Sexual health 2 - emergency contraception, menopause and erectile dysfunction Flashcards
What is emergency contraception
EC is an intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse (UPSI) or contraceptive failure
EC should be considered if a woman does not wish to conceive & has UPSI (unprotected sexual intercourse) or contraceptive failure
3 types of emergency contraceptive available
Prescription Only Medicine (POM)
Copper (intra-uterine device) IUD
Non-hormonal emergency contraceptive
IUDs can be used as a regular contraceptive method
Pharmacy (P) medicine
Levonorgestrel 1500mcg tablet (Levonelle)
Ulipristal Acetate 30mg tablet (EllaOne)
Emergency Hormonal contraceptives (EHC)
Neither of these should be relied upon for regular contraception (not designed/licensed for that purpose)
Copper IUD - Indication for use
and administration
Women of child-bearing age
Can be fitted for up to 120 hours (5 days) after unprotected sexual intercourse/failure of a contraceptive method, or up to five days after the earliest time of ovulation
Administration
Inserted into the uterus
Can be left in as the regular contraceptive method
How effective is Copper IUD and why it may not be an option
Effectiveness
Most effective form of EC
Examples of reasons why copper IUD may not be an option
Contraindication
Patient choice
Convenience
Day of the week/time of day pt attends pharmacy (may mean there is no time to get it fitted in the time frame)
Lack of access to appropriate expertise locally within required timeframe
Emergency Hormonal Contraceptive- as pharmacy medicines
Levonoregestrel - 72 hours of unprotected sex
1500mcg (1.5mg) tablet
Brand – Levonelle
Ulipristal Acetate - within 5 days
30mg tablet
Brand – EllaOne
Which questions should be asked when a request for EHC is made?
Age (there are age restrictions)
When was the last time patient had unprotected sex/failure of a contraceptive method?
Is there a chance the patient could be pregnant
Is the patient breast feeding
Is the patient taking any medication
Does the patient suffer from any medical conditions
When was her last period
Does she have a regular cycle (ascertain what is regular for that patient)
Has the patient used oral EHC before, and if they were fine with it, i.e. no allergy to active ingredient or excipients
Has the patient taken oral Ulipristal already in their current menstrual cycle
Has the patient ever been advised against taking an oral EHC by their doctor or another healthcare professional
Referral for emergency contraception
Suitable pts who would like a copper IUD
Patients with clinical conditions where use of oral EHC is not recommended, or oral EHC has reduced efficacy
Patients taking medicines which interact
Pregnancy/suspected pregnancy – patient should be referred to a doctor or family planning clinic (reassure patient that neither oral EHCs interrupt existing pregnancies)
Patients with a previous allergy to active ingredients contained in EHCs or excipients
If unprotected sex or failure of contraceptive occurred beyond the time limit for each respective EHC
If severe lower abdominal pain is experienced after taking oral EHC – could indicate ectopic pregnancy
Patient falls outside of the time frame for EHC
Patients in whom EHC is not suitable, but other emergency contraception may be
Menopause - what is it
Menopause is when menstruation stops permanently, and no more follicles (eggs) are produced (loss of follicular activity)
Clinically confirmed 12 months after the last period (amenorrhoea)
In the UK, the mean age of menopause is 51 years (usually occurring between the ages of 45 and 55)
The closer a woman is to menopause, the less oestrogen is produced by the ovaries
Stages of menopause
Early menopause
Cessation of ovarian function between 40 and 45 years, where other causes of amenorrhea have been ruled out
Premature menopause
Also referred to as ‘premature ovarian insufficiency’ (POI) or ‘premature ovarian failure’
Defined as the transient or permanent loss of ovarian function before the age of 40 years
Symptoms of menopause
A diagnosis of perimenopause or menopause should be suspected if there:
Is a change to the menstrual pattern
Are symptoms including hot flushes/night sweats (vasomotor symptoms), mood changes,
urogenital symptoms, altered sexual function, sleep disorders, and fatigue
Hormone replacement therapy (HRT) - what does it replace
HRT replaces oestrogen no longer being produced by the ovaries
Women with early menopause should be offered HRT
HRT is normally usually continued until the woman is at least 51 years old.
