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Amh-Summary-Obstetric-And-Gynaecological-Chapter-17.pdf
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AMH Summary: Chapter 17 – Obstetric and Gynaecological 1AMH SUMMARY: Chapter 17 – Obstetric & Gynaecological
- CONTRACEPTION -
DRUGS OF CHOICE FOR CONTRACEPTION
a) Combined oral contraceptives
b) Progestogens
c) Intrauterine devices IUD
d) Others
Emergency Contraception:
LEVONORGESTREL – Postinor, Norlevo
- prevent or delay ovulation and induce transient changes in endometrium. It can’t disrupt an
implanted fertilized egg.
- repeat dose if vomiting occurs within 2 hours
- no limit in recurrent use
- take within 72 hours of unprotected sex (24 hours most effective but still has a contraceptive effect
when taken up to 120 hours afterwards).
- 1.5mg immediately or 750mcg q12h
- safe during breastfeeding
COMBINED ORAL CONTRACEPTIVES (pill)
Indications: Contraception, Moderate Acne (Loette), Androgenisation (hirsutism and acne) in women
(cyproterone – Brenda-35, Diane-35, Juliet-35, Estelle-35), menstrual disorders, period pain, endometriosis,
PMS
Contraindications: history of breast, endometrial cancer, migraines, pregnancy, viral hepatitis
Precautions: diabetes, hypertension (monitor), depression, epilepsy, migraine, cholestatic jaundice, smoking
(increases risk of thromboembolism), hyperlipidaemia
Side Effects: breakthrough bleeding, nausea, vomiting, changes in weight, breast enlargement and
tenderness, headache, mood changes (eg depression), changes in libido, fluid retention, acne, thrush
Dosage: start in the first week of active tablets on day 1-5 of menses to be protected immediately. If start
active pills after this time, use additional contraception or avoid intercourse until 7 active pills have been
taken.
- Missing pills: <24 hours – take it asap and take the next pill at usual time
- Missing pills: >24 hours – take it asap and next pill at usual time (i.e. 2 pills at one time) but need to
wait 7 days for protection. But if the 7 days extend into inactive pills, then you need to skip the
inactive pills and go straight to a new pack of active pills (so no periods for this month)
Copyright © The Medicine Box 2012
, AMH Summary: Chapter 17 – Obstetric and Gynaecological 2
* If you missed active pills and need to take emergency contraceptive tablets, you should start taking your
pill again within 12 hours of taking the emergency contraceptive tablets. You will need to use additional
contraception, eg condoms, or avoid intercourse until you have taken active pills for 7 days.
Breakthrough Bleeding:
If breakthrough bleeding persists for >3 months and another cause cannot be identified (eg missed pills,
drug interaction), try the following (in order):
change to a monophasic COC if taking a triphasic COC
change the progestogen or increase dose (especially if bleeding occurs late in cycle)
take active tablets for 9 weeks in a row
change to a standard dose COC (with 30–35 micrograms ethinyloestradiol or 50 micrograms of
mestranol) if taking a low dose COC (with 20 micrograms ethinyloestradiol)
change the progestogen again
change to a high dose COC (with 50 micrograms ethinyloestradiol).
Drug Choice (Progesterone):
Levonorgestrel, norethisterone: lower risk of venous thromboembolism (VTE).
Gestodene, desogestrel: less androgenic activity than levonorgestrel but twice the risk of VTE.
Generally not first choice for new users.
Dienogest: one-third anti-androgenic activity to that of cyproterone. Benefits acne.
Drospirenone: anti-mineralocorticoid (mild diuretic and potassium retention) and anti-androgenic
activity.
Cyproterone: progestogenic and anti-androgenic. Used with an oestrogen to treat women with
androgenisation (severe acne, hirsutism). Higher risk of VTE and is not indicated in the absence of
androgenisation.
Table: Monophasic and Triphasic COCs
Monophasic = fixed dose of estrogen and progesterone in each active pill
Triphasic = both estrogen and progesterone content varies – more complex and high risk of fluid retention
and PMS
Monophasic Low Dose Monophasic Standard Dose Monophasic High Dose
Loette, Microgynon 20 Levlen, Microgynon 30, Microgynon 50 (ethinyloestradiol
(ethinyloestradiol Monofeme, Nordette 50 mcg/levonorgestrel 125 mcg)
20 mcg/levonorgestrel 100 mcg) (ethinyloestradiol
30 mcg/levonorgestrel 150 mcg)
Yaz (ethinyloestradiol Brevinor, Norimin
20mcg/drospirenone 3mg) (ethinyloestradiol
35 mcg/norethisterone 0.5 mg)
Brevinor-1, Norimin-1 Triphasic
(ethinyloestradiol
35 mcg/norethisterone 1 mg)
Copyright © The Medicine Box 2012
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