An 18-year-old female missed one Microgynon 30 pill and had unprotected sex. The document states that no action is needed if one pill is missed at any time in the cycle. It provides guidelines for missed combined oral contraceptive pills and progestogen-only pills. The failure rate for male sterilization (vasectomy) is stated as 1 in 2,000.
This document discusses polycystic ovary syndrome (PCOS) in a 22-year-old woman presenting with irregular periods, weight gain, acne, and excess hair growth. PCOS is characterized by irregular periods, polycystic ovaries, and signs of excess androgens. It is associated with insulin resistance and increased risk of diabetes and heart disease. Treatment involves lifestyle changes, birth control pills to regulate periods and excess hair, and fertility medications like clomiphene to induce ovulation. Women with PCOS require screening for metabolic and endocrine conditions.
This document discusses various topics related to contraception, including epidemiological data on unintended pregnancies in the UK, types of contraception and their mechanisms of action, criteria for contraceptive use, and disease-specific contraceptive options. It provides details on natural family planning methods, barrier methods, hormonal contraceptives including combined oral contraceptives and progestogen-only methods, intrauterine devices, and sterilization procedures. Effectiveness, side effects, and other considerations are described for each contraceptive method.
Menopausal hormone therapy quiz by Dr Sharda Jain Dr Jyoti Agarwal ,D Meenaks...Lifecare Centre
This document discusses menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT). It provides information on the standard dosages of estrogen and progestogen components in MHT. It also discusses the FDA approved indications for MHT, which include vasomotor symptoms, prevention of bone loss, and genitourinary symptoms, but not prevention of cognitive function. The risks associated with the estrogen and progestogen components are outlined, such as the increased risk of endometrial cancer with estrogen alone but not with continuous combined MHT. Transdermal estrogen is less likely to cause venous thromboembolism than oral estradiol. Standard dose MHT is best for premature ovarian insufficiency and
Menopausal Harmone Therapy & Indian Gynaecologists Dr Sharda Jain Lifecare Centre
This document discusses menopause and menopausal hormone therapy (MHT). It provides information on:
1) The average age of menopause for Indian women is 46.2 years. Premature menopause, which occurs before age 40, increases risks for cardiovascular disease, diabetes, and metabolic syndrome.
2) Lessons learned from the WHI study show that the risks of MHT depend on factors like age of starting treatment, type of estrogen and progestogen used, and whether the uterus is present. Not all progestogens have the same safety profile.
3) The choice of progestogen is important as some, like medroxyprogesterone acetate (MPA), may
This document discusses issues with progestin-based contraception including problems with timing of administration, potential weight gain, and irregular bleeding. It notes that progestin-only pills have a short duration of action of 20-24 hours and desogestrel is 97% effective at inhibiting ovulation. Missed pills for methods like DMPA can still be safe if administered slightly late. Weight gain may be higher in women using DMPA who start with a higher BMI, and the mechanism is thought to involve increased food intake and water retention. Irregular bleeding is a major reason for discontinuing methods, ranging from 10-25% for progestin-only pills to 46% for implants. Strategies are provided to
Menopause occurs when a woman's ovaries stop releasing eggs and estrogen levels decline. Common symptoms include hot flashes, night sweats, and mood changes. Hormone replacement therapy (HRT) can effectively treat many menopausal symptoms but also has some risks, including a small increased risk of blood clots, heart disease, and breast cancer. It is important for clinicians to evaluate each woman's individual risks and benefits when considering HRT.
This document discusses the management of endometriosis from a primary healthcare perspective. It defines endometriosis and outlines its clinical symptoms. Treatment options are classified as symptomatic, medical, or surgical. Medical treatment aims to induce atrophy of ectopic endometrial tissue through hormone suppression. Common medical treatments include combined estrogen-progestogen contraceptives, progestogen-only methods like the Mirena IUD, GnRH agonists, and dienogest. Surgical treatment includes procedures like laparoscopy to treat endometriotic lesions. Overall management focuses on alleviating symptoms through lifestyle changes and a combination of medical and surgical therapies depending on the severity of disease.
This document provides guidelines for the management of premenstrual syndrome (PMS). It defines PMS and classifies it according to the International Society for Premenstrual Disorders (ISPMD) consensus. Core premenstrual disorders are the most common type. The document discusses the prevalence, etiology, diagnosis and treatment of PMS, including complementary therapies, cognitive behavioral therapy, hormonal treatments like combined oral contraceptives, and non-hormonal medications like SSRIs. Treatment is often multidisciplinary and aims to reduce symptoms and improve quality of life.
This document discusses polycystic ovary syndrome (PCOS) in a 22-year-old woman presenting with irregular periods, weight gain, acne, and excess hair growth. PCOS is characterized by irregular periods, polycystic ovaries, and signs of excess androgens. It is associated with insulin resistance and increased risk of diabetes and heart disease. Treatment involves lifestyle changes, birth control pills to regulate periods and excess hair, and fertility medications like clomiphene to induce ovulation. Women with PCOS require screening for metabolic and endocrine conditions.
This document discusses various topics related to contraception, including epidemiological data on unintended pregnancies in the UK, types of contraception and their mechanisms of action, criteria for contraceptive use, and disease-specific contraceptive options. It provides details on natural family planning methods, barrier methods, hormonal contraceptives including combined oral contraceptives and progestogen-only methods, intrauterine devices, and sterilization procedures. Effectiveness, side effects, and other considerations are described for each contraceptive method.
Menopausal hormone therapy quiz by Dr Sharda Jain Dr Jyoti Agarwal ,D Meenaks...Lifecare Centre
This document discusses menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT). It provides information on the standard dosages of estrogen and progestogen components in MHT. It also discusses the FDA approved indications for MHT, which include vasomotor symptoms, prevention of bone loss, and genitourinary symptoms, but not prevention of cognitive function. The risks associated with the estrogen and progestogen components are outlined, such as the increased risk of endometrial cancer with estrogen alone but not with continuous combined MHT. Transdermal estrogen is less likely to cause venous thromboembolism than oral estradiol. Standard dose MHT is best for premature ovarian insufficiency and
Menopausal Harmone Therapy & Indian Gynaecologists Dr Sharda Jain Lifecare Centre
This document discusses menopause and menopausal hormone therapy (MHT). It provides information on:
1) The average age of menopause for Indian women is 46.2 years. Premature menopause, which occurs before age 40, increases risks for cardiovascular disease, diabetes, and metabolic syndrome.
2) Lessons learned from the WHI study show that the risks of MHT depend on factors like age of starting treatment, type of estrogen and progestogen used, and whether the uterus is present. Not all progestogens have the same safety profile.
3) The choice of progestogen is important as some, like medroxyprogesterone acetate (MPA), may
This document discusses issues with progestin-based contraception including problems with timing of administration, potential weight gain, and irregular bleeding. It notes that progestin-only pills have a short duration of action of 20-24 hours and desogestrel is 97% effective at inhibiting ovulation. Missed pills for methods like DMPA can still be safe if administered slightly late. Weight gain may be higher in women using DMPA who start with a higher BMI, and the mechanism is thought to involve increased food intake and water retention. Irregular bleeding is a major reason for discontinuing methods, ranging from 10-25% for progestin-only pills to 46% for implants. Strategies are provided to
Menopause occurs when a woman's ovaries stop releasing eggs and estrogen levels decline. Common symptoms include hot flashes, night sweats, and mood changes. Hormone replacement therapy (HRT) can effectively treat many menopausal symptoms but also has some risks, including a small increased risk of blood clots, heart disease, and breast cancer. It is important for clinicians to evaluate each woman's individual risks and benefits when considering HRT.
This document discusses the management of endometriosis from a primary healthcare perspective. It defines endometriosis and outlines its clinical symptoms. Treatment options are classified as symptomatic, medical, or surgical. Medical treatment aims to induce atrophy of ectopic endometrial tissue through hormone suppression. Common medical treatments include combined estrogen-progestogen contraceptives, progestogen-only methods like the Mirena IUD, GnRH agonists, and dienogest. Surgical treatment includes procedures like laparoscopy to treat endometriotic lesions. Overall management focuses on alleviating symptoms through lifestyle changes and a combination of medical and surgical therapies depending on the severity of disease.
This document provides guidelines for the management of premenstrual syndrome (PMS). It defines PMS and classifies it according to the International Society for Premenstrual Disorders (ISPMD) consensus. Core premenstrual disorders are the most common type. The document discusses the prevalence, etiology, diagnosis and treatment of PMS, including complementary therapies, cognitive behavioral therapy, hormonal treatments like combined oral contraceptives, and non-hormonal medications like SSRIs. Treatment is often multidisciplinary and aims to reduce symptoms and improve quality of life.
PMS affects 40% of women and causes psychological and physical symptoms related to the menstrual cycle. The exact cause is unknown but likely involves sensitivity to hormone fluctuations. Diagnosis requires tracking symptoms over two cycles which improve after menstruation. Treatment depends on severity but may include lifestyle changes, SSRIs, COCPs, or suppressing ovulation. CBT and some supplements like Vitex and calcium can also help reduce symptoms.
PANEL DISCUSSION Management Of Adolescent PCOS And Associated Fertility Conc...Lifecare Centre
This document summarizes a panel discussion on the management of adolescent polycystic ovarian syndrome (PCOS) and associated fertility concerns. It discusses the changing diagnostic criteria for PCOS over time, common symptoms like menstrual irregularities and hirsutism, tests used to diagnose PCOS and hyperandrogenism, and guidelines for treating issues like hirsutism, acne and hair loss. The panel addressed questions on various topics related to managing adolescent PCOS and emphasized the importance of coordination between specialists.
This document provides a step-by-step guide to menopausal hormone therapy. It discusses assessing candidates for therapy, treatment options including different hormones and administration routes, starting treatment, and follow up and stopping treatment. It addresses indications, contraindications, and recommendations for using hormone therapy in symptomatic menopausal women with risk factors like age, obesity, diabetes, or smoking. The guide emphasizes using the lowest effective dose for the shortest time needed to manage menopausal symptoms.
Nausea & Vomiting in Pregnancy :an update Dr Sharda Jain Lifecare Centre
1) Nausea and vomiting in pregnancy (NVP) is a common condition affecting around 85% of pregnant women. Symptoms typically appear between 4-9 weeks and subside by 12-16 weeks for most women.
2) Risk factors for NVP include young age, primigravida, obesity, multiple pregnancy, family history, and motion sickness. The etiology is unknown but may involve hormonal and metabolic changes.
3) Severe NVP is known as hyperemesis gravidarum (HG) and requires hospitalization. HG affects 0.3-2.3% of pregnancies and is characterized by over 5% weight loss, dehydration, and electrolyte
This document provides information about Dr. Laxmi Shrikhande's credentials and experience in gynecology and fertility. It then summarizes guidelines for assessing and managing polycystic ovary syndrome (PCOS) and infertility. Key recommendations include using letrozole as first-line pharmacological treatment for infertility in PCOS patients, and considering gonadotropins as second-line if letrozole fails. The risks of ovarian hyperstimulation syndrome are also discussed for PCOS patients undergoing fertility treatments like IVF.
This document summarizes special considerations for women with epilepsy across the reproductive years, including effects on sexuality, mood, menstruation, fertility, bone health, pregnancy, breastfeeding, and menopause. It discusses how epilepsy and antiepileptic drug use can impact these areas through mechanisms like hormonal changes, drug interactions, teratogenic risks, and bone loss. Management involves counseling, supplementation, contraception guidance, monitoring for side effects, and registry participation for pregnant patients.
This document discusses the many non-contraceptive benefits of combined oral contraceptives (COCP). It notes that 33% of adolescents using COCP do so for non-contraceptive reasons approved by research. COCP can effectively treat conditions like dysmenorrhea, dysmenorrhea, signs of androgenization, PMS, ovarian cysts, endometriosis, adenomyosis, myoma, and others. It discusses the mechanisms by which COCP provides these benefits and provides evidence from multiple studies. The document emphasizes that understanding these non-contraceptive benefits can enhance healthcare providers' care of patients.
