contraceptive and miscellaneous topics.pptx

Contraception and miscellaneous topics in gynecology for nursing students also suitable for final review before exams for medical students and midwife.
Talking about different types of contraception including hormonal and non hormonal, emergency and permanent.
Polycystic ovarian syndrome
Fibroids
Adenomyosis
Bartholin cyst and abcess
Endometriosis.

1. Principles of Contraception & Family Planning Dr abdulghani jaafar MBBS

2. Contraceptives

3. Key Definitions Contraception: Prevention of fertilization. Interception: Prevention of implantation (grouped under contraception). Family Planning: Intentional spacing and timing of pregnancies to optimize health and resources.

4. Importance of Contraception A. Maternal Benefits Enables reproductive autonomy. Prevents unplanned pregnancies. Reduces obstetric complications and maternal morbidity/mortality. Allows preconception optimization (e.g., chronic illness management). Barrier methods protect against STDs/HIV. B. Fetal Benefits Enhances pregnancy outcomes through planned conception. Early access to antenatal care. Allows early anomaly detection and intervention. C. Public Health Benefits Reduces maternal and infant mortality. Prevents transmission of STDs and HIV. Improves socioeconomic and educational outcomes.

5. Ideal Contraceptive Characteristics 100% effective. Localized action (minimal systemic side effects). Coitus-independent. No long- or short-term adverse effects. Immediate fertility return on discontinuation. Simple, affordable, widely available. Minimal motivation, supervision, or maintenance needed. Measures of Contraceptive Efficacy A. Pearl Index Failures per 100 woman-years (HWY) of use. Limitation: Assumes constant failure over time. B. Life Table Analysis Tracks failure rates over defined time intervals. Advantage: More accurate—accounts for dropouts, improved use, etc.

6. Contraceptive Methods Overview A. Hormonal Methods Combined Oral Contraceptives (COCs) Progestin-Only Pills (POPs) Depot Injections (DMPA, NET-EN) Implants (Norplant, Implanon ) LNG-Intrauterine System ( Mirena ) B. Non-Hormonal Methods Copper IUCD Barrier Methods: Male Condom Female Condom Cervical Cap Diaphragm (with spermicide) Spermicides (usually adjunct) C. Behavioral Methods Rhythm Method Coitus Interruptus D. Permanent Methods Vasectomy Tubal Ligation

7. Patient & Non-Patient Factors in Contraceptive Choice A. Patient-Related Reproductive plans (temporary/permanent). Medical conditions (age, chronic illnesses). Social: compliance, habits (e.g., smoking), SES, education. Lactation status. B. Non-Patient-Related Availability. Government policies/programs. Cultural/religious acceptability.

8. Hormonal Contraceptives

9. A. Combined Oral Contraceptives (COCs) Composition: Estrogen (EE/Mestranol) + Progestin (various generations). Mechanism: Suppresses LH surge → inhibits ovulation. Thickens cervical mucus. Thins endometrium. Affects tubal motility. Administration 21 active pills + 7 pill-free/placebo OR 28 pills (7 placebo). Missed Dose Protocol: 1 missed: Take ASAP, continue as normal. ≥2 missed: Take 1 ASAP, backup contraception 7 days, discard pack if <7 active pills left. Benefits Regulates cycles, reduces dysmenorrhea. ↓ risk of ovarian/endometrial cancer. ↓ benign breast disease, fibroids, endometriosis.

10. Side Effects Minor: Nausea, headache, acne, weight gain, mood changes. Major: ↑ VTE, stroke, MI, liver tumors, slight ↑ breast cancer risk. Contraindications Absolute: Thromboembolism, CAD, stroke, liver disease, estrogen-dependent cancers, pregnancy, breastfeeding. Relative: Smoking >35 yrs , obesity, diabetes, migraines, hypertension. Interactions ↓ efficacy: Rifampicin, anticonvulsants, Griseofulvin . ↑ toxicity: Anticoagulants, hypoglycemics , corticosteroids.

11. B. Progestin-Only Pills (POPs) Mechanism: Thickens cervical mucus. Thins endometrium. Ovulation suppression (~50%). Administration Take daily, same time. Missed Dose: <3 hrs late: Take ASAP. 3 hrs late: Backup contraception for 2 days. Benefits Suitable for breastfeeding and estrogen-intolerant patients. No effect on lactation. ↓ endometrial cancer, ectopic risk. Side Effects Irregular bleeding, acne, breast tenderness, mood changes. Contraindications Breast cancer, liver disease, undiagnosed AUB, ectopic history.

