Contraceptive update

Charlie FlemingConsultant in gynaecology & sexual health

Aneuran Bevan Health Board13/10/16

Overview

• IUDs

• Implants

• Emergency contraception

• Injectables

• Combined E+P

Intrauterine devices

• No age restrictions• IUS had endometrial protection for 5 years• If IUS fitted > 45 will last through menopause• IUCD fitted > 40 will last through menopause• IUS not suitable for emergency contraception• No evidence for cleaning the cervix or topical

lidocaine• Routine checkup not needed• Ignore asymptomatic ALOs• Control unscheduled bleeding with COC• Remember sexual history

Levosert (2013)

• Pharmaceutically the same as IUS (Mirena)

• 2 handed insertion

• Insertion tube 4.8mm v 4.4mm (? Significance)

• Licence for 3 years, not 5

• Cheaper: £66 v £88

Jaydess (2013) v Mirena

Dose LNG 13.5 52

Diameter tube 3.8mm 4.4mm

Duration 3 yrs 5 yrs

Cost £69 £88

Uses contraception Contraception + heavy K + HRT

Amenorrhoea less more

Efficacy Limited data ?

Loading same

Nexplanon (2013)

• Same as implanon, but barium sulphate on coating = radio-opaque

• Impalpable implants: refer to specialist!• Bleeding: 20% regular

33% infrequent20% amenorrhoea25% prolonged/ frequent

…...randomly random is the norm!Control bleeding with COC

Emergency contraceptionCopper IUD - any Levonorgestrel 1.5mg

LevonelleUlipristal acetate 30mgElla-one (2009)

When < 5/7 after earliest ovulation

<72 hrs in license72-96 hrs some effect<120 hrs little data

<120 hrs = 5/7

Efficacy Near 100% Better around ovulationHigher >96 hrs

Pros EffectivenessNo age restriction Ongoing contraception

Efficacy

Cons IUD skill neededNeeds STI assessment& possible prophylaxis

Not if > 1 UPSI this cycleNot if breast feedingNot with severe asthmaNot with anti-ulcer medsMay effect of hormonal contraception

Cost £9 £1 £17

Injectable progestogens

• Depo-provera up to 14 weeks

• OK < 50 years, consider osteoporosis risk factors

• Sayana press (2011): s/c form of depo

• Give upper anterior thigh or anterior abdomen over 5-7 seconds.

• Pharmacology & cost (£6-7 same as IM injection)

• Good if on blood thinners risk haematoma

• Opportunities for self administration

New COCsZoely (2013) Qlaira (2009) Eloine (2008)

Hormones 17B oestradiol 1.5mgNomegestrel 2.5mg

Oestradiol valerate 1-3mgDienogest

Ethinyl oestradiol 20mgDrospirinone 3mg(mini Yasmin)

Regime 24 active pills4 placebo tablets

Quadriphasic26 active tablets2 placebo tablets

24 active pills4 placebo tablets

Bleeding

Side effects ? lighter bleeding ? lighter bleeding ?progestogenic SEs

Pros As Qlaira ‘natural oestrogen’Anti androgenic P lipid, coagulation,

CHO effectsClinical relevance?

Cons Cost Cost Cost

Who for Anyone Anyone Anyone

Cost pcm mid range £ 9

E+P combined contraception: ring & patch

Evra (2002) Nuvaring (2001)

What daily hormone Norelgestromin 203 mcg(= norgestimate)34 mcg ethinyl oestradiol