Tender Love and Care (TLC) in Recurrent Pregnancy Loss (RPL) Dr Sharda Jain D...Lifecare Centre
This document discusses tender love and care (TLC) in recurrent pregnancy loss (RPL). It defines RPL as three or more consecutive pregnancy losses. RPL can have psychological impacts like depression, anxiety, and stress on both women and their partners. Providing psychological support through TLC which includes frequent checkups, clear communication, emotional support, encouragement of positive coping strategies, and involvement of partners can help improve mental health and pregnancy outcomes for those experiencing RPL. Studies show TLC through a dedicated early pregnancy clinic or supportive partner behaviors significantly decreases miscarriage rates and increases live birth rates compared to no specific care or support.
it is really frustrating to women and challenging to doctors when they face repeated loss of pregnancy what is called recurrent abortion: how to manage such problem?? this talk may help in answering this question
Menopausal hormone therapy (MHT) also called postmenopausal hormone therapy and hormone replacement therapy. Here is presentation on Menopausal hormone therapy by Dr. Laxmi Shrikhande
Hormones such as estrogen and progesterone play a role in epilepsy in women. Estrogen can lower the seizure threshold while progesterone may help reduce seizures. The ratio of estrogen to progesterone over the menstrual cycle influences seizure occurrence for some women. Treatment may involve adjusting epilepsy medications during expected hormone fluctuations or using progesterone supplements. Birth control choice needs consideration of potential interactions with anti-seizure medications. Premenstrual syndrome and polycystic ovarian syndrome are also linked to seizures in women.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
The document discusses guidelines for treating premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). It finds that drospirenone-containing combined oral contraceptives (COCs) and selective serotonin reuptake inhibitors (SSRIs) should be considered first-line pharmaceutical treatments for PMS. Cognitive behavioral therapy is also recommended routinely for severe PMS. For severe cases, gonadotropin-releasing hormone (GnRH) analogues may be used, usually to aid diagnosis or for short-term treatment. Surgery is only indicated for select refractory cases after unsuccessful medical management and GnRH analogue testing.
Hypertension in pregnancy is a major killer disease, this presentation explores the review of contemporary evidence in the management of acute severe hypertension,
Subchorionic haemorrhages (SCH) are echo-free areas located between the placental membranes and uterine wall that occur in approximately 9-18% of first trimester bleeding cases. Studies show that the risk of miscarriage, stillbirth, preterm birth, and other complications increases with SCH, especially when the hematoma is large or occurs later in pregnancy. Treatment options for SCH include expectant management, bed rest, progesterone supplementation, and medications like tranexamic acid. Progesterone may help reduce miscarriage risk by influencing the immune response in the decidua.
The document discusses Polycystic Ovary Syndrome (PCOS), the most common endocrinopathy among women of reproductive age. PCOS is diagnosed based on two of three criteria: irregular periods, signs of high androgen levels, and enlarged ovaries with cysts. Women with PCOS have increased risks of infertility, metabolic and cardiovascular issues. Key aspects of PCOS include irregular periods due to hormonal imbalances, high androgen levels, insulin resistance, and enlarged ovaries. Treatment focuses on lifestyle changes, medication to manage symptoms and address insulin resistance, and fertility support.
1. The document discusses obesity in gynecological practice, covering topics like menstruation, sexual function, fertility, contraception, benign gynecological problems, and gynecological malignancy.
2. Obesity is associated with earlier menarche, irregular cycles, and decreased fertility. It can also negatively impact sexual function and satisfaction. Treatment for infertility is less effective in obese patients.
3. Benign issues like menstrual problems, endometrial polyps, fibroids, urinary incontinence, and pelvic organ prolapse are more common in obese patients. Menopause onset is earlier and symptoms are more severe. Obesity may protect against osteoporosis but increase
This document summarizes information for women about managing epilepsy and overall health. It covers bone health, sleep, exercise, nutrition, vitamins, minerals and herbal medicines. It discusses how epilepsy medications can impact these areas and provides suggestions for screening, treatment and lifestyle habits to support bone and overall health.
This document provides information on emergency contraception (EC), including types of EC, how EC works, effectiveness, safety, side effects, instructions for clients, and follow-up care. It discusses EC options like emergency contraceptive pills containing levonorgestrel or the Yuzpe regimen, and copper IUDs. EC is very safe and reduces risk of pregnancy by 75% or more. Common side effects include nausea, vomiting, and irregular bleeding. Proper use and follow-up guidance is outlined. Post-abortion and postpartum family planning is also summarized.
benefit of contraception
unmeet need
medical eligibility
tiers of contraception
COC
POP
DMPA
Implant, Nexplanon
IUCD, interuterine device
Sterilization, Male and female
Emergency contraception: Youzups, Plan B, IUCD
Calendar methods
Adolescence
PMS affects 40% of women and causes psychological and physical symptoms related to the menstrual cycle. The exact cause is unknown but likely involves sensitivity to hormone fluctuations. Diagnosis requires tracking symptoms over two cycles which improve after menstruation. Treatment depends on severity but may include lifestyle changes, SSRIs, COCPs, or suppressing ovulation. CBT and some supplements like Vitex and calcium can also help reduce symptoms.
PANEL DISCUSSION Management Of Adolescent PCOS And Associated Fertility Conc...Lifecare Centre
This document summarizes a panel discussion on the management of adolescent polycystic ovarian syndrome (PCOS) and associated fertility concerns. It discusses the changing diagnostic criteria for PCOS over time, common symptoms like menstrual irregularities and hirsutism, tests used to diagnose PCOS and hyperandrogenism, and guidelines for treating issues like hirsutism, acne and hair loss. The panel addressed questions on various topics related to managing adolescent PCOS and emphasized the importance of coordination between specialists.
This document provides a step-by-step guide to menopausal hormone therapy. It discusses assessing candidates for therapy, treatment options including different hormones and administration routes, starting treatment, and follow up and stopping treatment. It addresses indications, contraindications, and recommendations for using hormone therapy in symptomatic menopausal women with risk factors like age, obesity, diabetes, or smoking. The guide emphasizes using the lowest effective dose for the shortest time needed to manage menopausal symptoms.
Nausea & Vomiting in Pregnancy :an update Dr Sharda Jain Lifecare Centre
1) Nausea and vomiting in pregnancy (NVP) is a common condition affecting around 85% of pregnant women. Symptoms typically appear between 4-9 weeks and subside by 12-16 weeks for most women.
2) Risk factors for NVP include young age, primigravida, obesity, multiple pregnancy, family history, and motion sickness. The etiology is unknown but may involve hormonal and metabolic changes.
3) Severe NVP is known as hyperemesis gravidarum (HG) and requires hospitalization. HG affects 0.3-2.3% of pregnancies and is characterized by over 5% weight loss, dehydration, and electrolyte
This document provides information about Dr. Laxmi Shrikhande's credentials and experience in gynecology and fertility. It then summarizes guidelines for assessing and managing polycystic ovary syndrome (PCOS) and infertility. Key recommendations include using letrozole as first-line pharmacological treatment for infertility in PCOS patients, and considering gonadotropins as second-line if letrozole fails. The risks of ovarian hyperstimulation syndrome are also discussed for PCOS patients undergoing fertility treatments like IVF.
This document summarizes special considerations for women with epilepsy across the reproductive years, including effects on sexuality, mood, menstruation, fertility, bone health, pregnancy, breastfeeding, and menopause. It discusses how epilepsy and antiepileptic drug use can impact these areas through mechanisms like hormonal changes, drug interactions, teratogenic risks, and bone loss. Management involves counseling, supplementation, contraception guidance, monitoring for side effects, and registry participation for pregnant patients.
This document discusses the many non-contraceptive benefits of combined oral contraceptives (COCP). It notes that 33% of adolescents using COCP do so for non-contraceptive reasons approved by research. COCP can effectively treat conditions like dysmenorrhea, dysmenorrhea, signs of androgenization, PMS, ovarian cysts, endometriosis, adenomyosis, myoma, and others. It discusses the mechanisms by which COCP provides these benefits and provides evidence from multiple studies. The document emphasizes that understanding these non-contraceptive benefits can enhance healthcare providers' care of patients.
Tender Love and Care (TLC) in Recurrent Pregnancy Loss (RPL) Dr Sharda Jain D...Lifecare Centre
This document discusses tender love and care (TLC) in recurrent pregnancy loss (RPL). It defines RPL as three or more consecutive pregnancy losses. RPL can have psychological impacts like depression, anxiety, and stress on both women and their partners. Providing psychological support through TLC which includes frequent checkups, clear communication, emotional support, encouragement of positive coping strategies, and involvement of partners can help improve mental health and pregnancy outcomes for those experiencing RPL. Studies show TLC through a dedicated early pregnancy clinic or supportive partner behaviors significantly decreases miscarriage rates and increases live birth rates compared to no specific care or support.
it is really frustrating to women and challenging to doctors when they face repeated loss of pregnancy what is called recurrent abortion: how to manage such problem?? this talk may help in answering this question
Menopausal hormone therapy (MHT) also called postmenopausal hormone therapy and hormone replacement therapy. Here is presentation on Menopausal hormone therapy by Dr. Laxmi Shrikhande
Hormones such as estrogen and progesterone play a role in epilepsy in women. Estrogen can lower the seizure threshold while progesterone may help reduce seizures. The ratio of estrogen to progesterone over the menstrual cycle influences seizure occurrence for some women. Treatment may involve adjusting epilepsy medications during expected hormone fluctuations or using progesterone supplements. Birth control choice needs consideration of potential interactions with anti-seizure medications. Premenstrual syndrome and polycystic ovarian syndrome are also linked to seizures in women.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
The document discusses guidelines for treating premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). It finds that drospirenone-containing combined oral contraceptives (COCs) and selective serotonin reuptake inhibitors (SSRIs) should be considered first-line pharmaceutical treatments for PMS. Cognitive behavioral therapy is also recommended routinely for severe PMS. For severe cases, gonadotropin-releasing hormone (GnRH) analogues may be used, usually to aid diagnosis or for short-term treatment. Surgery is only indicated for select refractory cases after unsuccessful medical management and GnRH analogue testing.
Hypertension in pregnancy is a major killer disease, this presentation explores the review of contemporary evidence in the management of acute severe hypertension,
Subchorionic haemorrhages (SCH) are echo-free areas located between the placental membranes and uterine wall that occur in approximately 9-18% of first trimester bleeding cases. Studies show that the risk of miscarriage, stillbirth, preterm birth, and other complications increases with SCH, especially when the hematoma is large or occurs later in pregnancy. Treatment options for SCH include expectant management, bed rest, progesterone supplementation, and medications like tranexamic acid. Progesterone may help reduce miscarriage risk by influencing the immune response in the decidua.
The document discusses Polycystic Ovary Syndrome (PCOS), the most common endocrinopathy among women of reproductive age. PCOS is diagnosed based on two of three criteria: irregular periods, signs of high androgen levels, and enlarged ovaries with cysts. Women with PCOS have increased risks of infertility, metabolic and cardiovascular issues. Key aspects of PCOS include irregular periods due to hormonal imbalances, high androgen levels, insulin resistance, and enlarged ovaries. Treatment focuses on lifestyle changes, medication to manage symptoms and address insulin resistance, and fertility support.
1. The document discusses obesity in gynecological practice, covering topics like menstruation, sexual function, fertility, contraception, benign gynecological problems, and gynecological malignancy.
2. Obesity is associated with earlier menarche, irregular cycles, and decreased fertility. It can also negatively impact sexual function and satisfaction. Treatment for infertility is less effective in obese patients.
