Gynaecology: Fertility Contraception Menopause

• Menopause: The Menopause | HRT — Choosing and Using | HRT Benefits and Risks | Non-hormonal Options and Vaginal Symptoms | Premature Ovarian Insufficiency
• Fertility: Subfertility — Assessment | Female Causes and Treatment | Male Factor Subfertility | IVF and Assisted Conception | Ovarian Hyperstimulation Syndrome
• Contraception: Choosing Contraception | Combined Hormonal Contraception | Missed Pills and Interactions | Progestogen-only Methods | Intrauterine Methods | Emergency Contraception | Barrier Methods and Sterilisation | Contraception for Young People
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

💊 Menopause, fertility and contraception — these are everyday topics across a woman's life. Most menopausal women benefit from HRT if they choose it, and its risks are small for most women under 60. About 1 in 7 couples have difficulty conceiving. Long-acting reversible contraception (implant, IUD, IUS) is the most effective, and the UKMEC criteria help you choose safely.
Your four questions for every patient: What does she want — symptom relief, a pregnancy, or to avoid one? Are there contraindications (UKMEC, VTE, breast cancer, migraine with aura)? Is she or could she be pregnant? What will she find acceptable and use well?

The Menopause

• Definitions:
  • Menopause — the last period, confirmed after 12 months without one. Average age 51 in the UK.
  • Perimenopause — the years of changing cycles and symptoms before and up to 12 months after the last period.
  • Premature ovarian insufficiency — menopause before 40; early menopause — 40–45.
• Symptoms:
  • Vasomotor — hot flushes and night sweats (most women; median about 7 years).
  • Mood — low mood, anxiety, irritability; poor sleep; "brain fog" and poor concentration.
  • Genitourinary syndrome of menopause — vaginal dryness, painful sex, urinary frequency and urgency, recurrent UTIs.
  • Joint and muscle aches; low libido; changes in periods (irregular, heavier or lighter).
• Long-term effects of low oestrogen — osteoporosis, increased cardiovascular risk.
• Diagnosis (NICE NG23):
  • Age over 45 with typical symptoms — diagnose clinically; no blood tests needed.
  • FSH — consider if aged 40–45 with symptoms; use for suspected POI under 40. (FSH is unreliable on combined hormonal contraception or high-dose progestogens.)
• Contraception is still needed — until 1 year after the last period if over 50, or 2 years if under 50; or until age 55. HRT is not contraceptive.

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HRT — Choosing and Using

• Oestrogen treats symptoms. Women with a womb need a progestogen as well, to protect the endometrium from hyperplasia and cancer.
• Types:
  • No womb (after hysterectomy) — oestrogen only.
  • With a womb — combined HRT:
    • Sequential (cyclical) — oestrogen every day, progestogen for 10–14 days a month — a monthly bleed. For perimenopausal women (periods within the last 12 months).
    • Continuous combined — both every day, no bleed. For postmenopausal women (over 12 months since the last period, or after 1 year of sequential HRT). Irregular bleeding is common in the first 3–6 months.
• Routes:
  • Oestrogen — tablets, transdermal patches, gel or spray. Transdermal doesn't raise VTE risk — preferred if BMI over 30, VTE risk factors, migraine, or on enzyme-inducing drugs.
  • Progestogen — micronised progesterone (Utrogestan — lower breast cancer and VTE risk than synthetic progestogens), oral synthetic progestogens, or the LNG-IUS (Mirena — also gives contraception; licensed for 5 years for endometrial protection).
  • Tibolone — a synthetic steroid with combined effects (postmenopausal women).
• Starting — lowest dose that controls symptoms; review at 3 months, then yearly. There's no fixed time limit; individualise.
• Side effects — breast tenderness, nausea, headaches, bloating, irregular bleeding (usually settle in 3 months).
• Unscheduled bleeding on HRT (after the first 3–6 months, or after a period of no bleeding) — refer to exclude endometrial cancer.
• Testosterone — consider for low libido if HRT alone doesn't help (specialist, off-label for women).
• Contraindications — current or past breast cancer (or other oestrogen-sensitive cancer), undiagnosed vaginal bleeding, untreated endometrial hyperplasia, active VTE or arterial disease (oral), active liver disease, pregnancy.

