TBL contraception Flashcards
What are the different types of progesterone that can be used in the contraceptive pill?
They are either 2nd generation progesterone which includes:
Levonorgesterol
Norethisterone
Norgestimate
3rd generation progesterones:
Desogesterol
Gestodene
4th generation progesterone:
Drospirenone
What is an appropriate dose of oestrogen to be found in combined contraceptive pills?
Either low dose 20mcg or standard dose 30-35mcg, no higher is given due to risk of thromboembolism
What is an example of a monophasic, biphasic or triphasic combined oral contraceptive?
Monophasic: Microgyon
Biphasic: Azurette
Triphasic: Trivora
Explain the principle of a monophasic combined pill?
It contains the same amount of oestrogen and progesterone in every single pill in the cycle and is prepared in 21 day or 28 day formulations.
Explain the principle of a biphasic combined pill?
They use a lower ratio of oestrogen: progesterone in the first half of the cycle and then a higher ratio in the second to mimic the natural levels during the menstrual cycle.
Explain the principle of a triphasic combined pill?
The combination of hormones changes approximately every week during the pill cycle, providing three phases.
Why would you chose biphasic or triphasic over a monophasic preparation?
Patients medical history
Personal preference
Previous contraceptive experience
Age related considerations
What are some of the advantages of the combined oral contraceptive pill?
Reduces menstrual pain and bleeding
Reduces risk of ovarian, endometrial and colorectal cancer
Predictable bleeding pattern
Maintains mineral bone density of pre-menopausal women under 50
Protects against pelvic inflammatory disease
What are some of the disadvantages of using the combined contraceptive pill?
No protection against STIs
Increased risk of breast cancer
Increased risk of ovarian cancer
Causes fluid retention so can lead to an increase in weight
Acne
Risk of venous thromboembolism
Breast tenderness
Mood swings
Increased risk of stroke
Breakthrough bleeding
What are the other four risk factors for developing deep vein thrombosis that are contra-indicated in use for combined oral contracpetives?
Family history (first degree relative who developed one under 55)
Surgery
Long haul flight
Obesity
When is combined oral contraceptives contra-indicated?
2 or more risk factors of DVT
Active liver disease
Breast feeding
Major surgery
Current or past history of VTE, stroke or ischaemic heart disease
How long in advance should you stop COC before surgery and restart after surgery?
4 weeks in advance due to risk of DVT and continue at first menses at least 2 weeks after full mobilization is regained.
Which surgery should you stop COC?
Any surgery to the legs or surgery that is going to cause immobilisation
If surgery is an emergency, what is the appropriate steps to implement to avoid DVT?
Compression hosiery and prescribe thrombo-prophylaxis (heparin)
What are some of the risk factors of DVT?
FH of VTE/arterial disease in first degree relative <45yrs
▪ Obesity – BMI > 30 (avoid if BMI >35)
▪ Long term immobilisation
▪ >35 yrs (avoid if >50 yrs)
▪ Smoking
▪ DM (avoid if diabetes complications)
▪ HT - >140/90 (avoid if >160/95)
▪ Migraine without aura (avoid if migraine with aura)
What are some of the benefits of the progesterone only pill?
Reliable and reversible
Does not have the oestrogen associated risks
Can use whilst breast feeding
Can be used in patients where the combined pill is contraindicated
Which patients are suitable for the progesterone only pill that can’t take the combined pill?
Heavy smokers (over 15 a day)
Over 35
Hypertension
Diabetes
Migraine
Major surgery
What are some of the disadvantages of the progesterone only pill?
Must be taken at the same time each day (three hours later than the normal dose means you are not protected).
Increases risk of ovarian cysts
Increases risk of breast cancer
Can cause menstrual irregularities
No STI protection
Do you have to alter progesterone only contraception before surgery?
No it does not need to be changed as it does not cause an increased risk of DVT.
What should you do if a women misses one or pill or starts the pack one day late on both the combined pill or the progesterone only pill?
Combined pill: Missing one pill
Take the pill immediately even if it means taking two pills in one day.
