contracepton for gps dr mazhar khan 7 april 2010

CONTRACEPTON FOR GP’SCONTRACEPTON FOR GP’S

Dr Mazhar KhanDr Mazhar Khan

7 April 20107 April 2010

AGENDAAGENDA StatisticsStatistics

Contraceptive EfficacyContraceptive Efficacy

Non-hormonal ContraceptionNon-hormonal Contraception

UKMEC/ WHO criteria for safe prescribingUKMEC/ WHO criteria for safe prescribing

Hormonal ContraceptionHormonal Contraception

CasesCases

StatisticsStatistics

UK has one of the highest rates of teenage pregnancies in the worldUK has one of the highest rates of teenage pregnancies in the world

UK has one of the highest levels of unintended pregnancies in the worldUK has one of the highest levels of unintended pregnancies in the world


Approximately 200,000 women in England/ Wales seek Approximately 200,000 women in England/ Wales seek abortion / yearabortion / year

62% of these women reported using contraception at the 62% of these women reported using contraception at the time of getting pregnanttime of getting pregnant

““Just cant remember to take the pill”Just cant remember to take the pill” “ “ Didn’t think I would get pregnant while on the pill “Didn’t think I would get pregnant while on the pill “ “ “ Doc, the condom broke” Doc, the condom broke”

38% of these women were not on a regular 38% of these women were not on a regular contraception or used no contraception at allcontraception or used no contraception at all

“ “ didn’t think at the time I needed one “didn’t think at the time I needed one “ “ “ didn’t think I would get pregnant at all “didn’t think I would get pregnant at all “ “ “ I was drunk ! “I was drunk ! “ “ “ It was a one night stand “It was a one night stand “


Pearl Index: No. of pregnancies/ 100 years of usePearl Index: No. of pregnancies/ 100 years of use

Contraceptive efficacy depends on:Contraceptive efficacy depends on: AgeAge Motivation of user/ compliance/ concordanceMotivation of user/ compliance/ concordance Duration of use of contraceptive methodDuration of use of contraceptive method Pearl indexPearl index Mechanism of action: Method that stops ovulation and is Mechanism of action: Method that stops ovulation and is

independent of user complianceindependent of user compliance


MethodMethod Pearl IndexPearl Index

None (young women)None (young women) 80-9080-90

None (age 40)None (age 40) 40-5040-50

None (age 45)None (age 45) 10-2010-20

None (age 50)None (age 50) 0-200-20

Contraceptive SpongeContraceptive Sponge 9-259-25

Rhythm MethodsRhythm Methods 6-256-25

Spermicide onlySpermicide only 4-254-25

Coitus InterruptusCoitus Interruptus 8-178-17

PersonaPersona 3-63-6

Male Condom (sheath)Male Condom (sheath) 2-152-15

MethodMethod Pearl IndexPearl Index

Female CondomFemale Condom 5-155-15

DiaphragmDiaphragm 4-204-20

IUCD (coil)IUCD (coil) 0.2-20.2-2

IUSIUS <0.5<0.5

POPPOP 0.3-40.3-4

COCCOC 0.1-40.1-4

ImplanonImplanon 0-0.10-0.1

Depo-ProveraDepo-Provera 0-10-1

Sterilisation - FemaleSterilisation - Female 0-0.50-0.5

Sterilisation - MaleSterilisation - Male 0-0.050-0.05

Pearl Index

Non-Hormonal ContraceptionNon-Hormonal Contraception

Calendar MethodCalendar Method

BBTBBT

Cervical Mucus TestCervical Mucus Test

Billings Ovulation MethodBillings Ovulation Method

PERSONAPERSONA

LactationLactation

Coitus InterruptusCoitus Interruptus

Natural Family PlanningNatural Family Planning


CondomsCondoms

Most commonly used NHCMost commonly used NHC

Pearl Index 2 – 15Pearl Index 2 – 15

Latex/ PolyurethaneLatex/ Polyurethane

Most come with the spermicidal, Most come with the spermicidal, Nonoxynol-9Nonoxynol-9

Beware of certain topical products/ Beware of certain topical products/ lubricantslubricants

Protection against STI’sProtection against STI’s

DisposableDisposable

Barrier Methods (Males)Barrier Methods (Males)


Femidom (female condom)Femidom (female condom)

Pearl Index 5 – 15Pearl Index 5 – 15

Latex/ PolyurethaneLatex/ Polyurethane

Most come with the spermicidal, Nonoxynol-9Most come with the spermicidal, Nonoxynol-9

Insertion – Prior to sexual intercourseInsertion – Prior to sexual intercourse

Removal – Does not need to be removed Removal – Does not need to be removed immediately after ejaculationimmediately after ejaculation

