Reproductive Medicine Flashcards
What are the 2 main forms of contraception?
- LARC (Long-acting reversible contraception) - IUS/IUD
- Non-LARC (short-acting) - CHC, POP, Diaphragm, Emergency Contraceptive
Give examples of the main types of contraceptive methods
- Hormonal
- Barrier
- Intrauterine
- Permanent
- ‘Fertility Awareness’
- Emergency
Describe the MoA of the main types of Contraceptive (IUD/IUS, COCP, POP, DMPA, LAM, SDI)
Main Mechanism – suppression of FSH and LH (negative feedback hypothalamus/pituitary) with EXCEPTION of Copper/Mirena Coil and Mini-Pill.
IUD: Copper Coil - toxic effects of copper on the ovum and sperm, preventing fertilization.
IUS: Mirena Coil - Progestin-based; Thickens mucus in the cervix to stop sperm from reaching or fertilizing an egg
Progesterone-Only Methods: Thicken cervical mucus, delaying ovum transport, inhibiting ovulation, and providing an endometrium hostile to implantation.
Emergency hormonal contraception – only temporarily delays ovulation (rather than suppression)
Prevention of Fertilisation: condoms, diaphragm & spermicide, female/male sterilisation, IUD, hormonal methods (cervical mucous effect)
Prevention of implantation: hormonal contraceptive methods – thin lining of endometrium. IUD as secondary moa – copper coil (emergency contraception).
Describe the MoA of the Combined Hormonal Contraceptives (CHCs)
- Suppression of FSH and LH (negative feedback hypothalamus/pituitary)
- Ovulation is inhibited by the oestrogen and progestogen components which act on the hypothalamo-pituitary axis to reduce production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
- Inhibits Ovulation - with no surge in LH and FSH to stimulate the ovaries, ovulation does not occur.
- Thickens Cervical mucus to prevent penetration of sperm
- Prevents implantation - reduces endometrial receptivity by inhibiting blastocyst implantation
- https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/
Side effects of COCP
Minor Side-Effects: Mood Changes, Breast Tenderness, Breakthrough bleeding within first 3m.
Major Side-Effects: VTE/DVT, MI (particularly smokers, HT and DM), Risk of stroke in Migraine with aura. Breast and Cervical cancer risk increased.
MoA of POP
- Thickens cervical mucus (previous ‘traditional’ POP i.e.)
- Delay ovum transport
- Inhibit ovulation (Primary)
- Providing an endometrium hostile to implantation.
Side effects of POP
The adverse effects of progestogen-only contraceptives include:
- Menstrual irregularities.
- Breast tenderness.
- Ovarian cysts.
- A possible increased risk of breast cancer.
MoA of Intrauterine System (IUS)
- Progestogen-only system
- The levonorgestrel intrauterine system (LNG-IUS) acts via its progestogenic effect (progestin; mimics progesterone) on the endometrium, which prevents implantation of the fertilized ovum.
- Prevents Endometrial Proliferation (Primary MoA) - this is mainly by reducing endometrial growth and preventing implantation. There is endometrial atrophy within one month of insertion.
- Progestogenic effects thickens cervical mucus to reduce penetration by sperm.
- Ovulation is usually not inhibited.
Side effects of Intrauterine System (IUS)
Risks and adverse effects of IUCs include:
- Unscheduled bleeding.
- Perforation of the uterine wall at the time of insertion or later.
- Ectopic pregnancy.
- Insertion may be unpleasant.
- Menstrual irregularities are common in the first six months. By 12 months, amenorrhoea or light bleeding is common.
- There are typical progestogenic side-effects (potentially acne/breast tenderness/headache/mood changes). These may resolve over time.
- Dysfunctional ovarian cysts; however, these usually resolve spontaneously.
MoA of Intrauterine Device (IUD)
- Copper IUD: toxic effects of copper on the ovum and sperm, preventing fertilization.
- Decreases sperm motility and survival
Side effects of Intrauterine Device (IUD)
Risks and adverse effects of IUCs include:
- Unscheduled bleeding.
- Perforation of the uterine wall at the time of insertion or later.
- Ectopic pregnancy.
Describe the main types of Emergency Contraception and when they are indicated
IUD
•Copper Coil IUD is the most effective 1st line (99% effective)
But Must fulfil 2 Criteria:
•Must be fitted within 5d of the earliest possible date of ovulation
OR
•5d after a single episode of sex
Oral Alternatives
•Ulipristal Acetate (EllaOne) – blocks progesterone Rs & LH surge. Can be used 5d after unprotected sex. Efficacy goes down with time. Progesterone cannot be used immediately afterwards for 5d or prior to Ulipristal.
•Levonelle – high-dose progesterone. Inhibits ovulation. Can be used within 72hrs. If >70kg, double dose indicated.
