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Contraception/HRT Flashcards

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1
Q

Describe the physiology of the monophasic COCP?

A

Releases high amounts of progesterone and oestrogen throughout the monthly cycle. These act as negative feedback on the pituitary gland, to reduce levels of FSH and LH, thus preventing stimulation of a follicle to mature. This overall prevents an egg from being released, thus causing contraceptive effects.

The low level of oestrogen also has local effects on the endometrial lining in order to maintain a constant thin endometrial lining. Progesterone works synergistically with oestrogen to do this.

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2
Q

what are the benefits of a monophasic COCP?

A

Highly effective contraceptive rates (> 99%)
Regular bleeding - predictable
Constant hormone levels - simple and easy to use, rather than remembering different doses and levels
Improvement in acne
Improvement in menorrhagia
reduced rates of ovarian and uterine cancer

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3
Q

what are the negatives of monophasic COCP?

A

Can have higher level of side effects than the multiphasic COCP
Does not follow natural fluctuations in hormones

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4
Q

what are some examples of the monophasic COCP?

A

Microgynan 30
Microgynan 20

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5
Q

what are some examples of multiphasic COCP?

A

Qlaira
Yaz

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6
Q

How do multiphasic COCP work?

A

Release varying levels of oestrogen and progesterone throughout the cycle, to mimic natural fluctuations more closely.
These can be biphasic or triphasic depending on the type. They typically have 2 pills which are placebo, to again mimic the natural fall in hormone levels towards the end of the cycle.

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7
Q

what are the benefits of multiphasic COCP?

A

reduced side effects
tolerated better
reduced uterine and ovarian cancer rates

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8
Q

what is the benefit of the Yaz pill specifically?

A

It is taken over 24 days, with 4 pill free days.
This reduces the amount of pre-menstrual symptoms, by reducing the amount of time without progestin/oestrogen. This stability reduces the risk of premenstrual symptoms.

Additionally, the Yaz pill contains drospirenone, a progestin that has anti-androgenic and mild diuretic properties similar to spironolactone. This can help reduce water retention, bloating, and symptoms related to excess androgens, such as oily skin and hair growth.

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9
Q

which is better for PMDD - the COCP continuous dosing or the Yaz pill?

A

Continuous Regimen: Ideal for those who want to completely avoid periods and associated symptoms, or those with severe PMS/PMDD.

Yaz 24/4 Regimen: Better suited for those who prefer to have some regularity in their cycle while still managing premenstrual symptoms.

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10
Q

what are the negatives of continuous dosing of the COCP?

A

Breakthrough bleeding
psychological discomfort due to the absence of periods
potential delays in detecting pregnancy
concerns about long-term effects

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11
Q

how long can you use the COCP continuously for?

A

3 months (12 weeks) followed by a 4- or 7-day break to allow for withdrawal bleeding
although many healthcare providers suggest 6, 9 or even 12 months. There is no specific rule.

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12
Q

what are the rules if you miss one COCP?

A

take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day

no additional contraceptive protection needed

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13
Q

what are the rules if you miss 2 or more pills in week 1 of COCP?

A

take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day

emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1.

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14
Q

what are the rules if you miss 2 or more pills in week 2 of COCP?

A

After seven consecutive days of taking the COC there is no need for emergency contraception.

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15
Q

what are the rules if you miss 2 or more pills in week 3 of COCP?

A

she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

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16
Q

what are the contraindications to the COCP?

A

< 6 wks postpartum
smoker over the age of 35 (>15 cigarettes per day)
hypertension (systolic > 160mmHg or diastolic > 100mmHg)
current of past histroy of venous thromboembolism (VTE)
ischemic heart disease
history of cerebrovascular accident
complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis)
migraine headache with focal neurological symptoms
breast cancer (current)
diabetes with retinopathy/nephropathy/neuropathy
severe cirrhosis
liver tumour (adenoma or hepatoma)

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17
Q

how do you start the COCP in a woman that is amenorrheic?

A

Start the combined oral contraceptive (COC) at any time, if it is reasonably certain that the woman is not pregnant.

if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days.

Additional contraception is required for 7 days (9 days for Qlaira®).

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18
Q

how do you start the COCP in a woman that is postpartum and not breastfeeding?

A

Start the COC on day 21 postpartum if there are no additional risk factors for venous thromboembolism.
Additional contraception is required for 7 days.

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19
Q

how do you start the COCP in a woman that is postpartum and is breastfeeding?

