Contraception cases

September 2014 Dr Angela Cooney

Sexual and Reproductive Health WA

Obesity and contraception

Josephine (Josie)

• 24 year old mother of 3 • 160 cm tall, 110kg, BMI 42 • First pregnancy age 17, was on the combined pill • Second pregnancy age 19, using condoms and withdrawal • Third pregnancy (new relationship) was planned, but now she

wants to stop!

• Why did Josie have 2 accidental pregnancies? • Failed COCP? Failed condoms/withdrawal?

• Not because she is overweight! • USER FAILURE, NOT METHOD FAILURE

What will you suggest to Josie?

• Sterilisation • Vasectomy • Double dose of the combined pill • IUD • Implant

Josie

• No other medical issues, no medications • Babe 7 weeks old • Not breastfeeding

1 Which method/s are safe to use in obesity? 2 Will any method/s lead to weight gain? 3 Does weight affect contraceptive efficacy?

6

WHO levels of contraindications

• 1. A condition for which there is no restriction for the use of the contraceptive method

• 2. A condition where the advantages of using the method generally outweigh the theoretical or proven risks

• 3. A condition where the theoretical or proven risks usually outweigh the advantages of using the method

• 4. A condition which represents an unacceptable health risk if the contraceptive method is used

Increased BMI & combined methods contraindication due to VTE risk

THE BIGGER SHE IS, THE GREATER THE RISK

UK Medical Eligibility Criteria for Contraceptive Use

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Do hormonal methods cause weight gain?

Overall conclusions from research: • No significant effect on weight of any method

– Except for Depo users who are already overweight

• Many women will avoid reliable methods because of fear of weight gain – reassure them always less weight gain than becoming pregnant!

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Raised BMI & effectiveness All methods appear to be effective at any BMI Recent concerns re Levonorgestrel emergency contraception from poorly designed studies

BUT TGA doing own review commencing this year. In the meantime BETTER THAN NOTHING….. Doubling of daily dose of progestogen-only pill in women > 70kg NO LONGER RECOMMENDED

Now, back to “Contraception For All Sizes”

• Emphasis on LARC (Long Acting Reversible Contraception)

• New ways of using an older method (extended use COCP)

• New understanding of risk factors – DVT and COCP – IUDs in young women – The Pill and cancer risk

So, what’s new??

NEW THINKING ABOUT OLDER METHODS – extended use COCP

WHICH WAY IS BEST, AND WHY?

2006-2012 US insurance database study Type of COCP pack likelihood of UPP (unplanned preg) 21/7 7.3% 24/4 6.9% 84/7 4.4% Howard et al. Comparison of pregnancy rates in users of extended and cyclic COC regimens in the United States

Contraception 89 (2014) 25-27

How can women use the COCP more effectively?

• 21/7, eg Levlen = traditional regime, monthly ‘period’

• 24/4, eg Yasmin = less chance of ovaries “waking up” and having breakthrough ovulation

• 84/7, eg ‘back-to-back’ = previously recommended for severe dysmenorrhoea, endometriosis

• 120/4, eg Yaz Flex = probably optimal for contraceptive effectiveness and minimising symptoms.

What the *&%# is Yaz Flex?

• CAN USE THE SAME EXTENDED REGIME WITH CHEAPER PILLS!!!!

• Scissors + Levlen/Femme-tabs/Norimin etc • Continue hormone pills until spotting/BTB,

then have a 4 day pill-free interval

What is QuickStart???

• Potential advantages

– fewer unplanned pregnancies – a higher chance that the woman will initiate the

method – minimised chance of forgotten instructions

• Potential disadvantages

– may not be able to exclude pregnancy for the cycle – pregnancy diagnosis delay – anxiety for woman re early pregnancy exposure

Quick Start = initiating a method of contraception outside

the recommended time

• DON’T ASK A WOMAN ON DAY 10 OF HER CYCLE TO WAIT FOR HER NEXT PERIOD

• What is the worst thing that can happen if she starts the pill now??

• Start today on the active pills, and allow 1 week to work, and do a pregnancy test in 4 weeks.

Method

Method is effective

Effect on

continuing pregnancy

Method may

mask pregnancy

Reversible

Comments

Preferred methods for Quick Start

Combined hormonal

7 days

None known

Unlikely

Yes

Risk of teratogenesis well studied, very LOW. Withdrawal bleed

Implant

7 days

None known

Yes

Yes

Teratogenesis unlikely. Long acting, and effective; rapidly reversible.

