Week 8 - Contraception & sexual health and Mental Health (A) Flashcards
Outline which contraceptive methods can be used in the management of dysmenorrhoea
- COCP / combined patch
- POP
- Progesterone implant
- Progesterone injection
- Progesterone coil (Mirena)
Can also use:
- Analgesia e.g. Paracetamol, Ibuprofen and aspirin
- Exercise
Outline which contraceptive methods can be used in the management of menorrhagia and some non-hormonal methods of management
- Progesterone coil
- COCP / combined patch
- POP
- Progesterone implant
- Progesterone injection
Non-hormonal:
- Tranexamic acid tablets
- Anti-inflammatory painkillers, such as ibuprofen or Mefenamic acid
- Surgery (endometrial ablation or hysterectomy)
Outline which contraceptive methods can be used in the management of endometriosis
- COCP / combined patch
- POP
- Progesterone coil
- Progesterone injection
- Progesterone implant
Outline the mode of action of COCP
- Pill containing oestrogen and progesterone
- Mainly works due to oestrogen preventing ovulation, with progesterone also causing thickening of cervical mucus and thinning of endometrial lining
Outline the indications for COCP
- Contraception
- Control heavy bleeding
- Acne
List some absolute contraindications for COCP (UKMEC 4)
UKMEC 4:
- Current breast cancer
- Migraine with aura (risk of stroke)
- Age > 35 and smoke > 15 per day
- History of VTE / current VTE
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Cirrhosis and liver tumours
- Major surgery with prolonged immobility
- Stroke or vascular disease
- Ischaemic heart disease, AF or cardiomyopathy
- SLE and antiphospholipid syndrome
Outline the 3 ways in which COCP can be taken
Tricycling:
3 x 21 active pills consecutively, followed by 4- or 7-day hormone-free interval
Continuous use:
Take pills consecutively with no breaks
Flexible extended use: Continuous use with no breaks between packs until breakthrough bleeding, occurs for 3-4 days, followed by 4-day break
List some important medical side effects of COCP
- VTE
- MI / stroke
- Breast cancer
- Cervical cancer
What is classed as a missed pill for COCP?
Pill that is not taken for > 24 hrs after it was due to be taken
Outline the missed pill rules for COCP, only missed 1 pill
Missed 1 pill only:
- Missing one pill, at any time, does not compromise contraception
- Pills missed at the beginning or end of the pack confer the most risk of pregnancy
- Take missed pill as soon as possible, can continue as normal
Outline the missed pill rules for COCP, missed 2 or more consecutively in the following scenarios:
- Missed 2 or more in the first week
- Missed 2 or more in the second week
- Missed 2 or more in the third week
FIRST week is the issue
Missed 2 or more in the FIRST week:
- Same as above (take missed when possible, continue as normal, 7 days contraception)
- BUT also need EMERGENCY CONTRACEPTION e.g. Levonestrol
Missed 2 or more in the second week:
- Same as above (take missed when possible, continue as normal, 7 days contraception)
- No additional measures needed
Missed 2 or more in the third week:
- Same as above (take missed when possible, continue as normal, 7 days contraception)
- Omit the pill free interval, start new packet immediately
List the rules for vomiting with the COCP
- Vomit within 2 hours of taking a pill = take another one as soon as possible
- Vomiting or diarrhoea for > 24 hours = follow the same advice as if they had missed pills
Outline mode of action of POP
- Pill containing progesterone
- Acts by thickening cervical mucus
Outline the indications for POP
- Contraception
- Treatment of dysmenorrhoea and menstrual-associated symptoms
Outline some contraindications for POP
- Stroke / coronary heart disease
- Breast cancer
- Severe liver cirrhosis
- Liver tumours
- SLE with +ve antiphospholipid antibodies
- Medication: antiretroviral therapy, enzyme-inducing anticonvulsants (not Lamotrigine) and enzyme-inducing antibiotics such as Rifampicin
Outline the correct use for POP (when it should be taken)
- Pills must be taken at about the same time each day
- Within three hours of the time taken the previous day
List some important side effects of POP
- Menstrual irregularities
- Acne
- Breast tenderness and breast enlargement
- Altered libido
- Mood changes
- Headache and migraine
- Nausea or vomiting
- Ovarian cysts