A

Do not start a COC if the woman is less than 6 weeks postpartum.

After 6 weeks and before 6 months postpartum, start the COC as for postpartum women who are not breastfeeding.

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20
Q

what are the negatives of the COCP?

A

people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be seen

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21
Q

what form do combined contraceptives come in?

A

transdermal patch
oral contraceptives
vaginal ring

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22
Q

how does the transdermal combined patch work?

A

Inhibition of Ovulation: The primary way the patch prevents pregnancy is by inhibiting ovulation. The hormones suppress the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland, preventing the ovary from releasing an egg each month.
Thickening of Cervical Mucus: The progestin in the patch also thickens the cervical mucus, making it difficult for sperm to travel through the cervix and reach an egg.
Thinning of the Endometrial Lining: The patch causes changes to the endometrium (the lining of the uterus), making it less suitable for implantation if an egg were to be fertilized.

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23
Q

how long do you wear the transdermal combined patch?

A

Each patch is worn for one week, and it is replaced with a new patch on the same day of the week for three consecutive weeks. After three weeks (21 days), no patch is worn during the fourth week, allowing for a withdrawal bleed similar to a menstrual period.

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24
Q

what is oestrogens role in maintaining bone density?

A

Estrogen plays a crucial role in maintaining bone density by inhibiting bone resorption (the process where bone is broken down) and promoting bone formation. A reduction in estrogen levels can lead to increased bone loss and a higher risk of osteoporosis.