HRT options
For vasomotor symptoms
Women with uterus - Oral or transdermal combined (oestradiol plus progestogen) preparation
Women without a uterus- Transdermal oestrogen only preparation
Eligible women under 50 - Choice of HRT or combined hormonal contraceptive, if there no contraindications
For mood disorders
Choice of oral or transdermal HRT preparations
For altered sexual function
Specialist advice required on the appropriateness of testosterone preparations (unlicensed indication)
For urogenital symptoms
HRT
Low dose vaginal oestrogen first-line & continue tx for as long as needed to relieve symptoms
REVIEW AFTER 3 MONTHS
Benefits of HRT
Fragility fractures
Risk decreases while on HRT
Benefit is maintained during tx, but decreases once tx stops
Benefit may continue in women who take HRT for longer
Risks of HRT
Venous thromboembolism (VTE)
Greater for oral than transdermal HRT preparations
Coronary heart disease (CHD) & stroke
Varies between women and is dependent upon presence of individual cardiovascular risk factors
Oral oestrogen (but not transdermal) is associated with a small increase on the risk of stroke
Breast cancer
Varies between women
Combined HRT with oestrogen & progestogen is associated with an increased risk, which is dependent upon duration of tx, which reduces after stopping HRT
Management when HRT unsuitable
Women can be offered:
Antidepressants, clonidine, gabapentin, and/or cognitive behavioural therapy (CBT) for vasomotor symptoms
Self-help resources and CBT for mood disorders
Vaginal moisturisers and/or lubricants for urogenital symptoms
Regular reviews to assess efficacy and tolerability of treatment(s)
A woman is potentially fertile for
2 years after her last period if she is younger than 50 years of age, and 1 year if she is over 50
OTC HRT - what can we give and what is the indication - who can use it
Estradiol is licensed as a pharmacy (P) medicine as Gina 10 microgram vaginal tablets
Indication
Tx of vaginal atrophy symptoms (dryness, soreness, itching, burning, irritation and painful sexual intercourse) due to oestrogen deficiency
Can only be used in postmenopausal women aged over 50 years – with or without a uterus, who have not had a period in the last one year
What is erectile dysfunction? (ED)
Inability to attain and/or maintain an erection hard enough for satisfactory sexual intercourse
It can occur occasionally or frequently
Men are able to self-recognise the condition
Can vary in severity from (a soft erection) to severe (no erection at all)
What are the causes of erectile dysfunction
Causes of ED
Physical
ED usually has an underlying physical cause
Patients with co-morbidities may be pre-disposed (hypertension, diabetes, hypercholesterolaemia, CVD and lower UTIs)
Psychological
Purely psychological causes only account 10% of cases
Causes can include performance anxiety, depression, lack of arousal and/or inhibition between partners, premature ejaculation, stress, low self-esteem, indifference
Medication induced
see BNF
Recreational drugs, including alcohol
What are the P medicines that can be used for erectile dysfunction
Sildenafil 50 mg (VIAGRA CONNECT) &
Tadalafil 10 mg (CIALIS)
What is the mode of action of sildenafil and tadalafil
On sexual stimulation, brain impulses reach the cavernous nerve which releases nitric oxide (NO) at nerve endings in penis
NO diffuses across endothelial cells into smooth muscle & stimulates the enzyme, guanylate cyclase. To convert GTP into cyclic GMP (cGMP).
cGMP starts a further cascade resulting in smooth muscle relaxation, cavernous bodies fill with blood and become rigid
cGMP is normally broken down by PDE5 to GMP, terminating the pathway
Sildenafil/tadalafil inhibits this action, thus increasing cGMP levels & maintaining levels for longer