Carry on as normal
You are still protected
Combined pill: Starting the pack a day late
Same advice as above, on starting the medication if you take your first pill more than five days after the start of your period you are not protected and need to use additional methods of contraception for 7 days.
Progesterone only: Missing one pill
If you are less than 3 hours late for a traditional POP Noriday, Micronor, Norgeston
If you are less than 12 hours later for a desorgesterol containing pill such as Cerelle or Cerazette
You are protected and just take the pill immediately even if it means taking two in one day and then carry on as normal
More than 3 or 12 hours, same advice as above but you are not protected and need to use extra protection for two days.
What should you do for the combined contraceptive pill if you miss more than 2 pills?
If you are in Week 1 of your pill cycle (pills 1-7)
Probably unprotected.
Take the last missed pill immediately and leaving the missed pills before and carry on as normal.
Will need to use additional contraception for the next 7 days.
Will need emergency contraception if you have unprotected sex in the 7 days after missing.
Still have pill break
Week 2: (pills 8-14 days)
Take the last missed pill immediately and leaving the missed pills before and carry on as normal.
Will need to use additional contraception for the next 7 days.
Do not need emergency contraception
Still have a pill break
Week 3: (pills 15-21 days)
Take the last missed pill immediately and leaving the missed pills before and carry on as normal.
Will need to use additional contraception for the next 7 days.
Do not need emergency contraception
If your pack usually has 21 pills in it, take the rest of the pills in your pack as normal and start a new pack the next day.
If your pack usually has 28 pills in it, take the rest of the active pills (the first 21 pills in the pack) as usual. When you have taken the last of the active pills, start a new pack the next day.
Do not have a pill break
What should you do if you are sick or have diarrhea with the contraceptive pill?
If you are sick or have diarrhea within 3 hours for the combined contraceptive pill or 2 hours for the progesterone only, you need to:
Take another pill
Carry on afterwards as normal taking your next pill at the normal time the following day
Do not need to use extra contraception for the following days or emergency contraception as long as your are not sick again.
If sickness carries on for more than 24 hours, count each sick day as a missed pill.
Which broad spectrum antibiotics interact with combined oral contraceptive?
Penicillin and tetracyclines
No longer need to use additional contraceptive methods whilst taking a course of antibiotics however GI disturbances of associated with the antibiotics may cause sickness/ diarrhea and therefore treat as appropriate.
Why can’t you take anti-epileptics with combined oral contraceptive?
They reduce the levels of progesterone and oestrogen
What are the options if you take anti-epileptic drugs?
Switch type of contraception to either the IUD or progesterone injection
Short term:
3packets of 30mcg monophasic
combined without a break followed by a short tablet-free 4 days plus CONDOMS
Short and long term:
‘Double dose’ (unlicensed) – take two pills daily to give at least
50mcg under ‘continuous’ or ‘tricycling’ regimen
Continue 28 days after stopping anti-epileptics
Which other drugs are enzyme inducers of the combined oral contraceptive pill?
Rifampicin and Rifabutin
St John’s Wort
Anti-retrovirals
Lamotrigne
What is the interaction with Lamotrigne?
Loss of seizure control and risk of toxicity in pill free period
Which type of drugs affect progesterone only pills?
Broad spectrum antibiotics do not impact the drug however enzyme inducers decrease the effectiveness and therefore you have to use additional methods of contraception until 28 days after.
What is the method of action of desogesterel?
Inhibits ovulation
What are the directions of application for a combined patch?
Apply a patch weekly for 3 weeks and then a 7-day patch free period. Should be placed on a dry, clean, hairless area such as the bum, upper torso (not breasts), arm or abdomen.
What is the formulation of the combined patch?
600mcg Ethinylestradiol + 6mg Norelgestromin
* Patch releasing:
▪ 20mcg/24hrs ethinylestradiol
▪ 150mcg/24hrs norelgestromin
What is the name of the combined patch?
Evra
What are some of the advantages of using a combined patch?