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HRT Benefits and Risks

• For most women under 60 (or within 10 years of menopause), the benefits outweigh the risks.
• Use tools such as decision aids and discuss individual risk (breast cancer family history, BMI, VTE).

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Non-hormonal Options and Vaginal Symptoms

• Lifestyle — regular exercise, weight loss, cool environment, layered clothing, reduce caffeine, alcohol and spicy food, stop smoking.
• CBT — helps flushes, low mood, anxiety and sleep (NICE).
• Non-hormonal drugs for vasomotor symptoms (when HRT is unsuitable, e.g. after breast cancer):
  • SSRIs or SNRIs (e.g. venlafaxine, citalopram) — avoid fluoxetine and paroxetine with tamoxifen (they reduce its effect).
  • Gabapentin; clonidine.
  • Neurokinin-3 receptor antagonists (e.g. fezolinetant) — newer licensed options; check current NICE status.
• Complementary therapies (black cohosh, isoflavones) — limited evidence; interactions and quality concerns.
• Genitourinary syndrome of menopause:
  • Vaginal oestrogen (cream, pessary, ring) — safe long term, no progestogen needed; can be used alongside systemic HRT.
  • Vaginal moisturisers and lubricants.
  • Ospemifene; vaginal DHEA (prasterone).
  • After breast cancer — non-hormonal first; vaginal oestrogen after discussion with the oncology team.
• Bone health — calcium, vitamin D, weight-bearing exercise; FRAX assessment; bisphosphonates if indicated (see the Bone Medicine chapter).

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Premature Ovarian Insufficiency

• Definition — loss of ovarian function before 40; affects about 1 in 100 women under 40.
• Diagnosis — irregular or absent periods for 4 months or more plus raised FSH (over 25 IU/L on two samples at least 4 weeks apart).
• Causes:
  • Idiopathic (most).
  • Autoimmune — with thyroid disease, Addison's, type 1 diabetes, coeliac disease.
  • Genetic — Turner syndrome, fragile X premutation (FMR1).
  • Iatrogenic — chemotherapy, pelvic radiotherapy, surgery (oophorectomy).
  • Infections (mumps, TB); galactosaemia.
• Tests — karyotype, fragile X, thyroid and adrenal antibodies, TFTs, DEXA scan.
• Management:
  • Hormone replacement until at least the average age of menopause (51) — HRT or combined hormonal contraception — to protect bone, heart and brain, as well as treat symptoms. (The usual HRT breast cancer risk data don't apply — it is replacing normal hormones.)
  • Fertility — spontaneous pregnancy still possible in about 5–10% (contraception if needed); egg donation IVF is the main option.
  • Psychological support; bone and cardiovascular monitoring.
• Fertility preservation (egg, embryo or ovarian tissue freezing) before cancer treatment.

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Subfertility — Assessment

• Definition — failure to conceive after 1 year of regular unprotected sex (every 2–3 days). About 80% of couples conceive within a year, and 90% within 2 years.
• Refer earlier (NICE CG156) if:
  • Woman aged 36 or over.
  • Known cause — irregular or absent periods, previous PID or pelvic surgery, endometriosis, undescended testes, previous chemotherapy.
• Causes (roughly):
  • Male factor — about 30%.
  • Ovulation disorders — about 25% (mostly PCOS).
  • Tubal damage — about 20%.
  • Unexplained — about 25%.
  • Endometriosis; uterine problems.
  • Often more than one factor.
• Advice for both partners:
  • Folic acid 400 micrograms (5 mg if indicated) for the woman.
  • Healthy weight — BMI 19–30 for the woman (fertility treatment may not be offered over 30–35); weight loss improves ovulation in PCOS.
  • Stop smoking; limit alcohol (up to 1–2 units once or twice a week for women; within limits for men).
  • Avoid recreational drugs and anabolic steroids; loose underwear; avoid heat for testes.
  • Check rubella immunity and cervical screening.
• Initial tests:
  • Woman — mid-luteal progesterone (7 days before the expected period — over 30 nmol/L confirms ovulation); FSH and LH (if irregular cycles); prolactin and TFTs if symptoms; chlamydia test; AMH or antral follicle count (ovarian reserve).
  • Man — semen analysis (repeat after 3 months if abnormal; sooner if severe).
  • Tubal patency — hysterosalpingography (HSG) or HyCoSy (ultrasound) if no known pelvic disease; laparoscopy and dye if known risk (endometriosis, previous PID).

