Contraception and the Menstraul Cycle Flashcards
1
Q
List hormonal methods of contraception
A
- Combined
- COC
- Contraceptive patch
- Vaginal ring
- Progesterone’s
- POP
- Implants
- Injections
- IUS
2
Q
List methods of non hormonal contraception
A
-
Barrier
- condoms
- female condomes
- Diphragm
- Sterilisation
- IUD (copper)
3
Q
List methods of emergency contraception
A
- Emergency contraceptive pills
- IUD/coil
4
Q
What are examples of barrier methods of contraception?
A
- Male condoms
- Female condoms
- Diaphragm
5
Q
What are benefits of male condoms?
A
- Only used during intercourse
- Reduces STI transmission
- Rarely side effects from use
6
Q
What are the limitations of male condoms?
A
- Can break, split or tear during use
- Can interrupt intercourse to put a male condom on
- Need to know the correct technique for using condoms
- Some patients are allergic to latex condoms
7
Q
What is the effectiveness of condoms from typical use?
A
82%
8
Q
What are the benefits of female condom use?
A
- Only used during intercourse
- Reduces STI transmission
- Rarely side effects from use
9
Q
What are limitations to female condom use?
A
- Can break, split or tear during use
- May interrupt intercourse to put the female condom in place
- Need to know the correct technique for using condoms
- Female condoms are not as widely available as male condoms
10
Q
What is the diaphragm form of contraception?
A
Silicone cup which is placed over the cervix as a barrier to sperm
11
Q
What are the benefits of diaphragm contraception?
A
- Only used during intercourse
- Can be put in place in advance of intercourse
- Rarely side effects from use
- Some protection against STIs
12
Q
What are the limitations of a diaphragm?
A
- Can break, split or tear during use
- May interrupt intercourse to put the diaphragm in
- Patients need to know the correct technique for using a diaphragm
- Does not protect against STIs
13
Q
What is the effectiveness of the female condom?
A
79%
14
Q
What is the combined contraceptive?
A
Contain forms of both oestrogen and progesterone
15
Q
What is the mechanism of of action of COCP?
A
STOPS OVULATION: They work by mimicking the luteal phase of the menstrual cycle, leading to inhibition of the hypothalamic-pituitary-gonadal axis. This prevents the release of LH and FSH needed for ovulation.
PREVENTS IMPLANTATION: By thinning the lining of the uterus.
INHIBITS SPERM PENETRATION: Combined contraceptives further reduce the risk of pregnancy by thickening the cervical mucus to prevent sperm passage and by thinning the endometrium to reduce the chance of implantation.
16
Q
How often is the oral contraceptive pill taken?
A
21 days followed by a 7 day break
20-35 micrograms
17
Q
What occurs within the pill-free week when a woman is using the COCP?
A
Withdrawal bleed
18
Q
What are examples of combined oral contraceptives?
A
- COCP
- Contraceptive patches
- Vaginal rings
19
Q
What are the benefits of the COCP?
A
- Does not interrupt intercourse
- Can be stopped at short notice if not tolerated
- May make periods more regular, lighter and less painful
- May reduce the risk of ovarian, endometrial and bowel cancer
- May have therapeutic benefits in gynaecological disorders including endometriosis and menorrhagia
20
Q
What are limitations of COCP?
A
- Effectiveness reduced if pill is forgotten
-
Side effects
- MINOR: Side effects may include headaches, nausea, breast tenderness and mood swings
- MAJOR: Increases the risk of VTE and stroke. Risk of cervical cancer and breast cancer.
- Vomiting and diarrhoea may affect effectiveness
- Certain drugs including some antibiotics (rifampicin) and anti-epileptic drugs may affect effectiveness - need increased dose
- Potentially increases the risk of breast cancer while using the COCP
- Does not protect from STIs
21
Q
What are contraindicaitons for the use of combined contraceptive options?
A
- Migraine with aura
- Current breast cancer
-
High VTE risk factors, such as:
- Atrial fibrillation
- SLE positive for antiphospholipid antibodies
- Age over 35 years old and smoking at least 15 cigarettes daily
- History of stroke
- History of VTE
- Major surgery with prolonged immobilisation
- Known thrombogenic mutations
- Complicated valvular or congenital heart disease
-
Other cardiovascular risk factors such as:
- Hypertension: >160mmHg / >100mmHg
- History of ischaemic heart disease
- Severe liver disease
22
Q
What part of combined contraceptive increases risk of VTE?