Beware of certain topical products/ lubricantsBeware of certain topical products/ lubricants

Protection against STI’sProtection against STI’s

Some evidence that polyurethane femidoms Some evidence that polyurethane femidoms can be washed, disinfected and reusedcan be washed, disinfected and reused

Barrier Methods (Females)Barrier Methods (Females)


Vaginal DiaphragmVaginal Diaphragm

Pearl Index 4 - 20Pearl Index 4 - 20

Latex/ SiliconeLatex/ Silicone

5 mls of spermicidal should be used 5 mls of spermicidal should be used

Insertion – Can be inserted up to 6 hrs prior to sexual intercourseInsertion – Can be inserted up to 6 hrs prior to sexual intercourse

Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 30 hrsnot be left in for > 30 hrs


Less protection against STI’sLess protection against STI’s

Can be washed, disinfected and reused – 1 yrCan be washed, disinfected and reused – 1 yr

Right size is important – size changes post delivery/ termination/ Right size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgsmiscarriage/ pelvic surgery/ wt change > 6.8 kgs

D. Adv – UTI’s , risk of TSS (2.4:100,000)D. Adv – UTI’s , risk of TSS (2.4:100,000)

Contraindications – Latex allergy, H/O TSS, poor vaginal tone, Contraindications – Latex allergy, H/O TSS, poor vaginal tone, prolapse (cystocele/ rectocele), HIVprolapse (cystocele/ rectocele), HIV



Cervical CapCervical Cap


Latex/ SiliconeLatex/ Silicone

Spermicidal should be used – fill about 1/3 rd Spermicidal should be used – fill about 1/3 rd

Insertion – Can be inserted up to 6 hrs prior to sexual intercourseInsertion – Can be inserted up to 6 hrs prior to sexual intercourse

Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 48 - 72 hrsnot be left in for > 48 - 72 hrs


Does not protect against all STI’sDoes not protect against all STI’s

Can be washed, disinfected and reused – 1 yrCan be washed, disinfected and reused – 1 yr

Right size is important – size changes post delivery/ termination/ Right size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgsmiscarriage/ pelvic surgery/ wt change > 6.8 kgs

D. Adv – Can be difficult to insert, risk of UTI’s, TSSD. Adv – Can be difficult to insert, risk of UTI’s, TSS

Contraindications – Latex allergy, H/O TSS, cervical diseases Contraindications – Latex allergy, H/O TSS, cervical diseases (malignancy, poor smear result, cervicitis) etc), HIV(malignancy, poor smear result, cervicitis) etc), HIV



Contraceptive SpongeContraceptive Sponge


Polyurethane FoamPolyurethane Foam

Contains a spermicidalContains a spermicidal

Insertion – Prior to sexual intercourse. Moisten with water Insertion – Prior to sexual intercourse. Moisten with water before insertionbefore insertion

Removal – Left for 6 hrs after last intra-vaginal ejaculation. Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 24 hrsShould not be left in for > 24 hrs

Does not protect against all STI’sDoes not protect against all STI’s

DisposableDisposable

D. Adv – Risk of UTI’s, TSSD. Adv – Risk of UTI’s, TSS

Contraindications – Latex allergy, H/O TSS, HIVContraindications – Latex allergy, H/O TSS, HIV


UKMECUKMEC

Faculty of Sexual & Reproductive Health Care

of the Royal College of Obstetricians & Gynecologists

Hormonal ContraceptionHormonal Contraception

(COC’s)(COC’s)

Mechanism of action:Mechanism of action: Inhibits ovulationInhibits ovulation Thickens cervical mucusThickens cervical mucus Renders endometrium unsuitable for implantationRenders endometrium unsuitable for implantation

Pearl Index:Pearl Index: 0.3 – 40.3 – 4 With perfect use it is 0.1 (true pill failure)With perfect use it is 0.1 (true pill failure)

Hormonal ContraceptionHormonal Contraception(COC’s)(COC’s)

11stst prescription of a COC prescription of a COC

UKMEC guidance will help in safe prescription of COCUKMEC guidance will help in safe prescription of COC

AgeAge BreastfeedingBreastfeeding PostpartumPostpartum SmokingSmoking Obesity – BMIObesity – BMI Risk factors for CVD – old age, smoking, obesity, hypertension, diabetesRisk factors for CVD – old age, smoking, obesity, hypertension, diabetes BPBP VTE and risk factors for VTEVTE and risk factors for VTE H/O IHD, Stroke, Hyperlipidemia, PVDH/O IHD, Stroke, Hyperlipidemia, PVD H/O Valvular heart diseaseH/O Valvular heart disease Headaches/ MigrainesHeadaches/ Migraines Breast disease/ Family Hx/1 breast diseaseBreast disease/ Family Hx/1 breast disease Endocrine Diseases – Diabetes (with/ without PVD)Endocrine Diseases – Diabetes (with/ without PVD) Liver/ Gall Bladder Diseases – Gall stones, Cholestasis, Hepatitis, Cirrhosis, Liver tumorsLiver/ Gall Bladder Diseases – Gall stones, Cholestasis, Hepatitis, Cirrhosis, Liver tumors AnaemiaAnaemia Raynauds Disease, SLERaynauds Disease, SLE Drug InteractionsDrug Interactions