Do not have to worry about taking it everyday
Does not interfere with sex
Very easy to apply and only needs to be changed every week
Very effective
What are some of the disadvantages of using the combined patch?
Can cause local skin reactions
Does not protect against STIs
Visible
May not stick
Same risks and side effects as the combined pill
Not appropriate for women over 90kg
Withdrawal bleeding normally starts a day later than the combined pill and can carry over into the next cycle.
What should you do if the patch comes off up to 24 hours in the first week?
In the first week it is recommended to start a new cycle of patches and use additional methods of contraception for up to 7 days and emergency contraception if required.
How does advice change if you have the patch off for up to 48 hours in the second or third week?
You do not need any additional precautions or emergency contraception like the first week, you should start a new patch immediately and change the day of swap over for the next cycle of patches.
What happens if the patch is removed for over 48 hours for the second or third week?
Start a new 4 week patch cycle immediately and therefore will need additional contraception for the next 7 days and emergency contraception if required.
What happens if it is over 48 hours for the second or third week?
Start a new 4 week patch cycle immediately and therefore will need additional contraception for the next 7 days and emergency contraception if required.
Why is the ethinylestradiol dose for a transdermal patch higher than for a pill?
To compensate for the lower bioavailability in the trans-dermal route.
When is the steady state concentration reached for Evra patches?
Two weeks after the first application
What are the steady state concentrations of the two components of the combined patch?
0.305 – 1.53ng/ml for norelgestromin and 11.2 – 137 pg/ml for ethinylestradiol
What are the two components of the combined vaginal ring?
Etonogesterol and ethinylestradiol
What is the release rate of the etonogesterol?
15mcg/24 hours
What is the release rate of ethinylestradiol in the combined contraceptive pill?
120mcg/24 hours
What are the directions for the vaginal ring?
Insert one for three weeks and then remove for one week.
Before dispensing it should be stored within the fridge but is then okay to be stored for 4 months at room temperature.
What are the five advantages of using the vaginal ring?
Very effective
Only have to insert once a month
Immediate contraception if inserted on first day of menstrual bleed
Does not interfere with sex
Absorption not affected by D&V
What are the five disadvantages of using the vaginal ring?
Same risks as the implant or combined oral contraceptives
Can cause local reactions (vaginal dryness and irritation)
Risk of expulsion
No protection against STIs
Same drug interactions as the combined pill (possibly less as it passes first pass metabolism in the liver)
When should you discard a vaginal ring that has been expulsed?
If the patient is within a third week of their cycle and the vaginal ring has been expulsed longer than 3 hours, if this occurs within week 1 and 2 then it does not have to be discarded.
What are the two options you have if your vaginal ring has been expulsed more than 3 hours in week 3?
Discard and then either start a new ring beginning a new three week cycle or have a 7 days break and use additional contraception and then start again.
What should you do if expulsion of the vaginal ring occurs in weeks 1 or 2?
Wash and reinsert and then use additional contraception for the next 7 days.
What happens if expulsion is just under 3 hours?
Wash and reinsert and no further action is required.
What polymer is used in the extended release version of the vaginal ring?
Ethylene vinyl Acetate copolymers and is known as Evatane
What are the two components of a Nuvaring?
11.7 mg etonogestrel and 2.7 mg ethinyl
estradiol
Briefly describe how Nuvaring mechanism works?
Low concentrations of hormones are released continously and are rapidly absorbed into the vaginal mucosa throughout the three week cycle.
Why does the vaginal ring have less side effects than some of the other types of hormonal contraception?
Its route of administration avoids first pass metabolism and therefore has an increased bioavailability so can be used at lower concentrations to achieve an optimum plasma concentration, because of this there are then less side effects.
What is the hormone of Depo-provera?
Medroxyprogesterone acetate
How often is the Depo-provera injection administered?
150mg intramuscular injection every 12 weeks, used for both short and long-term contraception.
Aside from Depo-provera, what is the other type of progesterone only injection and when is it used?
