OB: contraception and infertility + reproductive system concerns

2 types of infertility

• Primary: _____

• Secondary: _____

• 12 months of unprotected sex and still cant get pregnant

• patient has gotten pregnant before but cant get pregnant again

Different causes of infertility in women

Hormonal

• ____: person has NEVER had a regular ovulation before

  • SX: often seen in what population?

• ____: person had regular ovulation before but NOW has irregular ovulation

  • SX: often seen in what population?

• Obesity

• Thyroid issues

• PCOS

• EARLY menopause (duh bc if you get menopause early then… no babies)

• Nutritional issues

• Cancer/chemo

• Depression

• Teratogens

• HIGH consumption of alc or caffeine

• Hyperprolactinemia

• Amenorrhea after getting off oral contraceptives

Tubal/peritoneal

• loss of tube mobility or patency d/t infection, adhesions, endometriosis, tumors

Uterine issues

• infxn

• congenital uterine defects/tumors

Vaginal/cervical issues

• pH of cervical mucus

  • what type of cervical mucus GOOD for sperm?

• pH of vagina

• anti-sperm antibodies

• primary an-ovulation

• secondary an-ovulation

• clear and thin

Diagnosis for female infertility

• Determining ovulation:

  • ovulation kit: tests for LH surge 24-36hrs before ovulation occurs

  • progesterone levels 1 week prior to onset of menses

    • high progesterone levels indicate that recent ovulation HAS OCCURED

  • increased basal body temp

  • stretchy thin eggwhite cervical mucus

• Hormone analysis

• Ultrasonography (trans-vaginal ultrasound)

• ____: insertion of DYE into uterus/fallopian tubes to look for BLOCKAGES

• ____: to visualize uterus

  • GOLD STANDARD for detecting ____ inside uterus?

• ____: to visualize pelvic structures

• hysterosalpinography

• hysteroscopy

• fibroids

• laparascopy

Different causes of infertility in men

• low testosterone

• structural issue (cryptotorchidism, hypospadias, blocked vas deferens)

• Varicocele: ____

• low sperm count, inactive sperm, immature/abnormal sperm

• infections (STD, STI, Mumps)

• Radiation

• exposure to high temps (ex: _____)

• cancer/chemo

• obesity

• substance use (including steroids)

• enlarged vein in spermatic cord resulting in constricted spermatic cord

• hot tubs, tight underwear

Diagnosis for male infertility

• semen analysis

• ultrasonography of scrotum: ______

• genetic testing

• hormone analysis

• testicular biopsy

• to identify abnormalities with vessels and spermatic cord

Informed consent with birth control

• use what acronym?

• BRAIDED = benefits, risks, alternatives, inquiries, explanation, documentation

Natural methods to predict ovulation/avoid contraception

• Coitus interuptus: ____

  • how effective is this?

• Fertility awareness based ovulation (FAB): tracking days of ovulation to AVOID sex on those days

• Symptom-based method

  • 2-day method: if you notice cervical secretions today and yesterday → DONT have sex yet

  • discharge (ex: if discharge is thin stretchy eggwhite texture then DONT have sex)

  • basal body temp (if its increased then DONT have sex)

• Biologic biomarker methods (ex: using home test kits for testing LH surge)

• aka pullout method

• LEAST effective method

Spermicide methods

• how does spermicide work to prevent pregnancy?

  • most common spermicide drug is _____

• when to use/how to use?

• damages flagella to inhibit mobility to prevent sperm from reaching the cervix

• Nonoxynol

• insert DEEP into vagina 15mins-1hour before sex

Barrier methods

• condoms for men

  • can be used safely with what kinds of lube?

  • NEVER use with what kind of lube?

  • protects from some STI

• condoms for women

  • has flexible rings on both ends

  • how to use?

• diaphragm

  • dome-shaped device that covers the cervix

  • how to use?

  • requires yearly gyno exam to re-assess the fit

  • replace every 2 years

• cervical cap

  • how to use?

• contraceptive sponge: spermicide-containing sponge

• silicone or water based lubes = SAFE

• oil based lube = NOT SAFE bc ruins condom material

• closed-ended side covers the cervix + open ended side covers the labia

• cover the entire inside of dome with spermicide —> after sex, leave the device INSIDE for 6 hrs (to ensure all sperm die)

• after sex, leave the device INSIDE for 6 hrs (to ensure all sperm die)

Estrogen-progestin oral contraceptive (aka combo pill)

• MOA?

