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- CONTRACEPTION -
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
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)
* 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).
PROGESTOGENS (minipill)
Indications: contraception when can’t use oestrogen (breastfeeding, history of thromboembolism, smokers),
menstrual disorders
Side Effects: menstrual irregularity, prolonged bleeding, spotting, amenorrhoea, depression, weight gain
IUD
COPPER IUD – Multiload IUD
- SE: period pain, increased menstrual flow with possible menorrhagia, expulsion of device
(particularly in the first year)
- Replace every 5 years
- The copper IUD can be used as an emergency contraceptive (not the Mirena IUD).
VAGINAL RING
ETONOGESTREL with ETHINYLOESTRADIOL – NuvaRing
- Side Effects: vaginitis, vaginal discharge, irregular bleeding, headache, nausea, weight gain, breast
tenderness, mood changes, device-related problems (eg foreign body sensation, expulsion of ring)
- Insert ring into vagina during first 5 days of cycle and leave for 3 weeks; remove for a 1 week break,
then insert a new ring. Periods should start 2-3 days after ring is removed, insert a new one 1 week
after regardless of period or not.
- MENOPAUSE: HRT -
Indications: Short term relief of menopausal symptoms eg. hot flushes, night sweats (up to 5 years)
Oestrogen relieves symptoms (hot flushes, night sweats, urogenital atrophy). Progestogen reduces risk of
endometrial cancer associated with unopposed oestrogen.
Contraindications: thromboembolism, uterine bleeding, severe liver disease, breast cancer, coronary artery
disease
Side Effects: breast enlargement and tenderness, abnormal mammogram, headache, depression, change in
libido, weight change, irregular or breakthrough bleeding, spotting, endometrial hyperplasia (oestrogen-only
HRT), leg cramps, dry eye syndrome (oestrogen-only HRT)
Types of Treatment
- Oestrogen-only HRT: for women post-hysterectomy with no history of endometriosis.
- Vaginal oestrogen: first choice for urogenital symptoms. Stop treatment annually to see if its still
required.
- Combined HRT: for women with intact uterus, use combined HRT as oestrogen-only HRT increases
risk of endometrial cancer. But combined HRT has increased risk of breast cancer.
Practice Points
- tell doctor if there’s blood clots (swollen leg, difficulty breathing, chest pain), breast changes,
changes in vaginal bleeding
- use HRT at lowest effective dose for the shortest time possible. (2-3 years is sufficient in most
women)
- Review at least annually.
- Choose vaginal preparations for women who only have urogenital symptoms
Oestrogens
CONJUGATED EQUINE OESTROGENS – Premarin, Premia Continuous
OESTRADIOL – Estrofem, Progynova, Aerodiol spray, Vagifem pessary, Sandrena gel, Climara patches,
Femtran patches, Menorest patches, Trisequens tab, Estalis patches
OESTRIOL – Ovestin tab, pessaries, cream
- Indications: menopausal symptoms, adjunct to vaginal surgery
PIPERAZINE OESTRONE SULFATE – Ogen
Oestrogen/progestogen
TIBOLONE – Livial
- Do not start tibolone until at least 12 months after last period to avoid increased irregular bleeding.
Side Effects: abdominal pain, bloating, weight increase, vaginal bleeding or spotting, vaginal discharge and
itching, vaginitis, breast pain, hypertrichosis
Progestogens
MEDROXYPROGESTERONE – Provera, Depo-Provera etc
Indications: contraception (IM depot); uterine bleeding (oral); secondary amenorrhoea (oral); endometriosis
Precautions:
Adolescents—reduction in BMD with IM depot (during the period when peak bone mass is usually attained)
may be more significant than in adults; only use if other contraceptive methods are considered unsuitable or
unacceptable.
