1
Q
What is the definition of UKMEC Category 1?
A
A condition for which there is no restriction for the use of the contraceptive method
2
Q
What is the definition of UKMEC Category 2?
A
A condition for which the advantages of using the method generally outweighs the theoretical or proven risks
3
Q
What is the definition of UKMEC Category 3?
A
A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
The provision of a method requires expert clinical judgement and/or refer all to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or acceptable
4
Q
What is the definition of UKMEC Category 4?
A
A condition which represents an unacceptable health risk if the method is used
5
Q
Why is injectable contraception (Depo) no longer considered a LARC, in the RANZCOG guideline?
A
It is less effective than IUC and implants, and is user-dependent
6
Q
In whom should DMPA be avoided?
A
- Those who wish to become pregnant in near future (teratogenic)
- Undiagnosed abn vaginal bleeding
- Hx of breast cancer, stroke, IHD, impaired LFTs
- >50years
- risk of osteoporosis
- <18 should not be used first line - as not at peak bone mass
7
Q
What is failure rate DMPA?
Perfect use.
Actual use.
A
Perfect - 0.2% per year
Actual - 6% per year
8
Q
What are the benefits of depo?
A
- Not affected by cytochrome P450 enzyme inducing drugs (anti-epileptics)
- Better compliance and lower failure than oral contraceptives
- Ammenorhea in 54% women
- Helps dysmenorrhea
- Treatment for endometriosis
- May reduce pain of sickle cell crisis
9
Q
Disadvantages of depo.
A
- Irregular bleeding
- Weight gain - greatest for women BMI>30 (if gain >5% BW can expect ongoing wt gain)
- Reduced BMD (normalises on cessation of depo)
- Unpredictable delay in return of fertility up to 1 year after stopping depo
- May increase risk VTE (unclear)
- Small increased risk breast cancer (risk normalises on stopping depo)
- Small increased risk cervical cancer (risk normalises on stopping depo)
- NO EVIDENCE for mood change, libido
10
Q
How should unscheduled bleeding on depo or implant be managed?
A
- 3 months trial COCP cyclical/continuous to regulate cycle
- Mefanamic acid 500mg po tds
11
Q
How is the depot administered?
A
- IM injection every 13 weeks
- Can be given a week later without needing additional contraception
- If given in first 5 days of menstrual cycle no additional contraception is required
12
Q
How does the depo work?
A
- Primarily by inhibiting ovulation
- Increasing cervical mucus viscosity to prevent passage of sperm
- Affecting endometrial lining so as to make it less receptive to implantation
13
Q
Regarding the copper IUD as a form of emergency contraception: What is the pregnancy rate after this is given if used within 5 days of UPSI? When can copper IUD be used as form of emergency contraception?
A
Pregnancy rate <1%.
Timing:
- Up to 5 days post UPSI OR
- Up to 5 days after ovulation if date can be estimated.
14
Q
Regarding LNG / Prostinor as a form of emergency contraception: What is the pregnancy rate after this is given if used within 5 days of UPSI? When can Prostinor be used as form of emergency contraception? How does it prevent pregnancy?
A
Rate of pregnancy 2.2%.
Indications: - Within 3 days (72 Hours) of UPSI
Mode of action: delays ovulation and causes luteal dysfunction for 5-7 days, allowing time for viable sperm in genital tract to die. The closer it is given to ovulation, the less effective it is. A higher dose is required for obese women.
15
Q
Regarding ulipristal acetate as a form of emergency contraception: What is the pregnancy rate after this is given if used within 5 days of UPSI? When can ulipristal acetate be used as form of emergency contraception? How does it prevent pregnancy?
A
Pregnancy rate 1.4%. More effective than LNG-EC. (Note: not available in NZ).
Indications: up to 5 days (120 hours) after UPSI.
Mode of action: selective progesterone receptor modulator, delays/prevents ovulation. Therefore efficacy is REDUCED by concurrent use of progestogen containing drugs.
Progestogen based contraception should be delayed for > 5 days after taking ullipristal for EC.