Norethisterone enantate (Noristat)
This type of injection is only licensed for short-term use (maximum two injections, 200mg every 8 weeks)
What are some of the advantages of the injection? (4)
Effective and reversible
Does not interrupt sex
Convenient
Suitable for use before major surgery, surgery to legs or surgery which involves
long periods of immobilisation
What are some of the disadvantages of the injection?
Delay to return to fertility after use
Increases the risk of breast cancer
Decreases mineral bone density (risk of osteoporosis)
Must be done by a healthcare professional
Menstrual irregularities
Doesn’t protect against STIs
Same risks and complications associated with progesterone only pills
What should you do with a delayed injection?
For the depo-provera injection if the interval greater than 12 weeks and 5 days,
exclude pregnancy before next injection and additional precautions for 14 days
after injection.
Do broad spectrum antibiotics and an enzyme inducers interact with the progesterone only injection?
No there is no effect on its activity
What is the formulation of the depo-provera injection?
1mL intramuscular injection of 150mg/mL
What is the component of the contraceptive implant and what is its strength?
68mg Etonogestrol
How quickly after implantation does the implant protect?
Immediately after and is effective for three years
What are some of the advantages of the contraceptive implant?
Immediate protection
Does not interrupt sex
Very effective and rapidly reversible
Do not have to worry for three years
Can be used when breast feeding
Suitable for use before major surgery, surgery to legs or surgery which involves
long periods of immobilisation
What are some of the disadvantages of the implant?
Menstrual irregularities
Weight gain
Bruising at the site of administration
Must be done by a healthcare professional
Acne, breast pain, headache
Decrease in bone mineral density
No STI protection
Same risk factors as the progesterone only pill
Are there any drug interactions associated with the progesterone only implant?
Only enzyme inducers which reduce the effectiveness of the implant and alternatives should be used or use additional methods of contraception such as condoms for 28 days after
Describe the components of the contraceptive implant.
The core of the polymer is formulated with ethylene vinyl acetate, 68 mg of the
synthetic progestin etonogestrel, barium sulfate (radiopaque), magnesium
stearate, surrounded by an EVA copolymer skin.
What is the initial release rate of the contraceptive implant?
60-70 micrograms per day (Week 5/6)
How does the rate of release of the implant change from end of year 1 to 3?
35-45 micrograms per day and reduced to 25-30 micrograms a day.
What are some of the advantages of the intrauterine system?
Does not interrupt sex
Remains there for 5 years so does not have to be thought about daily
Periods become lighter and less painful
Convenient
Reversible
Effective as soon as inserted if put in during the first seven days of the cycle
Is the intrauterine system hormonal?
Yes it contains 52 mg levonorgestrel
How does the intrauterine system work?
Slow release of levonorgesterel which thickens the cervical mucus and sometimes stops ovulation
Describe some of the disadvantages of the intrauterine system.
Does not protect against STIs
Pain on insertion
Not suitable for everyone as it depends on the shape of the cervix
Expulsion
Can causes irregular periods
Acne, breast tenderness, mood irritability
Perforation
What does female sterilization involve and describe its method of contraception?
Cutting or sealing the fallopian tubes so whilst ovulation still occurs, the sperm cannot reach the eggs
What is the benefit of female sterilisation?
Does not interrupt sex
Once the process is complete, do not have to think about contraception again
What are some of the disadvantages of the female sterilisation process?
Cannot be reversed easily or at all
Does not protect against STIs
If it fails and pregnancy occurs then there is a risk of etopic pregnancy
Long NHS waiting list
Requires anaesthetic
What is a vasectomy?
A vasectomy is the male sterilisation process where the male vasa deferentia is cut as to prevent sperm from entering the female utereus under anaesthetic
What are the benefits of a vasectomy?
Quick and simple operation
Do not need to think about contraception again once it has worked
Does not interrupt sex
What are some of the disadvantages of a vasectomy?
No protection against STIs
May need to use additional contraception for up until 8 weeks until the semen test is negative
Reversal is difficult
Long NHS waiting lists
What are some of the key similarities and differences between the intrauterine system and device?
