Women's Health Flashcards
Compare between the various barrier techniques for the prevention
of pregnancy.
Male condoms:
CI: allergy to latex/rubber
Adv: STI protection
Disadv: High user failure rate
* Poor acceptance
* Possibility of breakage
Female condoms:
CI: allergy to polyurethane, Hx of Toxic shock syndrome
Adv: STI protection, Can be inserted ahead
of time
Disadv: very High user failure rate
* Dislike ring hanging outside vagina
Diaphragm with spermicide/cervical cap:
CI: allergy to latex/rubber/spermicide,Recurrent UTIs, History of TSS, Abnormal gynaecologic anatomy
Adv: cheap, reusable
Disadv: High user failure rate, Low protection against STIs, Increased risk of UTI, Cervical irritation
Describe the mechanism of action of the birth control pill.
Progestins -> thickening cervical mucus
to prevent sperm penetration, slowing
tubal motility (delay sperm transport),
and inducing endometrial atrophy
* Progestins block LH surge + estrogen
suppresses FSH release => prevent
ovulation
* Progestins provide most of contraceptive
effect, estrogen mostly to stabilize the
endometrial lining and provide cycle
control
Identify the contraindications of oral contraceptive therapy.
- Current breast CA/ recent history of
breast CA within 5 years - Hx of DVT/PE, acute DVT/PE and pts
with DVT/PE and on anticoagulant
therapy - Major surgery with prolonged
immobilization - < 21 days postpartum with other risk
factor - <6 weeks postpartum if
breastfeeding - Thrombogenic mutations
- SLE with + or unknown APLA
- Migraine with aura
- SBP > 160mmHg / DBP > 100mmHg
- HTN with vascular disease
- Current/History of ischemia heart
disease - Cardiomyopathy
- Smoking ≥ 15 sticks/day AND age ≥
35yo - History of cerebrovascular disease
- Diabetes >20 yrs or w/complications
Categorise the various non-oral, device-based, hormonal contraceptive options available to patients.
Transdermal
Contraceptives
* Both estrogen and progestin
component
* Typical use failure rate 7% ≈ COC
* Not as effective in patients
weighing > 90 kg
* Applied once weekly for 3 weeks
followed by 1 patch-free week
MOA ≈ COCs
* SE: Similar to COC + application
side reactions
Vaginal Rings
* Both estrogen and progestin
component
* Typical use failure rate 7% ≈
COC
* Used for 3 weeks then
discarded
* Unlike diaphragms/ cervical
caps, precise placement not
an issue as hormones are
absorbed
* SE: Similar to COC + tissue
irritation + risk of expulsion /VTE
Progestin Injections
* Depo-Provera® (depot medroxyprogesterone
acetate, DMPA)
* IM injection every 12 weeks
* Good for adherence issues but need regular
doctor visit
* Typical use failure rate 4% < COC
* Return to fertility might be delayed
* Will have variable breakthrough bleeding esp
the first 9 months (most freq SE)
* 50% become amenorrheic after 12 months
* 70% after 2 years
ADR: * Weight gain – more than other types of contraceptives
* Short term bone loss -> bone mineral density (BMD) ↓
* Bottomline = risk-benefit analysis
* Avoid in older women
* Avoid if have other
osteoporosis risk factors
eg long term steroids
* If >2 years, evaluate
other options too
Long acting reversible contraception (LARC):
Effects quickly reversible upon removal
* Despite benefits, not commonly used => invasiveness
Intrauterine devices (IUDs)
* MOA: inhibition of sperm migration, damage ovum, damage/disrupt transport
of fertilized ovum. If with progestin -> endometrial suppression, thicken mucus
* Should NOT be inserted if pregnant, current STI, undiagnosed vaginal bleeding,
malignancy of genital tract, uterine anomalies or uterine fibroids
* General risks: uterine perforation, expulsion, pelvic infection
Levonorgestrel IUD
* Menstrual flow decreased
* Typically spotting, amenorrhea
* Ideal if concomitant menorrhagia
* 5 years
Copper IUD
* Heavier menses/bleeding (compared to
levonorgestrel)
* Ideal if concomitant amenorrhoea
* 10 years
* Can be used as emergency
contraception
Subdermal Progestin Implants:
Single 4 cm long implant, containing 68 mg of etonogestrel
* Lasts for 3 years
* Irregular bleeding pattern - with continued use; amenorrhea
(22%), prolonged bleeding (18%), spotting (34%) and
frequent bleeding (7%)
Summarize the considerations in choosing which birth control method to use.