3. Benign issues like menstrual problems, endometrial polyps, fibroids, urinary incontinence, and pelvic organ prolapse are more common in obese patients. Menopause onset is earlier and symptoms are more severe. Obesity may protect against osteoporosis but increase
This document summarizes information for women about managing epilepsy and overall health. It covers bone health, sleep, exercise, nutrition, vitamins, minerals and herbal medicines. It discusses how epilepsy medications can impact these areas and provides suggestions for screening, treatment and lifestyle habits to support bone and overall health.
This document provides information on emergency contraception (EC), including types of EC, how EC works, effectiveness, safety, side effects, instructions for clients, and follow-up care. It discusses EC options like emergency contraceptive pills containing levonorgestrel or the Yuzpe regimen, and copper IUDs. EC is very safe and reduces risk of pregnancy by 75% or more. Common side effects include nausea, vomiting, and irregular bleeding. Proper use and follow-up guidance is outlined. Post-abortion and postpartum family planning is also summarized.
benefit of contraception
unmeet need
medical eligibility
tiers of contraception
COC
POP
DMPA
Implant, Nexplanon
IUCD, interuterine device
Sterilization, Male and female
Emergency contraception: Youzups, Plan B, IUCD
Calendar methods
Adolescence
Gynecology Medical Student notes describing use of contraceptives and application in the medical field. A guide on the criteria use of oral contraceptives and their indications for use.
This document discusses various methods of contraception. It begins by explaining that contraception is important for effective pre-pregnancy care, especially for high-risk women. It then provides details on many contraceptive methods, including natural/fertility awareness methods, barrier methods, hormonal methods, and long-acting reversible contraception (LARC) methods like IUDs, implants, and injections. For each method, it discusses effectiveness rates, mechanisms of action, administration instructions, benefits, risks, and other relevant details. The document emphasizes the importance of selecting the appropriate contraceptive method based on each individual woman's needs and circumstances.
This document provides an overview of various contraceptive methods, including their mechanisms of action, efficacy, advantages, disadvantages, and medical considerations. It discusses hormonal methods like combined and progestin-only oral contraceptives, implants, injectables, and IUDs. It also covers barrier methods, periodic abstinence, withdrawal, lactational amenorrhea, and breastfeeding as a contraceptive. For each method, key details are presented around effectiveness, side effects, proper use, and medical suitability.
This document provides information on various contraceptive methods including male and female condoms, diaphragms, spermicides, and oral contraceptives. It describes how each method works, effectiveness rates, proper use instructions, who can use each method, and potential side effects. The document is intended to educate about contraceptive options and their safe and effective use to prevent unwanted pregnancy and transmission of STIs.
This document summarizes new recommendations from the World Health Organization (WHO) on guidance for missed combined oral contraceptive pills (COCs). The WHO convened an expert panel to review evidence on contraceptive effectiveness when pills are missed on different days of the cycle. Based on this evidence, the WHO updated its Selected Practice Recommendations to provide revised rules on missed pills. The Faculty of Family Planning and Reproductive Health Care (FFPRHC) endorses the new WHO recommendations, which are presented in both tabular and flowchart formats. The recommendations provide guidance on emergency contraception and additional barrier methods depending on the number and timing of missed pills.
Safe Prescribing of Second Line Combined Oral Contraceptivemeducationdotnet
Here is what I would do next:
1. Perform a urine pregnancy test
2. Send for STI screening (chlamydia, gonorrhoea)
3. Consider pelvic ultrasound to check for ectopic pregnancy
4. Discuss options for changing contraception with the patient once investigations are complete
5. Review in 1 week with results of tests
6. Consider referral to gynaecology if pregnancy or infection is detected
The differential diagnosis includes:
- Ectopic pregnancy
- Intrauterine pregnancy
- Pelvic inflammatory disease
- Cervical infection
- Endometrial pathology
- Bleeding disorder
So in summary - investigate for pregnancy and infection, discuss
This document provides information about various contraceptive methods including hormonal contraceptives, intrauterine devices (IUDs), barrier methods, and permanent methods. It discusses classifications of contraceptives, mechanisms of action, use instructions, effectiveness, advantages and disadvantages of common methods like combined oral contraceptive pills, progestin-only pills, IUDs, implants, male condoms, and more. Key details about different hormonal formulations and the importance of proper use for maximizing effectiveness are also summarized.
This document discusses various hormonal contraceptive methods. It describes combined oral contraceptives (containing estrogen and progestin), progestogen-only contraceptives including the progestogen-only pill, implants containing etonogestrel, progestogen-only injectables such as depot medroxyprogesterone acetate, and the levonorgestrel intrauterine system. The methods are compared in terms of their mechanisms of action, administration, effectiveness, side effects, and contraindications. Combined oral contraceptives are highlighted as the most commonly used reversible contraceptive worldwide.
Here are the key points I would discuss with the couple:
1. Since the husband has hepatitis B, permanent sterilization methods like vasectomy may not be advisable as it involves surgical procedures.
2. For the wife, IUCD insertion carries a small risk of introducing infection into the uterus. So IUCD may not be the best option.
3. Barrier methods like condoms would help prevent disease transmission but they have higher failure rates compared to other long-acting reversible methods.
4. The safest option would be for the wife to use an injectable contraceptive like DMPA injections which is long-acting and very effective. It does not involve any surgical procedure or devices inside the body.
This document contains 11 scenarios describing different patient presentations related to contraception and consent for procedures. The scenarios cover topics such as contraceptive options for breastfeeding women, initiating contraception in the postpartum period, contraindications for various contraceptive methods based on medical conditions, obtaining consent from minors, and forensic evidence collection following sexual assault.
The document provides information on various contraceptive methods including hormonal contraception, barrier methods, intrauterine devices, and sterilization. It discusses the effectiveness, risks, benefits, and appropriate counseling for different contraceptive options. The document aims to educate healthcare providers on family planning to provide women with successful contraception that has a positive impact on their health and lives.
This document provides information on different types of oral contraceptives and how they work. It discusses combined oral contraceptives (COCs) which contain both estrogen and progesterone. COCs prevent ovulation and make implantation less likely. Their effectiveness depends on correct and consistent use. Side effects may include changes in bleeding patterns and headaches. It also discusses progestin-only pills (POPs) which contain progesterone only and work mainly by thickening cervical mucus. Injectable contraceptives like DMPA are administered through injection and provide contraception for 1-3 months by inhibiting ovulation. Implants are long-acting reversible methods involving rods inserted under the skin that release progestin.
This document provides information on different types of oral contraceptives and how they work. It discusses combined oral contraceptives (COCs) which contain both estrogen and progesterone. COCs prevent ovulation and make implantation less likely. Their effectiveness depends on correct and consistent use. Side effects may include changes in bleeding patterns and headaches. It also discusses progestin-only pills (POPs) which contain progesterone only and work mainly by thickening cervical mucus. Injectable contraceptives like DMPA are administered through injection and provide contraception for 1-3 months by inhibiting ovulation. Implants are long-acting reversible methods involving rods inserted under the skin that release progestin and prevent pregnancy for 3-5
This document provides information about various contraceptive methods. It discusses natural family planning methods, mechanical methods like condoms and diaphragms, and hormonal methods like oral contraceptive pills, injectables, implants, and intrauterine devices. For each method, it covers efficacy, mechanisms of action, usage instructions, benefits, side effects, and risks. The ideal is described as a contraceptive that is safe, effective, free of side effects, available, acceptable to users, and does not impact future fertility.
This document provides information about an Indian physician named Dr. Laxmi Shrikhande, including her professional accomplishments and roles. It lists that she has served as Chairperson Elect of the Indian College of OB/GYN, National Corresponding Editor of the Journal of OB/GYN of India, Founder Patron and President of ISOPARB Vidarbha Chapter, and various other leadership positions in medical organizations. It also notes some of the awards and recognition she has received for her work in women's health and related fields.
The document provides information on injectable contraceptives, including learning objectives, types available in Pakistan (DMPA, NET-EN, Mesigyna), how each works, effectiveness, advantages, limitations, side effects, client assessment, and site of insertion. The key points are that three injectable contraceptives are available, they prevent pregnancy for 2-3 months by inhibiting ovulation and thickening cervical mucus, they are very effective but can cause side effects like irregular bleeding, and clients must be properly assessed for medical eligibility.
The document discusses various methods of contraception, their effectiveness, side effects, and appropriate usage. It covers hormonal methods like combined oral contraceptives (pills), patches, rings, and progestogen-only pills, implants, and injections. It also discusses intrauterine devices (IUDs), barrier methods, natural family planning, and sterilization. Effectiveness depends on how the method works and how easy it is to use correctly. Side effects vary by method but can include changes to bleeding patterns, mood changes, weight gain, and risk of ectopic pregnancy if failure occurs. Appropriate medical factors are also outlined for selecting the best contraceptive option.
The document provides an update on contraception. It discusses various contraceptive methods including levonorgestrel emergency contraception, subcutaneous DMPA, and the lactational amenorrhea method. It addresses common misconceptions about contraceptive effectiveness and safety. The document is divided into multiple rounds testing knowledge of contraceptive guidelines through true/false and multiple choice questions.
This document provides guidelines for the diagnosis, management, and follow-up of urinary tract infections (UTIs) in children. It recommends obtaining a urine sample from infants and children presenting with unexplained fever over 38°C to test for a UTI. Clean-catch urine samples are preferred for testing, and if not possible, catheterization or suprapubic aspiration should be used. Urine samples that cannot be cultured within 4 hours should be refrigerated or preserved. Based on microscopy and culture results, treatment with oral or intravenous antibiotics is recommended depending on the child's age and location of the infection. Imaging may be used depending on risk factors, and prophylactic antibiotics should be considered for recurrent UTIs.
This document discusses drug interactions, including definitions, types, mechanisms, high risk patients, and how to handle interactions. It notes the main types are drug-drug, herbal-drug, food-drug, and drink-drug interactions. Mechanisms include effects on absorption, distribution, metabolism, and excretion. Absorption can be affected by changes in pH, bacteria, insoluble complexes, or motility. Metabolism interactions involve enzyme induction or inhibition. The document provides examples of interactions and notes some drugs are more prone to interactions. It outlines approaches to preventing or managing interactions.
This presentation discusses high-alert medications, which are drugs that carry an increased risk of harming patients if used incorrectly. It identifies common classes of high-alert medications like opioids, insulin, and anticoagulants. Case scenarios are presented to demonstrate potential harms from improper use. Strategies are described for safely monitoring high-alert medications through standardization, redundancy checks, simplifying processes, and close patient monitoring.
This document presents two patient cases with hematuria and outlines guidelines for evaluating microscopic hematuria. Case 1 involved a 30-year-old female with burning during urination but no other symptoms. Examination found RBCs and leukocytes in the urine. She was treated with antibiotics which improved her symptoms. Case 2 was a 21-year-old male with blood in urine and weight loss. Examination was normal except for RBCs in urine. The document then outlines the definition, common causes, risk factors, initial investigations including urine analysis and imaging, and recommendations for cystoscopy depending on patient characteristics when evaluating microscopic hematuria.
This document provides guidance on evaluating and treating patients presenting with vaginal discharge. It begins with an overview of the objectives and causes of vaginitis. The most common causes are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. It describes taking a thorough history and physical exam, with attention to symptoms, signs, and diagnostic tests to identify the specific condition. Treatment recommendations are provided for the main diagnoses of candidiasis, bacterial vaginosis, trichomoniasis, chlamydia, and gonorrhea. A case presentation demonstrates applying this approach to diagnose and treat a patient with trichomoniasis based on her history, exam findings, and tests.
The document discusses mediations during the month of Ramadhan. Ramadhan is considered a holy month in the Islamic calendar where Muslims fast from dawn to dusk and focus on acts of worship, reflection, and charity. During this month, Muslims are encouraged to resolve conflicts peacefully through open communication and forgiveness.
