WCS23 Fertility Regulation Flashcards
Assess client seeking for contraceptive provision
- ***Explore reason why requesting for contraception
- ***Previous contraceptive usage
- previous failures
- problems with specific methods - ***Previous OG history
- Previous medical history
- ***Motivation of couple
- Social, education, cultural background
—> Choose most suitable + Exclude contraindication
Contraceptive methods
- Natural
- Barrier
- Male
- Female - Hormonal (oral, injectable, patch)
- Combined
- Progestogen-only - Intrauterine device
- Copper IUCD
- Progestogen-releasing intrauterine system - Emergency contraception
- Sterilisation
- Male
- Female
- Natural methods
Periodic sexual abstinence around time of ovulation
Mechanism:
- Ovulate once a month
- Ovum live for **24 hours after ovulation
- Sperm live for **7 days in woman’s body
- Standard days method
- abstinence from day 8-19 (前6後5)
- for woman with regular cycle (26-32 days)
- woman who have ***>=2 cycles outside this range in past year NOT use this method - Calendar / Rhythm method
- abstinence from day being shortest cycle length (in past 12 months) minus 20 days
- until day being longest cycle length (in past 12 months) minus 10 days (i.e. longer unsafe period)
- for woman with fluctuation in cycle length
***Example:
- shortest cycle: 23 —> 23-20 = 3
- longest cycle: 36 —> 36-10 = 26
—> abstinence from day 3 to 26 - Basal body temperature method
- body temp ↓ at time of ovulation
- 1 day later ↑ by 0.5oC, stay at higher level till next menstruation
- abstinence begin from **1st day of menstruation until **3rd consecutive day of BBT elevation inclusive - Cervical mucus method
- mucus becomes **thin, clear, stretchy and slippery around ovulation time
- abstinence begin when such mucus is first noted, till **4 days after mucus cessation - Sympto-thermal method
- BBT + Cervical mucus method
- abstinence begin when mucus becomes sticky and moist, till 3rd of BBT shift / 4th day of mucus cessation (whichever ***later) - Urine LH test
- Ovulation tracking using OTC urine LH kits
- help woman understand her cycle pattern
- NOT recommended for contraceptive purpose
Advantages:
- No religious objection
- **No equipment / medication required
- **No physical SE
- Enhance communication and cooperation between couples (∵ shared responsibility)
Disadvantages:
- **No regular menstrual cycles —> Uncertainty to ovulation time
- High dependent on commitment and motivation of both partners
- Period of learning required
- Daily monitoring and recording of signs of fertility maybe inconvenient
- **Effectiveness lower than most other methods
- Failure rate: ***24-40 pregnancies per hundred women-year
Other methods:
7. Coitus interruptus (Withdrawal method)
- depends on men’s ability to withdraw before ejaculation
- not reliable ∵ pre-ejaculatory secretory fluid may contain sperm
- Lactation amenorrhea method
- anovulation due to breastfeeding
- 98% effective if fully breastfeeding, within 6 months postpartum and remaining amenorrhea
- NOT used if above criteria breached
- Barrier methods
Separate sperm / ovum by:
1. Mechanical means
2. Spermicide
Forms:
1. Male condom
- Breakage / Slippage
- Latex allergy
- Latex cannot use with **oil-based lubricants
- failure rate: up to **18 per hundred women-year
- Female condom
- permits continued intimacy in the resolution phase of intercourse
- hanging out look awkward and more expensive - Diaphragm (use with spermicidal jelly / cream)
- failure rate: ***6-20 per hundred women-year - Cervical cap