Contraindicated in severe asthma requiring corticosteroid use.
16
Q
What are the requirements for providing emergency contraception to women?
A
- Prompt and easy access
- Advice on dosage and admin in a setting that preserves patient confidentiality, privacy and dignity.
- Ongoing contraceptive advice as required.
- STI screening
- Medical review to exclude pregnancy if period is delayed.
- Advice on what to do if method not successful and pregnancy occurs.
17
Q
How is EC managed for women taking anti-epileptic medication?
A
- Recommend Cu IUCD (only EC not affected by enzyme inducing drugs)
- If refuses Cu IUCD - expert consensus recommends doubling LNG dose.
18
Q
What are the disadvantages of oral EC?
A
- Affected by enzyme inducing medications
- Less effective in women with BMI in obese range
- Less effective than Cu IUCD
- Does not work if taken after ovulation
- Does not provide ongoing contraception
19
Q
What can be offered to women who have had UPSI earlier in the cycle as well as within the last 5 days?
A
Ullipristal or LNG-EC
No evidence of teratogenicity or adverse birth outcome if taken in pregnancy.
20
Q
What advice should be given to breast feeding women taking oral EC?
A
Ullipristal - express and dump for 7 days
LNG - safe in breast feeding
21
Q
What are 9 advantages of using LARCs?
A
- Most effective reversible methods available
- High rates of user satisfaction; high continuation rates
- Set and forget methods that do not require daily adherence
- Require fewer visits to health services than other methods
- More cost effective for women and governments, including reduction in unplanned pregnancy
- Easily reversible
- Suitable for women of all ages, including nullips
- Do not affect fertility after removal
- Very few contraindications - most women are eligible
22
Q
An asymptomatic woman with an IUD in siture has a cervical smear with actinomyces seen. What would you recommend?
A
Do nothing. If asymptomatic correlates poorly with risk of PID.
23
Q
What systemic side-effects are associated with the Mirena?
A
- Acne
- Headache
- Breast tenderness
24
Q
What are the absolute contraindication to IUD use?
A
Pregnancy
GTD with rising b-HCG
Current PID
Insertion after puerperal sepsis or septic abortion
Relative…? :
Unexplained vaginal bleeding
Distortion of uterine cavity from fibroids or congenital abnormality
Endometrial cancer
25
What is the only absolute contraindication to the implant / Jadelle?
Current breast cancer
26
What is the risk of uterine perforation with Mirena insertion? How is this affected by breastfeeding?
1.4/1000
RR 6 with Breastfeeding postpartum
27
What is the risk of pelvic infection after Mirena insertion
A) in the first 20 days
B) After the first 20 days
A) In the first 20 days: 1/300. Mostly related to STIs (hence why screening is important)
B) After the first 20 days: same as general population
28
WHat counselling is important for IUD insertion
- Careful hx and exam - check for contraindications
- Discuss effectiveness, failure rates, possible short and long term complications
- Exclude pregnancy
* Screen for STIs
- Follow up visit at 3-6/52 OR advise women to present if abnormal bleeding, pregnant or can’t feel strings
29
What are the complications in a pregnancy with a Mirena in utero?
Ectopic pregnancy
50% risk of miscarriage
TPTL
APH
Morbidly adherent placenta
Mirena should be removed
30
If a Mirena is inserted at age 45+, how long can it be used until?
55
31
If a Cu IUD is inserted at 40+years, how long can it remain in stud?
1 year after LMP if \> 50 2 years after LMP if \>45
32
What is the expulsion rate of mirena?
1 in 20
33
What is the PEARL index for jadelle, mirena and Cu t380 IUD?
Jadelle - 0.05%
Mirena - 0.2%
Cu T380 - 0.8%
Pregnancy rate per 100 woman years (at 1 year).
34
How does the copper IUCD prevent pregnancy?
* PRIMARILY pre-fertilisation effects on spermatozoon and egg reduce blastocyst formation
* Copper content in cervical mucus prevents sperm passage
* Inflammatory effect on endometrium reduces implantation
35
How does the mirena prevent pregnancy?