Describe the main features of the Progesterone-Only Implant
- LARC
- Nexplanon®
- It contains 68 mg of etonogestrel
- Replaced every 3 years.
- It is radio-opaque and can be located by X-ray.
- Prevents pregnancy by inhibiting ovulation (Primary MoA). Thickens cervical mucus to inhibit sperm.
- Lowest failure rate: when used perfectly (consistently and correctly), 0.05% of women will conceive within the first year of use due to method failure.
What is the UKMEC Criteria
With respect to the contraceptive use:
- No restriction
- Advantages outweigh risks
- Risks outweigh advantages
- Unacceptible risk
Describe the general features of Combined Hormonal Contraception (CHC)
Includes
- Combined Contraceptive Oral Pill (COCP)
- Ring
- Patch
MoA:
- Stops ovulation
- Failure rate 8%
How to take:
- Start in the first 5d of period. Take daily for 21d followed by 7d break (withdraw bleed)
OR
- At any time in cycle when reasonably sure not pregnant + Condoms for 7d
Considerations
- Initial BP must be <140/90 prior to starting CHC. Therefore, BP must be checked prior to commencing and at 3m, then annually. Also check BMI.
- CHC is contra-indicated in migraine with aura.
Off Licence Indications (Recommended):
- Tricycling – take each day for 3 cycles the stop for 7d and restart
- Take continually – if you bleed for 4d or more, stop for 4d then start again
Describe the general features of Progesterone-Only Contraceptives
Includes:
- Progesterone-Only Pill (POP): Desogestrel (Cerazette). Failure rate: Perfect <1%; Typical = 9%
- Subdermal Implant (Nexplanon)
- Depo Provera/Sayana Press (DMPA) – ‘Domestos of the Contraceptive World’. Issues: No-show to follow-up. Pregnant (missed). Be cautious in early teens (<18yrs), RFs for Osteoporosis (poor absorption or FMHx) due to risk of osteoporosis,
MoAs:
POP: Inhibits Ovulation (older POPs act by thickening cervical mucous)
Depo Provera: Lowers Oestradiol and supresses FSH. Stops menstrual cycle. Not affected by enzyme-inducing medications useful in epilepsy.
Side-Effects
- Nausea, Spots, Irregular Bleeding (POP & Depo in first 9-12m) but amenorrhea with time, Headaches, Weight gain (Depot stimulates appetite).
How to take:
- Start in the first 5d of period. Take daily for 21d followed by 7d break (withdraw bleed)
OR
- At any time in cycle when reasonably sure not pregnant + Condoms for 7d (Effective after 2d for POP)
Risks:
- Lower risks compared to other contraceptives. Little effect on metabolism. Can be given in most circumstances including breast-feeding and high-risk individuals (smokers)
- Contraindicated in current breast cancer (UKMEC 4)
Describe the general features of sterilisation
Includes:
- Vasectomy – low failure rate.
- Female Sterilisation – high failure rate (2-3/1000) – greater than contraceptives
MoA:
- Vasectomy: Local or general anaesthetic. No-scalpel technique.
- Female Sterilisation: Removal
Complications
- Vasectomy: Anaesthetic, pain, infection, bleeding/haematoma.
- Female Sterilisation: clip/coil/ligation/removal/essure of fallopian tubes.
- Failure
- Vasectomy: usually due to early non-compliance with post-vasectomy seminal analysis (late-motile or >100,000 non-motile at 7m for efficacy)
Risks:
- Lower risks compared to other contraceptives. Little effect on metabolism. Can be given in most circumstances.
- Contraindicated in current breast cancer (UKMEC 4)
What are the main risk associated with CHC?
- Thrombosis – Venous (VTE) or Arterial
VTE Increased risk:
- Dose of oestrogen and type of progesterone (higher in newer CHCs such as Gestodene)
- Obesity
- Previous VTE
- Prescribe the most effective CHC with lowest risk.
- Safetynetting: Risks of CHC and Signs to look out for i.e. calf swelling, SOB.
Arterial Risks:
- MI, particularly smokers using COCP.
- Ischaemic Stroke in COCP. Migraine with aura – increased risk of ischaemic stroke with CHC. UKMEC 2 (benefits outweigh risks).
- HT COCP users (160/95) at greater risk of MI and stroke than HT non-COCP users.
- Breast & Cervical Cancer (long-term use >5yrs), but back to baseline after 10 years of stopping. Discuss HPV/Condom use.
- Check that the patient is up to date with cervical screening.
What are the protective factors of CHCs?
- CHC is protective for Ovarian (20% every 5 years; 50% reduction after 15 years) and Endometrial Cancer (20-50% reduction in endometrial cancer)
- 12% reduction in all-cause mortality and no overall increased risk of cancer
- CHC can be used to 55yrs if no RFs to restrict use
What are some of the benefits of CHCs?