Trauma Management in Primary Care Settingssnsharifa
1. The primary survey involves rapidly assessing and treating life-threatening injuries by evaluating the patient's airway, breathing, circulation, disability, and exposure (ABCDE). This includes establishing an open airway, assessing breathing and ventilation, treating hemorrhagic shock, and providing spinal immobilization and intravenous access when needed.
2. The secondary survey is a head-to-toe examination to identify any injuries that may have been missed during the primary survey. It includes detailed examination of specific body regions like the head, neck, chest, abdomen, and extremities.
3. Effective trauma management requires a coordinated team approach with assigned roles. The goals are to rapidly identify and treat life-threatening injuries,
This document discusses the evaluation and differential diagnosis of short stature in children. It defines short stature as a height more than 2 standard deviations below the mean for age and sex. The evaluation involves taking a history, performing a physical exam, assessing growth parameters, growth velocity, midparental height, bone age, and indications for further investigations. Common causes discussed are familial short stature, constitutional short stature, and pathological short stature. Treatment options mentioned include growth hormone, oxandrolone, IGF-1, and aromatase inhibitors.
This document summarizes guidelines for screening and managing osteoporosis. It defines osteoporosis as a bone density T-score of -2.5 or lower according to WHO standards. All women over 65 should be screened by DXA scan, while younger women are screened if their 10-year fracture risk equals or exceeds an average 65-year-old woman. First-line treatment includes bisphosphonates along with lifestyle modifications like calcium and vitamin D. Screening and treatment decisions are also based on additional risk factors like prior fractures, smoking, glucocorticoid use, and family history.
This document discusses occupational disorders such as occupational asthma. Some key points are: occupational asthma accounts for about 15% of new asthma cases in adults and results in over 1 million disability cases annually. Diagnosis involves a work history and objective tests like spirometry. Treatment involves avoiding the causal agent, though symptoms may persist, as well as medications like inhaled corticosteroids. The prognosis is generally poor, with only 1/3 achieving long-term recovery even after avoiding exposure.
This 62-year-old lady presented with 5 days of painful right knee associated with redness and limping after trauma to the knee. Examination found fullness, redness, tenderness, warmth and restricted movement of the right knee. Differential diagnoses included fracture, septic arthritis, and allergy.
This document discusses a 52-year-old woman presenting with hot flashes and depression for 14 months without a period. It defines perimenopause, menopause and postmenopause. It recommends diagnosing perimenopause based on symptoms in women over 45 and managing hot flashes with HRT. It advises against using FSH to diagnose menopause in women using hormonal contraception. The risks and benefits of HRT are discussed as well as non-hormonal options for treatment.
Carbohydrates provide an important source of energy. Low-carbohydrate diets restrict carbohydrate intake, often below 130g per day, to induce weight loss. Very low-carbohydrate ketogenic diets reduce carbohydrates to less than 50g per day to produce ketosis, where the body uses fat instead of glucose for fuel. While low-carb diets may aid short-term weight loss, long-term safety and effectiveness require more research due to potential vitamin deficiencies or unfavorable cholesterol changes with strict low-carb intake.
Insomnia is defined as difficulty falling asleep, staying asleep, or early awakening despite opportunities for sleep, associated with impaired daytime functioning for at least 3 nights per week for over a month. It can be acute (under 3 months) or chronic. Assessment involves medical history, sleep history, and screening for sleep apnea, depression/anxiety, and other medical issues. Treatment goals are to improve sleep quality and quantity and daytime functioning. Non-pharmacological treatments like CBT, sleep hygiene, and sleep restriction are recommended initially. Hypnotics may be used short-term but have risks and should be avoided for chronic insomnia when possible.
This document discusses an approach to evaluating a patient presenting with fever and rash. It defines fever and rash and outlines an approach involving assessing severity, confirming fever type and rash characteristics, considering differential diagnoses, and developing an action plan. It then discusses two specific cases: measles in a 9-month old child presenting with maculopapular rash and supportive care is recommended; and rubella with its characteristic rash and Forschheimer spots and no specific treatment required beyond supportive care. Prevention of both involves the MMR vaccine.
A 33-year-old woman presents with weight loss, sweating, and tremors. Her thyroid function tests show hyperthyroidism. Graves' disease is the most likely diagnosis as it is the most common cause of thyrotoxicosis and her symptoms are typical. While eye signs are seen in 30% of Graves' patients, their absence does not rule out the diagnosis.
A series of multiple choice questions related to ENT conditions are presented. The questions cover topics like facial pain, hearing tests, sinusitis, trigeminal neuralgia, Meniere's disease, hereditary haemorrhagic telangiectasia, auricular haematomas, allergic rhinitis, nasal polyps, Epstein-Barr virus, and neck lumps. For each clinical scenario, learners are asked to choose the most likely diagnosis from a list of options. Explanations are provided for various conditions and test results.
A woman who is 31 weeks pregnant presents with an itchy rash on her abdomen and thighs. The most likely diagnosis is polymorphic eruption of pregnancy, which is a pruritic condition associated with the last trimester that often appears on the abdominal striae. A 54-year-old man is referred for symmetrical, erythematous, tender nodules on his shins, which is consistent with the characteristics of erythema nodosum. A 34-year-old man presents with an itchy rash on his genitals, palms, and around a recent scar, indicating the diagnosis of lichen planus.
1) The document discusses HPV vaccines for adolescents, recommending vaccination at ages 11-12 to protect against cancers caused by HPV. It describes three HPV vaccines that protect against different HPV types.
2) HPV is very common and can cause various cancers as well as genital warts. While most infections resolve, persistent infections can lead to cancer.
3) HPV vaccines have been found to be very safe and effective in clinical trials and in decreasing HPV-related infections and diseases in vaccinated populations.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
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1. Womens Health ( MRCGP Qs ) : Contraception
Q1)_An 18-year-old female presentstoher GP as she has missedone of her Microgynon30 pills
yesterdaymorning. She has taken Microgynonfor the past 2 years and is currently 4 days intoa
packet of pills.She had sexual intercourse last nightand isunsure what to do. What is the correct
management?
A. Advise condomuse fornext7 days
B. Performa pregnancytest
C. Omitpill breakat endof pack
D. No action needed
E. Emergencycontraceptionshouldbe offered
As she has only missed one pill no action is needed. For further information please consult the link
to the FSRH guidelines.
The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
contraceptive issues seemed to be lacking. '
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over
recent years. The following recommendations are now made for women taken a combined oral
contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (at any time in the cycle)
take a pill as soon as possible and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take a pill as soon as possible and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a
row
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if
she had unprotected sexin the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC
there is no need for emergency contraception*
2. if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and
start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Q2)_Which one of the following statements regarding the link between intrauterine devices
(IUDs) and ectopic pregnancies is correct?
A. The proportion of pregnancies that are ectopic is increased and the absolute number is
increased
B. The proportion of pregnancies that are ectopic is increased but the absolute number
is decreased
C. Having an intrauterine device has no effect on the rate of ectopic pregnancies
D. The proportion of pregnancies that are ectopic is decreased and the absolute number is
decreased
E. The proportion of pregnancies that are ectopic is decreased but the absolute number is
increased
IUCD - the proportion of pregnancies that are ectopic is increased but the absolute number is
decreased
The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
contraceptive issues seemed to be lacking. '
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
3. IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Q3)_ Whichone of the followingisnot a recognisedadverse effectofthe combinedoral contraceptive
pill?
A. Increasedrisk of ovarian cancer
B. Increasedriskof deepveinthrombosis
C. Increasedriskof breastcancer
D. Increasedriskof ischaemicheartdisease
E. Increasedriskof cervical cancer
Combined oral contraceptive pill
increased risk of breast and cervical cancer
4. protective against ovarian and endometrial cancer
The combined oral contraceptive pill has actually been shown to reduce the risk of ovarian cancer
Combined oral contraceptive pill: advantages/disadvantages
Advantages of combined oral contraceptive pill
highly effective (failure rate < 1 per 100 woman years)
doesn't interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial and colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
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
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane
review did not support a causal relationship
Q4)_Which one of the following is not an absolute contraindication to combined oral
contraceptive pill use?
A. Blood pressure 165/100 (confirmed on three readings)
B. Continuous use before, during and after a total knee replacement
C. Breast feeding a 10-week-old baby
5. D. Deep vein thrombosis 9 years ago
E. A 39-year-old who smokes 20 cigarettes/day
Breast feeding < 6 weeks postpartum is UKMEC category 4 where as after this time it is UKMEC
category 3
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by
the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and
contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive
method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
breast feeding 6 weeks - 6 months postpartum
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
6. *The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
Q5)_ A 19-year-oldfemale presentsto surgery asking to start an oral contraceptive pill.She has no
significantpast medical history or familyhistory ofnote. If a combinedpill is chosen,what isthe most
appropriate of the options givenbelow?
A. Ethinylestradiol35 mcg withnorethisterone 1mg
B. Ethinylestradiol50 mcg withlevonorgestrel 150 mcg
C. Ethinylestradiol20 mcg withgestodene 75mcg
D. Ethinylestradiol20 mcg withnorethisterone 1mg
E. Ethinylestradiol 30 mcg with levonorgestrel 150 mcg
The faculty recommend a pill with 30 mcg of oestrogen for first-time combined oral contraceptive pill
users
Combined oral contraceptive pill: choice of pill
The combined oral contraceptive method (COC) varies by both the amount of oestrogen and
progestogen and also the presentation (e.g. everyday pill/phasic preparation, patches etc)
For first time users
consider using a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone
(e.g. Microgynon 30 - ethinylestradiol 30 mcg with levonorgestrel 150 mcg)
New COC
A product combining 20mcg ethinylestradiol with 3mg drospirenone is soon to be launched in the
UK. In the US and Europe it is branded as Yaz and has an interesting 24/4 regime, as opposed to
the normal 21/7 cycle. The idea is that a shorter pill-free interval is both better for patients with
troublesome premenstrual symptoms and is also more effective at preventing ovulation.
Q6)_A 29-year-old female presents to her GP as she missed her Micronor pill (progestogen
only) this morning and is unsure what to do. She normally takes the pill at around 0830 and it
is now 1100. What advice should be given?
A. Take missed pill now and no further action needed
B. Emergency contraception should be offered
7. C. Take missed pill now and advise condom use until pill taking re-established for 48 hours
D. Take missed pill now and omit pill break at end of pack
E. Perform a pregnancy test
Progestogen only pill: missed pill
The missed pill rules for the progestogen only pill is as follows:
If < 3 hours* late
continue as normal
If > 3 hours*
take missed pill as soon as possible
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for
48 hours
*for Cerazette (desogestrel) a 12 hour period is allowed
Q7)_A 33-year-old female presents to her GP as she missed her Noriday pill (progestogen
only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it
is now 1230. What advice should be given?
A. Take missed pill as soon as possible and advise condom use until pill taking
re-established for 48 hours
B. Take missed pill as soon as possible and omit pill break at end of pack
C. Perform a pregnancy test
D. Take missed pill as soon as possible and no further action needed
E. Emergency contraception should be offered
The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
contraceptive issues seemed to be lacking. '
Progestogen only pill: missed pill
The missed pill rules for the progestogen only pill is as follows:
If < 3 hours* late
8. continue as normal
If > 3 hours*
take missed pill as soon as possible
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for
48 hours
*for Cerazette (desogestrel) a 12 hour period is allowed
Q8)_A 19-year-old female is prescribed a 7 day course of penicillin for tonsillitis. She is
currently taking Microgynon 30. What is the most appropriate advice regarding
contraception?
A. Use condoms for 7 days only if antibiotic course overlaps with pill free interval
B. Use condoms for 14 days
C. There is no need for extra protection
D. Use condoms for 21 days
E. Use condoms for 7 days
The guidelines have changed. Please see below for more details.