Etonorgestrel 120ug15mcg ethinyl oestradiol

Regime 3 weekly patchesOne week free

3 weeks inOne week free

Bleeding As COC Less bleeding

Side effects As COC Less N+V & mastalgia

Pros ? Better compliance Personal choiceLower EE exposure

Cons Cost, skin reactions Cost, local effects

Monthly cost £15 £27

Who for? ? can’t swallow Anyone

Combined contraception & VTE

• Background risk = 4:10,000 woman years

• Pregnancy = 25:10,000 woman years

• Cyproterone acetate, desogestrel, gestodene, drospirinone and Evra +14

• LNG, norethisterone +6

Teenagers

• All methods OK as once menstruation has started, including IUDs

• Remember Fraser guidelines and sexual exploitation

• Depoprovera UKMEC 2. No need for add back oestrogen or DEXA scans

Contraception in the perimenopause 1

• No method is contraindicated by age alone• CHC may help with flushes• CHC Ca breast RR1.2, • CHC protects against Ca ovary, endometrium,

colon, may benign breast disease• Overall cancer risk is neutral-protective• v small CVA• Consider using 20ug CHC pill • Consider osteoporosis risk factors in women on

depo-provera

Contraception in the perimenopause 2

• Stop contraception after 12/12 is FMP < 50 yrs24/12 of FMP < 50yrs

• Keep going to age 55 if unsure of menstrual transition

• If >50 yrs consider 2 FSH levels 6/52 apart (not if using Depo and COC); 2 x >30iu/l = can stop contraception after 1 year

• For HRT + contraception: IUS + E2, POP + HRT, non-hormonal methods and HRT

UK Medical Eligibility Criteria UKMEC

UKMEC categories for the use of combined hormonal contraception with cardiovascular and cerebrovascular disease

Condition UKMEC category

Current and history of ischaemic heart disease 4 Personal history of VTE 4Current VTE (on anticoagulants) 4VTE in First-degree relative aged <45 years 3VTE in First-degree relative aged ≥45 years 2Stroke (history of cerebrovascular accident including TIA) 4Adequately controlled hypertension 3Systolic >140–159 mmHg or diastolic >90–94 mmHg 3Systolic ≥160 mmHg or diastolic ≥95 mmHg 4Vascular disease 4Multiple risk factors for cardiovascular disease (such as older age, smoking, diabetes, obesity, hypertension) 3/4

FSRH E-knowledge assessment• On line learning before doing clinical training for DFSRH, letters of

competence. £75 per attempt• Fertility awareness and the lactational amenorrhoea method• Combined contraception• Progestogen only contraception• Barrier contraception• Assessment and referral for IUDs, implants and sterilisation• Emergency contraception• Presentation, diagnosis, and testing for vaginal discharge and STIs• Management at GP/community SRH level of vaginal discharge,

pelvic pain and STIs – including male genital discharge, genital lumps, infestations and ulcers (not including management of HIV or blood borne viruses)

• Asymptomatic screening (male and female)• Testing for HIV and blood-borne viruses• Management of a woman presenting with an unplanned pregnancy

SRH essentials: one day course for nurses in primary care

• This course will give you the skills and confidence to:• Bring up the topic of contraception and sexual health with your

patient• Assess and safely reissue (not start for the first time):• Combined hormonal methods• Progestogen-only pill• Injection• Assess whether a woman is at risk of pregnancy• Decide which method/s of emergency contraception your patient

may safely consider• Identify when your patient is at risk of an STI• Decide when to refer to a GP, SRH colleague or other service

52 yo

• IUS fitted 7 yrs ago for contraception & menorrhagia, amenorrhoeic

• Worsening flushes last 12 months

• Wants to know if she’s menopausal

• Wants to know if she needs contraception

• Wants help with flushes

• What do you do?

25 yo student

• Implant fitted 2 yrs ago

• Amenorrhoea until 3 months ago, then prolonged light bleeding and PCB

• Fed up with the bleeding. Wants it out.

• 2 x TOP

• Medical history unremarkable

• What will you do?

Girl, 14

• Cerebral palsy, global delay, in wheelchair, learning age of 4

• Started menstruating 8 months ago

• Mother doesn’t want her to suffer and carersfind menstrual hygiene awkward. Mother wants something to stop periods.

• What do you do?

Thank you