• Pros?

• Cons?

• Signs of complications? (hint: ACHES acronym)

• suppress hypothalamus-pituitary —> insufficient FSH/LH release + immature endometrium + thick sticky mucus (bc progesterone dominates)

• less painful periods + less heavy periods + improves irregular cycles + improves endometriosis SX + protects against uterine/cervical cancers + improved sexual response

• thrombolytic events, hypertension, gallbladder and liver issues, fluid retention/water weight, breast tenderness, nausea, yeast infxn

• complications:

  • Abdominal pain ← gallbladder/liver issue

  • Chest pain or SOB ← clot issue

  • Headache ← hypertension

  • Eye issues ← hypertension

  • Severe leg pain ← clot issue

91 day oral contraceptive routine

• taken in 3 month windows

• pros?

Transdermal patches

• how to take it?

• what locations can you place this?

Vaginal ring

• how to take it?

• you only get your period 4x a year (instead of at the end of every month)

• 3 weeks “on” + 1 week “off” BUT make sure to switch out a new patch every week

• delivers continuous hormones; 3 weeks “on” + 1 week “off”

Progestin ONLY contraceptive

• inhibits ovulation + thickens cervical mucus

Routes

• Injection

  • brand name?

  • side effects?

• Under-the-skin implant

  • brand name?

• hormonal IUD

  • (more info abt this IUD in later knowt slides)

• Depo

• osteoporosis, weight gain (bc increased appetite), headache, mood change, spotting ***think: progestin makes u puffy, moody, spotty, bones spotty****

• Nexaplon

Emergency contraception

• needs to be taken within ___ days of unprotected sex or missed birth control pills in order to work

IUD

• sits inside uterus and stabilized via 2 strings

• can be hormonal (progestin) or non-hormonal (copper)

• complications? (hint: think PAINS acronym)

• complications

  • period late, spotting

  • abdominal pain, pain during sex

  • infection risk

  • not feeling well (sickness SX)

  • string missing ← indicates IUD fell out or has perforated into uterine wall

Sterilization

• female steriliation via ___

• male steriliation via ___

  • IMPORTANT post-op rules for male sterilization?

Induced abortions

• Induced abortions are usually done BEFORE 20 weeks

Types

• ___: done after 9 weeks

• ___: done 10 weeks after your recently missed period

  • via using abortion-inducing drugs (ex: ____)

• ___: done at 20 weeks MAXIMUM

• bilateral tubal ligation

• vasectomy (aka cutting the spermatic cord)

  • NO SEX for several months bc the body hasnt fully cleared out its sperm

• 1st trimester abortion

• medically induced abortion

  • misoprostol or mifepristine

• 2nd trimester abortion

Average duration of menses is ___ days with a total blood volume loss of ____

• Classic criteria used to evaluate for amenorrhea:

  • No period OR secondary sex characteristics by age ___

  • No period by age ___

  • No period by within ____ of breast development 

  • You usually have your period but its been absent for___months 

• 5

• 50mL

• 13

• 15

• 5

• 6 or more

Caused by

• Indicates issue with hypothalamus-pituitary:

  • Lesions

  • Low levels or total Inability to produce which hormones?

  • Defect in CNS neurotransmitters

• Other causes:

  • Stress

  • Weight loss

  • Anorexia nervosa (eating disorder)

  • Excessive exercise/training 

Diagnosis 

• Confirmed via assessment of health history + physical 

• Rule out whether you are/arent preggo → if you’re not preggo, then we continue to figure out the cause

GnRH, LH, FSH

***btw dysmenorrhea: painful period

Primary dysmenorrhea

• is this related or unrelated to pelvic pathology?

• Onset?

• Patho: prostaglandins trigger uterine contractions + vasospasm of uterine arterioles → decreased bloodflow(ischemia) → cramping

• SX: lower ab. cramping, nausea/vomit, back pain

• Treatment?

Secondary dysmenorrhea

• is this related or unrelated to pelvic pathology?

• Onset?

• Patho: the pelvic pathology and chronic inflammation → causes pain

• SX?

• Diagnosis?

• Treatment: treat underlying cause!!!!