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25
what are some common side effects in general of the COCP?
Nausea breast tenderness bloating and fluid retention headache dysmenorrhoea decreased libido breakthrough bleeding
26
If on a COCP and experiencing nausea, how should the COCP be adjusted?
reduce oestrogen dose exclude pregnancy take pills at night consider switching to progesterone only
27
if on COCP and experiencing breast tenderness, how should the COCP be adjusted?
reduce ostrogen and/or progesterone dose change to different type of progesterone consider using pill containing drospirenone
28
if on COCP and experiencing bloating and fluid retention, how should COCP be adjusted?
reduce oestrogen dose change to progesterone with mild diuretic effect such as drospirenone
29
if on COCP and experiencing headaches, how should COCP be adjusted
reduce oestrogen and/or change progesteron
30
if on COCP and experiencing dysmenorrhea, how should COCP be adjusted?
extended pill regimen to reduce frequency of bleeding
31
if on COCP and having breakthrough bleeding, how should COCP be adjusted?
if taking an ethinyloestradiol 20 microgram pill, increase oestrogen dose to a maximum of 35 micrograms change progesterone already try another form of contraception
32
what is the hormone content of microgynan 30?
ethinylestradiol 30 levonorgestrel 150
33
what are some specific side effects of COCP's such as microgynan and rigevidon?
oily hair or skin loss of libido bloating
34
what are some gynaecological red flags?
post menopausal bleeding abnormal discharge feeling of bloating/fullness pelvic masses ascites post-coital bleeding dyspaerunia lump/skin changes of vulva vulval itching vulval pain/soreness
35
what are some red flags of endometrial cancer?
post-menopausal bleeding heavier periods vaginal discharge weight loss
36
what are the risk factors for endometrial cancer?
Prolonged periods of unopposed oestrogen are the main risk factor. When oestrogen is not modified by the effects of progesterone, this is termed 'unopposed oestrogen'. PCOS - persistently high oestrogen causes proliferation of the endometrium family history of endometrial cancer Nulliparity Obesity - raises levels of oestrogen Tamoxifen use hereditary nonpolyposis colon cancer (HNPCC) - 30-60% lifetime risk of endometrial cancer Menopause past the age of 52
37
what are the types of endometrial cancer?
80% adenocarincoma 20% squamous cell carcinoma Endometrial cancers can also be subclassified into: oestrogen-dependent endometrioid (type 1) and oestrogen-independent non-endometrioid carcinomas (type 2).
38
what is the management of a woman who presents to the practice with first episode of post-menopausal bleeding?
referral via 2ww
39
what investigations are done to investigate a possible endometrial cancer? (these are typically done by the gynaecology team via 2ww)
TVUSS - measure the endometrial thickness Hysteroscopy + endometrial biopsy most women will also have bloods as routine + CXR. test for lynch syndrome.
40
what are the stages of endometrial cancer?
stage 1- confined to the corpus uteri stage 2- This involves the corpus and there is invasion into the cervical stroma but it has not extended outside the uterus stage 3- This has local or regional spread outside the uterus but still confined to the reproductive organs. stage 4 - This is involvement of the bladder or bowel mucosa, or distant metastasis
41
Management of stage 1 endometrial cancer?
Stage I requires total abdominal hysterectomy with bilateral salpingo-oophorectomy. The role of lymphadenectomy is debated. The use of progestogen in the treatment of stage IA endometrioid endometrial cancer without myometrial invasion is an option for those women who want to preserve their fertility.
42
Management of stage 2 endometrial cancer?
In stage II there should be radical hysterectomy with systematic pelvic node clearance.
43
Management of stage 3 and stage 4 endometrial cancer?
Stage III and IV are best treated with maximal de-bulking surgery in those women with good performance status and resectable tumour
44
what is the prognosis of endometrial cancer?
Those women who are diagnosed early have a far better prognosis. Most recurrences will occur within the first three years after treatment. The majority of women (80% in stage I) will be diagnosed with early-stage disease and are cured with surgery. For this group of women five-year survival rates are over 95%; however, five-year survival rates are much lower if there is regional spread or distant disease (68% and 17%, respectively)
45
what are some causes of endometrial thickening?
PCOS obesity adhesions fibroid with degeneration ovarian tumours endometrial hyperplasia
46
how should suspected endometrial thickening be investigated?
TVUSS on day 5-12 of the cycle
47
Management of endometrial thickening on USS?
refer via 2ww
48
Management of confirmed endometrial hyperplasia?
Usually using contraceptive methods containing progesterone to regulate the endometrial lining growth - i.e. IUS If pre-menopausal: Hormonal contraceptives - can have POP, COCP, implant, injections and IUS If menopausal: Progestin-only birth control pills Progestin injections Vaginal cream containing progestin An IUD that gradually releases progestin
49
what are the indications for considering HRT?
perimenopausal women with vasomotor symptoms perimenopausal women with low CVD risk women who have a high FRAX score (who have a high risk of osteoporosis fractures)
50
what type of HRT would you recommend to a perimenopausal woman who has vasomotor symptoms, who is 49 years old?
cyclical HRT - in order to avoid breakthrough bleeding
51
what type of HRT would you recommend for a woman who has vasomotor symptoms who has been postmenopausal for 2 years?
continuous HRT - less risk if unscheduled bleeding
52
what are the benefits of HRT?
improves hot flushing (77%); improves headaches (30%) and insomnia (55%) reverses genital tract atrophy improves psychological symptoms e.g. confidence improved in about 30% reduces osteoporosis and thus, fracture rate