- Cervical cap is tedious to wear over cervix
- Diaphragm + Cervical cap involve preparation prior to coitus - Spermicide (jelly, cream, foaming tablet, film, sponge)
- used alone without mechanical barrier —> **high failure rate
- messy
- vaginal irritation and discharge
- frequent use of nonoxynol-9 ↑ risk of HIV / STD transmission probably by vaginal **epithelial damage
- ***NOT used in those at high risk of or HIV / STD infection
- spermicide-lubricated condoms do NOT provide additional protection —> no longer encouraged
Advantages:
- No physical SE
- Provide immediate contraception
- **Easily accessible
- **Reduce transmission of HIV / STD
Disadvantages:
- User dependent (rely on motivation and compliance)
- **Discomfort, reduced sensation and sexual pleasure
- **Consistent + Correct use to be emphasised
- Emergency contraception as a back-up method should be taught
- Hormonal contraceptives
Combined (Estrogen + Progestogen) vs Progestogen-only
Forms:
1. Combined oral contraceptive (COC)
2. Progestogen-only pill (POP)
3. Combined injectable contraceptive (CIC)
4. Progestogen-only injectable
5. Transdermal contraceptive patch
Advantages:
- **Very effective reversible method
- Failure rate: **<0.5 per 100 women-year (with perfect use), up to ***9 (with typical use)
- Not interrupt spontaneity of coitus
Disadvantages:
- Missed pill leading to failure (except injection)
***MOA of COC, POP
COC / POP:
Progestogen:
- Negative feedback ↓ pulse frequency of GnRH release by hypothalamus
—> ↓ FSH secretion + ↓↓ LH secretion by anterior pituitary
—> ↓ FSH inhibit follicular development, preventing ↑ in estradiol levels
—> Progestogen negative feedback + Lack of estrogen positive feedback on LH secretion prevent a mid-cycle LH surge
—> Inhibition of follicular development and absence of an LH surge prevent ovulation
Estrogen:
- **Negative feedback on anterior pituitary
—> ↓↓ FSH secretion
—> Inhibition of follicular development and prevent ovulation
- **Better cycle control
—> to ***stabilize the endometrium
—> ↓ incidence of breakthrough bleeding
Combined oral contraceptive (COC)
**Ethinylestradiol 20-35 mcg + **Progestogen (Levonorgestrol, Gestodene, Desogestrel, Drospirenone)
- Natural Estradiol has been introduced
Mechanism:
1. **Inhibit ovulation (Progesterone: -ve feedback on FSH, LH)
2. **Thickens cervical mucus (Progesterone)
3. ***↓ Endometrial receptivity to embryo (Estrogen)
Use:
- 1 tablet OD at same time
- Starting from ***5th day of cycle for 21 days —> 7 day break (some contain placebo pills during break) —> allow shedding of endometrium
Non-contraceptive benefits:
- **Improve cycle regularity
- **↓ menstrual flow, dysmenorrhea
- ↓ ovarian cysts, benign breast lesions
- ↓ pelvic inflammatory disease
- Protect against **Ovarian + **Endometrial cancer
- NO adverse effect on fetus when COC used immediately before / inadvertently during pregnancy
Disadvantages:
- Small ↑ in MI / Stroke risk
- ↑ **thromboembolic risk
- Minimal ↑ **Breast / **Cervical cancer
- **N+V, dizziness, breast tenderness, fluid retention, ***weight gain, breakthrough bleeding (but usually disappear after a few cycles)
- After stopping COC —> fertility returns in ***1-3 months
- Non-prescription drug, but medical assessment should be undertaken to exclude CI, annual review to continue the pill
- no need to take a break for long term users
CI:
- **Full breastfeeding
- Non-breastfeeding women within **21 days post-partum
- **Heavy smokers >= 35 yo (>15 cigarettes / day)