- Acne - EE/Cyproterone acetate (Dianette) – antiandrogen/progestagen/antiglucocorticoid. Increased risk of VTE.
- Fewer functional ovarian cysts
- Reduced bleeding
- Premenstrual syndrome (PMS)
- Polycystic Ovarian Syndrome (PCOS)
- May protect against pelvic inflammatory disease (PID).
- Reduces incidence of benign breast disease, ovarian cysts, ovarian cancer and endometrial cancer.
MoA of Progesterone-only injectable contraceptives
- Inhibits ovulation (Primary).
- It also makes the endometrium unsuitable for implantation if fertilisation occurs.
- Thickens cervical mucus, making the mucus less easily penetrable to sperm.
Benefits of Progesterone-only Injectable Contraceptives
- Very effective and convenient. Provided that the injections are given on a regular basis (every 12 weeks for Depo-Provera®, every 13 weeks for Sayana Press®, every 8 weeks for Noristerat®), there is a very low failure rate.
- Can be used during breast-feeding.
- Amenorrhoea is common, which may be an advantage for women with menorrhagia or dysmenorrhoea.
- Self-administration may be an option for Sayana Press® in the future, although is currently outside the product licence.
Side-effects of Progesterone-Only Injectables
- It is not quickly reversible.
- There is an associated small loss of bone mineral density and possibly a subsequent increased fracture risk, which recovers after stopping.
- Contraceptive injections should not be used for women aged under 18 unless no other option is suitable.
- Consider other contraceptive options in women with other risk factors for osteoporosis.
- Menstrual irregularities common in women using this method, with irregular bleeding being a common reason for stopping. Amenorrhoea commonly develops with time, however, and women should be counselled about the possibility of early bleeding and encouraged to persevere.
- Weight gain of up to 2-3 kg in one year may occur. A higher initial BMI (≥30 kg/m2) makes this more likely, particularly in women aged less than 18.
- Delayed return of fertility of up to one year after stopping
- Possible increased risk of breast cancer; not clearly shown yet; also, a weak association with cervical cancer.
Benefits of IUS
- It is very effective, convenient and reversible.
- It reduces blood loss and dysmenorrhoea.
- It may reduce the risk of PID compared with normal IUCDs, because of thickening of cervical mucus.
- It does not significantly interact with other drugs, as its action is principally local.
- No demonstrable effect on bone density.
General features of Diaphragm
Indication:
•Individuals that do not wish to use any hormonal methods – individuals with preference for natural fertility. 71-88% effective with typical use.
MoA:
•Inserted into vagina prior to sex, must be left in vagina for 6hrs after sex then washed and re-inserted.
General Features of Natural Family Planning
Several methods are available, including calendar, temperature, observation of cervical mucus, and palpating the cervix. Devices (such as Persona®) and dipsticks can be purchased to help a woman keep track of her cycle and fertile times. The lactational amenorrhoea method (LAM) is also an effective natural family planning option for breast-feeding mothers. For LAM to be effective, a woman must be fully breast-feeding, have amenorrhoea and the baby must be less than 6 months old.
Benefits
- There are no side-effects.
- It complies with the religious practices of some patients.
Problems
- Considerable commitment from both partners is required.
- Unreliable with unpredictable cycles.
- Less effective than some other methods described above.
General features of migraine with aura
What is an Aura?
- A ‘change’ occurring 5-20 minutes before the onset of headache
- May be visual, typical scotoma (altered visual field)
- Altered sensation
- Changes in smell/taste
- Hemiparesis
- UKMEC 2 (Benefits Outweigh Risks). Consider other risks alongside – >35, smoker, obesity, FHx CHD etc.
What groups of individuals should COCP avoided in?
- Migraine with Aura
- Smokers (>15 per day)
- Age >35 years
- HT
- CVD or Congenital/Valvular heart disease with complications
- Previous DVT/VTE
- Previous stroke
- AF
- Active breast cancer
- Women with known thrombogenic mutations (eg, factor V Leiden deficiency, prothrombin mutation, proteins S, C and antithrombin deficiencies).
What group of contraceptives is used for its beneficial side-effect?
- LNG-IUS is recommended 1st Line in women with mennorhagia (and fibroids <3cm)
- POP generally causes ammenorhea so can be beneficial
- COCP can provide more regular periods so useful for dysmennorhea
- https://cks.nice.org.uk/topics/menorrhagia/management/management/
What are the types of failure associated with contraceptives?
Two types of contraceptive failure:
- User failure: when the contraceptive method was not being used properly.
- Method failure: pregnancy results even though the contraceptive method was used properly.
- User failure rates are much higher than method failure rates, especially in first year of use.
What is the ‘Fraser Criteria’?
Contraceptive advice or treatment can be provided to a competent young person aged under 16 years, without parental consent or knowledge, using the Fraser criteria. A health professional needs to be satisfied that:
- The young person could understand the advice and have sufficient maturity to understand what was involved in terms of the moral, social and emotional implications.
