‘FINGERS CROSSED’ is not a method of Contraception!

1. ‘FINGERS CROSSED’ is not a method of Contraception! Kathy Carpenter Advanced Nurse Practitioner

2. Why do we need contraception?

3. Improving ‘planning of families’ • Offering choices • Right product, right time • Managing expectations • Counselling re side effects • Managing adverse effects

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5. FACTS • At least 30% of pregnancies in the UK are unplanned. • One in five pregnancies end in abortion every year • 176 480 abortions were provided by NHS and NHS agencies in England in 2012 • 62% of women attending for an abortion were using contraception when they became pregnant • 37% of women attending for abortion had one or more previous abortions • Cost of unintended pregnancies to the NHS in England is estimated to be £817 million a year.

6. Historic Contraceptive choices 3000BC crocodile dung pessaries 2000BC women drank mercury Genesis – withdrawal method 1550BC Ebers Papyrus mixture dates, acacia bark, honey on wool pessary 200AD Soranus suggested jumping backwards 7 times after SI Native Americans drank dried beaver testicles European women in middle ages wore dried weasel testicles 1640AD male barriers from fish bladders Victorians block wood pessary

7. Influences Beliefs about bodily functions Cultural/religious beliefs Age Lifestyle Relationships Knowledge Medical conditions Medication Future fertility requirements Lactation

8. Counselling • What methods do they know about? • What methods have they not heard about? • Have they used any contraception before? • What methods have they used before? • What methods would they not consider?

9. Information we need prior to advising a method • Current or previous method • Last menstrual period • Previous pregnancies • Medical history • Family history • Smoker

10. Examinations prior to prescribing a method • Age: Fraser competence • Blood Pressure • Weight and BMI • STI Screening to be offered

11. Classification of methods

12. Methods of Contraception • Hormonal methods: combined pill, progesterone only pill, evra patch, nuva ring, IUS, depo provera injection, nexplanon implant, emergency contraception (morning after pill) • Non-hormonal methods: IUD, male and female condoms, spermicides, diaphragm, male and female sterilisation

15. What are the most effective methods of contraception?

16. User failure rates No method Spermicides Diaphragm Female condom Male Condom Pop Female sterilisation IUD Cu T 380A Depo provera Coc Mirena IUS Male sterilisation Nexplanon 85% 6-26% 6-20% 5-21% 3-14% 0.5-4% 0.5% 0.4-0.8% 0.3% 0.1-3% 0.1-0.2% 0.05% 0.05%

17. FPA Leaflet Contraception is divided into two types: • Methods with no user failure – these do not depend on the patient remembering to take or use them. ‘Fit and Forget’ • Methods with user failure – these are methods patient’s have to use and think about regularly or each time they have sex. They must be used according to instructions. • http://www.fpa.org.uk/contraception-help/your-guide-contraception#RmgAbLwjKfgARr0F.99

18. Fit and Forget Contraception

19. ‘Doc I want the pill’

20. How Combined Hormonal Contraception (CHC) works • Prevents ovulation • Thickens the mucus in the neck of the womb, harder for sperm to get into womb • Thins the lining of the womb, less chance for implantation

21. Contra-indications to CHC • Pregnant • Smoke and over 35 years of age • Overweight • Take certain medicines • Migraines with aura • Had a thrombosis or FH of this • Breast cancer or FH of this • Disease of gall bladder or liver • Diabetes with complications

22. Combined contraceptive pill • Microgynon 30/ED • Mercilon • Femodette • Loestrin 20/30 • Marvelon • Yasmin • Femodene • Ovranette • Cilest • Ovysmen • Logynon/ED • Qlaira

24. Evra Patch Transdermal system, apply once weekly for 3 weeks

25. Progesterone only methods Progesterone only pill Depo-Provera / Sayana Press Nexplanon Levonelle IUS

26. How progesterone only contraception works • Prevents ovulation • Thickens the mucus in the neck of the womb, harder for sperm to get into womb • Thins the lining of the womb, less chance for implantation

27. Contra-indications to POC • Pregnancy • Some forms of heart disease • Liver disease • Cysts of the ovary • Unexplained vaginal bleeding

28. Progesterone only Pill • Cerazette • Femulen • Micronor • Norgeston • Noriday • Desogestrel

29. Long Acting Reversible Contraceptive methods All LARC methods suitable for: • Nullips • Breastfeeding women • Post TOP • BMI>30 • Women with HIV • Women with diabetes • Women with migraine • Women with c/i to oestrogen

30. IUS Failure rate less than 1% at 5yrs Cost £87.32 Side effects Irregular bleeding Hormonal side effects Uterine perforation < 1 in 1000 PID with insertion < 1 in 100 Expulsion < 1 in 20 Ectopic pregnancy < 1 in 1000

31. IUDs Failure rate < 2% at 5 years No follow-up needed Risks Increased menstrual loss Perforation <1 in 1000 PID with insertion < 1 in 100 Expulsion < 1 in 20 Ectopic pregnancy < 1 in 1000 COST <£11 for 10yrs