Mini pill

48 hours

None known

Possible

Yes

Rapid onset, Strict adherence to timing

Can be used

DMPA

7 days

None known

Yes

No

Irreversible. Small studies show no teratogenesis. Long acting, effective

Can’t be used (exception copper IUD for emergency use)

IUD

Copper stat LNG: 7 days

↑ miscarriage, esp 2nd trimester

Yes: LNG Possible CU

Threads may disappear

Possible effect on the outcome of a pregnancy if the IUD cannot be removed.

International Active Surveillance Study of Women Taking Oral Contraceptives (INAS-OC), prospective study of 85,109 women in the United States and six European countries- results released June 2014. Incidence of DVT/TED NO DIFFERENCE BETWEEN DROSPIRENONE AND OTHER PROGESTOGENS “The results of this large-scale, post-marketing study should reassure GPs that for women whom they judge it appropriate to prescribe, the benefits of all low dose combined hormonal contraceptives with 35mcg or less of ethinylestradiol continue to outweigh the risks, irrespective of the progestogen type.” - Dr Deborah Bateson, Medical Director FPNSW. ANY COCP IS SAFER THAN BEING PREGNANT!!

What is it with Yasmin/Yaz and

thromboembolic disease??

0

50

100

150

200

250

300

No hormones Combined pill Pregnancy Immediatelypostpartum

VTE risk per 10,000 woman years

Popular Misconceptions

• POP “you can only use that if you are breastfeeding….”

• IUD “don’t even think about it until you have had 3 children/are over 30”

• “If you didn’t like Implanon, you won’t like Depo-Provera, cos they are the same…”

• SMALL increase in likelihood of being unable to insert IUD in nulliparous woman compared to parous woman

• Around 50% of all the IUD inserts I do are in women who are nulligravid, nulliparous, or have had C/Section delivery only

• Use of IUDs does NOT affect future fertility • Young, unsettled lifestyle far more suited

to LARC methods than to user-dependent method

IUDs and youth/parity

New Research – breast cancer and OCP

• Seattle, USA 2014 • Retrospective correlation of pill prescriptions and

diagnosis of invasive breast cancer 1990-2009 • Many formulations no longer used, and not

available in Australia • Diagnosis more likely with

– HIGH DOSE OESTROGEN (50-100ug), – Use of ethynodiol diacetate (a synthetic progestin

with oestrogenic effects) – Norethisterone in high dose (5mg) eg Primolut – not

used as a contraceptive pill in Australia

New Research –cancer and OCP

• Oxford FPA prospective study, 17,000 women from 1968-1974, followed until 2010

• OC use not associated with breast cancer (Rate Ratio 1.0 ever users vs never users)

• Increased risk of cancer cervix (RR 3.4) • Decreased risk cancer uterus and ovary

(RR 0.5 for both diseases) • Overall benefit outweighs adverse effect on

cancer

• 23 years old • Has had positive pregnancy test 2 days ago • Implanon inserted almost 3 months ago • What would you like to ask her?

SHANNON

• Ceased pill 4 months previously • Using condoms (sometimes) prior to

implant insertion • Implant inserted in Port Hedland • Not on any other medications • GP did pregnancy test prior to insertion,

negative • Inserted on day 16 of cycle

SHANNON

Sarah

• 32 years old • Implanon inserted by GP 2 years ago • Positive pregnancy test 5 weeks ago • Wants to continue the pregnancy • What do you want to know?

Sarah

• Other medications – krill oil; magnesium for leg cramps

• Prior to implant used Depo-provera for 4 years • Had no bleeding with implant for the first year,

then had regular cycles until 3 months ago • Spoke to a doctor who told her implant must be

removed or the baby would be deformed • GP (different one) assessed her to remove

implant, not palpable at insertion site • Ultrasound – not visible in arm

Sarah

• She wants to continue the pregnancy – what are the implications?

• Serum taken and sent to the Netherlands for etonorgestrel assay – NOT PRESENT

• = PROVIDER FAILURE!!!! Non-insertion pregnancy.

• 19 years old • Epilepsy since age 7 • On Trileptal (oxcarbazepine) and Sabril

(vigabatrin) • On Microgynon 50 for 2 years • UPP 3 months ago, medical TOP • What happened? What can she use?

Skye

Thank you very much