Women's health Flashcards
Intrauterine devices (IUDs) and intrauterine systems (IUS, e.g. Mirena) are both used as modes of contraception. IUS is also used for management of menorrhagia.
What’s the mode of action of IUD and IUS?
IUD: prevention of fertilisation by causing decreased sperm motility and survival.
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening.
When counselling patients for IUD and IUS, what are some of the differences ?
- can be relied upon immediately following insertion vs IUS that can be relied on after 7 days of insertion.
- IUDs and most commonly used IUS (Mirena - levonorgestrel 20mcg/24hrs) are effective for 5 yrs (although some IUDs effective for 10 yrs exist).
- if IUS is used for endometrial protection for those using oestrogen-only HRT, it is licensed for 4 yrs.
What are some of the problems with IUDs and IUSs?
- IUD make periods heavier, longer and more painful.
- IUS - initial frequent uterine bleeds and spotting. Later, typically only intermittent light menses with some women amenorrheic.
- Uterine performation 2 in 1000, higher risk in breastfeeding women.
- Ectopic pregnancy (EP) - proportion of ectopic pregnancies increased but absolute number of EP reduced compared to those not using contraception.
- infection - increased risk in first 20 days of insertion, afterwards back to baseline.
- Expulsion - risk is around 1 in 20, most likely in first 3 months.
What are the properties of some of the newer IUSs?
- Jaydess IUS - licensed for 3 yrs, has lesss levonorgestrel (LNG) than mirena (13.5mg vs 52mg) - this results in lower serum LNG.
- Kyleena IUS has 19.5mg LNG, licensed for 5 years. Rate of amenorrhoea is less with Kyleena vs Mirena.
what’s new regarding whooping cough and pregnancy?
Since the 2012 outbreak of whooping cough which resulted in death of 14 newborn children - women who are between 20-32 weeks pregnant are now offered whooping cough vaccine.
What are the emergency contraception (EC) options?
Two hormonal Ievonorgestrel and Ulipristal) and a IUD are the current EC options.
Main features of levonorgestrel used as EC?
- should be taken ASAP, must be within 72 hrs of UPSI.
- single dose of 1.5mg - dose be doubled for those with BMI>26 or weight >70kg.
- 84% effective if used within 72hrs.
- S.E: vomiting (1%), disturbance of current cycle ( in minority), if vomit within 3 hrs - repeat dose.
- can be taken more than once in a cycle.
- hormonal contraception can be started immediately after using levonorgestrel (levonelle) for EC.
What are features of Ulipristal when used for EC?
- Marketed as EllaOne.
- Primary mode of action thought to be inhibition of ovulation.
- 30mg oral dose ASAP but no later than 120hrs since UPSI.
- May reduce effectiveness of hormonal contraception, there these contraception should be started (re-started) 5 days after Ulipristal. Barrier method should be used in the meantime.
- Caution in patient with severe asthma.
- Ulipristal can be used more than once in the same cycle.
- breastfeeding should be delayed for 1 week after taking this.
Features of IUD when used as EC.
- must be inserted within 5 days of UPSI or
- if women presents after 5 days, then IUD may be fitted upto 5 days after the likely ovulation date.
- prophylactic Abx may be given if pt considred to be high-risk of STI.
- 99% effective, regardless of when in cycle used.
- may be left in situ for long-term contraception.
What’s the deal with statins and pregnancy?
statins should be discontinued in women 3 months before conception due to risk of congenital defects.
What are forms of ovulation induction?
- Exercise and weight loss
- Letrozole
- Clomiphene citrate
- Gonadotropin therapy.
How does Letrozole work and what are its common side effects?
- now considered 1st line medical therapy for pt with PCOS needing ovulation indcution.
- is aromatase inhibitor, reducing -ve feedback caused by oestrogen to pituitary gland, therefore increasing FSH and promoting follicular development.
- rate of mono-follicular development much higher wit this compared to clomiphene, which is a key goal in ovulation induction.
Side effects: fatigue (20%), dizziness (10%).
Clomiphene citrate - how does it work and what are its common side effects?
- selective oestrogen receptor modulator (SERMs) - act primarily at the hypothalamus, blocking the - ve feedback effect of oestrogens. This leads to increased GnRH pulse frequency and therefore, FSH and LH production, stimulating ovarian follicular development.
- Side effects: hot flushes (30%), abdo distension and pain (5%), nausea and vomiting (2%).
How does gonadotropin therapy work?
- usually for hypogonadotropic hypogonadism type of infertility.
- the risk of multi-follicular development and subsequent multiple preganancy is much higher as well as risk of ovarian hyperstimulation syndrome.
- mechanism of action - pulsatile GnRH therapy ileads to endogenous production of FSH and LH and subsequent follicular development.
Cervial screen, who is screened and how often?
Smear test is offered to all women between ages 25-64
- 25 - 49: 3 yrly
- 50 - 64: 5yrly
Special situations:
- in pregnancy, delayed until 3 months post-partum, unless missed screening or prev abnormal smear.
- those who have never been sexually active at low risk - so may wish to opt-out.