12. C. Injectable Progestins (e.g., DMPA) Types: DMPA 150 mg IM every 12 weeks. NET-EN 200 mg IM every 8 weeks. Mechanism Inhibits ovulation. Thickens cervical mucus. Thins endometrium. Benefits Very effective, convenient (few administrations/year). Suitable for breastfeeding. Reduces endometrial cancer and ectopic pregnancy risk. Side Effects Irregular menses/amenorrhea. Weight gain. Delayed fertility return (~10 months). ↓ bone mineral density (long-term use). Contraindications Breast cancer, suspected pregnancy, undiagnosed AUB.

13. Progestin Implants (Norplant, Implanon ) Mode of Action Thickens cervical mucus. Thins endometrium. Inhibits ovulation (mechanism similar to progestin-only pills). Administration Norplant: 6 subdermal rods (inserted in the arm). Effective for 5 years . Implanon : 1 subdermal rod (inserted in the arm). Effective for 3 years . Both require minor surgical procedure for insertion and removal. Efficacy Highly effective: Failure rate: 0.2/100 users in the 1st year . Similar to sterilization during the first 3 years. Benefits Minimal user compliance required. No significant metabolic effects on liver, lipids, or coagulation. All benefits of progestin-only pills apply.

14. Side Effects Menstrual irregularities (spotting, amenorrhea). Headache. Weight gain. Acne. Contraindications Breast cancer. Suspected pregnancy. Undiagnosed abnormal uterine bleeding (AUB).

15. Levonorgestrel -Releasing Intrauterine System (LNG-IUS – Mirena ) Mode of Action Thickens cervical mucus. Thins endometrium. Inhibits sperm motility and function (local effect). Ovulation is usually preserved . Composition & Administration Contains 52 mg LNG , releases 20 μg /day , lasts 5 years . Inserted transcervically : During days 1–7 of menses , or Post-abortion , or When pregnancy is reasonably excluded. Avoid insertion <6 weeks postpartum . Efficacy Highly effective: Failure rate: 0–0.2% in the 1st year . Comparable to sterilization. Benefits Minimal user compliance. Low systemic hormone levels. Non-contraceptive benefits: Reduces menorrhagia by 97% . Reduces dysmenorrhea. Treats endometrial hyperplasia. Decreases fibroid growth, PID, and ectopic risk. No metabolic effects.

16. Contraindications Pregnancy. Undiagnosed AUB. Active or high-risk PID. Abnormal uterine cavity. Breast cancer. Side Effects / Complications Menstrual irregularities. Headache. Acne. Weight gain. Insertion discomfort. Rare: Perforation ( 0.5% ). Expulsion. Infection.

17. Copper Intrauterine Device (IUCD – e.g., T-380A) Mode of Action Spermicidal: toxic to sperm. Interferes with sperm transport and implantation . Administration Inserted transcervically , similar to Mirena : During days 1–7 of menses , Post-abortion , or When pregnancy is reasonably excluded. Efficacy Highly effective. Benefits Immediate onset of action. Minimal compliance required. No hormones —ideal for those with hormonal contraindications. Fertility returns rapidly after removal. Side Effects / Complications ↑ Menstrual bleeding and cramps. ↑ PID risk (especially in 1st 20 days post-insertion). ↑ Ectopic risk if pregnancy occurs. Insertion discomfort. Rare: Uterine perforation. Expulsion. Infection.

18. Contraindications Pregnancy. Undiagnosed AUB. Active/high-risk PID. Abnormal uterine cavity. Special Considerations Missing thread: Evaluate with ultrasound or X-ray . Heavy bleeding: Observe or remove device. Infection: Treat with antibiotics ± removal.

19. Barrier Methods Types Male condom. Female condom. Diaphragm. Cervical cap. Spermicides (often combined with above). Mode of Action Physical barrier to sperm. Spermicides disrupt sperm membranes. Advantages Immediate effectiveness. Protection against STDs (esp. condoms). No systemic effects. No impact on future fertility or lactation. Disadvantages Coitus-dependent → ↓ spontaneity/pleasure. Requires consistent and correct use. Requires partner cooperation. Diaphragm & Cervical Cap: Need professional fitting. Must remain in place for ≥6 hours post-intercourse . Risk of latex or spermicide allergy.

20. Behavioral Methods Types Calendar (Rhythm) Method: Fertile window = Shortest cycle - 18 to Longest cycle - 11 . Basal Body Temperature (BBT) Monitoring. Cervical Mucus Method (Billings Method). Mode of Action Abstinence during fertile period . Advantages No cost. No side effects. Disadvantages Low efficacy. Requires strict abstinence during fertile days. Demands high motivation and accurate tracking. Requires regular cycles (esp. calendar method).