The intrauterine system is hormonal (52mg of Levonorgesterol) whereas the device is non-hormonal (contains copper) which works on being toxic to eggs and sperm.
They have a similar structure but work in different ways.
The system works by hormonal release causing thickening of the cervical mucus and stops ovulation whereas the device is very much a physical barrier and prevents implantation.
System stays in for 5 years whereas the device can stay in from 3-10 years
What are some of the specific disadvantages of the intrauterine device?
Cause period pain (Dysmenorrhoea)
Heavy menstrual bleeding (Menorrhagia)
Also can perforate or be expulsed
No STI protection
What are some of the directions for the diaphragm?
The flexible silicon diaphragm is coated with spermicide agent and should be placed into the vagina prior to sex alongside spermicide cream.
After sex it should be left in for at least 6 hours to maximize efficiency
Describe the difference in structure between the diaphragm and the cap?
The diaphragm is dome shaped whereas the cap is shaped like the top of a baby bottles but both have the same mechanism of action.
What are some of the unique advantages of the diaphragm and cap?
May protect against some STIs and reduce risk of cervical cancer
No major side effects
Maintains hormonal cycle
Can be used during periods
Put in any time before sex
What are some of the disadvantages of the diaphragm?
Have to interrupt to put spermicide in and you have to reapply if sex is three hours or more after the initial insertion
Holes decrease efficiency
Need proper insertion technique
Need good pelvic floor muscles
Which infection are you more prone to with the diaphragm?
Cystitis
Where can you get diaphragms from?
Doctors or sexual health clinics
What additional monitoring is required for diaphragms?
Need to be checked for the correct size and then monitored every 12 hours for changes in weight, if you have miscarried, had a baby or abortion.
When you know the size you can buy from pharmacies.
What are condoms made of?
Latex or polyurethane
What are some of the advantages of condoms?
Protection from STIs
Reversible
No side effects
Free from FPCs/ GUM clinics
Readily available
What are some of the disadvantages of condoms?
Lack of sensitivity
Latex allergy
Can’t use oil based lubrication as it destroys the latex
Interrupts sex
May slide off or tear
What are the additional advantages of the female condom?
Can be put in any time before sex, so doesn’t interrupt as much
Can use oil based lubricants with them
What are female condoms made of?
Soft polyurethane sheath
What are some of the disadvantages of the female condom?
Quite expensive
Still interrupts sex
Not widely accepted
Correct positioning is required
Describe natural family planning?
Using indicators of the menstrual cycle to predict when you are fertile and when you are not.
Body temperature, cervical mucus and assessment of the menstrual cycle as a whole indicates when you need to use extra protection.
Who is not suitable for natural family planning?
Those with irregular cycles (need to have regular 21, 28 or 35 day cycles). Even those with regular cycles it can take up to 3 to 6 cycles to learn effectively.
How long is the fertile window?
Whilst an egg is only there for 24 hours, sperm can live inside the body and fertilize an egg for up to 7 days therefore it is said to be between 8-9 days as a second egg can be released 24 hours after the first.
What are the advantages of the natural family planning?
No side effects
Nice transition when planning a pregnancy
Acceptable to all faiths and cultures
What are the disadvantages of the natural family planning?
Needs to be recorded
Need extra contraception during the fertile period
Affected by other factors such as stress, illness, lifestyle
No STI protection
By what mechanism does the implant and injection work?
Inhibits ovulation
Thickens cervical mucus
Reduces endometrium receptiveness
How does the oral progesterone only contraceptive pills work (how the vaginal ring also works) ?
Delays ovum transport
Thickens cervical mucus
Reduces endometrium receptiveness
Inhibits ovulation (up to 60%, not the main mechanism of action)
When are the peak serum levels are reached of the progesterone only contraceptive pill?
1.8 hours after administration
What is the bioavailability of the progesterone only contraceptive pill?
70%
What is the mechanism of action of the combined oral contraceptive pill?