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Female Causes and Treatment

• Ovulation disorders (WHO groups):
  • Group I — hypothalamic–pituitary failure (low FSH, LH and oestrogen: low weight, excess exercise, Kallmann syndrome) — restore weight; pulsatile GnRH or gonadotrophins.
  • Group II — hypothalamic–pituitary–ovarian dysfunction (normal FSH and oestrogen: mainly PCOS) — weight loss; letrozole or clomifene (with ultrasound monitoring — multiple pregnancy risk); metformin; laparoscopic ovarian drilling; gonadotrophins; IVF.
  • Group III — ovarian failure (high FSH: POI) — egg donation.
  • Hyperprolactinaemia — dopamine agonists (cabergoline, bromocriptine).
  • Thyroid disease — treat.
• Tubal disease (from PID, previous ectopic, surgery, endometriosis):
  • Tubal surgery for some; IVF for most.
  • Hydrosalpinx — remove or clip before IVF (fluid reduces success).
• Endometriosis — surgical treatment of endometriosis may help; IVF.
• Uterine problems — submucosal fibroids, polyps, septum, adhesions — hysteroscopic surgery.
• Age — the most important factor; fertility falls from the early 30s and more steeply after 37.
• Unexplained subfertility — try for 2 years in total, then IVF (NICE doesn't recommend clomifene for unexplained subfertility).

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Male Factor Subfertility

• Semen analysis (WHO 2021 lower reference limits — approximately):
  • Volume 1.4 mL or more.
  • Concentration 16 million/mL or more.
  • Total motility 42% or more; progressive motility 30% or more.
  • Normal forms 4% or more.
• Causes:
  • Testicular — undescended testes, mumps orchitis, trauma, torsion, chemotherapy or radiotherapy, varicocele, Klinefelter syndrome (47,XXY — small firm testes, azoospermia, gynaecomastia), Y chromosome microdeletions.
  • Hormonal — hypogonadotrophic hypogonadism (Kallmann), high prolactin, anabolic steroids and testosterone use (suppress sperm production).
  • Obstructive — vasectomy, infection (epididymitis), congenital absence of the vas deferens (cystic fibrosis gene variants).
  • Erectile or ejaculatory dysfunction; retrograde ejaculation (diabetes, prostate surgery, alpha-blockers).
  • Drugs and lifestyle — sulfasalazine, smoking, alcohol, obesity, cannabis, heat.
• Tests — FSH, LH, testosterone, prolactin; karyotype and Y microdeletion (severe oligospermia or azoospermia); CF testing (absent vas); scrotal ultrasound.
• Treatment:
  • Stop anabolic steroids and testosterone; lifestyle.
  • Gonadotrophins for hypogonadotrophic hypogonadism.
  • ICSI (intracytoplasmic sperm injection) — for severe male factor; surgical sperm retrieval if azoospermia.
  • Donor sperm.
• Sperm banking before cancer treatment.