Outline the missed pill rules for POP
Late if taken > 3 hours after the usual (most pills - if Desogestrel then it’s > 12 hours)
Even 1 missed pill counts as a missed pill (unlike COCP where 2 missed pills count as a missed pill)
- Missed pill should be taken as soon as possible
- The subsequent pills should be taken as usual but additional contraception should be used until pills have been taken correctly for 2 days
- No more than 2 pills should be taken on the same day
Consider the need for emergency contraception, if:
- > 2 pills have been missed
- Unprotected sexual intercourse has taken place during the time when the POP cover is doubtful
Outline the rules for vomiting / diarrhoea with POP
- May impair absorption of the hormone
- Throw up within 3 hours of taking pill, take another pill
- If not, additional contraception should be used during this phase and for 2 days afterwards
Outline the mode of action of progesterone implant
- Flexible rod releasing progesterone
- Inhibits ovulation, thickens cervical mucus and thins endometrial lining
Outline some contraindications for the progesterone implant
- Pregnancy
- History of stroke / serious heart disease
- Breast cancer
- Liver disease
- Arterial disease
- Unexplained vaginal bleeding
- Medications: enzyme-inducing drugs e.g. medications used in HIV, tuberculosis, epilepsy and the herbal remedy St John’s Wort
- Chance of pregnancy I.e. unprotected sex in the last 2 weeks
Outline the duration that the progesterone implant is valid for
3 years
Outline some important side effects of the progesterone implant
- Menstrual irregularities
- Acne
- Breast tenderness and breast enlargement
- Altered libido
- Mood changes
- Headache and migraine
- Nausea or vomiting
- Ovarian cysts
Outline the mode of action of progesterone coil (IUS)
- Small T shaped plastic device in the womb releasing progesterone
- Thickens cervical mucus
Outline the indications for progesterone coil (IUS)
- Contraception
- Treatment of idiopathic menorrhagia provided there is no underlying pathology
- Prevention of endometrial hyperplasia
Outline the contraindications for progesterone coil (IUS)
- Known or suspected pregnancy
- CIN
- PID / lower genital tract infection
- Postpartum endometritis
- Infected abortion during the past 3 months
- Cervicitis
- Endometrial / cervical malignancy
- Confirmed or suspected hormone dependent tumours including breast cancer
- Undiagnosed abnormal uterine bleeding
- Congenital or acquired uterine anomaly
- Large fibroids
- Conditions associated with increased susceptibility to infections
- Acute liver disease or liver tumour
Outline the duration for which the progesterone coil (IUS) is valid
3-5 years
List the important side effects of the progesterone coil (IUS)
- Perforation
- Expulsion
- PID
- Ectopic pregnancy
- Menstrual disturbance
- Headaches
- Acne
- Breast tenderness
- Mood disturbance
- Ovarian cysts
Outline the mode of action of the copper coil (IUD)
- Small copper and plastic device in the womb
- Copper is toxic to sperm – prevents fertilisation
Outline the indications for the copper coil (IUD)
- Contraception
- Emergency contraception (within 5 days of unprotected intercourse)
Outline the contraindications for the copper coil (IUD)
- Wilson’s disease
- Sensitivity to copper
- Pregnancy / suspected pregnancy
- PID / lower genital tract infection
- Congenital uterine abnormality
- Large fibroids
- Septic abortion or history of postpartum endometritis within the last 3 months
- Uterine / cervical malignancy
- Abnormal uterine bleeding
Outline the duration for which the copper coil (IUD) is valid
5-10 years
Outline the important side effects for the copper coil (IUD)
- Perforation
- Expulsion
- PID
- Ectopic pregnancy
- Menorrhagia or dysmenorrhoea
Outline the mode of action for the progesterone injection
- Injection of progestogen, slowly released over time
- Mainly prevents ovulation, progesterone also thickens cervical mucus and thins endometrial lining
Outline the duration for which the progesterone injection is valid
2-3 months (8-13 weeks)
Outline the contraindications for the progesterone injection
- Pregnancy
- Current / previous breast cancer
- Severe cirrhosis
- Liver tumours
- Severe arterial disease
- Risk factors for osteoporosis
- Unexplained vaginal bleeding
Outline the important side effects for the progesterone injection