A
Oestrogen
23
Q
What’s the risk of VTE?
A
5 in 100,000.
In pregnancy rises to 60/100,000.
24
Q
How do contraceptive patches work?
A
Contraceptive patches deliver their oestrogen and progesterone through the skin and inhibit ovulation as pill. They are approximately 4x4cm in size and can be applied to any skin except the breast, where the tissue is oestrogen sensitive
25
How are contraceptive patches used?
One patch is applied for **7 days** and then immediately changed for a new patch. **3 patches should be worn for 21** **days** in total and then there should be **7 days without a patch** when they have a period-like withdrawal bleed. **The next 21 days of patches should be started after exactly 7 days**. Can be worn on abdomen/upper outer arm/upper torsa/buttocks
26
What are benefits of contraceptive patches?
* **Do not need to remember daily like the pill - so better complicance**
* **Does not interrupt intercourse**
* **Can be stopped at short notice if not tolerated**
* **May make periods more regular, lighter and less painful**
* **May reduce the risk of ovarian, endometrial and bowel cancer**
* **Vomiting and diarrhoea do not affect effectiveness unlike the pill**
27
What are limitations of contraceptive patches?
* **Protection from pregnancy may be affected if they forget to change the patch or if it falls off**
* **Side effects may include headaches, nausea, breast tenderness and mood swings**
* **Certain drugs may affect effectiveness including some anti-epileptic drugs**
* **Increases the risk of VTE and stroke**
* **Potentially increases the risk of breast cancer while using the patch**
* **Does not protect from STIs**
28
How does the vaginal ring work?
The contraceptive vaginal ring (also known as the NuvaRing®) is a small plastic ring that is placed high in the vagina and secretes oestrogen and progesterone to prevent ovulation.
29
How is a vaginal ring used?
The ring is inserted into the vagina for 21 days and then removed for 7 days before the next ring is put in.
30
What are the benefits of vaginal rings?
* **Do not need to remember daily like the pill**
* **Does not interrupt intercourse**
* **Can be stopped at short notice if not tolerated**
* **May make periods more regular, lighter and less painful**
* **May reduce the risk of ovarian, endometrial and bowel cancer**
* **Vomiting and diarrhoea do not affect effectiveness unlike the pill**
31
What are limitations of the vaginal ring?
* **Side effects may include headaches, nausea, breast tenderness and mood swings**
* **Certain drugs may affect protection including some anti-epileptic drugs**
* **Increases the risk of VTE and stroke**
* **Potentially increases the risk of breast cancer while using the ring**
* **Does not protect from STIs**
32
Contraindications to oestrogen
* CVD risk factors (smoking, diabetes, hyeprtension, ishcaemic heart disease, stroke)
* Personal/close family of VTE
* Migraine with aura
* Breast cancer/carrier of BRCA gene
* Gall bladder and liver disease
* BMI\>35 years
* Sustained systolic BP \>140 or diastolic
Need height, weight, BMI
33
How does progesterone only pill work?
* **Desogestrel POP** - inhibiting ovulation, thickens cervical mucus and thinning the endometrium.
* **Norethisterone and levonorgestrel POPs -** thickens cervical mucus and thinning the endometrium.
34
What are examples of progesterone-only contraceptives?
* **POP**
* **Contraceptive injection**
* **Progesterone implant**
35
What are benefits of POP?
* **Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen**
* **Taken without breaks so don’t have to remember to start and stop pills**
* **Does not interrupt intercourse**
* **Can be stopped at short notice if not tolerated**
36
Progestogenic side effects
(DMPA, POI, POP, IUS)
* Acne, bleding, breast tenderness and mood change
* Bleeding problems are very common - heacy/spotting/prolonged
37
How would you take a Progesterone only pill?
Needs to be taken every day
* **Pills with etynodiol/norethistrone/levonogestrol -** have a 3hr window
* **Desogestrel POP** - 12h window
38
What are benefits of using POP?
* **Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen**
* **Taken without breaks so don’t have to remember to start and stop pills**
* **Does not interrupt intercourse**
* **Can be stopped at short notice if not tolerated**
39
What are limitations of POP?
* **Protection from pregnancy affected if pill is forgotten**
* **May cause irregular bleeding, amenorrhoea or more frequent bleeding**
* **Vomiting and diarrhoea may affect protection**
* **Certain drugs including some antibiotics may affect effectiveness**
* **Does not protect from STIs**
* **SE**
* **Wegiht gain, irregular bleeding, ovarian cysts, delay 2 fertility**
* **CI - severe liver disease, breast**
40
What are contraindications for PO contraceptive use?
