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repro 8 Flashcards

1
Q

Intrauterine device (IUD): emergency contraception

A
  • a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria
  • in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
  • must be inserted within 5 days of UPSI, or
  • if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
  • may inhibit fertilisation or implantation
  • may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
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2
Q

COCP absolute contraindications

A
  • more than 35 years old and smoking more than 15 cigarettes/day
  • migraine with aura
  • history of thromboembolic disease or thrombogenic mutation
  • history of stroke or ischaemic heart disease
  • breast feeding < 6 weeks post-partum
  • uncontrolled hypertension
  • current breast cancer
  • major surgery with prolonged immobilisation
  • positive antiphospholipid antibodies (e.g. in SLE)
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3
Q

COCP relative contraindications

A
  • more than 35 years old and smoking less than 15 cigarettes/day
  • BMI > 35 kg/m^2*
  • family history of thromboembolic disease in first degree relatives < 45 years
  • controlled hypertension
  • immobility e.g. wheel chair use
  • carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
  • current gallbladder disease
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4
Q

COCP: if 1 pill is missed

A
  • Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
  • No additional contraceptive protection needed
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5
Q

COCP: if 2 or more pills are missed

A
  • Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
  • the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
  • if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
  • if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
  • if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
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6
Q

Advise on starting the COCP

A

If the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days. Should be taken at the same time everyday.

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7
Q

Advantages of the COCP

A
  • highly effective (failure rate < 1 per 100 woman years)
  • doesn’t interfere with sex
  • contraceptive effects reversible upon stopping
  • usually makes periods regular, lighter and less painful
  • reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
  • reduced risk of colorectal cancer
  • may protect against pelvic inflammatory disease
  • may reduce ovarian cysts, benign breast disease, acne vulgaris
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8
Q

Disadvantages of the COCP

A
  • people may forget to take it
  • offers no protection against sexually transmitted infections
  • increased risk of venous thromboembolic disease
  • increased risk of breast and cervical cancer
  • increased risk of stroke and ischaemic heart disease (especially in smokers)
  • temporary side-effects such as headache, nausea, breast tenderness may be seen
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9
Q

IUS and IUD

A

Includes both the copper intrauterine device (IUD) and levonorgestrel releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia

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10
Q

IUS and IUD problems

A
  • IUDs make periods heavier, longer and more painful
  • the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
  • uterine perforation
  • the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
  • infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
  • expulsion: most likely to occur in the first 3 months
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11
Q

IUD contraindications

A
  • IUD: Postpartum or post-abortion sepsis, persistently elevated hCG or malignant disease, current pelvic inflammatory disease, untreated chlamydia or gonorrhoea infection, pelvic TB, cervical or endometrial cancer, unexplained vaginal bleeding (from UKMEC)
  • IUS: current breast cancer, fibroids of excessive size, untreated pelvic or uterine infection
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12
Q

Implantable device

A

Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.

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13
Q

Implantable device advantages

A
  • Most effective form of contraception
  • Long lasting: 3 years
  • Doesn’t contain oestrogen so can be used if there is a past history of thromboembolism, migraine etc
  • Can be inserted immediately following a termination of pregnancy
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14
Q

Implantable device disadvantages

A
  • Additional contraception is needed for the first 7 days if not inserted on day 1 to 5 of a women’s menstrual cycle
  • Irregular/heavy bleeding
  • Progesterone effect: headache, nausea, breast pain
  • Interactions: antiepileptics and rifampicin reduce efficacy, should take other contraception for 28 days
  • Contraindications: breast cancer, ischaemic heart disease/stroke, unexplained/suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer
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15
Q

Starting the POP

A
  • if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
  • if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
  • Should be taken at the same time each day without a pill free break unlike the COCP
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16
Q

POP advantages and disadvantages

A

Disadvantages= Irregular vaginal bleeding

Advantages= doesn’t contain oestrogen

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17
Q

Erectile dysfunction

A

persistent inability to attain and maintain an erection sufficient to perform satisfactory sexual performance. Symptom, not a disease. Causes can be split broadly into organic, psychogenic and mixed

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18
Q

Erectile dysfunction: factors favouring an organic cause

A
  • Gradual onset of symptoms
  • Lack of tumescence
  • Normal libido
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19
Q

Erectile dysfunction: factors favouring a psychogenic cause

A
  • Sudden onset of symptoms
  • Decreased libido
  • Good quality spontaneous or self-stimulated erections
  • Major life events
  • Problems or changes in a relationship
  • Previous psychological problems
  • History of premature ejaculation
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20
Q

Erectile dysfunction; risk factors

A
  • increasing age
  • cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
  • alcohol use
  • drugs: SSRIs, beta-blockers
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21
Q