Inhibition of ovulation - suppress release of FSH and LH
Thicken cervical mucus
Reduces endometrial receptiveness
Are natural or synthetic oestrogens used in birth control?
Synthetic as they are x200 times more potent than natural oestrogens
Where are gonado-trophins secreted from?
Hypothylamus
What effect does gonado-trophins have on the anterior pituitary in males and females?
Stimulates secretion of LH and FSH
Where do the LH and FSH travel to?
Via capillaries either to the testes in men or the ovaries in women
What does LH target in men?
The leyoig cells causes them to secrete testosterone
What are some of the downstream effects of testosterone?
Stimulates serotoli cells
Maintains libido
Stimulates bone and muscle growth
Maintains secondary characteristics
Maintains reproductive glands, organs
If testosterone levels are too high what happens?
Negative feedback loop acting on the anterior pituitary to reduce production of LH
Describe the downstream pathway of FSH production in men?
Targets serotoli cells stimulating androgen-binding protein. These synthesize spermatogonium which ends up in the seminiferous tubules.
When androgen binding protein is bound to testosterone it promotes spermatogenesis and spermiogenesis.
What else does serotoli cells produce?
Inhibin which then acts as a negative feedback loop, decreasing production of FSH in the anterior pituitary.
How many follicles mature and ovulate each month?
Only a handful of follicles mature and then a spike in LH concentration induces ovulation of the most mature follicle (can be two in some women)
Describe the hormone levels at Day 1 to 10 of the menstrual cycle.
Initially a steady increase in GNRH so a spike in FSH but then it decreases and LH maintains a lower steady level.
What is levels of FSH indirectly proportional to?
Oestrogen (when oestrogen levels are high, FSH levels are low and vice versa).
When is oestrogen produced in the menstrual cycle?
FSH acts on the ovaries and stimulates maturation into secondary follicles, these follicles produce oestrogen.
How is LH maintained at a steady level?
Despite high concentrations of GnRH, oestrogen, even at low levels, inhibits LH from the anterior pituitary and therefore causes a steady level.
Describe some of the functions of oestrogen.
Bone and muscle growth
Endometrial growth
Maintains female characteristics (breasts)
Induction of progesterone cycle
Protects HDL-cholestrol
Prevents heart disease
Increases coagulation and fibronlytic pathway
How do levels of oestrogen change after 10 days?
Continues to rise as more follicles mature, causing a decrease in FSH
What is the unique relationship between oestrogen and LH?
At low concentrations of oestrogen it stimulates a negative feedback loop with LH (decreases concentrations of LH) but at high concentrations of oestrogen it stimulates a positive feedback loop (increases concentration of LH). Therefore when oestrogen levels are high just after 10 days this causes a spike in LH levels triggering ovaluation.
When do LH levels drop?
Once the most mature follicle has ovaulated
When is the follicular phase?
14 days (after ovaluation)
Which three hormones does the corpus luteum secrete?
Oestrogen
Inhibin
Progesterone
Which hormones are detectable at 21 days of the menstrual cycle?
Oestrogen
Increase in inhibin and progesterone
What does inhibin suppress as the secondary luteum develops?
FSH secretion
What does progesterone suppress as the secondary luteum develops?
Negative feedback cycle on the hypothylamus inhibiting secretion of GnRH.
Which hormones affect endometrial growth?
Progesterone inhibits and oestrogen stimulates
When does oestrogen levels drop?
Around 21 days, as progesterone levels increases
Describe what happens when the corpus luteum disintergrates?
Inhibin, progesterone and oestrogen decreases
The decrease in progesterone means that GnRH is no longer suppressed and the concentration increases triggering the start of a new menstrual cycle.
Endometrium sheds causing a period
What are some of the functions of progesterone?
Thickens the cervical mucus
Drops at the end of the menstruation cycle
Suppresses menstruation and uterine contractility during pregnancy
At ovaluation it causes the body temperature to rise by 1 degree
Increases basal insulin
Describe the functions of prolactin?