Adverse Effects:Adverse Effects: Low estrogen side effectsLow estrogen side effects: BTB (check compliance, drug interactions, D/V or : BTB (check compliance, drug interactions, D/V or

malabsorption, rule out pregnancy, infection, gyn. Problems) – increase estrogen malabsorption, rule out pregnancy, infection, gyn. Problems) – increase estrogen component or try changing the pillcomponent or try changing the pill

High estrogen side effectsHigh estrogen side effects: nausea, dizziness, bloating, vaginal discharge, breast : nausea, dizziness, bloating, vaginal discharge, breast problems – try a lower estrogen pill or changing the pillproblems – try a lower estrogen pill or changing the pill

High progestogen side effectsHigh progestogen side effects: mood swings, reduced sexual drive, vaginal : mood swings, reduced sexual drive, vaginal dryness, breast tenderness, wt gain, acne – try a low progestogen pill or changing dryness, breast tenderness, wt gain, acne – try a low progestogen pill or changing the pillthe pill

Benefits of COC:Benefits of COC: Contraceptive benefitsContraceptive benefits –Good efficacy if good compliance, reversibility –Good efficacy if good compliance, reversibility Non-contraceptive benefitsNon-contraceptive benefits - periods regular, light, painless, protection against - periods regular, light, painless, protection against

ovarian cysts, ovarian tumors, benign breast diseases, endometrial ca, colorectal ovarian cysts, ovarian tumors, benign breast diseases, endometrial ca, colorectal ca, few extra uterine pregnanciesca, few extra uterine pregnancies



When to start the COC?When to start the COC? Ideally COC should be started on 1Ideally COC should be started on 1stst day of a normal 5 day period but can be day of a normal 5 day period but can be

started up to and including 5 days of the cycle without the need for additional started up to and including 5 days of the cycle without the need for additional contraceptive protectioncontraceptive protection

COC can be started at any other time in the cycle if it is reasonably certain the COC can be started at any other time in the cycle if it is reasonably certain the woman is not pregnant but additional contraceptive precaution is required for 1woman is not pregnant but additional contraceptive precaution is required for 1stst 7 7 daysdays

Which pill is suitable for women being given a 1Which pill is suitable for women being given a 1stst prescription of COC? prescription of COC? Monophasic (containing 30 mcg is the 1Monophasic (containing 30 mcg is the 1stst option) option) Biphasic (Logynon, Binovum)Biphasic (Logynon, Binovum) Triphasic (Trinovum)Triphasic (Trinovum)

““very few direct comparative data available to identify the best, 1very few direct comparative data available to identify the best, 1stst line COC’s and no line COC’s and no

evidence to support the use of biphasic or triphasic pills”evidence to support the use of biphasic or triphasic pills”



YasminYasmin

FemodetteFemodette FemodeneFemodene CilestCilest

Loestrin 20Loestrin 20 Microgynon 30Microgynon 30 OvysmennOvysmenn


11stst prescription of a COC prescription of a COCMissed Pill Advice


Follow up prescription of a COCFollow up prescription of a COC

Pill check - initially 3 mthsPill check - initially 3 mths - then 6 months x 2- then 6 months x 2 - then annually if no risk factors- then annually if no risk factors

Check well being/ adverse effects Check well being/ adverse effects New risk factors/ contraindicationsNew risk factors/ contraindications Menstrual historyMenstrual history BP, Smoking, BMI, concordanceBP, Smoking, BMI, concordance Cervical smearCervical smear Check educationCheck education

Missed pill adviceMissed pill advice Interaction with drugsInteraction with drugs Intercurrent illness – D/VIntercurrent illness – D/V Risk of STI’sRisk of STI’s

Future plan of wanting to concieveFuture plan of wanting to concieve Prenatal advice regarding diet, exercise, smoking, OTC F acid, RubellaPrenatal advice regarding diet, exercise, smoking, OTC F acid, Rubella

Unusual/ prolonged headaches Aura/ visual problems Speech disturbance Weakness/ paraesthesia in limbs Painful calf swelling Focal epilepsy Severe abdominal pain/ jaundice Fracture/ surgery/ immobilisation High BP Severe skin rash New risk factor for breast ca