- Up to 1 year delay to fertility returning
- Infection at injection site
Progesterone side effects:
- Menstrual irregularities
- Acne
- Breast tenderness and breast enlargement
- Altered libido
- Mood changes
- Headache and migraine
- Nausea or vomiting
- Ovarian cysts
Outline the correct use of combined contraceptive patch
- Only use 1 patch at a time, applied to: upper outer arm, upper chest (excluding breast), lower belly or bum
- Apply one patch per week on the same day each week for 3 consecutive weeks (days 1, 8, and 15), have a patch-free interval on week 4 (days 22–28), continue this cycle
Outline the 3 emergency contraceptives
1) Copper coil / IUD
2) Progestogen-only tablet = Levonorgestrel (Levonelle)
3) Selective progesterone-receptor modulator = Ulipristal acetate (EllaOne)
Outline how the copper coil / IUD works in emergency contraception
Prevents fertilisation and has some post-fertilisation effects, with a local endometrial inflammatory reaction preventing implantation
Outline how Levonorgestrel (Levonelle) works in emergency contraception
- High dose progesterone
- Prevents or delays ovulation
Outline how Ulipristal Acetate (EllaOne) works in emergency contraception
- Agonist and antagonist effects on progesterone receptors
- Prevents or delays ovulation
Outline in what order you would recommend these medications (based on how long it’s been since unprotected sex)
- Levonelle
- Ulipristal acetate
- Copper coil
< 72 hours = Levonelle (more effective sooner it’s taken)
72 - 120 hours = Ulipristal or copper IUD (100% effective)
List the menstrual issues helped by the use of hormonal contraceptives
- Menorrhagia
- Dysmenorrhoea
- Irregular menses
- Endometriosis
- Premenstrual syndrome
- Menstrual migraines
Plus:
- Iron-deficiency anaemia
- Menstrual flares of rheumatoid arthritis
List the non-menstrual conditions helped by the use of hormonal contraceptives
- Acne
- Hirsutism
- PCOS
- Perimenopausal symptoms
List some long acting / permanent contraceptive options if patient definitely doesn’t want to start a family
- Progesterone injection (can take up to a year)
- Tubal ligation
- Vasectomy
Outline the difference between Gillick competence and Fraser guidelines
Gillick competence relates children under the age of 16 to consent to any medical treatment
Fraser guidelines relates specifically to contraception
Outline what the doctor needs to assess Gillick competence
Doctor must be reasonably sure that the child is:
- Suitably intelligent and emotionally mature enough
- Fully understand the treatment
- Understand the nature of the consent the treatment requires
- Understand the consequences of that treatment
Outline the 5 Fraser guidelines
- Understands the advice
- Young person can’t be persuaded to tell their parents (either themselves or through the HCP)
- Likely to begin, or continue, sexual intercourse with or without contraception
- It’s in their best interests would dictate that they receive contraception or advice, with or without parental consent
- Unless the young person receives contraception, their physical or mental health are likely to suffer (e.g. through STIs or unwanted pregnancy)
Outline the difference between low mood and depression
Low mood:
- Common after distressing events or major life changes but sometimes for no obvious reason
- Will resolve after a couple of days or weeks
Depression:
- Feeling low in mood or no longer getting pleasure from things for most of each day
State the lifetime prevalence of depression and list some risk factors
Lifetime prevalence: 10%
Risk factors:
- Previous depression
- Family history
- Recent bereavement / stress / medical illness
- Post-natal
- Female
- Other personality disorders
- Corticosteroids
- Oral contraceptives
- Propranolol
State the triad of core symptoms of depression, as well as some additional symptoms
1) Low mood
2) Low energy
3) Anhedonia (lack of pleasure/enjoyment)
+/- suicidal ideation
- Poor concentration
- Weight changes
- Low libido
- Psychomotor retardation
- Guilt
- Sleep disturbance (increased sleep and difficult to get up in morning)
Mood can also be anxious, irritable or flat
List some blood tests to consider in someone presenting with depression features (physical tests)
Main:
- Bloods: FBC, TFT, U&Es
Others to consider:
- 24 hr free cortisol levels
- Vitamin B12