- Co-existing risk factors for **arterial CVS disease, hypertension
- History of **Venous thromboembolism / **IHD / **CVA / **Breast cancer / ***Migraine / Major surgery / Prolonged immobilisation
**Missed pill management:
- 1 pill missed: take missed pill asap, continue remaining pills as scheduled
- >=2 pills missed: take missed pill asap, continue reminding pills as scheduled, **additional protection for 7 days
- >=2 pills missed + in 3rd week: **omit pill-free interval, **start new pack right after active pills in current pack
Principle = 7-day rule (Felix Lai):
- 7 days are required to suppress ovulation in that cycle
- 中斷左連續7 day streak就要食翻夠7 day
Progestogen-only pill (POP)
***Desogestrel (Cerazette)
Mechanism:
1. Cervical mucus thickening (Progesterone)
2. Inhibits ovulation (Progesterone)
Main advantage:
- **Do not interfere with lactation —> suitable for breastfeeding
- **No Estrogen SE on BP, haemostatic, metabolic parameter
- Fertility returns **immediately upon discontinuation
- **Not cause osteoporosis vs Depo-Provera (∵ POP not induce hypoestrogenic state ∵ quick metabolism in body (∴ need to take within 12 hours)) (SpC FM)
- No need to stop at 50 vs Depo-provera, Can stop at 55 (when most women already menopaused) (SpC FM)
Disadvantages:
- **Menstrual irregularity e.g. Prolonged spotting, Irregular short cycles, Amenorrhoea (∵ **Endometrial atrophy)
- ***Regular pill taking (not later than 12 hours for Cerazette) required to ensure effectiveness
CI:
- ***Breast cancer
**Missed pill management (Felix Lai):
- <12 hours late: Take the missed pill ASAP + next pill at the usual time
- >12 hours late: Take the missed pill ASAP + next pill at the usual time + additional contraceptive for **48 hours after late pill is taken
- Emergency contraception should be considered if unprotected intercourse occurs during this 48-hour period
Injectable
Synthetic hormones IM injection
Form:
1. Combined injectable (Cyclofem)
- ***1 monthly
- better cycle control
- bleeding still occur
- adverse effects, CI ~ to COC
- Depo-Provera (Progesterone-only)
- Depot preparation of progestogen for **3 months
- Free from Estrogen SE —> can be used in lactating women, **↓ menstrual loss, **dysmenorrhea
- 0.5-1 year return of fertility after discontinuation
- Stop at **50 yo (age of menopause) (SpC FM)
SE: - Prolonged use cause **reduced / **absent menstruation (SpC FM)
- **Menstrual irregularity + **Hypo/Amenorrhoea may not be preferred -
**Osteoporosis
- Long-term may lower bone mass (∵ suppress HPO axis —> induce **hypoestrogenic state, occur 2-3 years after continued use (SpC FM)), usually recovers after discontinuation
- Should be educated on primary prevention of ***osteoporosis
- Assessment on risk factors for osteoporosis suggested before starting - ***Weight gain (not in POP) (SpC FM)
Mechanism:
1. Inhibit ovulation
2. Thickening of cervical mucus
Advantages:
- Very effective (***0.1-0.6% failure rate)
- Independent of coitus
- Use is not noticeable —> good for privacy
Other hormonal contraceptives
- Combined contraceptive patch (e.g. Evra)
- Vaginal ring (Nuvaring)
- Subdermal implant (Nexplanon)
Actions ~ COC, POP
Patch:
- changed **weekly for 3 consecutive weeks
- **1 patch-free week for withdrawal bleeding
Long term safety data still awaited
- Intrauterine device
Performed by medical personnel after counselling to exclude CI
- Inert IUCD
- phased out now
- may be used up to menopause - Copper IUCD
- Exact mechanism is not known
- Causing foreign body reaction in endometrium?