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IVF and Assisted Conception

• Intrauterine insemination (IUI) — prepared sperm placed in the womb: for donor sperm, same-sex couples, people unable to have vaginal sex.
• In vitro fertilisation (IVF):
  • Ovarian stimulation (injections of FSH) with a GnRH agonist or antagonist to prevent early ovulation.
  • Trigger (hCG or GnRH agonist), then egg collection by transvaginal needle under sedation.
  • Fertilisation in the lab (or ICSI), embryo culture, then embryo transfer (usually a single embryo to avoid twins).
  • Spare embryos can be frozen.
• NHS access (NICE CG156) — women under 40: up to 3 full cycles after 2 years of trying (or 12 cycles of IUI); 40–42: 1 cycle if certain criteria are met. Local commissioning rules vary.
• Success — falls with age (about 30–35% live birth per transfer under 35, under 5% over 44 with own eggs).
• Risks:
  • Ovarian hyperstimulation syndrome.
  • Multiple pregnancy (reduced by single embryo transfer).
  • Ectopic pregnancy (including heterotopic).
  • Slightly higher risk of pregnancy complications (pre-eclampsia, preterm birth, placenta praevia).
  • Emotional and financial strain.
• Regulation — the Human Fertilisation and Embryology Authority (HFEA) licenses clinics; donor-conceived people can learn the donor's identity at 18.
• Surrogacy and fertility preservation (egg and embryo freezing) are other options.

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Ovarian Hyperstimulation Syndrome

• What it is: An exaggerated response to ovarian stimulation — enlarged ovaries release vasoactive substances (VEGF), and fluid leaks out of the blood vessels.
• Risk factors — PCOS, young age, high AMH, many follicles, high oestradiol, hCG trigger, pregnancy (worse if pregnant).
• Features (days after egg collection or in early pregnancy):
  • Abdominal bloating and pain, nausea, vomiting.
  • Ascites, pleural effusion, breathlessness.
  • Haemoconcentration (raised haematocrit), low sodium, reduced urine output, AKI.
  • VTE (including unusual sites — neck veins).
  • Ovarian torsion.
• Management:
  • Mild — outpatient: analgesia (paracetamol, avoid NSAIDs), fluids to thirst, daily weight and fluid monitoring.
  • Moderate to severe — admit: fluid balance, IV fluids (careful), LMWH, analgesia, paracentesis for tense ascites, albumin, ITU if critical.
• Prevention — GnRH antagonist protocols, GnRH agonist trigger, freezing all embryos.

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Choosing Contraception

• Long-acting reversible contraception (LARC) — implant, IUD, IUS, injection — most effective because they don't rely on daily use.
• UKMEC (UK Medical Eligibility Criteria) categories:
  • 1 — no restriction.
  • 2 — benefits generally outweigh risks.
  • 3 — risks generally outweigh benefits (use only with specialist advice if no alternative).
  • 4 — unacceptable health risk — don't use.
• Consultation — medical history, BP and BMI (for combined methods), drug interactions, STI risk (condoms protect against STIs), future fertility plans, side effects, the woman's preferences.
• Quick starting — most methods can be started any day if pregnancy is reasonably excluded; use condoms for 7 days (combined methods, implant, injection) or 2 days (POP), and repeat a pregnancy test at 3 weeks if there was recent unprotected sex.

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Combined Hormonal Contraception