Androgenic SE:
Acne, oily skin, hirsutism
Factors favoring lower doses of EE (20-25 mcg):
- Adolescence
- Underweight (< 50 kg)
- Age > 35 years
- Peri-menopausal
- Fewer side effects
Factors favoring higher doses of EE
(30-35 mcg)
Obesity or weight > 70.5 kg
* Early to mid cycle breakthrough
bleeding/spotting
* Tendency to be non-adherent
Why do we need higher progestational
activity?
- Late cycle breakthrough bleeding
- Painful menstrual cramps
Adv of monophasic and multiphasic COC
Monophasic COC
Same amounts of estrogen & progestin in every pill:
* Less confusing, less
complicated missed-doses
instructions
Multiphasic COC
Variable amounts of estrogen and progestin
* Tend to have lower progestin
overall -> lesser side effects
Conventional cycle COC
21 days active pill + 7 day
placebo = 28 days
newer: 24 days active pill + 4 day
placebo = 28 days –> to reduce hormone fluctuations between cycles, less SE
Initiating a COC
First Day Method
* Start on first day of menstrual cycle
* No backup contraceptive required if on first day
Sunday Start
* Start on first Sunday after menstrual cycle
begins
* Require backup contraceptive for at least 7d
* May provide weekends free of menstrual periods
Quick start
* Start now
* Require backup contraceptive for at least 7 days and potentially until the next menstrual cycle begins
Factors in selecting a COC
- Hormonal content required
- Convenience
- Adherence level
- Tendency for oily skin, acne, hirsutism
- Medical conditions (eg premenstrual syndrome, dysmenorrhea)
CIs - breast cancer/VTE Hx
Extra-contraceptive benefits
- Relief from menstrual related problems
- Improvement in menstrual regularity
- Better for Acne
- Premenstrual dysphoric disorder
- Iron-deficient anemia
- Polycystic ovary syndrome
- Reduced risk from ovarian & endometrial cancers
- Reduced risk of ovarian cysts, ectopic pregnancy, pelvic inflammatory
diseases, endometriosis, uterine fibroids, benign breast disease
Breast Ca considerations
Healthy & young => benefit of pregnancy prevention > risk
* Age > 40 => avoid
* Family history/ risk factors of breast CA => avoid
* Current/ recent hx of breast CA (within 5 years) => STOP
Risk factors for VTE:
- > 35 yo
- Obesity
- Smoker
- Immobilization
- Cancer
- Hereditary thrombophilia
Consider
* Low dose estrogen with
older progestins
* Progestin-only
contraceptive
* Barrier methods 19
MI considerations
- Migraine with aura -> absolute contraindication to all COC ->
progestin-only/ barrier instead - Rest are risk factors to consider low dose estrogen/ progestin-
only / barrier instead
Managing Common Adverse Effects
Counsel to persevere on COC for 2-3 months
before changing products unless a serious
adverse effect (eg VTE/stroke/migraine with
aura/MI, etc)
Breakthrough bleeding:
If early/mid cycle -> increase estrogen
If late cycle -> increase progestin
Acne:
Change to less androgenic progestin
Can consider increase estrogen. If on progesterone only pills (POP), change to COC
Bloating
Reduce estrogen
Change to progestin with mild diuretic effect (Drospirenone)
Nausea/Vomiting
Reduce estrogen
Take pills at night / change to POP
Headache
Exclude migraine with aura first!
Usually occurs in pill-free week -> switch to extended cycle/continuous/shorter pill-free interval
Menstrual cramps
Increase progestin / switch to extended cycle or continuous
Breast tenderness/weight gain:
Keep both estrogen/progestin as low as possible
DDI of COCs
Rifampin, anticolvulsants, HIV antivirals
Missed dose procedures (for COC)
If one dose missed (less 48 hours
since a pill should have been taken):
* Take the missed dose
immediately and continue the
rest as usual
* This may mean 2 pills on the
same day
* No additional contraceptive
methods required
If two or more consecutive dose
missed (more than 48 hours):
* Take the missed dose
immediately and discard the rest
of the missed doses
* Continue the rest as usual (may
have 2 pills on the same day)
* Backup contraceptive required
for at least 1 week
If the pills were missed during last week of
hormonal tablets (eg day 15-21)
* Finish the remaining active pills in the
current pack
* SKIP the hormone-free interval and
start a new pack the next day
* Backup contraceptive for at least 7 days
Progesterone Only Pill (POP): “Mini Pill”
Good for breast feeding, intolerant to estrogen (eg N/V), conditions that
preclude estrogen
* Only true contraindication is with current/ recent history of breast cancer
* Norethindrone (norethisterone) or levonorgestrel – 28 active pills (continuous)
* Drospirenone - 24 active pills, 4 inactive
* Starting
* Within 5 days of menstrual cycle/bleeding -> no back up
* Any other day -> back up contraceptive for 2 days (7 days for
drospirenone)
* Missed doses:
* N/L: If late dose by > 3 hours => take extra and continue; backup for 2 days
* Drospirenone: if <24h, take extra and continue; if ≥2 active pills missed, backup needed
for 7 days
Emergency Contraception
Copper IUD: >99%
Insert within 5 days
inhibition of sperm migration, damage ovum, damage/disrupt transport of fertilized ovum
Ella tablet* (ulipristal 30mg): 60-80%
Take 1 tablet ASAP, within 120 hours (5
days)
Progestin receptor modulator: Slows release
of GnRH inhibiting ovulation, thins uterine
lining, directly inhibits follicular rupture
do not give to patient on progestin-only OC, or take progestin for 5 days after
Postinor 2 tablet (levonorgestrel 0.75mg):
Less than ulipristal
Take 2 tablets ASAP, preferably within
12 hours but not later than 72 hours
Progestin: Slows release of GnRH inhibiting
ovulation, thins uterine lining
^ less effective in morbidly obese patients
Nausea common side effect with oral options:
if patient vomits within 3 hours of taking tablet, REDOSE
Identify common symptoms of the
menopause transition.