Erectile dysfunction investigations

A
  • Calculate their 10 year cardiovascular risk by measuring lipids and fasting glucose serum levels
  • Free testosterone should also be measured in the morning between 9 and 11am.
  • If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels.
  • If any of these are abnormal refer to endocrinology for further assessment.
22
Q

Erectile dysfunction: management

A
  • PDE-5 inhibitors (such as sildenafil, ‘Viagra’)= they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology, sildenafil can be purchased over-the-counter without a prescription.
  • Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
  • for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
  • people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
23
Q

Subfertility: basic investigations

A
  • Semen analysis
  • Serum progesterone 7 days prior to expected next period i.e. day 21
  • Chlamydia screening, BMI, rubella immunity in the mother
24
Q

Subfertility; key counselling advice

A
  • Folic acid 400mg
  • Aim for BMI 20-25
  • Regular sexual intercourse every 2 to 3 days
  • Smoking/drinking advice
25
Q

When to be concerned about infertility

A

Investigations and referral for infertility should be started when the couple has been trying to conceive for 12 months. This can be reduced to 6 months if the women is older than 35 as her ovarian stores are likely to be already reduced

26
Q

Infertility causes

A
  • Sperm problems (30%)
  • Ovulation problems (25%)
  • Tubal problems (15%)
  • Uterine problems (10%)
  • Unexplained (20%)
27
Q

Female hormone testing involves

A
  • Serum LH and FSH on day 2 to 5 of the cycle
  • Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
  • Anti-Mullerian hormone
  • Thyroid function tests when symptoms are suggestive
  • Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
28
Q

Female hormone testing results

A
  • High FSH suggests poor ovarian reserve
  • High LH suggests PCOS
  • A rise in progesterone on day 21 indicates that ovulation has occurred
  • Anti-Mullerian hormone, high levels suggest good ovarian reserve. Can be measured any time in the cycle
29
Q

Infertility: further investigations often performed in secondary care

A
  • Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
  • Hysterosalpingogram to look at the patency of the fallopian tubes
  • Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
30
Q

Semen analysis

A

after 2 days of sexual abstinence but no more then 7 after. Repeat at 3 months, earlier if grossly abnormal. The semen sample needs to be complete and if not the man should report this, should be delivered to lab within an hour.

31
Q

Secondary infertility treatment in men

A
  • Microbiology tests
  • Sperm culture
  • Endocrine tests
  • Imaging of the urogenital tract
  • Testicular biopsy
32
Q

Assisted pregnancy techniques

A
  • IUI- intrauterine insemination
  • In vitro fertilisation
  • ICSI= Intra-cytoplasmic sperm injection
  • In females Gonadotrophins or Clomiphene citrate to induce ovulation
  • Pro-nuclear transfer: 3 parents baby, done if the mother is carrying a mitochondrial disease
33
Q

Primary amenorrhoea

A
  1. No menstruation by the age of 14 years accompanied by failure to develop sec. sexual characteristics.
  2. No menstruation by age of 16 when growth and sexual development are normal.
34
Q

Secondary amenorrhoea

A
  1. Secondary absence of menses for six months (or greater than 3 times the previous cycle interval) in a women who has menstruated before.
  2. Pregnancy, lactation or hysterectomy must be excluded
  3. Prepubertal and post-menopausal conditions are also to be excluded as physiological causes
35
Q

Causes of amenorrhoea

A
  1. Disorder of outflow tract and or uterus
  2. Disorders of the ovary
  3. Disorders of the anterior pituitary
  4. Disorders of the Hypothalamus
36
Q

Outflow tract anomalies

A
  1. Imperforate hymen
  2. Transverse vaginal septum- failure of the Mullerian derived upper vagina to fuse with the urogenital sinus derived lower vagina
  3. Vaginal agenesis
  4. Testicular feminisation
  5. Asherman’s syndrome
37
Q

Disorders of the outflow tract and or uterus- Cryptomenorrhoea

A
  1. Absence of normal vaginal opening or imperforate hymen, prevent menstrual loss from escaping
  2. Features: primary amenorrhoea in a teenage girl with normal sexual development present
  3. Complaining of lower abdo pain, possible difficulty of mict, palpable lower abdo swelling (haematometra). Bulging, bluish membrane at the lower end of the vagina (Haematocopos).
  4. Management: incise membrane
38
Q

Testicular feminization: androgen insensitivity

A
  1. Phenotype is woman. Genotype is man (xy) testes are present and mullerein inhibiting factor, testosterone levels as in maleTreatment: gonadectomy after puberty (HRT), there is a germ cell malignancy risk
  2. Treatment: vaginal reconstruction (dilation vs vaginoplasty)
  3. Inherited by an X-linked recessive gene… (familial)
  4. Resulting in absence of cytosol androgen receptor
39
Q