53
how does HRT impact risk of stroke?
Explain to women that taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke
54
in which forms can you prescribe sequential HRT?
oral transdermal
55
when does the perimenopause state usually happen?
Perimenopause usually occurs between the ages of 40 and 50. The average age of onset is 47 and can last between 4-8 years
56
what are the risks with oral HRT?
increased risk of VTE - highest risk during the first 12 months increased risk of CHD - using combined oral HRT started past the age of 60 years slight increase in breast Ca incidence - particularly when using HRT for more than 5 years
57
what are common SE of oestrogen component of HRT and COCP?
fluid retention breast tenderness bloating nausea headaches
58
what are common SE of progesterone in HRT or POP?
* Fluid retention * Breast tenderness * Headaches * Mood swings * PMT-like symptoms
59
in which patients with menorrhagia should a LNG-IUS be considered first line?
no identified pathology fibroids < 3cm in diameter suspected adenomyosis
60
what are some non-hormonal options for management of heavy menstrual bleeding?
tranexamic acid NSAID's
61
what are some hormonal options for heavy menstrual bleeding?
COCP cyclical POP
62
symptoms of fibroids?
bowel/urinary symptoms - if pressing on the abdomen bulky uterus heavy and painful periods
63
what are absolute contraindications to the COCP?
current breast Ca breastfeeding and < 6 weeks postpartum age > 35 years and > 15 cigarettes/day elevated BP history of DVT/PE IHD or stroke migraines with aura (at any age) diabetes for > 20 years
64
what are some relative contraindications to COCP?
history of breast ca > 5 years breastfeeding and 6 weeks to <6 months post partum age 35 years and smokes < 15 per day elevated BP (systolic 140-159, or diastolic 90) known hyperlipidaemia
65
management of bartholins abscess?
flucloxacillin 500mg QDS or erythromycin 500mg QDS Review - if persistent , not responding to abx, worsening - referral for I+D
66
what are some conservative management fir bartholin cyst?
warm baths hot compress analgesia
67
symptoms of BV?
fishy smelling discharge thin discharge can be grey in colour can cause local irritation , no pruritis may be asymptomatic
68
what is the cause of BV?
gardnerella vaginallis
69
what are the investigations for BV?
microscopy - "clue cells" seen epithelial cells densely covered with bacilli positive amine test - a fishy ammoniacal smell when the discharge is mixed with 10% potassium hydroxide
70
what is the 1st line treatment for BV?
metronidazole 400mg BD for 7 days
71
management of pelvic organ prolapse?
pelvic floor muscle training pessary lifestyle advise - re weight loss, minimising straining or constipation, avoidance of heavy lifting / coughing or high impact exercise surgical management
72
what are the different types of incontinence?
overactive bladder stress incontinence urge incontinence mixed incontinence
73
what is overactive bladder/urge incontinence?
overactivity of the detrusor muscle, whereby the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
74
what is stress incontinence?
leaking small amounts when coughing or laughing
75
what different types of contraception are there?
barrier - condoms , femidoms hormonal pills - cocp, POP hormonal patch - combined transdermal patch hormonal injection - progesterone hormonal implant - progesterone implant IUS - progesterone IUD - copper
76
what are the different types of long act reversible contraceptives?
implantable contraceptives injectable contraceptives - although these are not considered to the LARCs intrauterine system (IUS): progesterone releasing coil intrauterine device (IUD): copper coil
77
what is the UKMEC guidance for combined contraceptives in obesity?
if BMI 30-34 - UKMEC 2 if BMI > 35 - UKMEC 3 due to risk of thromboembolism
78
which type of contraceptive causes weight gain?
depo-provera
79
what is the main injectable contraception in the UK?
depo-provera
80
what is contained in the depo-provera?
medroxyprogesterone acetate 150mg
81
how does the depo-provera work?
releases high dose progesterone which acts to inhibit ovulation and thicken the cervical mucous to prevent sperm entering.
82
how is the depo-provera given?
IM injection every 12 weeks
83
what are the negative effects of the depo-provera?
irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time
84
which contraceptive increases the risk of osteoporosis?
depo-provera
85
what are the contraindications for depo-provera?
current breast Ca
86
how quickly does fertility return after stopping the depo-provera?
can have delayed fertility return of up to 12 months
87
why is migraine with aura an absolute contraindication for COCP?
migraine with aura is an absolute contraindication to combined oral contraceptive pill use due to the increased risk of stroke.
88
how late can a depo-provera been taken?
latest 14 weeks
89
how does the mirena coil work?
progesterone effect on the endometrium to thin the lining over time, and stimulates production of a cervix mucous plug
90
what is the failure rate of IUS?
1-2% in 1000 over 5 years
91
why is it important to ensure a woman is not pregnant prior to fitting IUS?
increased risk of ectopic pregnancy
92
benefits of the mirena coil?
improves dysmenorrhoea and menorrhagia (licensed for this)
93
how long can mirena coil be used for HRT purposes?
5 years - very strict!
94
how long can a mirena remain in situ for contraceptive purposes in woman over the age of 45 years?
licensed until enters the menopause
95
what are the negatives of copper IUD?
can make periods heavier and more painful continue to have regular bleeds
96
what is the equivalent progesterone that is absorbed into the blood when having a mirena coil compared to the POP?
2 progesterone only pills a week
97
negatives or side effects of mirena coil?
increases risk of ectopic (but overall is lower than general population) can have irregular bleeding can have progestognenic side effects.- breast tenderness, acne, weight gain