Combined oral contraceptive pill: special situations
Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may
interfere with the enterohepatic circulation of oestrogen and thus make the combined oral
contraceptive pill ineffective - 'extra- precautions' were advised for the duration of antibiotic
treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines
abandoning this approach. The latest edition of the BNF has been updated in line with this
guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Switching combined oral contraceptive pills
9. the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give
contradictory advice. The Clinical Effectiveness Unit of the FSRH have stated in the
Combined Oral Contraception guidelines that the pill free interval does not need to be
omitted (please see link). The BNF however advises missing the pill free interval if the
progesterone changes. Given the uncertainty it is best to follow the BNF
Q9)_A 19-year-oldfemale isprescribeda 7 day course of amoxicillinfora lowerrespiratory tract
infection.She is currentlytaking Cerazette (desogestrel).Whatisthe most appropriate advice
regarding contraception?
A. Use condomsfor14 days
B. Use condomsfor21 days
C. Use condomsfor7 days
D. There is no needfor extra protections
E. Use condomsfor7 days,onlyantibioticcourse overlapswithpill free interval
Progestogen only pill + antibiotics - no need for extra precautions
Progestogen only pill: counselling
Women who are considering taking the progestogen only pill (POP) should be counselled in a
number of areas:
Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection,
otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2
days
if switching from a combined oral contraceptive (COC) gives immediate protection if
continued directly from the end of a pill packet (i.e. Day 21)
10. Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra
precautions (e.g. Condoms) should be used until pill taking has been re-established for 48
hours
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see
above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce effectiveness
Other information
discussion on STIs
*for Cerazette (desogestrel) a 12 hour period is allowed
**unless the antibiotic alters the P450 enzyme system, for example rifampicin
Q10)_What is the failure rate of male sterilisation?
A. 1 in 100
B. 1 in 200
C. 1 in 300
D. 1 in 400
E. 1 in 2,000
11. Male sterilisation - failure rate = 1 in 2,000
Sterilisation
Male sterilisation - vasectomy
failure rate: 1 per 2,000*
simple operation, can be done under LA (some GA), go home after a couple of hours
doesn't work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have
unprotected sex (usually at 16 and 20 weeks)
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain
(affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and
approximately 25% after more than 10 years
Female sterilisation
failure rate: 1 per 200*
usually done by laparoscopy under general anaesthetic
generally done as a day case
many different techniques involving clips (e.g. Filshie clips) , blockage, rings (Falope rings)
and salpingectomy
complications: increased risk of ectopic if sterilisation fails, general complications of
GA/laparoscopy
the current success rate of female sterilisation reversal is between 50-60%
*source = Royal College of Obstetricians and Gynaecologists
Q11)_A 34-year-old female has a TT380 Slimline intrauterine device fitted for contraception on
day 14 of her cycle. She has not been sexually active since her last period. How long will it
take before it can be relied upon as a method of contraception?
A. Immediately
12. B. 2 days
C. 5 days
D. 7 days
E. Until first day of next period
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
13. the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Q12)_A 19-year-old woman is seen the day after being discharged from hospital following a
termination of pregnancy at 14 weeks. She is keen to start the combined oral contraceptive
(COC) pill despite discussing long acting reversible contraceptives. What is the most
appropriate action?
A. Start COC immediately
B. Start COC after 7 days
C. Refuse to prescribe a contraceptive unless she chooses a long acting reversible
contraceptive
D. Start COC on first day of next period
E. Start COC after 21 days
The COC can be started immediately after a miscarriage or abortion. Women are protected from
pregnancy straight away.
Combined oral contraceptive pill: counselling
Women who are considering taking the combined oral contraceptive pill (COC) should be counselled
in a number of areas:
Potential harms and benefits, including
the COC is > 99% effective if taken correctly
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
Advice on taking the pill, including
14. 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
should be taken at the same time everyday
taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
advice that intercourse during the pill-free period is only safe if the next pack is started on
time
Discussion on situations here efficacy may be reduced*
if vomiting within 2 hours of taking COC pill
if taking liver enzyme inducing drugs
Other information
discussion on STIs
*Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may
interfere with the enterohepatic circulation of oestrogen and thus make the combined oral
contraceptive pill ineffective - 'extra-precautions' were advised for the duration of antibiotic
treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines
abandoning this approach. The latest edition of the BNF has been updated in line with this
guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Q13)_A 44-year-oldfemale has a Mirena(intrauterine system) fittedfor contraceptionon day 12 of
her cycle.How longwill it take before it can be reliedupon as a methodof contraception?
A. Immediately
B. 2 days
C. 5 days
D. 7 days
15. E. Until firstday of nextperiod
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
16. the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Q14)_ What is the failure rate offemale sterilisation?
A. 1 in100
B. 1 in200
C. 1 in300
D. 1 in400
E. 1 in500
Female sterilisation - failure rate = 1 in 200
Sterilisation
Male sterilisation - vasectomy
failure rate: 1 per 2,000*
simple operation, can be done under LA (some GA), go home after a couple of hours
doesn't work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have
unprotected sex (usually at 16 and 20 weeks)
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain
(affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and
approximately 25% after more than 10 years
Female sterilisation
failure rate: 1 per 200*
usually done by laparoscopy under general anaesthetic
generally done as a day case
17. many different techniques involving clips (e.g. Filshie clips) , blockage, rings (Falope rings)
and salpingectomy
complications: increased risk of ectopic if sterilisation fails, general complications of
GA/laparoscopy
the current success rate of female sterilisation reversal is between 50-60%
*source = Royal College of Obstetricians and Gynaecologists
Q15)_A 44-year-old man attends for counselling with regards to a vasectomy. Which one of
the following statements is true regarding vasectomy?
A. Vasectomy is effective immediately
B. Female sterilisation is more effective
C. Two negative semen samples should be obtained at 2 and 4 weeks before other
contraceptive methods are stopped
D. Chronic testicular pain is seen in more than 5%of patients
E. Sexual intercourse should be avoided for one month to reduce the chance of a
sperm granuloma
Sterilisation
Male sterilisation - vasectomy
failure rate: 1 per 2,000*
simple operation, can be done under LA (some GA), go home after a couple of hours
doesn't work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have
unprotected sex (usually at 16 and 20 weeks)
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain
(affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and
approximately 25% after more than 10 years
Female sterilisation
failure rate: 1 per 200*
usually done by laparoscopy under general anaesthetic
generally done as a day case
18. many different techniques involving clips (e.g. Filshie clips) , blockage, rings (Falope rings)
and salpingectomy
complications: increased risk of ectopic if sterilisation fails, general complications of
GA/laparoscopy
the current success rate of female sterilisation reversal is between 50-60%
*source = Royal College of Obstetricians and Gynaecologists
Q16)_ A 33-year-old woman is reviewed following a routine cervical smear. She had an
intrauterine device (IUD) inserted for contraception 2 years ago. She is currently well and
reports no new problems. The smear report shows no evidence of dyskaryosis but states that
Actinomyces-like organisms had been identified. What is the most appropriate management?
A. Remove IUD + high vaginal swab in 1 month
B. No action needed
C. Remove IUD + oral doxycycline
D. Oral metronidazole
E. Remove IUD + oral metronidazole
Actinomyces-like organisms (ALOs) are a commensal of the female genital tract. Current advice
from the Faculty of Sexual and Reproductive Healthcare suggests IUDs need not be removed if the
patient is asymptomatic.
If the patient was symptomatic then IUD removal should be considered along with penicillin therapy
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
19. Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Q17)_ A female patientasks for advice about havingan intrauterine device inserted(aTT380
Slimline).Whatadvice shouldbe givenregardingthe likelyeffectonher periods?
A. Periodswill tend to be longer,heavierand more painful
B. Theywill stopafter6 monthsin > 50% of users
C. Periodswill tendtobe lighter,shorterandlesspainful
D. Continual, lightbleedingisseenin50%
E. Theywill stopafter6 monthsin > 90% of users
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
20. IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Q18)_ Whichone of the followingisan absolute contraindicationto combinedoral contraceptive pill
use?
A. Controlledhypertension
B. Historyof cholestasis
C. 36-year-oldwoman smoking20 cigarettes/day
D. BMI of 38 kg/m^2
E. Migraine withoutaura
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by
the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and
contraindications according to a four point scale, as detailed below:
21. UKMEC 1: a condition for which there is no restriction for the use of the contraceptive
method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
breast feeding 6 weeks - 6 months postpartum
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
*The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
Q19)_A 22-year-old woman presents for her Depo-provera injection. She apologises as she
forgot about her appointment last week. You calculate she received her last injection 12
weeks and 4 day ago. What is the most appropriate course of action?
A. Do a pregnancy test today + give injection if negative
B. Give injection today and no further action
C. Give injection today + use condoms for 7 days + pregnancy test in 21 days
22. D. Do not give injection + do pregnancy test in 21 days
E. Give injection today + use condoms for 7 days
Depo-provera can be given up to 14 weeks with no extra precautions
See below - there is a discrepancy between the widely followed 14 week rule and the advice in the
BNF. However, this answer is still consistent with the BNF guidance.
Injectable contraceptives
Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone
acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up
to 14 weeks after the last dose without the need for extra precautions**
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus
thickening and endometrial thinning.
Disadvantages include the fact that the injection cannot be reversed once given. There is also a
potential delayed return to fertility (maybe up to 12 months)
Adverse effects
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
*Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It
is given every 8 weeks
**the BNF gives different advice, stating a pregnancy test should be done if the interval is greater
than 12 weeks and 5 days - this is however not commonly adhered to in the family planning
community
Q20)_A 25-year-old female presents to her GP as she has missed two consecutive
Microgynon 30 pills. She has taken the Microgynon for the past 5 years and is currently 11
days into a packet of pills. Last night she had sexualintercourse with a new partner but
unfortunately the condom split. What is the correct management?
A. Perform a pregnancy test
23. B. No action needed
C. Advise condom use for next 7 days
D. Emergency contraception should be offered
E. Omit pill break at end of pack
Updated guidance from the FSRH states the following after a woman has missed two pills:
'If you have missed two or more pills (i.e. more than 48 hours late), anywhere in the pack … continue
taking the rest of the pack as usual and use an extra method of contraception for the next 7 days'
For further information please consult the link to the FSRH guidelines. As this was a new partner
consideration should be given to STI screening after an appropriate interval.
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over
recent years. The following recommendations are now made for women taken a combined oral
contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (at any time in the cycle)
take a pill as soon as possible and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take a pill as soon as possible and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a
row
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if
she had unprotected sexin the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC
there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and
start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Q21)_Which one of the following is most associated with combined oral contraceptive pill use?
24. A. Increased dysmenorrhoea
B. Increased incidence of benign breast disease
C. Worsening of acne
D. Increased risk of colorectal cancer
E. Increased risk of cervicalcancer
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
Combined oral contraceptive pill: advantages/disadvantages
Advantages of combined oral contraceptive pill
highly effective (failure rate < 1 per 100 woman years)
doesn't interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial and colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
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
25. Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane
review did not support a causal relationship
Q22)_A 36-year-old female starts Cerazette (desogestrel) on day 7 of her cycle. How long will
it take before it can be relied upon as a method of contraception?
A. Immediately
B. 2 days
C. 5 days
D. 7 days
E. Until first day of next period
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Progestogen only pill: counselling
Women who are considering taking the progestogen only pill (POP) should be counselled in a
number of areas:
Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection,
otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2
days
if switching from a combined oral contraceptive (COC) gives immediate protection if
continued directly from the end of a pill packet (i.e. Day 21)
26. Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra
precautions (e.g. Condoms) should be used until pill taking has been re-established for 48
hours
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see
above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce effectiveness
Other information
discussion on STIs
*for Cerazette (desogestrel) a 12 hour period is allowed
**unless the antibiotic alters the P450 enzyme system, for example rifampicin
Q23)_A 29-year-old woman who is 2 weeks postpartum consults you regarding
contraception. She is interested in having an intrauterine device (IUD) inserted and asks
when it could be fitted. She had a emergency caesarean section for failure to progress. What
is the most appropriate advice to give?