Asherman’s syndrome

A
  1. Secondary amenorrhoea following distruction of the endometrium by overzealous curettage, multiple synechae show up on Hysterography
  2. Management: under general anaesthetic, breakdown intrauterine adhesions through hysteroscope. Insert an IUCD to deter reformation and use hormone therapy
40
Q

Ovarian causes of amenorrhoea

A
  1. Chromosomal abnormalities- turner syndrome -> gonadal dysgenesis
  2. Gonadal agenesis: failure of gonadal development, no other congenital abnormalities
  3. Resistant ovary syndrome
  4. Premature menopause
  5. PCOS
41
Q

Amenorrhoea: PCOS

A

Most common cause
1. Mostly present with classical Stein-Leventhal syndrome (oligomenorrhoea, obesity, hirsuitism, and infertility.
2. Many women will have sec. amenorrhoea with no obesity or hirsuitism
3. Diagnosis is made by finding increased LH/FSH ratio +/- raised androg
4. USS + polycystic ovaries
5. Association with subfertility type 2 Diabetes and endometrial hyperplasia

42
Q

Premature menopause

A
  1. Ovarian failure <35 years of age
  2. Auto-immune disease associated with Addisons
  3. Viral infection i.e. Mumps
  4. Cytotoxic drugs/radiotherapy
43
Q

Pituitary causes of amenorrhoea

A
  1. Pituitary tumour causing hyperprolactinaemia. 40% of patients with hyperprolactinaemia will have a pituitary adenoma. Causes secondary amenorrhoea, can cause visual changes and some milk discharge from the nipple
  2. Craniopharyngioma- other intracranial tumour
  3. Sheehans syndrome- necrosis of the anterior pituitary due to severe PPH. Pan or partial hypopituitarism
  4. Other causes of increased prolactin- Drugs i.e. phenothiazine, methyldopa, metoclopramide, anti-histamines and morphine
44
Q

Hypothalamic amenorrhoea

A
  1. Classic Kallmann syndrome (KS) and idiopathic hypogonadotropic hypogonadism (IHH)- rare genetic conditions
  2. Gonadotropin-releasing hormone (GnRH) deficiency
  3. Hypothalamic-pituitary function is otherwise normal, and hypothalamic-pituitary imaging reveals no space-occupying lesions.
  4. Anosmia (lack of sense of smell) or severe hyposmia is present in patients with Kallmann syndrome in contrast to idiopathic hypogonadotropic hypogonadism.
  5. Deficient hypothalamic GnRH secretion leads to the markedly abnormal gonadotropin secretion
  6. The result is hypogonadism; infertility; and absent, incomplete, or partial pubertal maturation. No periods or secondary sexual characteristics
45
Q

Disorders of the Hypothalamus

A
  1. Commonest reason for hypogonadotropic secondary amenorrhoea
  2. Often associated with stress i.e. in migrants, young women when leaving home, university students
  3. Diagnosis by exclusion of pituitary lesions
  4. Hormone therapy or ovulation induction is not indicated unless patient wishes to become pregnant
46
Q

Weight loss amenorrhoea

A
  1. A loss of >10kg is frequently associated with amenorrhoea. Typically in young women and teenage girls
  2. Joggers amenorrhoea: in athletes due to redistribution between proportion of body fat mass and body muscle mass. May also be mediated by exercise related changes in beta-endorphins
  3. Anorexia nervosa- associated with secondary amenorrhoea
47
Q

Examination of patient with amenorrhoea

A
  1. Breast development, abdominal and pelvic examination
  2. Presence of hirsutism, virlization
  3. Beta-hCG, FSH, TSH
  4. Prolactin, pelvic ultrasound scan
48
Q

Amenorrhoea- breasts absent

A
  1. Uterus absent: Gonadal agenesis in 46XY
  2. Gonadal failure/agenesis in 46XX
49
Q

Amenorrhoea- breasts present

A
  1. Uterus absent: enzyme deficiency in testosterone synthesis, Testicular feminization, Mullerian agenesis
  2. Uterus present: Disruption of the hypothalamic pituitary axis. Hypothalmic, pituitary or ovarian pathogenesis. Congenital abnormalities of the genital tract
50
Q

Investigations for amenorrhoea

A
  1. FSH ,LH, Prolactin level and TFT
  2. Karyotyping…if chromosomal. anomaly is suspected on clinical grounds
  3. Progesterone withdrawal test to check endogenous estrogen. if bleeding PV-reactive endom. and patent outflow tract.
  4. Uss pelvis

Year 5 (24 decks)

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