98
what are the different types of IUS?
mirena jaydess Kyleena - less progesterone, equivalent of 1 POP per week, however failure rate higher of 61 in 1000 of contraception
99
what is the expulsion rate of mirena coil?
1 in 20 within the first 3 months , after that significantly less likely
100
what is the risk of perforation when fitting the IUS/IUD?
2 in 1000
101
what would make the risk of perforation higher when fitting IUS/IUD?
6 fold higher risk in women who are breastfeeding and have a baby < 6 months
102
when can you not fit a coil in a woman who has had a baby?
cannot fit it between 48 hours to 6 weeks post delivery
103
which is the only contraceptive causes a delay in fertility return
depo-provera
104
when is the risk of infection highest after coil fitting?
first 8 weeks highest in women who are high risk for STI's
105
contraindications to the combined pill?
personal preference liver cirrhosis breast cancer migraine with aura previous DVT or at risk of DVT HTN systolic > 160, diastolic > 100 age 35 or older and smokes > 15 / day BMI > 35 history of stroke / IHD or risk of these age > 50
106
contraindications to POP?
active liver disease - i.e.e decompensated liver cirrhosis or liver tumour active breast cancer
107
what is the failure rate of nexplanon?
1-2% in 1000
108
how does nexplanon work?
inhibits ovulation
109
what hormone is found in nexplanon?
desogestrel
110
what drugs should be avoided with the implant?
enzyme inducing drugs
111
at what age should contraception be stopped?
POP can continue until 55 years after this age it can safely be stopped as chances of pregnancy are low, but if a woman wishes to continue for personal reasons, another option can be considered (even if she is still having some menstrual loss) COCP - should be stopped at 50 years or menopausal - i.e. no periods for 12 months
112
what is UKMEC 3?
the risks generally outweigh the benefits but the method can be considered for use with clinical judgement and/ or specialist referral if other methods are unacceptable.
113
what is UKMEC 4?
absolute contraindication - not allowed to be prescribed
114
what is UKMEC 2?
A condition where the advantages of using the method generally outweigh the theoretical or proven risks
115
when to take out IUS in woman with absent periods in menopause however unsure as has IUS in situ?
if on hormonal contraception - over 50 years and absent periods for 1 year -> do a spot FSH, if raised -> come back in 12 months and remove IUS if on hormonal contraception - under age of 50 years and absent periods for 1 year -> do spot FSH and advise to come back in 24 months for removal
116
what should be done if a woman has stroke or heart attack whilst on POP?
this becomes a UKMEC 3 and should consider swapping to copper IUD
117
what is the rate of irregular bleeding with the implant?
18% of women will have irregular problematic bleeding with the implant - there is a chance this would settle after 6 months
118
what management plan can be made if a woman has had problematic bleeding a few weeks after implant fitting?
can trial 3 month additional COCP to reset the endometrium usually bleeding improves after this, but if this does not, may need to have this implant removed
119
can women who have PCOS have the implant?
yes - can have the implant and they do not need to have 4 breakthrough bleeds per year, they can have as many bleeds as they have
120
what MEC is unexplained vaginal bleeding?
UKMEC 4 - should be investigated prior to commencing contraception/mirena , if happy this is a hormonal cause and not pathological then can be treated with contraceptive options
121
what monitoring should be done for women over age of 50 years who wish to continue depo provera?
review their decision every 2 years due to the risk of osteoporosis / effect on bone density
122
what is used for medical termination of pregnancy in the uk?
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
123
what monitoring is required after medical termination of pregnancy?
multi level pregnancy test 2 weeks after to detect level of hCG
124
what are the surgical management options for termination of pregnancy?
vacuum aspiration electric vacuum aspiration dilatation and evacuation cervical priming with misoprostol +/- mifepristone is used before procedures
125
up until how many weeks can a woman decide to terminate her pregnancy?
23+6 weeks
126
what are fibroids?
benign smooth muscle tumours of the uterus that develop usually in response to oestrogen
127
how common are fibroids?
thought to occur in around 20% white and 50% afro-carribean women
128
symptoms of fibroids?
can be asymptomatic menorrhagia lower abdo pain bloating urinary symptoms subfertility can rarely cause polycythaemia due to autonomous production of EPO
129
how are fibroids diagnosed?
TVUSS
130
medical management of menorrhagia secondary to fibroids?
IUS - however cannot be inserted in GP if distorted uterine cavity COCP POP LARC progesterone inj mefanemic acid / tranexamic acid
131
surgical management of firboids?
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically hysteroscopic endometrial ablation hysterectomy uterine artery embolization
132
what is a complication of firboids that can occur in pregnancy?
red degeneration - haemorrhage into tumour
133
When should a woman with fibroids be referred to secondary care?
An uncertain diagnosis. Severe heavy menstrual bleeding or compressive symptoms. Symptoms which cannot be successfully managed in primary care. Confirmed fibroids measuring 3 cm or more in diameter or suspected submucosal fibroids (for example on pelvic ultrasound scan). Suspected fertility or obstetric issues associated with fibroids. Rapid or unexpected growth of fibroids after the menopause.
134
when should sperm sample be repeated if found to be abnormal when doing fertility investigations?
around 3 months after the first sperm sample - to allow sufficient time for the cycle of spermatozoa formation to be completed
135

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