A. An IUD can be inserted 4 weeks postpartum
B. An IUD can be inserted 12 months postpartum
C. An IUD can be inserted today
D. An IUD can be inserted 12 weeks postpartum
E. An IUD is contraindicated in the long-term
27. Guidelines do not suggest there is a need to wait any longer despite the caesarean section.
Intrauterine contraceptive devices: insertion
Very few contraindications to insertion of an intrauterine contraceptive device exist. Below are some
conditions mentioned by the Faculty of Family Planning and Reproductive Health Care. Please see
the link for the full list.
UKMEC Category 3 (Risks outweigh benefits)*
between 48 hours and 4 weeks postpartum (increased risk of perforation)
initiation of method** in women with ovarian cancer
UKMEC Category 4 (Unacceptable risk)
pregnancy
current pelvic infection, puerperal sepsis, immediate post-septic abortion
unexplained vaginal bleeding which is suspicious
uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity
NICE produced guidelines in 2005 on screening for sexually transmitted infections (STI) before
insertion of an intrauterine contraceptive device
Chlamydia trachomatis in women at risk of STIs
Neisseria gonorrhoeae in women at risk of STIs, in areas where it is prevalent
any STIs in women who request it
For women at increased risk of STIs prophylactic antibiotics should be given before inserting an
intrauterine contraceptive device if testing has not yet been completed
*current venous thromboembolism (on anticoagulants) has recently been downgraded from UKMEC
3 to UKMEC 1
**as opposed to continuation of the method
Q24)-A 23-year-old female presents as she would like to switch from Microgynon 30 to
another combined oral contraceptive (COC) due to mood swings.It is decided to start
Marvelon. What advice should be given about switching her COC?
A. 'Overlap' for 7 days after starting the new COC
B. Stop Microgynon, wait until first day of next normal menstrual period before commencing
new pill
28. C. Finish the current pill packet and the start the new COC without a pill free interval and use
condoms for 7 days
D. Finish the current pill packet and the start the new COC without a pill free interval
E. Switch at any time as the oestrogen content of the pill is the same
Difficult one as the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give
contradictory advice. The Clinical Effectiveness Unit of the FSRH have produced a statement that
the pill free interval does not need to be omitted (please see link). The BNF however advises
missing the pill free interval if the progesterone changes. Given the uncertainty it is best to follow the
BNF
Combined oral contraceptive pill: special situations
Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may
interfere with the enterohepatic circulation of oestrogen and thus make the combined oral
contraceptive pill ineffective - 'extra- precautions' were advised for the duration of antibiotic
treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines
abandoning this approach. The latest edition of the BNF has been updated in line with this
guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Switching combined oral contraceptive pills
the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give
contradictory advice. The Clinical Effectiveness Unit of the FSRH have stated in the
Combined Oral Contraception guidelines that the pill free interval does not need to be
omitted (please see link). The BNF however advises missing the pill free interval if the
progesterone changes. Given the uncertainty it is best to follow the BNF
Q25)_ A 27-year-old female presents to her GP as she missed her Cerazette pill (progestogen
only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it
is now 1430. What advice should be given?
A. Emergency contraception should be offered
B. Perform a pregnancy test
C. Take missed pill as soon as possible and omit pill break at end of pack
29. D. Take missed pill now and no further action needed
E. Take missed pill now and advise condom use until pill taking re-established for 48
hours
As Cerazette has a 12-hour window this patient should take the pill now with no further action being
needed
Progestogen only pill: missed pill
The missed pill rules for the progestogen only pill is as follows:
If < 3 hours* late
continue as normal
If > 3 hours*
take missed pill as soon as possible
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for
48 hours
*for Cerazette (desogestrel) a 12 hour period is allowed
Q26)- What is the most common adverse effect experienced by women taking the
progestogen only pill?
A. Irregular vaginal bleeding
B. Acne
C. Mood swings
D. Reduced libido
E. Weight gain
The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
contraceptive issues seemed to be lacking. '
Progestogen only pill: advantages/disadvantages
30. Advantages
highly effective (failure rate = 1 per 100 woman years)
doesn't interfere with sex
contraceptive effects reversible upon stopping
can be used whilst breast-feeding
can be used in situations where the combined oral contraceptive pill is contraindicated e.g. in
smokers > 35 years of age and women with a history of venous thromboembolic disease
Disadvantages
irregular periods: some users may not have periods whilst others may have irregular or light
periods. This is the most common adverse effect
doesn't protect against sexually transmitted infections
increased incidence of functional ovarian cysts
common side-effects include breast tenderness, weight gain, acne and headaches. These
symptoms generally subside after the first few months
Q27)- A 45-year-old woman requests insertion of an intrauterine device (IUD). Which one of
the following statements regarding the expulsion rate is correct?
A. Occurs in around 1 in 200 women, and is more likely in the first 3 months
B. Occurs in around 1 in 20 women, and is more likely after having the IUD for more
than 3 years
C. Occurs in around 1 in 500 women, and is more likely in the first 3 months
D. Occurs in around 1 in 20 women, and is more likely in the first 3 months
E. Occurs in around 1 in 200 women, and is more likely after having the IUD for more
than 3 years
Expulsion is the most common reason for IUD failure, hence the importance of checking the threads
after each period
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
31. both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Q28)- Which one of the following contraceptives may decrease bone mineral density in
women?
A. Depo Provera (injectable contraceptive)
B. Progestogen only pill
C. Mirena (intrauterine system)
D. Implanon (implantable contraceptive)
E. Combined oral contraceptive pill
Injectable contraceptives
32. Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone
acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up
to 14 weeks after the last dose without the need for extra precautions**
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus
thickening and endometrial thinning.
Disadvantages include the fact that the injection cannot be reversed once given. There is also a
potential delayed return to fertility (maybe up to 12 months)
Adverse effects
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
*Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It
is given every 8 weeks
**the BNF gives different advice, stating a pregnancy test should be done if the interval is greater
than 12 weeks and 5 days - this is however not commonly adhered to in the family planning
community
Q29)_ Which one of the following is less common in women who take the combined oral
contraceptive pill?
A. Stroke
B. Endometrial cancer
C. Pulmonary embolism
D. Cervical cancer
E. Ischaemic heart disease
Combined oral contraceptive pill
increased risk of breast and cervical cancer
33. protective against ovarian and endometrial cancer
Combined oral contraceptive pill: advantages/disadvantages
Advantages of combined oral contraceptive pill
highly effective (failure rate < 1 per 100 woman years)
doesn't interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial and colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
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
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane
review did not support a causal relationship
Q29)_ Which one of the following statements regarding the link between intrauterine devices
(IUDs) and pelvic inflammatory disease (PID) is correct?
A. Decreased risk in first 20 days then returns to normal
B. There is no link between IUDs and PID
C. Overall decreased risk throughout lifetime of IUD
D. Overall increased risk throughout lifetime of IUD
E. Increased risk in first 20 days then returns to normal
34. The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
contraceptive issues seemed to be lacking. '
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs)
and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the
management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility
and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women
typically have intermittent light menses with less dysmenorrhoea and some women become
amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days
after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
35. Q30)_ Which one of the following is an absolute contraindication to the use of the
progesterone only pill?
A. Immobility following surgery
B. Breast cancer 3 years ago
C. Previous stroke
D. History of antiphospholipid syndrome
E. Concurrent use of rifampicin
Progestogen only pill: contraindications
The decision of whether to start a women a particular type of contraceptive is now guided by the UK
Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and
contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive
method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
active liver disease or past tumour
liver enzyme inducers
breast cancer more than 5 years ago
undiagnosed vaginal bleeding
Examples of UKMEC 4 conditions include
pregnancy
breast cancer within the last 5 years
Q31)_ You are considering prescribing ulipristal (EllaOne) for a woman who has presented
requesting emergency contraception. How long after unprotected sexual intercourse may
ulipristal be used?
A. 72 hours
B. 96 hours
36. C. 120 hours (5 days)
D. 144 hours (6 days)
E. 168 hours (7 days)
Ulipristal (EllaOne) - a new type of emergency hormonal contraception, can be used up to 120 hours
post UPSI
Emergency contraception
There are two methods currently available in the UK:
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception ('emergency pill', 'morning-after
pill'); levonorgestrel and ulipristal, a progesterone receptor modulator.
Levonorgestrel
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen
in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
Ulipristal
a progesterone receptor modulator currently marketed as EllaOne. The primary
mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
37. caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle is not recommended
Intrauterine device (IUD)
must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the
likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually
transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be
removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and
unlicensed indication
Q32)_ A 23-year-old female has a Nexplanon inserted on day 18 of her 28 day cycle. At what
point can the Nexplanon be relied upon to provide contraception?
A. After 2 days
B. At the end of the next menstrual period
C. Immediately
D. After 7 days
E. At the start of the next menstrual period
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
38. contraceptive issues seemed to be lacking. '
Implantable contraceptives
Implanon is a non-biodegradable subdermal contraceptive implant which is currently being phased
out and replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as
Implanon. The two main differences are:
the applicator has been redesigned to try and prevent 'deep' insertions (i.e.
subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in
the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is
preventing ovulation. They also work by thickening the cervical mucus.
Key points
highly effective: failure rate 0.07/100 women/year
long-acting: lasts 3 years
doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Disadvantages include
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5
of a woman's menstrual cycle
Adverse effects
irregular/heavy bleeding is the main problem
'progestogen effects': headache, nausea, breast pain
Q33)_ Which one of the following is an absolute contraindication to combined oral
contraceptive pill use?
A. Concurrent use of St John's Wort
B. Family history of thromboembolic disease in first degree relatives < 45 years
C. Immobility (e.g. wheelchair use)
39. D. Migraine with aura
E. Diabetes mellitus (diagnosed 11 years ago)
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by
the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and
contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive
method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
breast feeding 6 weeks - 6 months postpartum
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
*The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
40. Q34)_ Which one of the following is an absolute contraindication to combined oral
contraceptive pill use?
A. 37-year-old woman smoking 10 cigarettes/day
B. 4 weeks post-partum and breast feeding
C. Being a wheelchair user
D. BMI of 43 kg / m^2
E. Family history of thromboembolic disease in first degree relatives < 45 years
Option A, C, D & E are relative contraindications (UKMEC 3) whilst option B is an absolute
contraindication (UKMEC 4).
The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by
the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and
contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive
method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
breast feeding 6 weeks - 6 months postpartum
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
41. history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
*The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
Q35)_ What is the main mechanism of action of Cerazette (desogestrel)?
A. Thickens cervical mucous
B. Inhibits ovulation
C. Causes endometrial thinning
D. Inhibits implantation
E. Toxic to sperm
Cerazette inhibits ovulation in around 97-99% of cycles.
Progestogen only pill: types
Second generation
norethisterone
levonorgestrel
ethynodiol diacetate
Third generation
desogestrel (Cerazette)
Cerazette
new third generation type of progestogen only pill (POP) containing desogestrel
inhibits ovulation in the majority of women
users can take the pill up to 12 hours late rather than 3 hours like other POPs
42. Q36)_ Each one of the following would decrease the effectiveness of the combined oral
contraceptive pill, except:
A. Rifampicin
B. Sodium valproate
C. Carbamazepine
D. St John's Wort
E. Phenytoin
P450 enzyme system
Induction usually requires prolonged exposure to the inducing drug, as opposed to P450 inhibitors,
where effects are often seen rapidly
Inducers of the P450 system include
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John's Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline)
Inhibitors of the P450 system include
antibiotics: ciprofloxacin, erythromycin
isoniazid
cimetidine, omeprazole
amiodarone
allopurinol
imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
ritonavir
sodium valproate
acute alcohol intake
quinupristin
Q37)- What is the main mechanism of action of Nexplanon (etonogestrelcontraceptive
implant)?