21. Surgical Sterilization

22. Procedure: Occlusion of vas deferens (no-scalpel or conventional). Efficacy: Very effective. Not sterile immediately—requires ~ 3 months or 20 ejaculations . Use backup method until confirmed azoospermia . Advantages Simple, outpatient. Low complication risk. Disadvantages Delayed sterility. Possible irreversible infertility. Development of antisperm antibodies. Psychological regret possible. Male Sterilization (Vasectomy)

23. Female Sterilization (Tubal Ligation) Timing During follicular phase , Postpartum , Post-abortion , When pregnancy is excluded . Techniques Pomeroy (laparotomy). Filshie clips . Falope rings . Laparoscopic or hysteroscopic (plugs) approach. Efficacy Highly effective. Sterility is immediate . Advantages Permanent contraception. No ongoing effort or maintenance. Disadvantages Surgical risks. Irreversible or poor reversibility. Potential for regret. Small failure rate ( 0.1–0.4% ).

24. Emergency Contraception (EC) Indications Unprotected intercourse. Known/suspected contraceptive failure. Sexual assault. Must be used within method-specific timeframes .

25. Methods 1. Combined Pills ( Yuzpe Method) Dosage: 2 doses of: 100 μg ethinyl estradiol + 0.5 mg levonorgestrel / norgestrel . 12 hours apart . Timing: ≤ 72 hours post-intercourse. Failure Rate: ~ 2% . Side Effects: Nausea, vomiting common. 2. Progestin-Only Pills Dosage: 1.5 mg levonorgestrel single dose, or 0.75 mg × 2 doses (12 hours apart). Timing: ≤ 72 hours , ideally ≤ 24 hours . Failure Rate: ~ 1–3% . Better tolerated than Yuzpe . 3. Copper IUCD Timing: ≤ 120 hours (5 days) . Failure Rate: < 1% . Most effective EC method. Provides ongoing contraception if retained.

26. Common Benign Gynecologic Conditions

27. . Anatomy & Function Bartholin glands (greater vestibular glands): 2 small mucus-secreting glands located at the posterolateral vaginal introitus (4 and 8 o'clock) Function: Provide vaginal lubrication, especially during sexual arousal. BARTHOLIN CYST AND ABSCESS

28. Bartholin Cyst Cause : Obstruction of the Bartholin duct → glandular secretion builds up → non-infected cyst Clinical Features : Painless, unilateral vulvar mass near introitus Size may vary (1–4 cm or more) No signs of inflammation Diagnosis : Physical examination: soft, fluctuant, mobile mass Transillumination or US if uncertain Management : Asymptomatic: No treatment required Symptomatic: Sitz baths Word catheter insertion (placed for ~4 weeks to allow epithelialization) Marsupialization (creates a new permanent drainage tract) Excision : Recurrent cases or postmenopausal (rule out malignancy)

29. Bartholin Abscess Cause : Secondary bacterial infection of a cyst (common organisms: E. coli , Staph aureus , anaerobes, N. gonorrhoeae ) Clinical Features : Severe localized pain, swelling, redness Difficulty walking/sitting Fever or systemic signs in some cases Diagnosis : Tender, warm, fluctuant mass Surrounding cellulitis may be present Treatment : Incision and drainage is primary treatment Word catheter placement for healing Antibiotics if systemic symptoms or cellulitis (e.g., Amoxicillin- Clavulanate or Clindamycin + Metronidazole) Culture of purulent discharge if recurrent

30. A. Epidemiology & Definition Most common endocrine disorder in women of reproductive age (6–12%) Rotterdam Criteria (2 of 3 required for diagnosis): Oligo/anovulation Hyperandrogenism (clinical or biochemical) Polycystic ovaries on ultrasound POLYCYSTIC OVARIAN SYNDROME (PCOS)

31. Pathophysiology ↑ LH/FSH ratio → increased theca cell androgen production Insulin resistance → compensatory hyperinsulinemia → further ↑ androgens Anovulation → no progesterone → unopposed estrogen → endometrial hyperplasia C. Clinical Features Menstrual disturbances : oligomenorrhea , amenorrhea Hyperandrogenism : acne, hirsutism, androgenic alopecia Infertility (anovulation) Metabolic : obesity, acanthosis nigricans , insulin resistance, ↑ risk of type 2 diabetes

32. Diagnosis Hormonal profile : ↑ LH:FSH (>2:1) ↑ Testosterone, DHEAS Normal prolactin and TSH Pelvic ultrasound : ≥12 follicles per ovary or ovarian volume >10 mL (“string of pearls”) Exclude other causes: CAH, Cushing’s, prolactinoma , thyroid disorders E. Management Lifestyle : weight loss (5–10%) can restore ovulation Menstrual regulation : Combined oral contraceptives (COCs) Anti-androgens : Spironolactone (with COC), finasteride Infertility : First-line: Letrozole Others: Clomiphene, gonadotropins, IVF Metformin : improves insulin sensitivity, may restore ovulation