- Folic acid
List some questionnaires to consider in someone presenting with depression features / ongoing monitoring
Most commonly used: Patient health questionnaire 9 (PHQ-9) - symptoms of depressed mood and anhedonia
Patient health questionnaire 2 (PHQ-2) - symptoms of major depression
Specialised:
- Edinburgh postnatal depression scale
- Geriatric depression scale
- Cornell scale for depression in dementia
Outline treatment pathway for mild depression
1st line:
- Consider antidepressant
- Psychotherapy e.g. CBT
- Supportive interventions
Outline treatment pathway for moderate depression
1st line:
- Antidepressant
- Consider psychotherapy e.g. CBT
- Consider immediate symptom management with benzodiazepine or antipsychotic
Outline treatment pathway for severe depression
- Psychiatric referral
- Hospitalisation
- Electroconvulsive therapy or antidepressant
- Consider immediate symptom management with benzodiazepine or antipsychotic
Outline some treatment options for resistant depression
- Reassess and switch antidepressant
- Monoamine oxidase inhibitor
- Electroconvulsive therapy
List some complications of depression (think social and physiological)
Social:
- Impacts work / college
- Impacts on relationships and looking after dependents
- Reduced quality of life
- Risk of associated alcohol and substance misuse
Physiological:
- Self-harm
- Self-neglect
- Suicide
Outline the general prognosis of depression
- Course of illness is episodic, feel well in between acute depressive episodes
- Depressive episodes typically last 3–6 months with treatment
- Most people recover within 12 months
Outline what criteria is used to diagnose anxiety and 6 of the key symptoms
DSM-5-TR criteria -
- Excessive anxiety and worry, most days for at least 6 months, about a number of events
- Trouble controlling the worry
- Clinically significant distress or impairment in functioning
- No other cause identified
3 of 6 symptoms for > 6 months:
- Restlessness / nervousness
- Irritability
- Muscle tension
- Poor concentration
- Easily fatigued
- Sleep disturbance
List some risk factors for anxiety
- Previous anxiety or other anxiety disorder
- Female
- Family history
- Physical or emotional stress
- History of trauma (physical, sexual or emotional)
- Chronic physical health condition
List some investigations to consider in someone presenting with symptoms of anxiety
- Bloods: TFT
- Urine drug screen / 24 hr urine for metanephrines
- Pulmonary function tests
- ECG
List some treatments that can be used in the treatment of anxiety
1) CBT
2) SSRI or SNRI or atypical antidepressant
3) Tricyclic antidepressant
Consider alongside all:
- Muscle relaxation / mindfulness
- Sleep hygiene
- Regular exercise
List some complications of anxiety (think social and psychological)
Social:
- Suicide
- Social isolation
- Problems functioning at school or work
- Poor quality of life
Psychological
- Depression
- Insomnia
- Digestive or bowel problems / IBS
- Headaches and chronic pain
- Risk of substance abuse
List some medical conditions that may present similarly to anxiety
- Anaemia
- Hyperthyroidism
- Respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and asthma
- Drug misuse or withdrawal
- Withdrawal from alcohol, anti-anxiety medications (benzodiazepines) or other medications
- Heart disease
- Diabetes
- Chronic pain or irritable bowel syndrome
- Catecholamine producing tumors
Outline the general difference between stress and generalised anxiety disorder
Under stress, people experience mental and physical symptoms, such as irritability, anger, fatigue, muscle pain, digestive troubles, and difficulty sleeping and generally resolves once the stressor does
Anxiety is defined by persistent, excessive worries that don’t go away even in the absence of a stressor
State the screening tool used to assess anxiety in primary care
GAD7 questionnaire
Outline the rules for starting COCP in the following scenarios:
- Start on first day of a period
- Start any other time in the menstrual cycle
- New mothers (when can they start)
First day of a natural period:
- Protected from pregnancy immediately
- No additional contraception required
Starts at any other time of menstrual cycle:
- Additional contraception for 7 days (condoms)
New mothers:
- If not breastfeeding: 3 weeks postpartum
- If breastfeeding: 6 weeks postpartum
