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Benefits & risks of combined estrogen-progestin contraceptives
- • Pregnancy prevention
- • Endometrial & ovarian cancer risk reduction
- • Menstrual regulation with reduction in iron deficiency anemia
- • Reduction in risk of benign breast disease
- • Venous thromboembolism
- • Hypertenston
- • Hepatic adenoma
- • Very rarely stroke and myocardial infarction
Risks of OCP Use
- 1. Hypertension due to increased angiotensinogen synthesis by estrogen during hepatic first-pass metabolism.
- 2. Increased risk of thromboembolism due to the hypercoagulable properties of estrogen.
- Women with uncontrolled hypertension, end organ damage, or are age more than 35 and use tobacco should not be placed on combination OCPs.
"Emergency" (or postcoital) contraception
- It refers to medications or devices used after intercourse to prevent pregnancy by delaying ovulation or impairing implantation.They are not effective after implantation (when pregnancy has started).
- The copper intrauterine device (IUD), a precoital contraceptive, is the most effective emergency contraceptive. It may be inserted up to 5 days following unprotected intercourse.
- Age and parity are not contraindications; therefore, it may be used in nulligravid adolescents.
- However, acute cervicitis and pelvic Inflammatory disease are contraindications.
- Condoms should be used in conjunction with an IUD to prevent sexually transmitted infections.
Levonorgestrel and Ulipristal pills
They are designed for emergency contraception only. They work by preventing oocyte release and delaying ovulation. Although these pills are more accessible (eg, IUD requires a provider trained in its insertion), they are less effective than the copper IUD.
Levonorgestrel-containing Intrauterine device (IUD)
- It is a long-acting, reversible contraceptive that prevents pregnancy by releasing levonorgestrel (a progestin), which creates a physical barrier by thickening cervical mucus and impairing implantation through decidualization of the endometrium.
- It has an efficacy of more than 99% and is approved for use in the United states for up to 5 years.
- Common side effect is amenorrhea, which can be used to improve anemia and abnormal uterine bleeding.
- Side effects include mood changes, breast tenderness, headaches. Weight gain is not a side effect.
Emergency Contraception Option
Side effects and risks of combination oral contraceptives
- • Breakthrough bleeding
- • Breast tenderness, nausea, bloating
- • Amenorrhea
- • Hypertension
- • Venous thromboembolic disease
- • Decreased risk of ovarian & endometrial cancer
- • Increased risk of cervical cancer
- • Liver disorders (eg, hepatic adenoma)
- • Increased triglycerides (due to estrogen component)
Mechanism of OCPs in Primary Dysmenorrhea
OCPs decrease pain symptoms by thinning the endometrial lining, reducing prostaglandin release, and decreasing uterine contractions.
Absolute Contraindication to Combined OCPs
OCPs and Breast Cancer
- Hormone-containing methods of contraception are avoided in patients with breast cancer, as estrogen and progesterone may have a proliferative effect on breast tissue.
- This is particularly concerning with hormonal receptor-positive breast cancer and BRCA2 carriers tend to have estrogen receptor-positive breast cancer.
Contraception in Breast Cancer Patient
- A copper intrauterine device (IUD) is a safe, long term, hormone-free method of contraception.
- It is 99% effective and prevents pregnancy by creating a chronic cytotoxic inflammatory response. A copper IUD can be placed for a maximum or 10 years.
Complications of DES in Daughters
- • Clear cell adenocarcinoma of the vagina & cervix (40 fold increased risk )
- • Structural anomalies of the reproductive tract (eg, hooded cervix, T-shaped uterus, small uterine cavity, vaginal septae, vaginal adenosis)
- • Pregnancy problems (eg, ectopic pregnancy, pre term delivery)
- • lnfertility
Complications of DES in Male child
Males exposed in utero are at risk of cryptorchidism, microphallus, hypospadias, and testicular hypoplasia.