* PRIMARILY pre-fertilisation effects on spermatozoon and egg due to foreign body effect reduce blastocyst formation
* Anovulation in ONLY 25% women
* Progestogenic effect on cervical mucus to increase viscosity and prevent sperm passage
* Induces atrophy and increased phagocytic cells in endometrium to prevent implantation
36
What proportion of mirena users are amenorrheic at 1 year?
20%
Proportion increases with duration of use.
37
What is the relationship between IUCD and ectopic pregnancy?
* IUCD reduce the overall risk of ectopic pregnancy compared to women without contraception, by significantly reducing the rate of all pregnancies
* If pregnant with an IUCD in situ, risk of ectopic pregnancy up to 50% in some studies
38
What is the estimated incidence of VTE per 10,000 women years of:
* Young women not using combined hormonal contraception?
* Women on COCP with 2nd generation progestogen?
* Women on COCP with drosperinone?
No COCP: 1-5 per 10,000
COCP with LNG or NET: 5-9 per 10,000.
COCP with drosperinone: 10.22 per 10,000
39
What is the estimated incidence of VTE per 10,000 women years of: Pregnant or postpartum women
Pregnant 5-20 per 10,000
Postpartum up to 40-60 per 10,000
40
What is the efficacy for COCP and POP perfect and actual use?
Perfect = 99.7%
Actual = 91% (PI = 9%)
41
What are the broad formulations of COC?
* Pill, vaginal ring or patch
* Estradiol, ethinyl estradiol or estradiolvalereate with a progestogen
* Monophasic or multiphasic regimes
42
Advantages of COCP.
* Are very effective with correct use;
* Are readily accessible to most women;
* Are easily reversible with no delay in return of fertility;
* Provide predictable withdrawal bleeds and the ability to manipulate cycles;
* Can be used to manage menstrual problems, e.g. heavy menstrual bleeding (HMB), and dysmenorrhea
* Can manage symptoms of endometriosis
* Can improve acne;
* Can reduce the risk of endometrial and ovarian cancer;
* Can reduce the risk of bowel cancer;
* Can be used to manage pre-menstrual syndrome (PMS), and its more severe form pre-menstrual dysphoric disorder (PMDD),
* Can reduce the incidence of functional ovarian cysts and benign ovarian tumours
* Can be useful in managing symptoms of polycystic ovarian syndrome;
* Used for management of VMS in perimenopause
43
Disadvantages of COCP
* Typical use failure rates are high;
* Some formulations are relatively expensive;
* As an oestrogen containing contraceptive method, there are rare but serious risks including venous thromboembolism (VTE) and arterial disease
* Some common conditions limit use, e.g. migraine with aura (absolute contraindication; UKMEC 4) and BMI of ≥ 35kg/m2 (strong relative contraindication; UK MEC 3).
* Increased risk of cervical cancer
* Possible small increased risk of breast cancer - though return to normal after stopping, and overall COCP is protective against all cause cancer.
44
Contraindications to COCP.
Breastfeeding and ≤6 weeks postpartum
Smoker ≥35 year and ≥ 15 cigarettes/day
Presence of multiple risk factors for CVD including older age, smoking, diabetes, hypertension
Hypertension with systolic ≥160mmHg or diastolic ≥95mmHg
Vascular disease
Major surgery with prolonged immobilisation
Current or past history of venous thromboembolism (VTE);
Known thrombogenic mutations \* (Factor V Leiden, Prothrombin mutation, Protein S, Protein C and
Antithrombin deficiencies)
Migraine with aura
Current or past history of Ischemic Heart Disease (IHD);
Complicated valvular heart disease
Diabetes complicated by nephropathy, retinopathy or vascular disease
Breast cancer;
Severe Liver disease including cirrhosis hepatocellular adenoma and hepatoma
Raynaud’s with lupus anticoagulant
SLE with antiphospolipid antibodies
45
What is the evidence for tricycling and continuous use COCP?