STOP


Estradiol Valerate + DienogestEstradiol Valerate + Dienogest

4 sequential phases4 sequential phases

Pearl Index: 0.4 – 0.5Pearl Index: 0.4 – 0.5

Missed pill: may need 9 days extra Missed pill: may need 9 days extra precautions +/- ECprecautions +/- EC

Hormonal ContraceptionHormonal Contraception(Transdermal - EVRA)(Transdermal - EVRA)

Failure rate <1% if used correctlyFailure rate <1% if used correctly

Each patch lasts a weekEach patch lasts a week

Change a patch every week for 3 Change a patch every week for 3 weeks followed by a weeks breakweeks followed by a weeks break

If the patch comes off, do not If the patch comes off, do not reattach it – adv to use a new onereattach it – adv to use a new one

Hormonal ContraceptionHormonal Contraception(POP’s)(POP’s)

Inhibits cervical mucus (Cerazette also inhibits ovulation)Inhibits cervical mucus (Cerazette also inhibits ovulation)

Pearl index: Micronor :- 0.3 – 4; Cerazette:- 0.17Pearl index: Micronor :- 0.3 – 4; Cerazette:- 0.17

Start on day 1 of period , no PFIStart on day 1 of period , no PFI

Window period: Minipill :- 3 hrs; Cerazette:- 12 hrs. Window period: Minipill :- 3 hrs; Cerazette:- 12 hrs.

If missed/ delayed pill then take other pills as usual + extra precautions for 48 hrs +/- ECIf missed/ delayed pill then take other pills as usual + extra precautions for 48 hrs +/- EC

Can be started 3 weeks postpartum Can be started 3 weeks postpartum

Not affected by broad spectrum antibiotics but by enzyme inducersNot affected by broad spectrum antibiotics but by enzyme inducers

Can be taken with HRT in perimenopausal period until menopauseCan be taken with HRT in perimenopausal period until menopause

Refer to UKMEC for contraindicationsRefer to UKMEC for contraindications

LARC’SLARC’S Women requesting any contraception should be given information about

and offered choice of all methods including LARC NICE LARC GUIDELINES 30, DOH: 0CT

2005

QOF Sexual Health - contraception (8 new points plus 2 points from current CON indicators, CON 1 and 2 which will be removed) Three new indicators, as recommended in the 2008 expert panel report:

SH 1: The practice can produce a register of women who have been prescribed any method of contraception at least once in the last year. (4 points)

SH 3: The percentage of women prescribed an oral or patch contraceptive method in the last year who have received information from the practice about long acting reversible methods of contraception in the previous 15 months. (3 points; thresholds 40 – 90%)

SH 4: The percentage of women prescribed emergency hormonal contraception at least once in the year by the practice who have received information from the practice about long acting reversible methods of contraception at the time of, or within one month of, the prescription. (3 points; thresholds 40 – 90%)

LARC’SLARC’S

All currently available LARC methods (IUD, IUS, Implanon, DEPO) are most cost effective than COC even at 1 yr of age

IUD, IUS and Implanon are more cost effective than injectable contraception

Increased uptake of LARC methods will reduce the number of unintended pregnancies

NICE recommendations for LARCS: Provision of information and informed choice to patients Training of health care professionals

NICE LARC GUIDELINES 30, DOH: 0CT 2005

LARC’SLARC’S(IUD’S)(IUD’S)

Inhibits fertilisation and implantation

License: 5 – 10 years (If > 40, can retain the device until no longer needed, even beyond the duration of UK marketing association)

Pearl Index: 0.02 – 2

STI screen prior to insertion

Adverse effects: heavy, painful bleeding likely

Risks: < 1:1000 chance of uterine perforation < 1:100 chance of PID following IUD insertion but risk increases if already has STI 1:1000 in 5 yrs chance of an ectopic pregnancy but 1:20 chance of ectopic if gets

pregnant while on the coil


Contraindications: Refer to UKMEC

Insertion: Anytime during periods. Anytime when not pregnant + 7 days extra precautions Immediately post 1st/ 2nd trimester abortion 4 weeks post partum irrespective of mode of delivery

Follow up – After 1st period/ 3 – 6 weeks post insertion Check for threads, expulsion, infection, perforation.(USS if unable to locate the IUD)

Heave periods while on IUD: NSAIDS/ Tx acid Short course of low estrogen COC Change to IUS

Cervical smear may show Actinomycoses

If IUD and pregnant, remove coil before 12 weeks


Flexi-T 300 I.U.D. T-safe CU380A GyneFix IUD

Multi-Safe 375 IUD Multisafe 375 Short Stem IUD Nova-T 380 IUD

LARC’SLARC’S(IUS)(IUS)