Differentials of Dysmenorrhea
Diagnosis and Management of Primary Dysmenorrhea
- In women with a normal examination, the presence of painful menses in the absence of dyspareunia or gastrointestinal symptoms is most consistent with primary dysmenorrhea.
- The treatment objective is pain relief to minimize disruption in the patient's life. First-line treatment consists of nonsteroidal anti-inflammatory medication and/or hormonal contraception. Most women respond well to these oral medications within 3 months.
Management of Suspected Ectopic Pregnancy
B hCG in detection of Early Pregnancy
- B-hCG should generally increase every 2 days in viable pregnancies but rise at a slower rate in ectopic and nonviable intrauterine pregnancies.
- An Intrauterine pregnancy should be seen with TVUS at a B-hCG of 1500-2000 lU/l.
- Serum B-hCG levels would not be needed if initial TVUS detected an intrauterine pregnancy or if a gestational sac with yolk sac was clearly identified in an ectopic location.
Endometrial Hyperplasia and Cancer
Obesity and Endometrial Cancer
- Obesity leads to increased circulating estrogen concentrations through the conversion of androgens into estradiol and estrone in adipose cells.
- The endometrium proliferates without differentiation due to unopposed estrogen exposure, which leads to hyperplasia and eventually adenocarcinoma.
Peripheral Estrogen Conversion In adipose tissue
- Is a common cause of chronic pelvic pain (more than 6 months) in reproductive-age women.
- Most commonly, patients report dysmenorrhea as well as noncyclic pain that can be exacerbated by exercise.
- Physical examination findings include a fixed and immobile uterus and rectovaginal nodularity.
- USG: homogeneous cystic ovarian mass is highly suggestive of an ovarian endometrioma.
- Infertility is a common consequence of endometriosis.
- Surgical resection of endometriomas usually improves fertility.
Management of Endometriosis
- NSAIDS(eg, ibuprofen, naproxen) and/or combined (estrogen and progestin) oral contraceptives (COCs) are first-line empiric treatment options that are appropriate without definitive surgical diagnosis.
- COCs therapy is thought to reduce pain by ovulation suppression, which may result in atrophy of endometrial tissue.
- Failure of conservative treatment, presence of an adnexal mass, and infertility necessitate laparoscopic evaluation.
3 Ds of Endometriosis
- The hallmarks of endometriosis (the "3 Ds") are dysmenorrhea, deep dyspareunia and dyschezia (pain with defecation).
- Dyspareunia and dyschezia are caused by implants in the posterior cul-de-sac.
- Other features include pelvic pain and infertility
Laparoscopy in the management of endometriosis
- Laparoscopy is indicated after failure of empiric therapy.
- Laparoscopy allows for direct visualization, biopsy, and removal of endometriotic lesions.
- Unless estrogenic stimulation is suppressed, symptoms eventually return with the regrowth of endometriosis.
- Definitive treatment in women who have completed childbearing is with hysterectomy and oophorectomy.
Infertility in Endometriosis
- Cyclic accumulation of ectopic foci of hemorrhage and adhesions can distort pelvic anatomy and impair fertility by obstructing oocyte release or sperm entry. The presence of an endometrioma (ovarian endometriosis cyst) is also associated with impaired ovarian function.
- Laparoscopic resection of endometriosis, especially ovarian endometriomas, improves conception rates.
Female sexual interest/arousal disorder,
- It is a common sexual disorder in women characterized by lack of, or significantly reduced, sexual interest/arousal that is not better explained by another medical disorder, substance/medication-related issue or a relationship problem.
- Common features include absent/reduced interest in sexual activity, absent/reduced sexual thoughts and fantasies, lack of initiation of sexual activity and/or receptivity to partner's attempts to initiate, and decreased arousal, excitement ,pleasure in response to sexual cues and encounters.
- Diagnosis requires ruling out psychological, medical, and substance/medication-related issues that may affect sexuality (eg, depression, diabetes. use of selective serotonin reuptake inhibitors [SSRIs], chronic alcohol abuse).