Stimulates milk secretion
Reduces GnRH (blocking the effects of LH on the ovaries)
What produces prolactin?
Hypothylamus
What is prolactin inhibited by?
Dopamine
What are some of the effects of Hyperprolactinaemia?
Results in galactorrhoea (milky nipple discharge)
Menstrual abnormalities
Subfertility
Impotence
Reduces libido
What is the cause of Hyperprolactinaemia?
Tumour, drugs
What are some of the treatments for Hyperprolactinaemia?
Dopamine agonists (as they inhibit prolactin)
What are some of the causes of male hypogonadism?
Hypopituitism
Gonadotrophin deficiency
Drugs
Hyperprolactinaemia
Primary gonadal disease
What is primary gonadal disease caused by?
Chemotherapy, radiation
Renal kidney failure
Congenital
Structural
Alcohol/ cirrosis
If fertility is not required, what is the treatment for male hypogonadism?
Testosterone and esters (which can come in gels, capsules and injections)
When fertility is required, what is the treatment for male hypogonadism?
Gonadotrophins
* Menotrophin - FSH + LH
* Lutropin - LH
* Follitropin – FSH
* Human Chorionic gonadotrophin
or gonado-releasing hormone
What are some co-exisiting conditions alongside male hypogonadism?
Metabolic syndrome
COPD
What are some of the causes of female hypogonadism?
Hypopituitism
Polycystic ovary syndrome
Drugs
Gonadotropin deficiency
Hyperprolactinaemia
Ovarian failure
Fallopian tube defects
Androgen excess
What are some of the symptoms of female hypogonadism?
Subfertility
Breast reduction
Loss of sexual hair
Poor libido
Dry vagina
Dyspareunia
Amenorrhoea
What the two drugs types used to treat erectile dysfunction?
Phosphodiesterase type-5 inhibitors
Alprostadil
What drugs are used to treat female hypogonadism?
The same as those used to treat infertility:
Gonadotrophins
Clomifene
Pulsatile GnRH (Gonadorelin)
What is polycystic ovary syndrome?
Caused by small ovarian cysts where there is excess androgen production
What are some of the symptoms of PCOS?
Irregular periods or no periods at all
Subfertility due to lack of ovaluation
Acne
Obesity
Hirsuitism (excessive hair growth)
Thinning of hair or hair loss from the head
High levels of insulin
What health risks are associated with PCOS in later life?
Type 2 diabetes and hyperlipidemia
What are some of the treatment for PCOS?
Mainly for relief of the symptoms caused by PCOS.
Hituitism:
COC’s
Cyproterone acetate - 50-100mg daily
Co-cyprindiol 2000/35
Menstrual disturbance:
COC’s
Metformin (unlicensed)
Infertility:
Clomifene
What are some of the symptoms of endometriosis?
Chronic pelvic pain
Dysmenorrhoea
Dyspareunia,
Menorrhagia
Back-pain
G. I symptoms
Urinary symptoms
Fatigue
Depression
Infertility
What is endometrosis?
Endometriosis is a condition where tissue similar to the lining of the womb grows in other places, such as the ovaries and fallopian tubes.
What treatments are available for endometrosis?
Pain relief - NSAIDS
And when treatment depends on age, severity and parity (whether they want children or not):
Progesterones
COCs
Gonadorelin analogues
Danazol
Surgery
When is surgery the first line treatment for endometrosis?
If fertility matters
What are some of the treatments if fertility is not required?
Chemotherapies
Anabolic steroids
Which drugs can induce infertility?
- Chlorambucil
- Cyclophosphamide
- Methotrexate
- Vincristine
- Anabolic steroids
- Sulphasalazine
Which drugs can induce Hyperprolactinaemia?
- Methyldopa
- Metoclopramide
- Cimetidine
- Phenothiazines (eg chlorpromazine)
Which drugs can induce Amenorrhoea?
- High dose corticosteroids
- Danazol
- Isoniazid
- Spironolactone
Which drugs can induce erectile dysfunction?