Inhibits fertilisation and implantation, thickens cervical mucus

License: 5 yrs as a contraceptive (If > 40, can retain the device until no longer needed, even beyond the duration of UK marketing association)

Pearl Index: < 0.5

STI screen prior to insertion

Adverse effects: Irregular bleeding common in 1st 6 mths of insertion – oligomenorrhoea/ amenorrhoea

likely by the end of 1 yr of use No evidence of wt gain. Slight effect on mood, acne a possibility

Risks: < 1:1000 chance of uterine perforation < 1:100 chance of PID following IUD insertion but risk increases if already has STI 1:1000 in 5 yrs chance of an ectopic pregnancy but 1:20 chance of ectopic if gets

pregnant while on IUS < 1:20 chance of expulsion in 5 yrs

LARC’SLARC’S(IUS)(IUS)

Contraindications: Refer to UKMEC

Insertion: Anytime during periods. Anytime when not pregnant + 7 days

extra precautions Immediately post 1st/ 2nd trimester abortion 4 weeks post partum irrespective of mode of delivery

Follow up – After 1st period/ 3 – 6 weeks post insertion Check for threads, expulsion, infection, perforation(USS if unable to locate the IUS)

Cervical smear may show Actinomycoses

If IUS and pregnant, remove before 12 weeks

LARC’SLARC’S(POIC’s – Depo-Provera)(POIC’s – Depo-Provera)

Inhibits ovulationInhibits ovulation

Pearl Index: 0 – 1Pearl Index: 0 – 1

Repeated every 12 weeksRepeated every 12 weeks

Could be a delay up to 1 yr in return of fertility after stopping Could be a delay up to 1 yr in return of fertility after stopping

Adverse effects:Adverse effects: Amenorrhoea likely but irregular/ heavy bleeding can happen (Rx with Tx acid/ add Amenorrhoea likely but irregular/ heavy bleeding can happen (Rx with Tx acid/ add

oestrogens)oestrogens) Wt gain: 2-3 kg in a yearWt gain: 2-3 kg in a year Reduced BMD but no increase in risk of fracturesReduced BMD but no increase in risk of fractures Not associated with acne/ depression/ headachesNot associated with acne/ depression/ headaches No evidence of congenital malformation if pregnant while on DEPONo evidence of congenital malformation if pregnant while on DEPO

Contraindications – Follow UKMECContraindications – Follow UKMEC

License: 2-3 yearsLicense: 2-3 years

Injection: Same as IUD/IUS but can be given immediately post partumInjection: Same as IUD/IUS but can be given immediately post partum

LARC’SLARC’S(POIC’s – Depo-Provera)(POIC’s – Depo-Provera)

Timing of Timing of DEPODEPO

Has Has unprotected unprotected

sex sex occurred?occurred?

Can DEPO Can DEPO be given?be given?

Is EC Is EC indicated?indicated?

Are condoms or Are condoms or abstinence abstinence advised?advised?

Should Should pregnancy pregnancy

test be test be performed?performed?

< 14 weeks < 14 weeks since the since the previous previous injectioninjection

N/A as N/A as injection not injection not

latelateYesYes NoNo NoNo NoNo

> 14 weeks > 14 weeks since the since the previous previous injectioninjection

NoNo YesYes NoNo

Yes, for next 7 daysYes, for next 7 days

NoNo

Yes, in the last Yes, in the last 3 days3 days YesYes YesYes

Yes, for next 7 daysYes, for next 7 days Yes, 3 Yes, 3 weeks laterweeks later

Yes, 5 days Yes, 5 days backback YesYes

Yes, offer Yes, offer Cu coil as Cu coil as

ECECNoNo

Yes, 3 Yes, 3 weeks laterweeks later

Yes, > 5 days Yes, > 5 days backback NoNo NoNo

Yes, for 3 weeks Yes, for 3 weeks until pregnancy test until pregnancy test confirmed –ve and confirmed –ve and

for 7 days after for 7 days after giving DEPOgiving DEPO

Yes, initially Yes, initially and 3 weeks and 3 weeks

laterlater

LARC’SLARC’S(POSDI’s - Implanon)(POSDI’s - Implanon)

Inhibits ovulationInhibits ovulation

Pearl Index: 0 – 0.1Pearl Index: 0 – 0.1

License: 3 yearsLicense: 3 years

Adverse effects: Adverse effects: Irregular/ frequent/ prolonged bleeding 1Irregular/ frequent/ prolonged bleeding 1stst 6 months in about 50 % (33% stop 6 months in about 50 % (33% stop

using it by 1 year due to this) 20% rendered amenorrhoeic by the end of 1 yearusing it by 1 year due to this) 20% rendered amenorrhoeic by the end of 1 year