- It is a form of gestational trophoblastic neoplasia, a malignancy that arises from placental trophoblastic tissue and secretes B-hCG .
- Although it most commonly follows a hydatidiform mole, choriocarcinoma can occur after a normal gestation or spontaneous abortion.
Diagnosis of Choriocarcinoma
- Choriocarcinoma typically presents less than 6 months after a pregnancy.
- Presenting symptom include irregular vaginal bleeding, an enlarged uterus, and pelvic pain.
- Choriocarcinoma is an aggressive type of gestational trophoblastic neoplasia; the most common site of metastatic spread is to the lungs.
- Symptoms of pulmonary metastasis include chest pain, hemoptysis, and dyspnea.
- When choriocarcinoma is suspected, obtaining a quantitative B-hCG level helps to confirm the diagnosis.
Granulosa cell tumor
- It is an ovarian malignancy occurring in postmenopausal women or more rarely in prepubertal girls (Precocious Puberty).
- Because the tumor secretes estrogen, typical symptoms (eg, breast tenderness, postmenopausal bleeding, precocious puberty) are due to hormonal effects.
- Physical examination shows a large pelvic/adnexal mass that is confirmed by ultrasound.
- Unopposed estrogen stimulation can lead to endometrial hyperplasia or carcinoma, which presents as postmenopausal bleeding and appears on ultrasonography as a thickened endometrium.
- It consists of hemolysis, elevated liver enzymes, low platelet count. It is a life-threatening pregnancy complication that may be a severe type of preeclampsia.
- It is associated with numerous complications (eg, eclampsia, acute respiratory distress syndrome, disseminated intravascular coagulation, prematurity).
Pathophysiology of HELLP Syndrome
- HELLP syndrome is thought to result from abnormal placentation, triggering systemic inflammation and activation of the coagulation system and complement cascade.
- Circulating platelets are rapidly consumed, and microangiopathic hemolytic anemia (MAHA) is particularly detrimental to the liver. The resulting hepatocellular necrosis and thrombi in the portal system cause elevated liver enzymes, liver swelling, and distension of the hepatic (Glisson) capsule.
- MAHA causes increased bilirubin production (indirect hyperbilirubinemia) and red blood cell fragments on blood smear.
Treatment of HELLP syndrome
- It begins with stabilization of the patient, which typically includes the administration of antihypertensive medication and/or magnesium for seizure prophylaxis.
- After maternal stabilization, delivery is the only definitive treatment.
- Delivery should occur promptly at more than 34 weeks gestation or at any gestational age with abnormal fetal testing or severe or worsening maternal status.
Human chorionic gonadotropin (hCG)
- It is a hormone secreted by the syncytiotrophoblast and is responsible for preserving the corpus futeum during early pregnancy in order to maintain progesterone secretion until the placenta is able to produce progesterone on its own.
- Production of hCG begins about eight days after fertilization, and the levels of hCG double every 48 hours until they peak at six to eight weeks gestation.
Structure and Function of HCG
- The hCG is composed of two subunits: alpha and beta. The alpha subunit is common to hCG, TSH, LH, and FSH. The beta subunit is specific to hCG, and is used as the basis of virtually all pregnancy tests.
- Other biological functions of hCG include the promotion of male sexual differentiation and stimulation of the maternal thyroid gland.
- It is due to hypothalamic dysfunction, a condition commonly associated with severe life stressors, eating disorders (eg. low caloric intake),chronic illness and excessive exercise.
- In this condition, gonadotropin-releasing hormone (GnRH) pulses secreted by the hypothalamus decrease in amplitude and frequency and cause pituitary LH and FSH production to decrease.
- The low LH and FSH production causes the suppression of ovulation leading to oligomenorrhea/amenorrhea and infertility.
- There is also low estrogen production in the ovary. Physical examination is typically normal, although a low BMI may be present.
- First-line treatment is with lifestyle changes, specifically increased caloric intake and exercise reduction.
- It is a rare genetic disorder marked by either total absence or poor functioning of the enzyme that converts androgens into estrogens.