33. A. Overview Benign smooth muscle tumors of the uterus Affects up to 70% of women by age 50 Estrogen- and progesterone-dependent UTERINE FIBROIDS (LEIOMYOMAS)

34. Types Subserosal : beneath outer serosa, often pedunculated Intramural : within the myometrium (most common) Submucosal : beneath endometrium → most associated with heavy bleeding Cervical fibroids (rare) C. Clinical Features Menorrhagia (most common symptom) Pelvic pressure, bloating Dysmenorrhea Urinary frequency, constipation Infertility, miscarriage (esp. submucosal ) Diagnosis Transvaginal ultrasound : first-line MRI: better delineation pre-surgery Hysteroscopy or saline infusion sonography (for submucosal ) E. Management Medical : NSAIDs Tranexamic acid (for bleeding) COCs or progestins GnRH agonists (temporary shrinkage) SPRMs (e.g., ulipristal acetate) Surgical : Myomectomy : fertility preservation Hysterectomy : definitive Uterine artery embolization : for non-surgical candidates

35. Definition Functional endometrial glands and stroma outside uterine cavity B. Common Sites Ovaries ( endometriomas or “chocolate cysts”) Peritoneum, uterosacral ligaments, pouch of Douglas Rectovaginal septum, bladder C. Pathogenesis Theories Retrograde menstruation Coelomic metaplasia Lymphatic/ hematogenous spread Immune dysfunction ENDOMETRIOSIS

36. Clinical Features Pelvic pain , dysmenorrhea Deep dyspareunia Infertility (30–40%) Painful bowel movements ( dyschezia ), fatigue Diagnosis Gold standard : Laparoscopy with histologic confirmation US: useful for endometriomas only MRI: assess deep infiltrating disease Management Medical : NSAIDs, COCs, progestins GnRH agonists/antagonists (induce pseudo-menopause) Surgical : Excision or ablation of implants Ovarian cystectomy Hysterectomy ± BSO for severe/refractory cases

37. A. Definition Presence of endometrial tissue within the myometrium B. Clinical Features Heavy menstrual bleeding Severe dysmenorrhea Bulky, globular, tender uterus More common in parous women >40 years Diagnosis Clinical suspicion Transvaginal ultrasound: “ myometrial cysts,” asymmetric thickening MRI: best imaging modality Definitive : Histology after hysterectomy D. Treatment NSAIDs COCs or LNG-IUS (e.g., Mirena ) GnRH agonists Hysterectomy (curative) ADENOMYOSIS

38. OVARIAN CYSTS A. Functional Cysts Follicular cysts : failed ovulation Corpus luteum cysts : persistence after ovulation Theca lutein cysts : high hCG states (molar pregnancy) B. Benign Neoplastic Cysts Serous cystadenoma : unilocular , thin-walled Mucinous cystadenoma : large, multiloculated Dermoid cyst (mature teratoma ) : Contains hair, fat, teeth Risk of torsion Needs surgical removal

39. D. Diagnosis Transvaginal US: primary tool Simple ( unilocular , thin wall) vs. complex Tumor markers : CA-125 (limited in premenopausal) CT/MRI for characterization if needed E. Management Observation if: Simple, <5 cm, premenopausal, asymptomatic Surgical: Cystectomy (benign) Oophorectomy (suspicious, postmenopausal, torsion) C. Clinical Features Asymptomatic (most) Pelvic pain Pressure symptoms Cyst rupture or torsion (acute abdomen)

40. OTHER BENIGN LESIONS Endometrial Polyps Localized hyperplasia of endometrial glands/stroma AUB, infertility TVUS or hysteroscopy Treated with polypectomy B. Cervical Polyps Arise from endocervical canal AUB, postcoital bleeding Polypectomy + histology to rule out malignancy Nabothian Cysts Mucus retention cysts on cervix Benign, small, asymptomatic No treatment needed D. Paraovarian Cysts Arise from remnants of Wolffian duct Adjacent to but separate from ovary Usually asymptomatic, require monitoring or removal if symptomatic

41. Condition Main Symptom Diagnostic Tool Treatment Bartholin Abscess Vulvar pain/swelling Clinical Drainage + abx PCOS Irregular periods Hormones + US COCs, Letrozole, Metformin Fibroids Heavy bleeding US/MRI Medical, Myomectomy Endometriosis Pelvic pain Laparoscopy Hormonal, Surgery Adenomyosis Heavy & painful periods MRI LNG-IUS, Hysterectomy Ovarian cysts Asymptomatic or pain US Observe or Surgery Polyps AUB TVUS/Hysteroscopy Polypectomy

42. All the best