Reassurance, Tx acid, low dose COC (Mercilon) in a tricycle fashionReassurance, Tx acid, low dose COC (Mercilon) in a tricycle fashion Acne possibleAcne possible Not associated with weight gain, mood swings, reduced libido, headachesNot associated with weight gain, mood swings, reduced libido, headaches

Contraindications – refer to UKMECContraindications – refer to UKMEC

LARC’SLARC’S(POSDI’s - Implanon)(POSDI’s - Implanon)

Insertion of ImplanonInsertion of Implanon

Timing – same as DEPOTiming – same as DEPO

Site – Non-dominant arm, 10 cm above Site – Non-dominant arm, 10 cm above the medial epicondyle as opposed to the medial epicondyle as opposed to bicipital grove bicipital grove

Impalpable Implanon – deep insertion/ Impalpable Implanon – deep insertion/ failed insertion/ migration. Locate with failed insertion/ migration. Locate with an USS. If deep insertion, referan USS. If deep insertion, refer

Removal – straight switch to another Removal – straight switch to another Implanon/ ContraceptionImplanon/ Contraception

Emergency ContraceptionEmergency Contraception

Hormonal EC – Levonorgestrel (Levonelle)Hormonal EC – Levonorgestrel (Levonelle)

Non-hormonal EC – Cu IUDNon-hormonal EC – Cu IUD

EC in futureEC in future

Emergency ContraceptionEmergency Contraception(Hormonal EC – Levonelle)(Hormonal EC – Levonelle)

Inhibits ovulation – hence works best when given in pre-ovulatory stage. If Inhibits ovulation – hence works best when given in pre-ovulatory stage. If taken before ovulation, it can inhibit ovulation for 5-7 daystaken before ovulation, it can inhibit ovulation for 5-7 days

License – 1.5 mg single dose of Levonelle used within 72 hrs post UPSI. License – 1.5 mg single dose of Levonelle used within 72 hrs post UPSI. Can be tried up to 5 days post UPSI if in pre-ovulatory stage and IUD Can be tried up to 5 days post UPSI if in pre-ovulatory stage and IUD declined (unlicensed)declined (unlicensed)

Contraindications: UKMEC says no absolute contraindicationsContraindications: UKMEC says no absolute contraindications

Drug Interactions – If on liver enzyme inducers, Cu IUD preferred. If Drug Interactions – If on liver enzyme inducers, Cu IUD preferred. If declined then a single dose of 3 mg is given (unlicensed)declined then a single dose of 3 mg is given (unlicensed)

Emergency ContraceptionEmergency Contraception(Hormonal EC – Levonelle)(Hormonal EC – Levonelle)

History:History: Assess for competence if young and document as “Fraser ruling competent”Assess for competence if young and document as “Fraser ruling competent” Full sexual Hx including last/ previous UPSI’sFull sexual Hx including last/ previous UPSI’s LMP (if pre-ovulatory)LMP (if pre-ovulatory) Assess risk of STI – offer everyone a STI screenAssess risk of STI – offer everyone a STI screen Advice about LARCAdvice about LARC Start a regular contraception when issuing EC if possibleStart a regular contraception when issuing EC if possible Counsel about LevonelleCounsel about Levonelle

Adverse effects:Adverse effects: Nausea, vomiting (if vomiting within 2 hrs of taking it, repeat dose)Nausea, vomiting (if vomiting within 2 hrs of taking it, repeat dose) Next period earlier/ late, lighter. If delayed/ lighter than expected – preg. testNext period earlier/ late, lighter. If delayed/ lighter than expected – preg. test

Consider advance provision of Levonelle in some casesConsider advance provision of Levonelle in some cases

Emergency ContraceptionEmergency Contraception(Non-hormonal EC – Cu IUD “Multiload 375”)(Non-hormonal EC – Cu IUD “Multiload 375”)

Inhibits fertilisation; Inhibits implantationInhibits fertilisation; Inhibits implantation

License – Up to 5 days post UPSI or before License – Up to 5 days post UPSI or before day 19 of a regular cycleday 19 of a regular cycle

Always offer a emergency IUD even if Always offer a emergency IUD even if presents within 72 hrs post UPSIpresents within 72 hrs post UPSI

Can be removed at anytime during next Can be removed at anytime during next period if not had UPSI since next period period if not had UPSI since next period and alternative cover started at the right and alternative cover started at the right timetime

History taking vital as for levonelleHistory taking vital as for levonelle

If at risk of STI (<25 yrs and > 1 sexual If at risk of STI (<25 yrs and > 1 sexual partner in the last 1 yr) insert EC-IUD but partner in the last 1 yr) insert EC-IUD but give prophylaxisgive prophylaxis