• Forms — combined oral contraceptive pill (COC), patch (weekly), vaginal ring (monthly). Contain an oestrogen (usually ethinylestradiol) and a progestogen.
• How it works — stops ovulation; also thickens cervical mucus.
• How to take — 21 days on, 7-day break (withdrawal bleed), or tailored regimens (shorter breaks, or continuous use with no break) — fewer bleeds and less risk of escape ovulation (FSRH supports these).
• Benefits:
  • Lighter, less painful, regular bleeds; helps PMS, endometriosis and acne.
  • Reduced ovarian, endometrial and bowel cancer risk (lasting for years after stopping).
  • Fewer functional ovarian cysts and benign breast disease.
• Risks:
  • VTE — about 2–3 times baseline (still lower than in pregnancy); higher with some progestogens (desogestrel, gestodene, drospirenone) than levonorgestrel or norethisterone.
  • Arterial disease — stroke and MI (small; higher with smoking, migraine with aura, hypertension).
  • Breast cancer — small increase while using, returns to baseline 10 years after stopping.
  • Cervical cancer — small increase with long-term use.
  • Side effects — nausea, breast tenderness, headaches, mood change, breakthrough bleeding.
• UKMEC 4 (don't use) — examples:
  • Migraine with aura (any age).
  • Age 35 or over and smoking 15 or more cigarettes a day.
  • BP 160/100 or more (or vascular disease).
  • Current or previous VTE; known thrombogenic mutation (e.g. factor V Leiden).
  • Ischaemic heart disease, stroke, complicated valvular heart disease.
  • Current breast cancer.
  • Major surgery with prolonged immobilisation.
  • Under 6 weeks after birth if breastfeeding (under 21 days if not breastfeeding).
  • SLE with positive antiphospholipid antibodies; severe cirrhosis; liver tumours.
• UKMEC 3 — examples: BMI 35 or more; age 35 or over and smoking under 15 a day or stopped under a year ago; controlled hypertension; multiple cardiovascular risk factors; breast cancer over 5 years ago; immobility.
• Stop 4 weeks before major elective surgery or surgery causing immobility.

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Missed Pills and Interactions

• Combined pill (FSRH):
  • One pill missed (24–48 hours since the last pill should have been taken) — take it as soon as possible (even if two in one day), continue as normal. No extra precautions.
  • Two or more pills missed (48 hours or more) — take the most recent missed pill now, continue the rest, and use condoms or abstain for 7 days.
    • In week 1 — consider emergency contraception if unprotected sex in the pill-free interval or week 1.
    • In week 2 — no EC needed if pills taken correctly in the previous 7 days.
    • In week 3 — skip the pill-free interval (start the next pack straight away).
• Progestogen-only pill:
  • Desogestrel (and drospirenone POP) — 12-hour window (24 hours for drospirenone); traditional POPs — 3-hour window.
  • Late — take it as soon as possible, continue, use condoms for 2 days; EC if sex in those 2 days.
• Vomiting within 2 hours or severe diarrhoea — treat as a missed pill.
• Enzyme-inducing drugs (reduce effectiveness of pills, patch, ring, implant, POP):
  • Rifampicin, rifabutin.
  • Carbamazepine, phenytoin, phenobarbital, topiramate, oxcarbazepine.
  • St John's wort.
  • Some HIV drugs (efavirenz, ritonavir-boosted).
  • Modafinil; bosentan.
  • Effect lasts 28 days after stopping. Use an IUD, IUS or injection instead.
• Lamotrigine — combined methods lower lamotrigine levels (seizure risk), especially in the pill-free week.
• Antibiotics (non-enzyme-inducing) don't reduce effectiveness.

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Progestogen-only Methods

• Progestogen-only pill (POP):
  • Desogestrel — inhibits ovulation; taken every day with no break; available from pharmacies without prescription.
  • Safe for most women who can't take oestrogen (migraine with aura, smokers over 35, VTE history, breastfeeding).
  • Side effects — irregular bleeding (the main reason people stop), headache, acne, breast tenderness, mood change.
• Implant (Nexplanon — etonogestrel rod in the upper arm):
  • 3 years; the most effective reversible method.
  • Irregular bleeding (about a third amenorrhoea, a fifth frequent or prolonged bleeding).
  • Fertility returns quickly after removal.
  • Rare — deep insertion, nerve damage, migration.
• Injection (DMPA — medroxyprogesterone acetate):
  • Every 13 weeks — IM (Depo-Provera) or SC self-injection (Sayana Press).
  • Weight gain (especially in under-18s with obesity), irregular bleeding then often amenorrhoea.
  • Reduced bone density (recovers after stopping) — caution under 18 and over 45; review every 2 years.
  • Delayed return of fertility — up to a year.
• Progestogen-only methods are UKMEC 4 only in current breast cancer (and UKMEC 3 for some other conditions, e.g. severe liver disease, IHD or stroke on the method).
• Bleeding problems — exclude pregnancy, STIs and cervical pathology; a short course of COC (if suitable) or NSAIDs can help.