Cochrane did not find any increase in adverse effects.
46
What it the relative increased risk from 3rd/4th generation progestogen containing COCP as compared with 2nd generation?
RR 1.4-1.8
47
Until what age can women continue COCP?
* Aged 50
* NB Age ≥ 40 is UKMEC 2 (in absence other risk factors)
48
Side effects of COCP.
Headaches
Mood changes
Unscheduled bleeding
49
What are the different regimes for taking the COCP?
* Standard regime (21 active pills, 7 pill/ring/patch free days)
* Shortened hormone free interval HFI (4 pill/ring/patch free days)
* Continuous use (skip the pill free days)
* Extended use (tricycling)
* Extended use with shortened HFI (tricycling with 4 HFI days)
50
What are the benefits of tailored COCP regimes?
* Withdrawal bleed may be heavy or painful - reducing or avoiding HFI reduces this
* Reduces the symptoms associated with HFI including mood changes and headaches
* Reduces the risk of ‘escape ovulation’ - as ovarian suppression drops during the pill free week (particularly in low dose oestrogen), so missed pills in the subsequent week carry increased risk of ovulation and contraceptive failure
51
What is the best COCP to start in new patients and why?
≤30mcg estradiol with NET or LNG, monophasic formulation
→ lowest risk of VTE and arterial clots
52
What contraceptive options are available?
- Lactational amennorhea - Barrier methods - COCP - POP - Depo-provera - Implant - CuT380 or mirena IUD - Sterilisation - Natural methods - i.e. monitoring for ovulation and abstinence
53
How does LAM work?
- Regular lactation inhibits the normal pulsatile release of LH causing anovulation and amenorrhea.
54
What is the effectiveness of LAM (%)? What does effective LAM require?
- 98% when breast feeding criteria are met - as below: - Exclusive breast feeding day and night - Amenorrhoea for \> 56 days post partum - Less than 6 months postpartum
55
How long can LAM be relied upon if adequate breast feeding levels maintained?
- 6 months
56
What are the specific risks of COCP in the postnatal period?
- Increased risk of VTE postnatally (particularly in higher risk groups) - Can be transferred in breast milk - Within first 6 weeks postnatally some evidence of slower infant weight gain
57
When can COCP be started postnatally and what is the advice?
- In otherwise low risk women - after 21 days - If additional risks for VTE (obesity, HTN, DM, operative delivery etc) - after 6 weeks - If breast feeding - after 6 weeks NB. if started \>21 days after delivery, alternative contraception should be used for 7 days
58
When can an IUD be placed postnatally?
- Immediate placement - 10mins after delivery of placenta to 48 hours postpartum - Interval placement - \> 4 weeks postpartum NB. ' early placement' i.e after 48 hours and before 4 weeks has the highest rate of expulsion - up to 30%
59
What is the risk of expulsion of IUD when placed immediately postpartum (after 10 mins of placental delivery) versus interval placement (after \>4 weeks postpartum)?
- Immediate placement = 1/10 - interval placement = 1/20 BUT at 6 months ongoing use is comparable between groups.
60
Why are natural approaches not recommended in the postnatal period?
Because it's a stupid method of contraception!! - Ovulation may occur prior to first period so difficult to anticipate - Ovulation can be erratic postpartum - The usual signs and symptoms of ovulation can be missed in symptoms and fatigue postnatally
61
How does COCP prevent pregnancy?
* PRIMARILY by acting on HPO axis to suppress FSH and LH and prevent ovulation
* Progestogen effects:
* increase cervical mucus viscosity to preven sperm passage
* reduce tubal motility to reduce chance of fertilisation
* thinning of endometrium to prevent implantation
62
What is the risk of ectopic if fall pregnant on POP?
1:10
63
Regarding vasectomy: What is the mechanism of action? What is the failure rate? What are the complications? How do you confirm procedure was successful?
Mechanism of action: interruption of vas deferens presents sperm secretion into semen.