Emergency ContraceptionEmergency Contraception(Future EC)(Future EC)

EllaoneEllaone

Selective progesterone receptor Selective progesterone receptor modulatormodulator

Used up to 120 hours post UPSIUsed up to 120 hours post UPSI

Dose – one dose of 30 mgDose – one dose of 30 mg

Extra – precautions until next periodExtra – precautions until next period

Cannot give > 1/ monthCannot give > 1/ month

Can cause headaches, nausea, Can cause headaches, nausea, abdominal painabdominal pain

Emergency ContraceptionEmergency Contraception(Future EC)(Future EC)

MifepristoneMifepristone

Progesterone antagonistProgesterone antagonist

Effective EC when taken in a single dose up to 120 hours post UPSIEffective EC when taken in a single dose up to 120 hours post UPSI

Single dose – 25 – 50 mgSingle dose – 25 – 50 mg

Not licensed for EC in the UKNot licensed for EC in the UK

Case StudiesCase Studies

Case - 1Case - 1

Nicola Peel is a 35 yr old P4+2 Nicola Peel is a 35 yr old P4+2 recently has a TOP. She came to recently has a TOP. She came to discuss about contraception. Her discuss about contraception. Her periods are heavy but regular. Her periods are heavy but regular. Her BMI is 35 and she takes BMI is 35 and she takes Metformin for diabetes. She is a Metformin for diabetes. She is a non smoker and her BP is normalnon smoker and her BP is normal

What are the issues here?What are the issues here? What contraceptives would you What contraceptives would you

discuss with her?discuss with her?

Case - 2Case - 2 Janet, 36 yr old requesting a Janet, 36 yr old requesting a

COC. She smokes 20 COC. She smokes 20 cigarettes/ day, BMI – 35.cigarettes/ day, BMI – 35.

What are the issues in her case?What are the issues in her case? What contraceptive methods What contraceptive methods

would you discuss with her?would you discuss with her?

She promised to stop smoking She promised to stop smoking and returned 6 months later and returned 6 months later requesting a COC. requesting a COC.

Will you issue it? What will you Will you issue it? What will you discuss with her?discuss with her?

Case - 3Case - 3

You see Linda, mother of 3, who You see Linda, mother of 3, who is requesting a COC. Her BP is is requesting a COC. Her BP is 140/ 90. She is not on any anti-140/ 90. She is not on any anti-hypertensive. She is 35 yr old. Her hypertensive. She is 35 yr old. Her mother had a thrombosis in the mother had a thrombosis in the past.past.

What are the things you will What are the things you will discuss with her?discuss with her?

What contraceptive will you offer What contraceptive will you offer her?her?

Case - 4Case - 4 Liz is 19 yrs old. She attends Liz is 19 yrs old. She attends

surgery to discuss contraception. surgery to discuss contraception. She is an epileptic and currently She is an epileptic and currently on Valproate. A letter from on Valproate. A letter from hospital advices you to change it hospital advices you to change it to Lamotrigine as her epilepsy to Lamotrigine as her epilepsy wasn’t under control. She wishes wasn’t under control. She wishes to start Microgynon. She also to start Microgynon. She also suffers from depression.suffers from depression.

Would you offer her CHC?Would you offer her CHC? What are your thoughts?What are your thoughts? Which contraception would be Which contraception would be

safe for her? safe for her?

Case - 5Case - 5 Maria, 21, a Spanish student has been Maria, 21, a Spanish student has been

using Evra patches for 2 years. She using Evra patches for 2 years. She came to see you for repeat came to see you for repeat prescription. She informs you of she prescription. She informs you of she suffers from severe headaches at suffers from severe headaches at times, mainly during her periods and times, mainly during her periods and sees flashing lights in her Lt eye sees flashing lights in her Lt eye associated with numbness in her Lt associated with numbness in her Lt arm before headaches start. She takes arm before headaches start. She takes Atenolol and 5HT agonist for her Atenolol and 5HT agonist for her headaches. She does not smoke. Her headaches. She does not smoke. Her BMI and BP are normalBMI and BP are normal

Will you continue issuing her the Will you continue issuing her the patches?patches?

What are the alternatives?What are the alternatives?

Case - 6Case - 6 Tiffany is 25 yrs old. She has 2 Tiffany is 25 yrs old. She has 2

children. She is currently in a children. She is currently in a new relationship for the last 2 new relationship for the last 2 months. She has multiple months. She has multiple sexual partners in the last 1 sexual partners in the last 1 year. She is keen on a copper year. She is keen on a copper coil.coil.

What would you discuss with What would you discuss with her?her?

What other LARC methods will What other LARC methods will be safe and suitable for her?be safe and suitable for her?