• UNRELATED to pelvic pathology

• soon after menarche

• Prostaglandins trigger uterine contractions + vasospasm of uterine arterioles → decreased bloodflow(ischemia) → cramping

• NSAIDs + Oral contraceptives

• RELATED to pelvic pathology (ex: endometriosis, PID, fibroids, adenomyosis)

• later in adult life (age 25+)

• pelvic pain BEFORE period begins, painful pee/poop, painful sex, heavy irregular bleeding

• larascopy

PMS (Pre-menstrual syndrome)

• Combo of physical and mental SX that begin during ___ phase + SX resolve after ____

• SX: bloated/weight gain, pelvic pain, tender breasts, food cravings, mood changes

• Treatment: _____

• luteal

• menses (so during early follicular phase)

• Lifestyle modification (diet, exercise, natural diuretics like parsley) ← BEST method

Endometriosis 

• what is endometriosis?

  • adhesions/scar tissue seen @ wherever it proliferates

Caused by

• 2 theories

  • 1) Retrograde menstruation: menstrual blood containing viable endometrial cells will flow backwards into fallopian tube and into other locations → these re-located cells still respond to E/P like normal endometrial tissue → when it eventually bleeds it causes inflammation and pelvic pain

  • 2) Interaction bxn amount of retrograde menstruation and a woman’s immune response based on genetics/ethnciity 

Manifestations

• Pelvic pain

• Abnormal vaginal bleeding 

• Painful poop 

• Pain after sex

Diagnosis

• ?

Treatment

• NSAIDS

• Oral contraceptives (to shrink endometrial tissue)

• Surgery

• when endometrial tissue grows somewhere OUTSIDE the uterus (ex: pelvis, GI tract, resp tract)

• larascopy

Abnormal uterine bleeding 

AUB: bleeding that’s irregular in amount, duration, or timing

Types

• Oligomenorrhea: ____

• Hypomenorrhea: ____

• Menorrhagia: ____

• Metrorrhagia: ____

• Meno-metorrhagia: ____

Caused by

• ?

Treatment 

• Treat underlying cause

• Oral contraceptives 

• Dilation & Cutterage used to:

  • Remove excess endometrial tissue

  • Control acute heavy bleeding

• infrequent periods that occur every 40 days (think: Oligo = occasional periods)

• abnormally low blood volume

• abnormally high blood volume

• bleeding inbetween periods = aka irregular period timing (think: metro = middle = bleeding inbetween periods)

• mix of heavy and irregular periods

• Possible pregnancy, UTI/STI, Lesions, Neoplasms, Trauma, Certain medical conditions 

Menopause

• Menopause:____

• Perimenopausal: during this phase, the patient experiences _____

  • IMPORTANT PATIENT EDUCATION: ____

• _____: entire timeframe of moving from reproductive phase → perimenopause → menopause → post-menopause 

• what is surgical menopause?

Changes during menopause

**Physiologic

• Complete cessation of menses

• describe the hormone changes?

• is the endometrium thick or thin?

**Physical

• Vaginal atrophy 

• Hot flash/night sweats 

• Anxious 

• Insomnia 

• amenorrhea for 12 months in a row (INCLUDES absent spotting)

• irregular periods

• during those 12 months of perimenopause, there is a HIGH risk of getting PREGNANT (bc of the fluctuating hormones and stuff)

• climacteric

• removal of uterus + both ovaries

• high FSH/LH but low estrogen/progesterone (← bc the brain senses low E/P and tries to overcompensate with excess release of FSH/LH)

• thin

Menopause (continued)

2 main health risks of perimenopausal/menopausal women 

• ?

Therapies and care

• Menopause hormone therapy (MHT): using estrogen or estrogen-progestin combo

• Alternative therapy methods = homeopathy, acupuncture, herbal methods

• Comfort measures for menopause SX;

  • For hot flashes → cooling measures, fans, wear layered clothing, avoid triggers that cause flushing/hot body temp

  • For insomnia → avoid daytime naps, avoid liquids after dinner

  • For headaches → rest, natural diuretics (ex: parsley)

  • For urogenital → kegel exercise, stay hydrated, lube for dry vagina 

  • Nutrition focused on preventing osteoporosis and obesity

  • Exercsie

• 2 main health risks

  • Osteoporosis ← bc low estrogen levels

  • Coronary heart disease ← bc estrogen is cardio-protective so the low estrogen levels AFTER menopause result in high lipid levels (high LDL, low HDL)