Reproductive Medicine Flashcards
1
Q
What are the 2 main forms of contraception?
A
- LARC (Long-acting reversible contraception) - IUS/IUD
- Non-LARC (short-acting) - CHC, POP, Diaphragm, Emergency Contraceptive
2
Q
Give examples of the main types of contraceptive methods
A
- Hormonal
- Barrier
- Intrauterine
- Permanent
- ‘Fertility Awareness’
- Emergency
3
Q
Describe the MoA of the main types of Contraceptive (IUD/IUS, COCP, POP, DMPA, LAM, SDI)
A
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).
4
Q
Describe the MoA of the Combined Hormonal Contraceptives (CHCs)
A
- 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/
5
Q
Side effects of COCP
A
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.
6
Q
MoA of POP
A
- Thickens cervical mucus (previous ‘traditional’ POP i.e.)
- Delay ovum transport
- Inhibit ovulation (Primary)
- Providing an endometrium hostile to implantation.
7
Q
Side effects of POP
A
The adverse effects of progestogen-only contraceptives include:
- Menstrual irregularities.
- Breast tenderness.
- Ovarian cysts.
- A possible increased risk of breast cancer.
8
Q
MoA of Intrauterine System (IUS)
A
- 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.
9
Q
Side effects of Intrauterine System (IUS)
A
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.
10
Q
MoA of Intrauterine Device (IUD)
A
- Copper IUD: toxic effects of copper on the ovum and sperm, preventing fertilization.
- Decreases sperm motility and survival
11
Q
Side effects of Intrauterine Device (IUD)
A
Risks and adverse effects of IUCs include:
- Unscheduled bleeding.
- Perforation of the uterine wall at the time of insertion or later.
- Ectopic pregnancy.
12
Q
Describe the main types of Emergency Contraception and when they are indicated
A
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.
13
Q
Describe the main features of the Progesterone-Only Implant
A
- 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.
14
Q
What is the UKMEC Criteria
A
With respect to the contraceptive use:
- No restriction
- Advantages outweigh risks
- Risks outweigh advantages
- Unacceptible risk
15
Q
Describe the general features of Combined Hormonal Contraception (CHC)
A
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
16
Q
Describe the general features of Progesterone-Only Contraceptives
A
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)
17
Q
Describe the general features of sterilisation
A
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)
18
Q
What are the main risk associated with CHC?
A
- 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.
19
Q
What are the protective factors of CHCs?
A
- 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
20
Q
What are some of the benefits of CHCs?
A
- 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.
21
Q
MoA of Progesterone-only injectable contraceptives
A
- 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.
22
Q
Benefits of Progesterone-only Injectable Contraceptives
A
- 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.
23
Q
Side-effects of Progesterone-Only Injectables
A
- 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.
24
Q
Benefits of IUS
A
- 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.
25
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.
26
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.
27
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.
28
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).
29
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/](https://cks.nice.org.uk/topics/menorrhagia/management/management/)
30
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.
31
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.
[https://patient.info/doctor/contraception-and-young-people](https://patient.info/doctor/contraception-and-young-people)
32
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).
33
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.**
34
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.**
[https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)
35
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
* [https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)
36
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.
[https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)
37
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.
38
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
[https://cks.nice.org.uk/topics/contraception-assessment/](https://cks.nice.org.uk/topics/contraception-assessment/)
[https://patient.info/doctor/contraception-general-overview](https://patient.info/doctor/contraception-general-overview)
39
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