Failure rate: 0.15%
Complications: haematoma, bleeding, infection, recanalisation/failure.
Perform post-vasectomy semen analysis 6 weeks after to exclude early failure:
- Do not need further sample if azoospermia on first.
- Need additional contraception until azoospermia.
- Long-term failure rate following clearance reduced to 0.05% (1 in 2000).
64
What long term benefit does tubal ligation confer?
Reduces risk of ovarian cancer.
65
What is the recommend interpregnancy interval following a normal vaginal delivery?
12 months
66
A short interpregnancy interval (\<12 months) is associated with what complications?
- Preterm birth and PPROM
- IUGR
- Low birthweight
67
If a woman is breastfeeding but has no other risk factors for VTE, how soon can you prescribe COC for her?
After 6 weeks postpartum.
68
Outline Gillick competence for prescribing contraception to girls under the age of consent without parents' consent or knowledge
- Understands practitioner's advice.
- Cannot be persuaded to inform parents
- Very likely to have sexual intercourse with or without contraception.
- Physical or mental health likely to suffer unless contraception received
- Best interests requires practitioner to give her contraception without parental consent.
69
What is the fertile window?
7 days before ovulation until 24 hours after Semen is said to be viable for 7 days (likely an overestimate) Ovary survival life of 24h
70
What are the three criteria that need to be met for lactational amenorrhoea? How effective is it?
\< 6 months postpartum
Amenorrhoeic
Exclusively breastfeeding
If above criteria met, over 98% effective at preventing pregnancy
71
For a postpartum who is not exclusively breastfeeding, how soon should she start contraception?
D21
Earliest expected ovulation is D28
72
What are known predictors of regret with TL
Age \< 30
Nulliparous, low parity
Single
Unhappy relationship, in conflict Remarriage, change in partner, change in relationship status
Death of a child
Desire to have more children
Psychological, psychosexual problems
Coercion
Timing of procedure in relation to pregnancy (TL should not be performed at time of CS unless documented at least 2 weeks before)
73
What is the failure rate of Filshie Clip TL?
1: 200
If applied at CS, higher rate of failure - up to 1:100
74
What are Filshie clips?
Non-absorbable titanium and silicone rubber clips TL
75
When should a TL be performed?
Ideally in early-mid follicular phase To reduce risk of pregnancy at time of procedure
76
When should a post-vasectomy semen analysis occur? And why?
12 weeks post-vasectomy
To confirm clearance of stored spermatoazoa downstream of the vasectomy site and to identify early failure to recanalisation
All men should be informed of the need to use additional contraception until PVSA has been undertaken and clearance given
77
When does fertility return and when should contraception be initiated by after miscarriage/ectopic/TOP?
5 days
78
What are the rules for quick starting contraception?
* Counsel women re. all contraceptive options
* Choose most appropriate options with regard to UKMEC criteria
* For most methods, if started days 1-5 of cycle - no further contraception required
* For mirena, if started day 1-7 - no further contraception required
* For Cu IUCD can start anytime in cycle and no further contraception required
* If further contraception required, most methods require 7 days of barrier/alternative contraception
* POP requires only 2 days of alternative contraception
79
With typical use, what is the failure rate (PEARL index) for no contraception?
Fertility awareness methods?
Condoms?
* no contraception - 85%
* fertility awareness methods - 24%
* Condoms - 18%
Pregnancies per 100 women years (at 1 year)
General Gynaecology
flashcards
Decks in class (16)
# Cards
-
Endometrial hyperplasia22
-
Fibroids36
-
VWD and clotting disorders3
-
Hirsuitism12
-
PCOS42
-
Hyperprolactinaemia7
-
Endometriosis and adenomyosis98
-
Ovarian torsion10
-
Ovarian cysts in premenopausal women25
-
Ovarian cysts in postmenopausal women25
-
RANZCOG questions on ovarian cysts25
-
Contraception79
-
PMS25
-
Endometrial polyps10
-
Menstrual Disorders (HMB, AUB)39
-
Benign vulval pathology42