Side Effects: IM, 50% become amenorrhoeic within 12 months, delayed return of menstrual periods after
stopping (may take >6 months), loss of BMD, weight gain
Dosage:
Contraception: IM 150mg very 12 week. Protection immediate if given within 5 days after start of
menstrual cycle. Delay until 21 days after delivey if not breastfeeding or until 6 weeks if
breastfeeding.
Endometriosis: IM 50mg each week, or 100mg every 2 weeks for months; oral 10mg tds
Dysfunctional uterine bleeding: 5-10mg d for 10-14 dys during assumed second half of cycle.
Secondary amenorrhoea: 5-10mg d for 5-10 days during assumed second half of cycle.
HRT: 5-10mg d for 10-14 days of each month with continuous oestrogen, or 1.25-5mg d with
continuous oestrogen.
Dosage:
Contraception: 350mcg d beginning first day of menstruation
Delay of menstruation: 5mg bd-tds for up to 14 days, start 3-5 days before expected menstruation.
Dysfunctional uterine bleeding: to stop bleeding – 5mg tds for 10 days. To regulate bleeding – 5mg
d-bd for days 16-25 of cycle.
Endometriosis: 5-10mg d; continue treatment for at least 4-6 months.
HRT: 1.25mg d for 10-14 days of each month with continuous oestrogen.
Practice Points:
- There are no inactive pills so must be taken continuously.
- If forget to take a pill, take it as soon as you remember. If more than 3 hours, you are not protected.
Resume normal pill taking, but use additional contraceptive methods for the next 48 hours.
Emergency pill should be used if unprotected intercourse has occurred.
COCs
Progestogens
- Levonorgestrel IUD (Mirena) is effective long term. It may be taken for 6 months before full benefit is seen.
Side effects include spotting and breast tenderness and may take 3-6 months to settle.
- Depot medroxyprogesterone (Depo-Provera): use in amenorrhoea is limited.
Danazol (Azol)
- poorly tolerated due to androgenic side effects. Must be used with effective non-hormonal contraception.
GnRH Agonists
- poorly tolerated due to hypo-oestrogenic side effects and can be costly. Must be used with effective non-
hormonal contraception
- ENDOMETRIOSIS –
Endometriosis is the presence of endometrial tissue outside the uterus. Patients may be asymptomatic or
have pelvic pain, menstrual changes, bowel symptoms or infertility.
NSAIDs
NSAIDs may be adequate for symptom relief in some women and can be used with other treatments. They
are effective in relieving dysmenorrhoea, however, evidence is inconclusive regarding their effect on pain
due to endometriosis.
Progestogens
Norethisterone, dydrogesterone and IM or oral medroxyprogesterone can all be used long term. Adverse
effects include irregular bleeding and weight gain. Continuous oral progestogens and IM
medroxyprogesterone also provide contraception if no doses are missed.
Limited evidence suggests the levonorgestrel IUD may also be effective in reducing pain associated with
endometriosis.
Danazol, gestrinone
Danazol and gestrinone both have androgenic adverse effects that limit their use: duration of treatment is 6–
9 months with danazol and 6 months with gestrinone. An effective non-hormonal method of contraception
must be used during treatment.
NAFARELIN: 200mcg bd for 6 months (1 spray in one nostril in the morning and 1 spray in the other nostril
at night); may be increased up to 400mcg bd.
- DELAY LABOUR –
Delay delivery for 24-48 hours
NIFEDIPINE - Adalat
- relaxes uterine smooth muscle
Indication: preterm labour (<34 weeks gestation)
Dosage: initially 20mg. repeat after 30min if uterine contractions persist. If contractions continue after 3
hours, give 20mg every 3-8 hours until contractions cease. Maximum 160mg/day. Maintenance after 72
hours if necessary, give daily dose until 34 weeks gestation.
Dosage: IV 100-250mcg
Treatment: consider delivery of baby depending on gestational age and condition. Magnesium sulfate is the
drug of choice to prevent seizures in women with pre-eclampsia.