43. A. Thickens cervical mucus
B. Thins endometrial lining
C. Inhibition of ovulation
D. Causes fallopian tube dysfunction
E. Prevents implantation
Nexplanon - main mechanism of action is inhibition of ovulation
Implantable contraceptives
Implanon is a non-biodegradable subdermal contraceptive implant which is currently being phased
out and replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as
Implanon. The two main differences are:
the applicator has been redesigned to try and prevent 'deep' insertions (i.e.
subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in
the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is
preventing ovulation. They also work by thickening the cervical mucus.
Key points
highly effective: failure rate 0.07/100 women/year
long-acting: lasts 3 years
doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Disadvantages include
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5
of a woman's menstrual cycle
Adverse effects
44. irregular/heavy bleeding is the main problem
'progestogen effects': headache, nausea, breast pain
Q38)_ A 16-year-old female with a history of acne requests to start a combined oral
contraceptive pill (COC). She has been taking oxytetracycline for the past 2 months. What is
the most appropriate advice?
A. A double-dose COC should be used
B. Condoms should be used for the first 14 days of COC use
C. She can start using a COC with usual advice
D. A COC is inappropriate and an alternative method of contraception should be
considered
E. Condoms should be used for the first 21 days of COC use
The usual rules regarding starting the COC should still be adhered to, i.e. use condoms for 7 days if
not started on the first day of next period
Combined oral contraceptive pill: special situations
Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may
interfere with the enterohepatic circulation of oestrogen and thus make the combined oral
contraceptive pill ineffective - 'extra- precautions' were advised for the duration of antibiotic
treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines
abandoning this approach. The latest edition of the BNF has been updated in line with this
guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Switching combined oral contraceptive pills
the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give
contradictory advice. The Clinical Effectiveness Unit of the FSRH have stated in the
Combined Oral Contraception guidelines that the pill free interval does not need to be
omitted (please see link). The BNF however advises missing the pill free interval if the
progesterone changes. Given the uncertainty it is best to follow the BNF
45. Q39)_ A 33-year-old obese woman presents to surgery requesting advice about
contraception. Her body mass index is 36 kg/m^2. What is the most suitable prescription?
A. Desogestrel (Cerazette) 150 mcg od (double dose)
B. Microgynon 30, two tablets a day as directed
C. Microgynon 30, one tablet a day as directed
D. Norethisterone (Noriday) 5mg tds
E. Desogestrel (Cerazette) 75 mcg od (standard dose)
There is little evidence to support the practice of prescribing double the dose of POP in obese
woman. Whilst some practitioners may err on the side of caution and prescribe double the dose of
POP for woman using older preparations this is not justifiable with Cerazette, given the high plasma
levels achieved with this drug.
Progestogen only pill: counselling
Women who are considering taking the progestogen only pill (POP) should be counselled in a
number of areas:
Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection,
otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2
days
if switching from a combined oral contraceptive (COC) gives immediate protection if
continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills
if < 3 hours* late: continue as normal
46. if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra
precautions (e.g. Condoms) should be used until pill taking has been re-established for 48
hours
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see
above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce effectiveness
Other information
discussion on STIs
*for Cerazette (desogestrel) a 12 hour period is allowed
**unless the antibiotic alters the P450 enzyme system, for example rifampicin.
Q40)_ A woman rings for advice 4 days post-partum. She is keen to start her progestogen-
only pill again. There have been no problems since giving birth and breast feeding is going
well. What is the most appropriate advice?
A. Contraindicated if breast-feeding
B. Start on day 21, effective immediately
C. Start immediately, effective immediately
D. Start on day 21, effective after 2 days
E. Start on day 7, effective immediately
Post-partum contraception
Progestogen only pill (POP)
may be started from day 21 - this will provide immediate contraception. If used earlier may
cause breakthrough bleeding
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant
47. Combined oral contraceptive pill (COC)
absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
relatively contraindicated - UKMEC 3 - if breast feeding 6 weeks - 6 months postpartum
the COC may reduce breast milk production in lactating mothers
may be started from day 21 - this will provide immediate contraception
after day 21 additional contraception should be used for the first 7 days
Q41)_ Concurrent use of which one of the following would make combined oral contraceptive
pill less effective?
A. Fluconazole
B. Sodium valproate
C. Allopurinol
D. Isoniazid
E. Carbamazepine
P450 enzyme system
Induction usually requires prolonged exposure to the inducing drug, as opposed to P450 inhibitors,
where effects are often seen rapidly
Inducers of the P450 system include
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John's Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline)
Inhibitors of the P450 system include
antibiotics: ciprofloxacin, erythromycin
isoniazid
cimetidine, omeprazole
amiodarone
allopurinol
48. imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
ritonavir
sodium valproate
acute alcohol intake
quinupristin
Q42)_ Concurrent use of which one of the following would make the combined oral
contraceptive pill less effective?
A. Fluconazole
B. Cimetidine
C. St John's Wort
D. Fluoxetine
E. Isoniazid
St John's Wort is an inducers of the P450 enzyme system in the liver. This results in the combined
oral contraceptive pill being metabolised faster and hence may reduce effectiveness.
P450 enzyme system
Induction usually requires prolonged exposure to the inducing drug, as opposed to P450 inhibitors,
where effects are often seen rapidly
Inducers of the P450 system include
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John's Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline)
Inhibitors of the P450 system include
antibiotics: ciprofloxacin, erythromycin
isoniazid
cimetidine, omeprazole
amiodarone
49. allopurinol
imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
ritonavir
sodium valproate
acute alcohol intake
quinupristin
Q43)_ A 17-year-old female presents requesting advice as she forgot to take her Microgynon
30 pills on a weekend away. She is normally very good at remembering her pill but has
missed days 10, 11 and 12 of her packet and it is now day 13. Although she took the day 13
pill this morning she is concerned she may become pregnant and she had unprotected
sexual intercourse whilst away. What is the most appropriate management?
A. No action needed
B. No action needed but omit pill break at end of pack
C. Offer emergency contraception - hormonal
D. Offer emergency contraception - intrauterine device
E. No action needed but use condoms for next 7 days
Tough question. As the patient had taken the pill for 7 days in a row previously she is protected for
the next 7 days. The FSRH guidelines state: 'after seven consecutive pills have been taken there is
no need for emergency contraception' - please consult the link. The guidelines also recommend in
this situation using condoms for the next 7 days.
The October 2011 AKT feedback stated: 'With regard to AKT 13, knowledge about basic
contraceptive issues seemed to be lacking. '
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over
recent years. The following recommendations are now made for women taken a combined oral
contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (at any time in the cycle)
take a pill as soon as possible and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take a pill as soon as possible and then continue taking pills daily, one each day
50. the women should use condoms or abstain from sex until she has taken pills for 7 days in a
row
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if
she had unprotected sexin the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC
there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and
start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Q44)_ Which one of the following is an absolute contraindication to combined oral
contraceptive pill use?
A. Known thrombogenic mutation
B. Family history of thromboembolic disease in first degree relatives < 45 years
C. Hyperlipidaemia
D. Concurrent use of rifampicin
E. Immobility (e.g. wheelchair use).
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by
the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and
contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive
method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
51. family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
breast feeding 6 weeks - 6 months postpartum
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
*The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
Q45)_ Which one of the following statements regarding the use of ulipristal (EllaOne) for
emergency contraception is true?
A. Should be used concomitantly with levonorgestrel to increase efficacy
B. Can be used more than once in a menstrual cycle if clinically indicated
C. May reduce the effectiveness of combined oral contraceptive pills
D. Is more effective than an intrauterine device if used before 72 hours has elapsed
E. Two doses are taken 12 hours apart
Emergency contraception
There are two methods currently available in the UK:
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception ('emergency pill', 'morning-after
pill'); levonorgestrel and ulipristal, a progesterone receptor modulator.
52. Levonorgestrel
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen
in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
Ulipristal
a progesterone receptor modulator currently marketed as EllaOne. The primary
mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle is not recommended
Intrauterine device (IUD)
must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the
likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually
transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be
removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and
unlicensed indication
53. Q46)_A 19-year-old woman elects to have an implantable contraceptive. What is the main
advantage of Nexplanon over Implanon?
A. Length of contraceptive effect increased from 3 to 5 years
B. Works immediately regardless of when inserted
C. Less irregular bleeding
D. No local anaesthetic required for insertion
E. New design makes the insertion of implants that are too deep less likely
Implantable contraceptives
Implanon is a non-biodegradable subdermal contraceptive implant which is currently being phased
out and replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as
Implanon. The two main differences are:
the applicator has been redesigned to try and prevent 'deep' insertions (i.e.
subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in
the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is
preventing ovulation. They also work by thickening the cervical mucus.
Key points
highly effective: failure rate 0.07/100 women/year
long-acting: lasts 3 years
doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Disadvantages include
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5
of a woman's menstrual cycle
Adverse effects
irregular/heavy bleeding is the main problem
54. 'progestogen effects': headache, nausea, breast pain
Q47)_ You are considering offering one of your female patients the intrauterine system
(Mirena) as a method of contraception. Which one of the following is most likely to represent
a contraindication to this?
A. Epilepsy
B. Being 5 weeks post-partum
C. Current treatment for ovarian cancer
D. Past history of ectopic pregnancy
E. Past history of pelvic inflammatory disease
Intrauterine contraceptive devices: insertion
Very few contraindications to insertion of an intrauterine contraceptive device exist. Below are some
conditions mentioned by the Faculty of Family Planning and Reproductive Health Care. Please see
the link for the full list.
UKMEC Category 3 (Risks outweigh benefits)*
between 48 hours and 4 weeks postpartum (increased risk of perforation)
initiation of method** in women with ovarian cancer
UKMEC Category 4 (Unacceptable risk)
pregnancy
current pelvic infection, puerperal sepsis, immediate post-septic abortion
unexplained vaginal bleeding which is suspicious
uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity
NICE produced guidelines in 2005 on screening for sexually transmitted infections (STI) before
insertion of an intrauterine contraceptive device
Chlamydia trachomatis in women at risk of STIs
Neisseria gonorrhoeae in women at risk of STIs, in areas where it is prevalent
any STIs in women who request it
For women at increased risk of STIs prophylactic antibiotics should be given before inserting an
intrauterine contraceptive device if testing has not yet been completed
55. *current venous thromboembolism (on anticoagulants) has recently been downgraded from UKMEC
3 to UKMEC 1
**as opposed to continuation of the method
56. Womens Health ( MRCGP Qs ) : Gynecology.
Q1-A 17-year-old girl presents due to painful periods. These have been present for the past
three years and are associated with a normal amount of blood loss. Her periods are regular
and there is no abnormal bleeding. She is not yet sexually active. What is the most
appropriate first-line treatment?
A. Tranexamic acid
B. Referral for relaxation therapy
C. Paracetamol
D. Combined oral contraceptive pill
E. Ibuprofen
NSAIDs are offered first-line as they will inhibit prostaglandin synthesis, one of the main causes of
dysmenorrhoea pains.
Dysmenorrhoea
Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally
divided into primary and secondary dysmenorrhoea.
Primary dysmenorrhoea
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of
menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial
prostaglandin production is thought to be partially responsible.
Features
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh
Management
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They
work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
Secondary dysmenorrhoea
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an
57. underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before
the onset of the period. Causes include:
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids
Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to
gynaecology for investigation.
*this refers to normal copper coils. Note that the intrauterine system (Mirena) may help
dysmenorrhoea
Q2)_ A 57-year-old female presents due to problems with urine leakage over the past six
months. She describes frequent voiding and not always being able to get to the toilet in time.
