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Finals > Reproductive Medicine > Flashcards

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
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2
Q

Give examples of the main types of contraceptive methods

A
  • Hormonal
  • Barrier
  • Intrauterine
  • Permanent
  • ‘Fertility Awareness’
  • Emergency
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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).

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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/
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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.

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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.
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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.
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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.
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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.
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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
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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.
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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.

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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.
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14
Q

What is the UKMEC Criteria

A

With respect to the contraceptive use:

  1. No restriction
  2. Advantages outweigh risks
  3. Risks outweigh advantages
  4. Unacceptible risk
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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
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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
Q

General features of Diaphragm

A

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
Q

General Features of Natural Family Planning

A

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
Q

General features of migraine with aura

A

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
Q

What groups of individuals should COCP avoided in?

A
  • 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
Q

What group of contraceptives is used for its beneficial side-effect?

A
30
Q

What are the types of failure associated with contraceptives?

A

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
Q

What is the ‘Fraser Criteria’?

A

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

32
Q

Give examples of issues which may alter the efficacy of the COCP?

A
  • 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
Q

With respect to assessment of pregnancy before starting contraception, what should be done?

A

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
Q

What general advice should be given if a woman has vomiting or diarrhoea when on COCP?

A
  • 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/

35
Q

What advice should be given regarding starting the COCP?

A
  • 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

36
Q

What is the general advice for COCP for the special circumstances: Amenorrhoea, postpartum, termination or miscarriage

A

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/

37
Q

How should a girl under the age of 13 seeking contraception be managed?

A
  • 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
Q

What is the general assessment for contraception?

A
  • 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://patient.info/doctor/contraception-general-overview

39
Q

What is the general advice for women who have missed the COCP or POP?

A
  • 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

Finals (21 decks)

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