- LABOUR -
- Ripen cervix and induce labour: Prostaglandins (mainly dinoprostone PGE2 gel)
- induction of uterine contraction: oxytocin, ergometrine, prostaglandins
- post partum haemorrhage: oxytocin, ergometrine, prostaglandins
- delivery of placenta: oxytocin, misoprostol
OXYTOCIC DRUGS
CARBETOCIN – Duratocin inj
Indication: prevents postpartum haemorrhage (PPH)
Side Effects: nausea, vomiting, abdominal pain, itch, flushing, feeling of warmth, sweating, dizziness,
hypotension
ERGOMETRINE inj
Indication: PPH; third stage labour (in combination with oxytocin) – not appropriate for labour induction.
Side Effects: nausea and vomiting
Dosage: 200mcg IM following delivery of placenta for prevention; or IV 25-50mcg every 2-3 minutes for
treatment.
- note: combination with ergometrine may increase likelihood of side effects and has little advantage
over oxytocin alone.
PROSTAGLANDINS
Side Effects: nausea, vomiting, diarrhoea, back pain, transient hypertension or hypotension,
bronchoconstriction, headache, epigastric pain, vasovagal symptoms, blurred vision, facial flush, fever,
altered fetal heart rate, uterine hypercontractility and hypertonus
Prostaglandin E1 analogue
GEMEPROST - Cervagem
Indication: Termination of pregnancy in second trimester
Side Effects: vaginal bleeding and uterine pain in the interval between pessary insertion and surgical
intervention (severity increases if interval is >3 hours)
Dosage: insert 1 pessary every 3 hours until effect. Maximum 5 pessaries in 24 hours.
MISOPROSTOL – Cytotec
Indication: termination of second trimester; medical management of miscarriage; intrauterine fetal death
Prostaglandin E2
DINOPROSTONE – Prostin E2 Vaginal Gel; Cervidil pessary
Indication: induction of labour
Dosage: 1-2mg of vaginal gel q6h; insert one pessary and remove when contractions begin.
Prostaglandin F2 alpha
DINOPROST – Prostin F2 alpha inj
Indications: rarely used in termination; severe PPH refractory to other measures.
- LACTATION –
Lactation Suppression
Dopamine agonists: cabergoline & bromocriptine
CABERGOLINE – Cabaser, Dostinex
- preferred over bromocriptine due to fewer side effects
Dosage: 0.5mg each week in 1-2 doses
Lactation Stimulation
Dopamine antagonists: metoclopramide & domperidone
DOMPERIDONE – Motilium
Side Effects: dry mouth, headache
Dosage: 10mg tds, taper dose over 7-10 days before stopping.
- VAGINAL INFECTIONS –
THRUSH
For acute episodes use clotrimazole, miconazole or nystatin. Single doses are usually effective for first or
infrequent episodes. They may damage contraceptive diaphragms and latex condoms.
Oral antifungals (fluconazole) is effective for acute episodes and should be considered if creams have failed.
Antifungal prophylaxis with weekly oral fluconazole for up to 6 months is indicated in women with recurrent
thrush (4+ episodes in 12 months) or severe symptoms.
Pregnancy – use vaginal antifungals for 1 week (vaginal applicators may be used with care). A single
150mg fluconazole appears safe and may be used if vaginal antifungals have failed.
BACTERIAL VAGINOSIS
Symptoms: vaginal discharge without soreness, itching or irritation.
Treatment with oral metronidazole or clindamycin (vaginal/oral). Aci-Jel may be used to reduced symptoms
and prevent recurrence.
TRICHOMONIASIS
Women may have symptoms of vaginal discharge, itching and irritation and is sexually transmitted. Treat all
individuals with a single dose of metronidazole or tinidazole.
TREATMENT
Increase calcium intake to 1200-1500mg daily.
Use 50-100mg daily of pyridoxine (vitamin B6)
Monophasic COCs
SSRIs (fluoxetine, sertraline)
Reference
Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2011
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