- Copper may inhibit **sperm function, transport and reduce gamete viability
- **5-10 years duration - Progestogen-releasing intrauterine system
- Levonorgestrel-intrauterine system (LNG-IUS) (Mirena)
- Progestogen-releasing depot
- Failure rate **<1 per hundred women-year
- **5 years duration
Advantage:
- **Highly effective
- **Long acting
- Reversible
- User independent
- Effective immediately after insertion
- **No systemic SE
- **Improving menorrhagia, dysmenorrhea (LNG-IUS)
Adverse effects:
- Copper IUCD:
—> **Menorrhagia
—> **Dysmenorrhea
- LNG-IUS:
—> **Prolonged spotting in first 3-6 months, **reduced / ***absent menstruation subsequently
—> Pain
—> Vaginal bleeding
—> Increased vaginal discharge - Increased ***risk of infection in 20 days after insertion (very low long term infection risk)
—> Proper pre-insertion screening and aseptic technique - ***Traumatic perforation of uterus
- ***Expulsion / Translocation of device
CI:
- **Known / suspected pregnancy
- Women beyond 40 hours but within 4 days postpartum
- **Current infection of genital tract
- **Undiagnosed vaginal bleeding
- **Uterine abnormalities with endometrial cavity distortion
- **Current gestational trophoblastic neoplasia
- Women with increased risk of STD, severe thrombocytopenia
- **Breast cancer (LNG-IUS)
- Emergency contraception
Back-up for contraceptive failure / after rape
- **Hormonal preparation within 3-5 days / **IUCD within 5 days
- Neither are abortifacient
Hormonal methods:
1. Yuzpe regimen
- Ethinylestradiol 100 mcg + Levonorgestrol 0.5 mg / Norgestrel 1 mg
- 2 doses 12 hours apart
- ***Levonorgestrel-only regimen (recommended)
- Levonorgestrel 1.5 mg single dose - **Ulipristal 30 mg (up to **120 hours after unprotected sex)
- Interfere with ovulation
- 1-2% failure rate
- Not advised to be used repeated, reliable regular birth control method should be adopted
- N+V (Yuzpe, but much less with Levonorgestrel-only)
- No known CI
- No known teratogenic effects even if inadvertently during pregnancy
IUCD:
- Prevent implantation
- **Copper-IUCD: within **5 days
- failure rate <0.1%
- can be continued for long term contraception
(No Mirena / LNG-IUS (self notes))
- Sterilisation
Permanent
—> suitable for couples who no longer want children
—> Counselled carefully on **irreversibility + **operative risks
Later regret of decision:
- < 30 yo
- single / married < 5 years
- not having children of both sexes
- unstable marital relationship
- coercion from others
- objection from spouse
- recent life crisis (e.g. after pregnancy termination / delivery, separation / divorce, death of spouse)
Female sterilisation
- Mini-laparotomy / Laparoscopy
- Occlude Fallopian tube by **ligation, application of clips / rings, diathermy, resection
- failure rate **~2-5 per 1000 lifetime risk
- Risks:
—> operative complications (visceral damage, bleeding, wound complications)
—> risk of ***ectopic pregnancy in case of failure
Male sterilisation:
- **Vasectomy
- local anaesthesia as a day surgery
- failure rate **0.5 per 1000 lifetime risk
- **not immediately effective
- reliable birth control until **>=2 negative semen tests consecutively
Termination of pregnancy
Legal regulations:
1. **2 registered practitioners:
—> Continuance of pregnancy would involve risk to life of pregnant women / injury to **physical / **mental health of pregnant women, greater than if the pregnancy are terminated
OR
—> Substantial risk that if child were born, it would suffer from such physical / mental abnormality as to be seriously **handicapped (e.g. Patau, Edwards’, Hydrops fetalis) (NOT Cooley’s, Down) (SpC FM)
(Abortion of >24 weeks is NOT authorised unless approved by 2 registered medical practitioner that mother’s life is at risk)
- Any treatment must be carried out in a hospital ***approved in the Government Gazette / the Family Planning Association of Hong Kong
Pre-abortion counselling / assessment:
- Understanding, sympathetic, non-judgemental, respect client’s informed decision, not to imply irresponsible / immoral acts / induce guilt
- Reasons for requesting TOP
- Contraceptive history: reason for contraceptive failure, plan for future contraception
- Options: **continuation of pregnancy, **adoption, ***termination of pregnancy
- Psychosocial issues
- Explain method and risks
- Medical, drug, allergy history
- Rh type
- Ascertain dating by history, examination +/- USG
- Screening / Empirical antibiotic prophylaxis for STI
1st trimester induced abortion
Misoprostol: stimulate uterine contraction + cervical dilatation —> expulsion of conceptus
Medical (**NOT licensed in HK (Felix)):
**Mifepristone (Anti-progestogen) 200mg PO —> ***Misoprostol 800mcg PV / Sublingual 1-3 days later (applicable up to 9 weeks of gestation)
- Complete abortion rate >95%
- less invasive
- avoid risk of anaesthesia / surgical procedure
Surgical:
***Suction evacuation
- quicker in achieving complete abortion