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Intrauterine Methods

• Copper IUD:
  • Hormone-free; copper is toxic to sperm and eggs and prevents implantation.
  • Lasts 5–10 years (depending on device); if fitted at 40 or over, it can stay until after the menopause.
  • Works immediately; the most effective emergency contraception.
  • Side effects — heavier, longer, more painful periods.
• Levonorgestrel IUS:
  • Releases progestogen locally — thins the lining, thickens mucus.
  • 52 mg (Mirena, Levosert, Benilexa) — contraception for up to 8 years (Mirena; check the specific device); 5 years for endometrial protection in HRT.
  • Lower-dose devices — Kyleena (5 years), Jaydess (3 years).
  • Lighter periods (often amenorrhoea); irregular spotting at first; treats heavy periods.
  • If fitted at 45 or over (52 mg), can stay until age 55 for contraception.
• Risks of both:
  • Pain at insertion; vasovagal reaction.
  • Infection — small risk in the first 20 days (screen for STIs if at risk).
  • Expulsion (about 1 in 20), most in the first 3 months.
  • Perforation — about 1 in 1,000 (higher when breastfeeding or soon after birth).
  • If pregnancy occurs, a higher proportion are ectopic (though overall ectopic risk is lower than using no contraception).
• Lost threads — use other contraception, pregnancy test, ultrasound to locate (X-ray if not in the womb — perforation).
• Contraindications — pregnancy, current PID or untreated STI, unexplained bleeding, distorted cavity, cervical or endometrial cancer, Wilson's disease (copper).

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Emergency Contraception

• Oral EC delays ovulation — it won't work if ovulation has already happened; it is not an abortifacient.
• Vomiting within 3 hours — repeat the dose.
• Follow-up — pregnancy test at 3 weeks; STI testing; start ongoing contraception (quick start).
• Available free from sexual health clinics, many pharmacies and GPs; can be given in advance.
• Safeguarding — consider coercion, sexual assault, or child sexual exploitation, especially in young people.

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Barrier Methods and Sterilisation

• Condoms (male and female) — the only methods that also protect against STIs; advise using with other methods ("double Dutch"). Oil-based lubricants damage latex.
• Diaphragm or cap with spermicide — less effective; left in for 6 hours after sex.
• Fertility awareness methods — tracking temperature, mucus and cycle; needs commitment and regular cycles; apps vary in accuracy.
• Female sterilisation — laparoscopic clips (Filshie) or salpingectomy:
  • Permanent; about 1 in 200 lifetime failure (higher ectopic proportion if it fails).
  • General anaesthetic; use contraception until the next period after the procedure.
  • LARC is as effective — discuss as an alternative.
• Vasectomy:
  • Local anaesthetic, quicker and safer than female sterilisation.
  • Not effective immediately — use contraception until semen analysis is clear (about 12 weeks after).
  • Failure about 1 in 2,000 after clearance; chronic testicular pain in a few.
• Counselling — both are intended to be permanent; regret is more common in those under 30 or making the decision at a time of crisis (e.g. at caesarean).

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Contraception for Young People

• Under 16 — contraception can be provided without parental consent if the young person is Gillick competent and the Fraser guidelines are met:
  • They understand the advice.
  • They can't be persuaded to tell their parents (or allow you to).
  • They are likely to have sex with or without contraception.
  • Their physical or mental health is likely to suffer without contraception.
  • It is in their best interests.
• Confidentiality — keep it, unless there is a risk of serious harm.
• Safeguarding:
  • Under 13 — cannot legally consent to sex; always discuss with the safeguarding lead and refer.
  • 13–15 — assess for exploitation (age gap, gifts, alcohol or drugs, coercion, missing from home), and act on concerns.
  • Spotting the signs of child sexual exploitation (CSE).
• Good choices — LARC is safe and effective at any age (including nulliparous); DMPA with caution under 18 (bone density); always promote condoms.

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Drug Reference Table

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Spot the Diagnosis