* **Current breast cancer**
* **Trophoblastic disease**
* **Liver disease - acute hepatitis, decompensated cirrhosis**
* **Migraine with aura**
* **IHD**
* **Stroke/TIA**
* **SLE with antiphospholipid antibodies**
* **Undiagnosed vaginal bleeding**
41
What is the DepotProvera injection?
Injection containing progesterone only carried out every 12 weeks. It is typically administered intramuscularly into the buttocks
42
How does the DepoProvera injection work?
It is typically administered intramuscularly into the buttocks. The systemic progesterone inhibits ovulation, thickens the cervical mucus and thins the endometrium.
43
What are benefits of DepoProvera?
* **Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen**
* **Do not need to remember to take a pill daily**
* **Does not interrupt intercourse**
* **Reduced risk of endometrial cancer, ectopic pregnancy, sickle cell crises**
* **May help menorrhagia** (v. effective - epridos usually absent after 3rd injection)
* Contraceptive effects last for 14 weeks - periods can then take months to return to normal
44
What are limitations of DepoProvera?
* **May cause irregular bleeding, amenorrhoea or more frequent bleeding**
* **Patient needs to tolerate injections**
* **Effectiveness reduced if late getting next injection**
* **Can affect bone mineral density if used long-term - peak bone mass acheived in teen years so not used in those \<18 or \>45**
* **Certain drugs including some antibiotics may affect effectiveness**
* **Does not protect from STIs**
* **Weight gain of 2-3kg/year**
* **Review after 2 years**
45
How long does a progesterone implant last for eg Mirena?
**Lasts for 3 years**
46
How does the progesterone implant work?
Inhibits ovulation as well as thickening the cervical mucus and thinning the endometrium.
47
What are benefits of the progesterone implant?
* **Once inserted, it lasts for 3 years**
* **Suitable for those who cannot use oestrogen**
* **Very effective in preventing pregnancy**
* **Does not interrupt intercourse**
48
When is the ideal time to insert progesterone implant?
**Days 1-5 of cycle** - any other time use condom for 7 days
49
What are limitations of progesterone implant?
* **May cause irregular bleeding, amenorrhoea or more frequent bleeding**
* **Can cause or worsen acne**
* **Procedure to fit and remove it which has a risk of bruising and infection**
* **Does not protect from STIs**
50
What are contraindications to the IUS?
Endometrial/cervical/ovarian cancer
51
When is the best time to give the progesterone injection?
**Days 1-5** - any other time use condoms for 7 days
52
How would you advise using the vaginal ring?
Insert into vagina on day 1 of cycle, than leave in for 3 weeks
53
If someone vomits \<2hrs after taking an oral contraceptive pill, what advice would you give them?
Take another pill
54
What advice would you give someone who had missed their pills for \> 48 hrs?
Continue pills as per usual, but use condoms for 7 days. If this includes 7 day break, start next pack without break
55
When would you consider emergency contraception in someone on COCP?
If 2 or more pills missed in 1st 7 days of pack + unprotected intercourse
56
When would you consider emergency contraception in someone on POP?
If 1 or more POP missed or taken \> 3hrs late (or 12hrs if Desogestrel) and unprotected sex has occured
57
When would you consider emergency contraception in failure of barrier method?
If it fails - spliting/slippage
58
When would you consider emergency contraception in someone on progesterone injection?
If \> 12 weeks 5 days from last injection and unprotected sex has occured
59
If someone has diarrhoea, what advise would you give them regarding contraception?
Consult package insert
* **Continue pills if able** - also use condoms for number of days of diarrhoea
* **If not taken for \>48hrs** - use condoms for 7 days + days of diarrhoea
60
When would you start contraception postnatally?
Start 21 days after birth
61
When may those whho are under the age of 16 be prescribed contraceptionwithout parental consent?
Fraser guidelines
1. **They understand doctor's advise**
2. **Cannot be persuaded to inform parents**
3. **Likely to continue/begin intercourse regardless of contraception**
4. **Their physical/mental health may be affected if they don't have it**
5. **Young person's best interests require that the doctors gives advice and/or treatment without parental consent**
62
How does the hormonal coil work?
Release progesterone locally. They prevent pregnancy by thinning the endometrium to prevent implantation and by thickening cervical mucus to prevent sperm passage.
63
What is the most commonly used hormonal coil?
Mirena coil
64
How long does the mirena coil last?