- Anti-androgens
- Anticholinergics
- Antidepressants
- Beta-blockers
- Metoclopramide
- Phenothiazines
- Spironolactone
- Thiazide diuretics
What are the two main types of emergency contraception?
EllaOne (Ulipristal acetate)
Levonelle (levonorgestrel) or an emergency coil (IUD)
What are the three main considerations for deciding whether to supply emergency contraception?
Is the supply allowed?
Is it necessary/appropriate?
Are there any cautions or contra-indications for using EHC?
What are the two methods of supplying oral emergency contraception?
Either by patient group directions or by
Selling it
When is the Levonelle supply licensed?
For those over the age of 16
Within 72 hours of unprotected sex
When is EllaOne supply licensed?
Within 5 days of unprotected sex
Can Pharmacists provide an advanced supply of the emergency contraception?
Yes they can as long as they are:
Competent
Intend to use the medicine appropriately
It is clinically appropriate
Can you give EllaOne to under 16s?
Yes it is not contraindicated by the manufacturer however you need to assess whether it could be linked to child abuse.
If the child is under 13 and is requesting EC, what should you do?
Under 13, too young to consent to any sexual conduct and it should be reported to social services unless there are exceptional
circumstances backed by documented reasons for not sharing information.
Is it an offence to have sex under the age of 16?
Yes, however it will not be prosecuted if they are of a similar age and it is consensual. Provide contraception advice.
What should you do if you suspect harm?
Try to gain consent before disclosing patient information however where the risk of harm is greater than breaking confidentiality this should be followed.
When is the critical time for loss of contraceptive protection?
At the beginning or end of the cycle
When is emergency contraception required for missed pill doses (combined)?
Emergency contraception is recommended if 2 or more combined oral contraceptive
tablets are missed from the first 7 tablets in a packet and unprotected intercourse has
occurred since finishing the last packet.
When is emergency contraception required for missed pill doses (progesterone only)?
If one or more tablets are missed or taken more than 3 hours late (12
hours for desogestrel) and unprotected intercourse has occurred before 2 further
tablets have been correctly taken.
What is recommended if the patient is requesting EC if they have taken CYP3A4 enzyme inducer in the last 4 weeks?
Levonelle and EllaOne should not be given if the patient has had any of the CYP3A4 in the last four weeks. Normally it is recommended that the patient is referred and given the a copper intrauterine device.
If this is not recommended two doses of Levonelle should be given.
At what weight is both oral EC less effective?
Above 70kg
If a patient vomits within 3 hours of the EC, what is recommended?
Repeat dose
What can happen if the patient takes two Levonelles within the same menstrual cycle?
It can causes menstrual abnormalities (cycle disruption)
What clinical conditions should ECs not be taken with?
EllaOne:
Severe asthma, who are taking oral glucocorticoid
Severe liver impairment
Levonelle:
Severe malabsorption syndrome
At risk of an etopic pregnancy
Severe inflammation of the fallopian tubes
Severe liver dysfunction
Can you breast feed after taking the EC?
EllaOne:
Shouldn’t breastfeed for a week afterwards and therefore should express to maintain lactation
Levonelle:
Does not have an impact on the baby however they should take the EC immediately after breastfeeding in order to ensure minimal amount in the next feed.
Which types of contraceptions does EllaOne reduce the efficiency of?
Combined oral and progesterone only. If the patient is taking progesterone only they should be restarted 5 days afterwards.
Does Levonelle affect any contraceptives?
No they can be resumed as normal after taking the EC.
What is the Fraser criteria?
The criteria used to determine whether it is suitable to supply EC to under 16s.
What is the 5 criteria of the Fraser outline?
They have the maturity and
intelligence to understand the
nature and implications of the
proposed treatment
They cannot be persuaded to tell
her parents or to allow the
practitioner to tell them
They are very likely to begin or
continue having sexual intercourse
with or without contraceptive
treatment
Their physical or mental health is
likely to suffer unless they receive
the advice or treatment
The advice or treatment is in the
young person’s best interests.