- In utero the placenta will not be able to make estrogens, leading to masculinization of the mother that resolves after delivery.
- The high levels of gestational androgens result in a virilized XX child with normal internal genitalia but ambiguous external genitalia.
- Clitoromegaly is often seen when excessive androgens are present in utero.
- Later in life patients will have delayed puberty, osteoporosis, undetectable circulating estrogens, high concentrations of gonadotropins and polycystic ovaries.
- Prolactin production is inhibited by dopamine and stimulated by serotonin and TRH.
- An increase in TSH and TRH production and, consequently, in prolactin release may be the result of hypothyroidism.
- Hyperprolactinemia may also affect GnRH and gonadotropin secretion and, thus result in amenorrhea.
- Other causes of high prolactin levels include dopamine antagonists (antipsychotics, tricyclic antidepressants, and MAO Inhibitors), hypothalamic and pituitary tumors.
- It is defined as failure to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient age less than 35. (After age 35, infertility investigation can begin after 6 months).
- Pelvic inflammatory disease (PID) is an important cause of infertility due to tubal scarring and obstruction.
- The first-line imaging test to assess fallopian tube patency is a hysterosalpingogram, which involves infusion of radiocontrast into the cervix under fluoroscopy.
- Hysterosalplngogram is minimally invasive and also can identify uterine cavity anomalies (eg, bicornuate uterus).
Male factor Infertility
- The etiology of infertility is varied, with as many as 25% of cases due to male factor. Therefore, evaluation of an infertile couple includes identification of possible causes in both partners.
- The gold standard test for male factor infertility is semen analysis.
- It evaluates sperm concentration, motility, and morphology and allows for identification of azoospermia and severe oligospermia as obvious causes of infertility.
- Treatment of male factor infertility may include artificial insemination techniques and use of donor sperm
Ovarian Reserve with Ageing
- Women are born with their lifetime supply of oocytes, and a sharp decline in conception rates is notable after age 35.
- Due to this decline, lack of conception after 6 months of unprotected intercourse in women age more than 35 is considered infertility.
Investigating Age related infertile Women
- As ovarian reserve and function decline in females more than 35 years, estradiol and inhibin production decreases and the normal negative feedback mechanism is suppressed.
- This causes FSH levels to become increasingly elevated as ovarian function decreases. Therefore. day 3 (eg, early follicular phase) FSH testing can be performed to assess ovarian function.
- Assisted reproductive techniques (eg, in vitro fertilization, oocyte/embryo donation) are available to couples with age-related infertility.
Ultrasound Assessment of Gestational Age
- First trimester ultrasound with crown-rump length measurement is the most accurate method of determining gestational age.
- It becomes less accurate as the pregnancy progresses as there is minimal variability in size among fetuses during the first trimester.
Lichen sclerosus (LS)
- It is a chronic inflammatory condition of the anogenital region that can affect women at any age. This condition can have an autoimmune pathogenesis and often coexists with other autoimmune conditions (eg, type 1 diabetes mellitus, thyroid abnormalities). Extragenital Involvement (eg, buttocks, lower back, abdomen, under breasts, shoulders, armpits) is also possible.
- The perianal skin may also be involved, resulting in a "figure of 8" appearance.
- Anogenital symptoms include intense pruritus, dyspareunia, dysuria, and painful defecation.
Diagnosis of Lichen Sclerosis
- Physical examination reveals porcelain-white polygonal patches with atrophy (eg, regression, obliteration) of normal genital structures.
- The skin is classically described as "cigarette paper" quality (eg, thin, white, crinkled).
- Sclerosus and scarring lead to obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus.
- Although the diagnosis can be made clinically, a punch biopsy is recommended for definitive diagnosis.
- LS is a vulvar premalignant lesion as vulvar squamous cell carcinoma (SCC) occurs with greater frequency in these patients. A vulvar punch biopsy can rule out vulvar malignancy.
Atropic Vaginitis vs Lichen Sclerosis