3-5 years
65
What are the benefits of mirena coil?
* **It lasts for 3 or 5 years**
* **Suitable for those who cannot take oestrogen**
* **Very effective in preventing pregnancy**
* **Does not interrupt intercourse**
* **More likely than the implant to reduce heavy menstruation**
66
What are limitations of the mirena coil?
* **Can make menstruation irregular especially in the first 6 months from fitting and can cause amenorrhoea**
* **Can cause acne, headaches and breast tenderness**
* **Procedure to fit and remove it which some find too painful to tolerate and has a risk of infection and uterine perforation**
* **Can be expelled from the uterus**
* **If pregnancy occurs, more likely to be an ectopic pregnancy**
* **Does not protect from STIs**
67
How does the copper coil work?
Prevent pregnancy by creating an inhospitable environment for the sperm and ovum to survive in the uterus.
68
How long does the copper coil last for?
10 years
69
What are benefits of the copper coil?
* **It lasts for 10 years**
* **Suitable for women who cannot use hormonal contraceptives**
* **Very effective in preventing pregnancy**
* **Does not interrupt intercourse to use it**
* **Effectiveness unaffected by other medications**
* **Can be used as emergency contraception**
70
What are limitations of the copper coil?
* **Can cause heavier, longer and more painful menstruation**
* **Procedure to fit and remove it which some find too painful to tolerate and has a risk of infection and uterine perforation**
* **Can be expelled from the uterus**
* **If pregnancy occurs, more likely to be an ectopic pregnancy**
* **Does not protect from STIs**
71
What general problems can occur with intrauterine contraceptive devices?
* **May be expelled** - nulliparous or fibroids in uterus
* **Can cause PID in first 21 days**
* **Can cause dysmenorrhoea and menorrhagia**
* **Risk of ectopic pregnancy**
72
What are contraindications to intrauterine devices?
* **Pregnancy**
* **Current pelvic infection/STD**
* **Alelrgy to copper**
* **Wilson's Disease**
* **Heavy/painful periods**
* **Trophoblastic disease**
* **Gynaecological malignancy**
* **Undiagnosed abnormal uterine bleeding**
* **Distorted cavity**
73
What are the main types of female sterilisation?
* **Tubal occlusion with surgical clips**
* **Hysteroscopic sterilisation using fallopian implants**
* **Salpingectomy**
74
What are the benefits of female sterilisation techniques?
* **Permanent contraception**
* **Does not interrupt intercourse**
* **Does not affect their hormonal levels**
* **Effectiveness unaffected by other medications**
* **Small risk ectopic**
* **Reversal not funded by NHS**
75
What are limitations to female sterilisation?
* **Carries risks of surgery including bleeding and infection**
* **Many women experience pain after their surgery**
* **Very difficult to reverse**
* **Women need to be informed that in rare cases they can still become pregnant**
* **If pregnancy occurs, more likely to be an ectopic pregnancy**
* **Does not protect from STIs**
76
What are the options for male sterilisation?
**Vasectomy** - local anaesthetic to the scrotum and testicles to remove a section of each vas deferens. This stops sperm from entering the semen. From around 8 weeks a semen kit is mailed out and men are asked to provide a sample of ejaculation to be tested for sperm. 2 negative samples needed before op considered a sucess.
77
What are benefits of male sterilisation?
* **Permanent contraception**
* **Does not interrupt intercourse**
* **Less invasive and lower risk procedure than female sterilisation (done under local)**
78
What are limitations of male sterilisation?
* **Carries risks of surgery including bleeding and infection**
* **Some men experience pain after their surgery**
* **Very difficult to reverse**
* **Contraception should be used afterwards until semen confirmed to be sperm-free**
* **Does not protect from STIs**
* **Takes at least 2 months to become effective**
79
What are examples of emergency contraception?
* **Levonelle**
* **ellaOne**
* **Copper coil**
80
How does levonelle work?
A high dose of the synthetic progesterone Levonorgestrel. It is thought to prevent pregnancy by delaying or stopping ovulation
81
How long after intercourse is the Levonelle effective?
72 hours
Although efficacy reduces overtime
82
Does of levonelle (levonorgestrel)
1500ug
Note that dose coubles after taking liver inducing drugs - eg rigampicin, anticonvulsants, rifabutilin, tacrolimus, certain HIV drugs
83
How does ellaOne (ulipristal) work?
Contains ulipristal acetate, prevents pregnancy by delaying or stopping ovulation
84
How long after intercourse is EllaOne effective?