- They could neither persuade the young person to inform the parents, nor to allow the health professional to inform them, that contraceptive advice was being sought.
- The young person would be very likely to begin or to continue having sexual intercourse with or without contraceptive treatment.
- Without contraceptive advice or treatment, the young person’s physical or mental health or both would be likely to suffer.
- The young person’s best interests required the health professional to give contraceptive advice or treatment or both without parental consent.
Give examples of issues which may alter the efficacy of the COCP?
- Vomiting and Diarrhoea
- Herbal Medicines - St John’s Wart
- Concurrent medication — liver enzyme-inducing drugs (such as antiepileptics and anti-retrovirals) can affect some forms of contraception.
- If the woman is taking teratogenic drugs (for example lithium or warfarin), more effective methods of contraception should be used (such as a progestogen-only implant, or intrauterine contraception).
With respect to assessment of pregnancy before starting contraception, what should be done?
Health professionals can be ‘reasonably certain’ that a woman is not pregnant if there are no signs or symptoms of pregnancy and one or more of the following criteria are met. The woman:
- Has not had sexual intercourse since the last normal menses.
- Has used a reliable method of contraception correctly and consistently.
- Is within the first 7 days of the onset of a normal menstrual period.
- Is within 4 weeks postpartum for non-breastfeeding women.
- Is within the first 7 days post-termination of pregnancy, or miscarriage.
- Is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
- A pregnancy test is performed no sooner than 3 weeks since the last episode of unprotected sexual intercourse (UPSI) and is negative.
What general advice should be given if a woman has vomiting or diarrhoea when on COCP?
- If a woman vomits (for any reason) within 3 hours of taking a combined oral contraceptive (COC), advise her to take another pill as soon as possible.
If vomiting or diarrhoea persists for more than 24 hours, advise her:
- To follow the instructions for missed pills, counting each day of vomiting and/or diarrhoea as a missed pill.
- To avoid sexual intercourse or use a barrier method of contraception (such as condoms) during the illness interval and for 7 days afterwards.
- That if the illness occurs while taking the last 7 pills, she should omit any pill-free interval (or inactive tablets) and start the next cycle immediately.
What advice should be given regarding starting the COCP?
- Start the combined oral contraceptive (COC) on day 1 of the menstrual cycle. No additional contraception is required.
- If anytime out of If the COC is started at any other time in the menstrual cycle, provided a barrier method has been used consistently and correctly and/or it is reasonably certain that the woman is not pregnant:
Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for the first 7 days
What is the general advice for COCP for the special circumstances: Amenorrhoea, postpartum, termination or miscarriage
Amenorrhoea, postpartum, termination of pregnancy, or miscarriage
If the woman is amenorrhoeic: Start the combined oral contraceptive (COC) at any time, if it is reasonably certain that the woman is not pregnant.
- Additional contraception is required for 7 days
If the woman is postpartum and not breastfeeding: Start the COC on day 21 postpartum if no additional risk factors for venous thromboembolism exist.
- Additional contraception is required for 7 days.
- If it has been more than 21 days postpartum and menstrual cycles have returned, start the COC as for other women having menstrual cycles.
- If it has been more than 21 days postpartum and menstrual cycles have not returned, start the COC as for a woman who is amenorrhoeic.
If the woman is postpartum and breastfeeding:
- Do not start a COC if the woman is less than 6 weeks postpartum.
- After 6 weeks and before 6 months postpartum, start the COC as for postpartum women who are not breastfeeding.
- If the woman has had a miscarriage or termination of pregnancy:If gestation is less than 24 weeks, start the COC within 5 days of surgical or the first stage of medical termination, but ideally on day 1 or 2 (except Qlaira® and Zoely®). No additional contraception is required.
- If the COC is started at any other time, provided it is reasonably certain that the woman is not pregnant, advise the woman to use a barrier method of contraception (such as condoms) for 7 days (9 days for Qlaira®).
- If gestation is 24 weeks or more, start the COC as for a woman who is postpartum.
How should a girl under the age of 13 seeking contraception be managed?
- Report immediately to child protection services.
- Any child under the age of 13 which has had any form of sexual intercourse should be regarded as statutory rape.
What is the general assessment for contraception?
- ICE
- Preferences
- Co-Morbidities
- Contraindications - Migraine with Aura, Prev. DVT/VTE/PE. Hx stroke. CVD. Smoker or Age >35.
- Sexually Active
- Gynae & Sexual History - LMP, STIs
What is the general advice for women who have missed the COCP or POP?
- Generally COCP must be taken within 2 hrs
- POP must be taken within 3 hrs if ‘traditional’
- POP must be taken within 12 hrs if newer class (desogestrel)
- Otherwise should be treated as a missed pill