She denies losing urine when coughing or sneezing.What is the most appropriate initial
treatment?
A. Trial of oxybutynin
B. Bladder retraining
C. Regular toileting
D. Pelvic floor muscle training
E. Topical oestrogen cream
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the UK population. It is
more common in elderly females. NICE released guidance on the management of UI in 2006
Causes
58. overactive bladder (OAB)/urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation
bladder diaries should be completed for a minimum of 3 days
urine dipstick and culture
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence
is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the
intervals between voiding)
bladder stabilising drugs: immediate release oxybutynin is first-line
surgical management: e.g. sacral nerve stimulation
If stress incontinence is predominant:
pelvic floor muscle training (for a minimum of 3 months)
surgical procedures: e.g. retropubic mid-urethral tape procedures
Q3)_ A 49-year-old female consults her GP asking about hormone replacement therapy
(HRT). What is the most compelling indication for starting HRT?
A. Prevention of ischaemic heart disease
B. Prevention of osteoporosis
C. Reversal of vaginal atrophy
D. Control of vasomotor symptoms such as flushing
E. Prevention of Alzheimer's disease
Main indication for HRT: control of vasomotor symptoms
59. Hormone replacement therapy: indications
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen, combined with
a progestogen (in women with a uterus), to help alleviate menopausal symptoms.
The indications for HRT have changed significantly over the past ten years as the long-term risks
became apparent, primarily as a result of the Women's Health Initiative (WHI) study.
Indications
vasomotor symptoms such as flushing, insomnia and headaches
premature menopause: should be continued until the age of 50 years
osteoporosis: but should only be used as second-line treatment
The main indication is the control of vasomotor symptoms. The other indications such as
reversal of vaginal atrophy and prevention of osteoporosis should be treated with other agents
as first-line therapies
Other benefits include a reduced incidence of colorectal cancer
Q4)_ A 24-year-old woman presents for review complaining of heavy periods. This has
been a problem for a number of years now.She has a 28 day cycle and has heavy
bleeding for 5 days. There is no intermenstrual or post-coital bleeding. General and
gynaecological examination is unremarkable. What is the minimum set of investigations
that this patient should be offered?
A. FBC
B. FBC + ferritin
C. No investigations if the gynaecological examination is normal
D. FBC + pelvic ultrasound
E. FBC + TFT
Menorrhagia - all women should have a FBC
Menorrhagia: management
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously
60. difficult to quantify. The management has therefore shifted towards what the woman considers to be
excessive. Prior to the 1990's many women underwent a hysterectomy to treat heavy periods but
since that time the approach has altered radically. The management of menorrhagia now depends
on whether a women needs contraception.
Investigations
a full blood count should be performed in all women
further investigations are based upon the history and examination findings
Does not require contraception
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or
tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual
bleeding.
Q5)_ A 31-year-old woman presents as she has noted an offensive, fishy vaginal
discharge. She describes a grey, watery discharge. What is the most likely diagnosis?
A. Trichomonas vaginalis
B. Candida
C. Chlamydia
D. Bacterial vaginosis
E. Physiological discharge
Vaginal discharge
Vaginal discharge is a common presenting symptom and is not always pathological
Common causes
61. physiological
Candida
Trichomonas vaginalis
bacterial vaginosis
Less common causes
whilst cervical infections such as Chlamydia and Gonorrhoea can cause a vaginal discharge
this is rarely the presenting symptoms
ectropion
foreign body
cervical cancer
Key features of the common causes are listed below
Condition Key features
Candida 'Cottage cheese'discharge
Vulvitis
Itch
Trichomonas vaginalis Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Bacterial vaginosis Offensive, thin, white/grey, 'fishy' discharge
Q6)- A 53-year-old woman presents with urgency and frequency. Two weeks ago she
consulted with a colleague as she felt 'dry' during intercourse. She has been treated for
urinary tract infections on multiple occasions in the past but urine culture is always
negative. Her only medication is cyclical hormone replacement therapy. A vaginal
examination is performed which shows no evidence of vaginal atrophy and no masses
are felt. An ultrasound is requested:
Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 3 cm simple
ovarian cyst noted on left ovary. Right ovary and uterus normal
What is the most appropriate next step?
A. Refer for urodynamics
B. Pelvic floor muscle training
C. Trial topical oestrogen
62. D. Urgent referral to gynaecology
E. Refer for bladder retraining
Any ovarian mass in a post-menopausal woman needs to be investigated.
Ovarian enlargement: management
The initial imaging modality for suspected ovarian cysts/tumours is ultrasound. The report will usually
report that the cyst is either:
simple: unilocular, more likely to be physiological or benign
complex: multilocular, more likely to be malignant
Management depends on the age of the patient and whether the patient is symptomatic. It should be
remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.
Premenopausal women
a conservative approach may be taken for younger women (especially if < 35 years) as
malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as 'simple' then it
is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and
referral considered if it persists.
Postmenopausal women
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be
referred to gynaecology for assessment
Q7)_A 34-year-old woman is reviewed in surgery. She complains of a long history of deep
pain during intercourse and painful periods. There is a previous history of lower
abdominal pain and in the past she has been diagnosed with irritable bowel syndrome.
She is upset because she would like to start a family but the pain is putting her off sex.
What is the most suitable management?
A. Trial of combined oral contraceptive pill
B. Discuss benefits of intrauterine system
C. Refer to gynaecology
D. Refer for psychosexual counselling
E. Arrange pelvic ultrasound
63. The combination of deep dyspareunia and lower abdominal pain make a diagnosis of endometriosis
likely. Initial treatment options such as the combined pill are not an option in a woman trying to
conceive. For a definitive diagnosis the patient should ideally have a laparoscopy. A pelvic
ultrasound is not the investigation of choice in endometriosis and may be normal with mild-moderate
disease
Endometriosis
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue
outside of the uterine cavity. Up to 10-15% of women have a degree of endometriosis
Clinical features
chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility
Less common features
urinary symptoms e.g. dysuria, urgency
dyschezia (painful bowel movements)
Investigation
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are
significant the patient should be referred for a definitive diagnosis
Management depends on clinical features - there is poor correlation between laparoscopic findings
and severity of symptoms
NSAIDs and other analgesia for symptomatic relief
combined oral contraceptive pill
progestogens e.g. medroxyprogesterone acetate
gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudomenopause'
due to the low oestrogen levels
intrauterine system (Mirena)
drug therapy unfortunately does not seem to have a significant impact on fertility rates
Surgery
64. some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian
cysts may improve fertility
Q8-9-10)_ Theme: Pelvic pain
A. Appendicitis B. Ovarian torsion
C. Urogenital prolapse D. Endometriosis
E. Urinary tract infection F. Ovarian cyst
G. Threatened miscarriage H. Irritable bowel syndrome
I. Pelvic inflammatory disease J. Ectopic pregnancy
For each one of the following scenarios please select the most likely diagnosis:
8. A 24-year-old woman presents with crampy suprapubic pain and light vaginal bleeding. Her
last period was 9 weeks ago. Vaginal examination shows a small amount of blood around the
cervix but is otherwise unremarkable.
Threatened miscarriage
Ectopic pregnancy should also be considered here as a number of women will not have the
typical findings of cervical excitation.
9. A 67-year-old woman presents with a heavy, dragging sensation in the suprapubic region.
She also has frequency and urgency.
Urogenital prolapse
Women who have a urogenital prolapse typically describe a 'bearing down', 'heaviness' or
'dragging' sensation.
10. A 29-year-old woman presents with suprapubic pain, irregular periods, dysuria and pain
during intercourse. There is cervical excitation on examination.
Pelvic inflammatory disease
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy.
Pelvic pain
In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also
experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz). The
table below gives characteristic features for other conditions causing pelvic pain:
Usually acute
Ectopic pregnancy A typical historyis a female with a history of 6-8 weeks amenorrhoea who presents with
65. lower abdominal pain and later develops vaginal bleeding
Shoulder tip pain and cervical excitation may be seen
Urinary tract infection Dysuria and frequency are common butwomen mayexperience suprapubic burning
secondaryto cystitis
Appendicitis Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing's sign:more pain in RIF than LIF when palpating LIF
Pelvic inflammatory
disease
Pelvic pain, fever, deep dyspareunia,vaginal discharge,dysuria and menstrual irregularities
may occur
Cervical excitation may be found on examination
Ovarian torsion Usuallysudden onsetunilateral lower abdominal pain.Onsetmaycoincide with exercise.
Nausea and vomiting are common
Unilateral,tender adnexal mass on examination
Miscarriage Vaginal bleeding and crampylower abdominal pain following a period ofamenorrhoea
Usually chronic
Endometriosis Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
Irritable bowel
syndrome
Extremely common.The most consistentfeatures are abdominal pain,bloating and change
in bowel habit
Features such as lethargy, nausea,backache and bladder symptoms mayalso be present
Ovarian cyst Unilateral dull ache which maybe intermittentor only occur during intercourse.Torsion or
rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
Urogenital prolapse Seen in older women
Sensation ofpressure,heaviness,'bearing-down'
Urinary symptoms:incontinence,frequency,urgency
Q11)_ A 47-year-old woman presents to surgery seeking advice regarding contraception. She
has recently started in a new relationship but is unsure if she requires contraception, as she
thinks she may be going through the menopause. She is e xperiencing hot flushes and her
last period was 7 months ago. What is the most appropriate advice?
A. Contraception is needed until 36 months after her last period
B. Contraception is needed until 18 months after her last period
C. Contraception is needed until 24 months after her last period
66. D. Contraception is needed until 12 months after her last period
E. She no longer requires contraception
Need for contraception after the menopause
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Menopause
The average women in the UK goes through the menopause when she is 51 years old. The
climacteric is the period prior to the menopause where women may experience symptoms, as
ovarian function starts to fail
Diagnosis
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
It is recommend to use effective contraception until the diagnosis has been confirmed using the
above criteria
Q12)_You receive the results of a 29-year-old female who has recently had a routine cervical
smear. Her last smear 4 years ago was reported as normal. The results are reported as
follows:
Moderate dyskaryosis
What is the most appropriate management?
A. Repeat smear in 6 months
B. Repeat smear immediately
C. Refer to a gynaecological oncologist
D. Repeat smear in 3 months
E. Refer to colposcopy
67. Cervical cancer screening: interpretation of results
The table below outlines the management of abnormal cervical smears (around 5% of all smears).
Cervical intraepithelial neoplasia is abbreviated to CIN
Mild dyskaryosis Consistentwith CIN I. Previouslywomen were offered a repeatsmear after 6 months and
referral for colposcopyifchanges persisted
Whilstthis is still acceptable itis now considered bestpractice to refer women immediatelyfor
colposcopy
Moderate
dyskaryosis
Consistentwith CIN II. Refer for colposcopy
Severe
dyskaryosis
Consistentwith CIN III. Refer for colposcopy
Inadequate Repeatsmear - if persistent(3 inadequate samples),assessmentbycolposcopy
Q13-14-15)-Theme: Ovarian cysts
A. Dermoid cyst (teratoma) B. Endometriotic cyst
C. Granulosa cell tumour D. Clear cell tumour
E. Corpus luteum cyst F. Mucinous cystadenoma
G. Follicular cyst H. Serous cystadenoma
I. Dysgerminoma J. Fibroma
For each one of the following please select the answer from the list above:
13. Most common type of ovarian pathology associated with Meigs' syndrome
The correct answer is Fibroma
Meigs' syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural
effusion
14. Most common benign ovarian tumour in women under the age of 25 years
The correct answer is Dermoid cyst (teratoma)
15. The most common cause of ovarian enlargement in women of a reproductive age
The correct answer is Follicular cyst
Ovarian cysts: types