plugs
Types of female sterilisation (tubal occlusion)
Hysteroscopic - micro-inserts passed through hysteroscope and insert into proximal section of fallopian tube
Laparascopic - tubal rings/clips used to occlude fallopian tubes or diathermy to destroy segment of tube
Mini-laparotomy - fallopian tubes partially removed and ligated or occluded with tubal ring or clip
Advantages of vasectomy
Very effective in preventing pregnancy
Permanent
Sex not interrupted
Disadvantages of vasectomy
Require minor surgical procedure - small risk of haematoma and infection
Effective contraception required until azoospermia confirmed - 12 weeks
Regret
Not easily reversed - not routinely on NHS
Does not protect against STIs
Failure
Risks of vasectomy
Small risk of testicular or scrotal chronic pain
Advantages of tubal occlusion
Very effective in preventing pregnancy
Permanent
Sex not interrupted
Disadvantages of tubal occlusion
Requires surgical procedure Regret Cannot be easily reversed Does not protect against STIs Can fail
Risks of tubal occlusion
Laparoscopic procedure - bowel, bladder or blood vessel damage
If occlusion fails pregnancy may be ectopic
Requires general anaesthetic
No increased risk of heavier/irregular periods when over 30
Method of action of copper IUDs
Toxic effects of copper on ovum and sperm - preventing fertilisation
Advantages of copper IUDs
Very safe and effective
Effective immediately after insertion - emergency contraception
Long term - replaced every 5-10 years
No hormonal side effects
Sex not interrupted
Immediately reversible
Used with breastfeeding
Inserted from 4 weeks postpartum
Used immediately following surgical or medical termination
No drug interactions
Reduced risk of endometrial and cervical cancer
Disadvantages of copper IUDs
Internal pelvic exam - prior to insertion
Some bleeding/spotting may occur immediately after insertion
Severe cramps and pain beyond 3-5 days insertion
Woman cannot discontinue on her own - must be removed by trained professional
Adverse effects
Adverse effects of copper IUD
Pain on insertion Perforation of wall of the uterus Expulsion PID Ectopic pregnancy Unscheduled bleeding
Define medically unexplained symptoms
Persistent physical complaints that don’t appear to be symptoms of a medical conditions
Examples of medically unexplained symptoms
Tingling in hands/feet
Tremor in hand
Headaches/migraines
Changes in sight
Possible causes of medically unexplained symptoms
Chronic fatigue syndrome
IBS
Fibromyalgia
Management of medically unexplained symptoms
Lifestyle changes - regular physical activity - better rest - manage stress CBT Antidepressant drugs Neurology Psychotherapy
Risk factors for medically unexplained symptoms
Women
Younger people
People who’ve recently had an infection or physical illness or those affected by ill health or death of relative
Previous depression or anxiety