Clinical Presentation/Symptoms
1. Vasomotor symptoms (VMS) aka hot flushes & night sweats
* Intense feeling of heat on face
* Rapid/irregular HR
* Flushing/reddened face
* Perspiration
* Cold sweats
* Sleep disturbances
* Feeling of anxiety
* Several times a day
* Thought to be due to thermoregulatory dysfunction, initiated at the level of the hypothalamus by estrogen withdrawal
- Genitourinary syndrome of
menopause (GSM)
* Collection of symptoms due to
changes to labia, clitoris,
vestibule, vagina, urethra &
bladder because of decreased
estrogen
* Genital dryness
* Burning/ irritation/ pain
* Sexual symptoms of
lubrication difficulty
* Impaired sexual function/
libido/ painful intercourse
* Urinary urgency
* Dysuria
* Recurrent UTI 6
Clinical Presentation/Symptoms
3. Psychological / cognitive
* Likely multi-factorial (stress/ hormonal fluctuations)
* Depression/ Anxiety
* Poor concentration/memory
* Mood swings
- Bone fragility
* Decreased estrogen -> more bone loss
* inc risk of osteoporosis and fractures
* inc joint pain
Examine the various risks and benefits of
menopausal hormone therapy (MHT)
(previously called hormone replacement
therapy (HRT))
Comment on the appropriateness of a
hormone replacement regimen for a
patient
Estrogen + Progestin:
Continuous-cyclic
* Progestin added on either 1st
or 15th of month, for 10-14
days
* Withdrawal bleeding when
progestin stopped
* Regulate menses ->
predictable bleeding
Continuous-combined
* Estrogen & Progestin daily
* No withdrawal bleeding although
chance of breakthrough bleeding
initially
* After several months, amenorrhea
likely to occur
Recognise the non‐hormonal options for
management of menopause symptoms
Mild Vasomotor
* Layered clothing that can be removed or added as necessary
* Lower room temp
* Less spicy food / caffeine / hot drinks
* More exercise
* Dietary supplements
conflicting:
Isoflavones & Black
Cohosh
Mild Vulvovaginal
* Nonhormonal vaginal lubricants / moisturizers
give _______ for pts without an intact uterus
Estrogen only
Rationale for Progestin in MHT
- Added on to patients with an intact
uterus to protect the endometrium
from overgrowth (& risk of
endometrial cancer)
Types available: Dydrogesterone,
norethisterone,
medroxyprogesterone, micronized
progesterone, norgestrel,
levonorgestrel, gestodene,
desogestrel, norgestimate
It may take ______ months of use before seeing a vast improvement of
menopausal symptoms
2-3
Monitoring for MHT:
Upon initiation:
* Annual mammography
* Endometrial surveillance
* Unopposed estrogen: any vaginal bleeding
* Continuous-cyclic: if bleeding occurs when progestin is still on
* Continuous-combined: if bleeding is prolonged, heavier than normal,
frequent, persists after >10 months after treatment started
* Upon discontinuation, 50% chance of symptoms returning
other pharmacological for VMS
Antidepressants
* Serotonin and
norepinephrine
reuptake inhibitors
(SNRIs) esp
venlafaxine
* Selective serotonin
reuptake inhibitors
(SSRIs) esp
paroxetine
Gabapentin
* Night sweating
* Sleep disturbances
Tibolone ($$$)
* Synthetic steroid with estrogenic, progestogenic and androgenic effects
* Improves mood, libido, menopause symptoms, vaginal atrophy (less than estrogen)
* Protects against bone loss
* Risk of stroke, breast CA recurrence,
endometrial cancer
* Only indicated in postmenopausal women ≥ 12 months since last natural period