Case - 7Case - 7

Nicola, 25, mother of 2, recently Nicola, 25, mother of 2, recently had a normal delivery 4 weeks had a normal delivery 4 weeks ago, requests a COC. Her BMI is ago, requests a COC. Her BMI is normal, she doesn’t smoke. She is normal, she doesn’t smoke. She is breast feeding.breast feeding.

Is this the right time to start COC Is this the right time to start COC for her?for her?

What contraceptive options are What contraceptive options are you left with?you left with?

Would you consider an IUD/IUS?Would you consider an IUD/IUS?

Case - 8Case - 8

A 16 yr old girl on long term Tetracycline for her acne attends A 16 yr old girl on long term Tetracycline for her acne attends having had a UPSI last night. She is on day 12 of her cycle.having had a UPSI last night. She is on day 12 of her cycle.

What are your concerns? What are your concerns?

What would you offer her?What would you offer her?

What advice will you give her?What advice will you give her?

Case - 9Case - 9

A 25 yr old attends following a burst condom 48 hrs ago. She is on A 25 yr old attends following a burst condom 48 hrs ago. She is on day 8 of her 28 day cycle. She is taking St John’s Wort.day 8 of her 28 day cycle. She is taking St John’s Wort.




Case - 10Case - 10

A 30 yr old women attends the clinic having had repeated UPSI’s A 30 yr old women attends the clinic having had repeated UPSI’s since her normal period. The 1since her normal period. The 1stst UPSI was on day 6 of her cycle. UPSI was on day 6 of her cycle. She has a 28 day cycle. She is now day 16.She has a 28 day cycle. She is now day 16.




Case - 11Case - 11

A 20 yr old attends the clinic having had 3 UPSI’s – most recent was A 20 yr old attends the clinic having had 3 UPSI’s – most recent was last night and the 1last night and the 1stst episode was 7 days back. She is now on day episode was 7 days back. She is now on day 25 of her cycle. Her usual cycle is 28-30 days.25 of her cycle. Her usual cycle is 28-30 days.




Case - 12Case - 12

A 25 yr old woman telephones the clinic for advice. She uses a 30 A 25 yr old woman telephones the clinic for advice. She uses a 30 mcg COC. She is usually a regular pill taker but has missed 3 pills. mcg COC. She is usually a regular pill taker but has missed 3 pills. These were the 2These were the 2ndnd week of her pill packet (pills 9,11 and 14). She week of her pill packet (pills 9,11 and 14). She had sex last night immediately following the 3had sex last night immediately following the 3rdrd missed pill. What do missed pill. What do you advice?you advice?

She should attend the clinic for an EC?She should attend the clinic for an EC? Reassure her that EC is not needed and ask her to carry on taking the Reassure her that EC is not needed and ask her to carry on taking the

remaining pills?remaining pills? She should continue with her COC but use condoms until 7 concecutive She should continue with her COC but use condoms until 7 concecutive

pills?pills? She should run 2 packets of pills together avoiding her next pill free She should run 2 packets of pills together avoiding her next pill free

week?week?

Case - 13Case - 13

Mrs G is using a POP as contraceptive. She is now aged 49 and Mrs G is using a POP as contraceptive. She is now aged 49 and wonders how long she should continue with her contraception. She wonders how long she should continue with her contraception. She hasn’t had a period for 1 yr. She is getting vasomotor menopausal hasn’t had a period for 1 yr. She is getting vasomotor menopausal symptoms. She is sexually active.symptoms. She is sexually active.

How long should she continue with her contraception for?How long should she continue with her contraception for? Will you change her contraception?Will you change her contraception? How can you be sure she is post-menopausal?How can you be sure she is post-menopausal? How will you control her vaso-motor symptoms?How will you control her vaso-motor symptoms?

Contraception over 40Contraception over 40

Contraception over 40Contraception over 40

Average age of menopause is 50.7 yrs

Diagnosis of menopause –

1 yr amenorrhoea if > 50 yrs or 2 yrs if < 50 yrs

+

Clinical symptoms

+

Blood tests – Raised FSH (> 30 IU/L) and LH on 2 occasions done 1-2 mths apart

No single indicator is considered reliable

Useful WebsitesUseful Websites

www.ffprhc.org.uk

BNF onlineBNF online

www.mims.co.ukwww.mims.co.uk

ReferencesReferences

Faculty of Family Planning and Faculty of Family Planning and Reproductive Health Care Reproductive Health Care Clinical GuidanceClinical Guidance

Guillebaud, J. Contraception Guillebaud, J. Contraception Today. 5Today. 5thth ed. Martin Dunitz, ed. Martin Dunitz, 20052005

Life, why contraception is viable

Please, put her out of my misery..

contracepton for gps dr mazhar khan 7 april 2010

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