120 hours
85
When is ellaOnes efficacy reduced?
When the woman is taking POP
86
How long after intercourse is the copper coil effective as emergency contraception?
120 hours
87
What is the most effective form of emergency contraception?
Copper coil
88
How long after intercourse than the intrauterine copper coil bet taken?
Taken up to 5 days after sex
Should return after next period for removal/thread check if planning to continue to use it
89
Advantages of IUD
Highly effective, fertility returns on removal
No hormones
Can last for up to 10 years
90
Disadvatnages of IUD
During insertion can perforate and enter abdo cavity (rare)
Small chance of infection
If device fails there is a 20% change the pregnancy will be ectopic
Periods ca be heavier
91
What hormone is produced from the hypothalamus that signals the pituitary gland to release gonadotrophins?
GnRH
92
What hormones are released from the pituitary gland when stimulated by GnRH?
* **LH**
* **FSH**
93
What is the mechnism of action of FSH?
* **Development of ovarian follicles**
* **Secretion of oestrogen**
* **Secretion of inhibin**
94
What is the dominant follicle in the menstrual cycle also known as?
**Groofian follicle** - Most sensitive to FSH
95
What is the mechanism of LH?
* Production of oestrogen which is required for ovulation and thickening of the endometrium
* Conversion of the Graafian follicle into the progesterone producing corpus luteum
* Progesterone causes the endometrium to become receptive to implantation of a fertilised ovum
96
What are the negative feedback hormones for the HPG axis?
* **Oestrogen**
* **Progesterone**
* **Inhibin**
97
What happens to FSH and LH during pregnancy?
Remain inhibited due to cessation of menstruation
98
What occurs in the follicular phase of the menstrual cycle?
1. **FSH rise causes stimulation of a few ovarian follicles** - 1st follicle to become fully mature will produce large amounts of oestrogen, which inhibits other follicles
2. **Oestrogen causes** - Endometrial thickening, Thinning of cervical mucous to allow easier passage of sperm. It also inhibits LH production
3. **Ovum matures -** oestrogen reaches a threshold level which conversely causes a sudden spike in LH around day 12 - causes the membrane to become thinner.
4. **Follicle ruptures** - releasing a secondary oocyte, which quickly matures and is released into the peritoneal space and is taken into the fallopian tube via fimbriae
99
What occurs in the luteal phase of the menstrual cycle?
1. **LH and FSH** - cause the remaining graafian follicle to develop into the corpus luteum - begins to produce progesterone from coprus luteum
2. **Progesterone** - causes endometrium to become receptive to implantation of the blastocyst
3. **Oestrogen** - secreted by the adrenal glands, gives negative feedback causing decreased LH and FSH. This causes coprus luteum to degenerate, resulting in progesterone levels decreasing
4. **Menstruation** - stimulated by decreased prrogesterone. Entire cycle starts again after this
100
What happens if an ovum becomes fertilised?
* **Ovum produces BHCG** - prevents degeneration of corpus luteum
* **Continued progesterone production** - prevents menstruation
* **Placenta takes over corpus luteum** - 8 weeks
101
When is a woman most fertile?
Between 5 days before ovulation until 1 to 2 days after.
Days 8-17 there is a 20-30% risk of pregnancy
Days 1-7 there is a 23% risk
102
What occurs in the proliferative phase of the uterine cycle?
* **Endometrium exposed increased oestrogen** - causes repair and growth of the functional endometrial layer
* **Continued exposure to oestrogen** - Increased endometrial thickness, vascularity and number of secretory glands
103
What occurs in the secretory phase of the uterine cycle?
**Progesterone develops uterus** - causes endometrial glands to begin secreting various substances, making the uterus a more welcoming environment for an embryo to implant.
104
What occurs during the menstrual phase of the uterine cycle?
**Decreased progesterone production**.- cause the spiral arteries in the functional endometrium to contract, leading to the functional endometrium to become ischaemic and necrotic. This sheds and exits out through the vagina
105
What are symptoms experienced during menstruation?
* **Abdominal pain and cramps**
* **Vaginal bleeding**
* **Nausea**
* **Diarrhoea**
* **Sweating**
* **Fatigue**
* **Irritability**
* **Dysphoria (unhappiness)**
106
How can breastfeeding affect periods?
Can cause ammenhorroea. Lactational ammenhorea produces 98% contraceptive cover.
107
Difference between IUS and IUD
IUS is progestogen eg Mirena
IUD is copper
