contraception update jo swallow st1s october 2011
TRANSCRIPT
Contraception Update
Jo Swallow
ST1s October 2011.
Objectives
To know what forms of contraception are available and when they are necessary
To know the contraindications for each and how to identify them
What to check for on f/u consultations To know how to access information for
ourselves and patients To know how to approach a consultation for :
A contraception request An emergency contraception request
Brainstorm!
What forms of contraception are there?
Rank them now in order of efficacy,
(most effective at the top)
Pearl index
Method Failure %rates per hundred women years Sterilisation male 0.0 to 0.2 Sterilisation female0.0 to 0.3 (1.8% at 10 years) Implanon0.0 Mirena0.0 to 0.2 Depo-Proverax0.0 to 0.2 Combined oral contraceptive pill0.2 to 3 (3 with poor compliance) Progestogen-only pill (second generation)0.3 to 4 (0.5 over age 35) IUDs 0.3 to 2 Diaphragm/cervical Cap 5 to 20 Condom (male, female) 5 to 15 Coitus interruptus 8 to 17 Natural methods 5 to 25 Spermicides 5 to 25
Case 1-Lois A
Lois 15yrs attends asking to go on the pill.
In groups of 3,
History factors? Examination factors?
?Pill choice
COCP/POP
What did you think?
A reminder, re child protection.Frazer/Gillick competence
<13yrs not legally capable of consenting to sexual activity
13-16 discuss and consider
Pros/cons of cocp
Important things to worry about with the COCP?
VTE Cancer –breast/ovarian Stroke
Use the BNF cautions contraindications list… 2 strikes and you’re out!
VTE with COCPRisk of VTE per 100.000
Healthy, non pregnant, no COCP
5 per yr
Cocp with levonorgestrol 15 per year
Cocp with gestodene or desogestrol
25 per year
Pregnant 60 per year
VTE with COCP:Effect of weight….
BMI>30
2 x risk
BMI >39
4 x risk
Healthy,no COCP 5 10 20
Cocp with levonorgestrol
15 30 60
Cocp with gestodene or desogestrol
25 50 100
Pregnant 60 120 240
Dianette/Yasmin
Heard the news?
Cardiovascular Risk
Absolute risk of MI in non smoking age <35 very low irrespective of COCP use
Excess risk <35 approx 3/1,000,000/yr >35 Excess risk approx 400/1,000,000/yr 10x risk if smoke
Migraine
Migraine with aura =absolute CI (WHO 4)
Migraine +ergots=absolute CI Migraine +tryptan = relative CI Migraine +1 other RF=relative CI Migraine + No Aura +no additional stroke
risk factors = OK
Case 1 -Lois B
Lois returns to see you with symptoms of a urine infection,
She reports that although she is quite good at remembering her pills, she does forget occasionally, is this ok?
Antibiotics and the pill
But ILL rules, (D/V still apply, and abx can induce these!)
Missed pills
New rules Can miss one anywhere in pack no prob
even if extend pill free interval to 8 days If std dose 30 can miss 2/3**** If low dose oestrogen (20) can miss ***
Case 1 –Lois C
Lois returns, 4 months later, she is now 16.
Her parents has been complaining about her mood swings and she wonders if the pill is to blame. She hasn’t told them that she takes it.
What might you consider?
Progestogens
C19 derivatives
E.g Norethisterone Levonorgestorel
More androgenic More likely to cause
side effects
C21 derivatives
E.g Medroxyprogestogen acetate
Dydrogesterone
Less androgenic
Side Effects
Oestrogenic Fluid retention Bloating Breast tenderness Nausea Headache Dyspepsia (take with food) Consider changing dose,
changing oestrogen or changing delivery
Progestogenic (In a cyclical pattern) Fluid retention Breast tenderness Mood swings Depression Acne Backache Reduce progestogen
duration to 10 days per cycle, change progestogen c19/21 derivatives, delivery
Case 2- The condom split
Michelle 15 yrs attends asking for ‘the emergency pill’
Groups of 3 What do you need to ask? What other issues does this present?
Emergency contraception
What actually happened? ?regular partner or one off STI risk? Menstrual cycle and current position, other
contraception? (?earliest ovulation) When was the accident? Any other upsi in this cycle ?used before ?consensual, age of partner, ?Frazer
competant
Case 2 - Michelle B
It transpires that the condom split yesterday evening around 11pm,
They also had sex 3.5 days ago using the withdrawal method
What is the most effective measure for her now?
What other options are there?
Levonelle is effective up to 72 (120 hrs) If >48-72 hrs consider Ella One, (ullipristal) Always consider copper iud
(up to 5 days or, up to 5 days> earliest ovulation) Levonelle efficacy: 95% - 1st 24hr, 85% 48, 70% 72 Ella one efficacy: ….. Remember pt’s on enzyme inducers may require double
dosing of MAP
Things to discuss:
Mode of action Vomiting Enzyme inducing drugs Next Period -87% within 7 days of expected:
may be early or late, Most of rest 7-14d late ?Preg test
? Quickstart FUTURE contraception, Condoms have a 5% failure rate when used
PERFECTLY
Emergency Contraception
IUCD (not IUS) Up to 5 days after date of UPSI or
expected ovulation Failure rate <1%