32. Sub-dermal implant Failure rate <1/1000 at 3 years Regular follow-up not required Cost £85 Side effects 20% amenorrhoea 50% bleeding irregularity Hormonal side effects Not to be used with epileptic drugs Position of implant important for removal

33. Injectables Failure rate 4/1000 over 2 years Delay up to one year – return to fertility Costs £21.71/annum

34. Emergency Contraception

35. Don’t forget Cu IUDs > 99% effective 120 hours after UPSI STI risk assessment +/- prophylactic antibiotics Give oral EC if delay in IUD insertion Can keep IUD - LARC

36. Levonelle Inhibits ovulation Effective up to 96 hrs Repeat dose if vomiting within 2 hours Multiple doses possible

37. ella One • Licensed for use up to 120 hours after unprotected sex • No reduction in efficacy over the 120 hours • Better choice for women with BMI over 30 • £16.95

39. Female sterilisation Regret 20% women <30 6% women >30 Failure rate 1 in 200 1 in 130 post- LSCS Menstrual problems

41. Age and contraception • Although pregnancy is less likely around the menopause, over the age of 40 years it is still important to use contraception. Most need to be used until a woman has gone through the menopause or are aged 55 years. • The implant can be continued until the age of 55 years. • The contraceptive injection is usually stopped at 50 years and another method of contraception should then be used. • The POP can be continued until the age of 55 years, after which time they will no longer need to use contraception.

42. The patch can safely be used by women over the age of 40 with no other medical problems. However, it should not be used if they are aged over 35 years and a smoker, or are aged over 40 years and have cardiovascular disease, or a history of a stroke or migraine. The patch should be stopped and another form of contraception used when they reach the age of 50 years. • The COCP should be stopped and another form of contraception used when they reach the age of 50 years.

43. If an IUCD is inserted aged 40 years or over, then this can remain in place until the woman has gone through the menopause and no longer requires contraception. That is, for one year after the periods stop if they are aged over 50 years, or two years after the periods stop if they are aged under 50 years • The IUS can be continued until the age of 55 years, after which time they will no longer need to use contraception.

44. Any Questions?

45. Sexual Health Screening • What are sexually transmitted infections? • Why do we offer screening? • What tests do we offer? • How do we treat different infections?

46. Sexually Transmitted Infections (STI’s) • STI’s are very infectious and very common. They are spread through unprotected sex or genital contact with someone who has an infection. • Chlamydia • HIV • Gonorrhoea • Syphilis • Genital warts • Genital Herpes • Trichomonas Vaginalis • Pubic Lice • Scabies

47. Chlamydia • Chlamydia is one of the most common STIs in the UK and is easily passed on during sex. Most people don’t experience any symptoms so are unaware they are infected. • In women, chlamydia can cause pain or a burning sensation when urinating, a vaginal discharge, pain in the lower abdomen during or after sex, and bleeding during or after sex, or between periods. It can also cause heavy periods. • In men, chlamydia can cause pain or a burning sensation when urinating, a white, cloudy or watery discharge from the tip of the penis, and pain or tenderness in the testicles. • It's also possible to have a chlamydia infection in your rectum (bottom), throat or eyes. • Diagnosing chlamydia is easily done with a urine test or by taking a swab of the affected area. The infection is easily treated with antibiotics, but can lead to serious long-term health problems if left untreated, including infertility. 

48. HIV Human Immunodeficiency Virus • HIV is most commonly passed on through unprotected sex. It can also be transmitted by coming into contact with infected blood - for example, sharing needles to inject steroids or drugs. • The HIV virus attacks and weakens the immune system, making it less able to fight infections and disease. There's no cure for HIV but there are treatments that allow most people to live a long and otherwise healthy life. • AIDs is the final stage of an HIV infection, when your body can no longer fight life-threatening infections. • Most people with HIV will look and feel healthy and have no symptoms. When you first develop HIV you may experience a flu-like illness with a fever, sore throat or rash. This is called a seroconversion illness. • A simple blood test is usually used to test for an HIV infection. Some clinics may also offer a rapid test using a finger prick blood test or saliva sample.

49. Gonorrhoea • Gonorrhoea is a bacterial STI easily passed on during sex. • About 50% of women and 10% of men don’t experience any symptoms and are unaware they’re infected. • In women, gonorrhoea can cause pain or a burning sensation when urinating, a vaginal discharge (often watery, yellow or green), pain in the lower abdomen during or after sex, and bleeding during or after sex or between periods, sometimes causing heavy periods. • In men, gonorrhoea can cause pain or a burning sensation when urinating, a white, yellow or green discharge from the tip of the penis, and pain or tenderness in the testicles. • It's also possible to have a gonorrhoea infection in your rectum, throat or eyes. • Gonorrhoea can be easily diagnosed using a urine test, or by taking a swab of the affected area. The infection is easily treated with antibiotics, but can lead to serious long-term health problems if left untreated, including infertility.

50. Trichomonas Vaginalis • Trichomonas vaginalis (TV) is an STI caused by a tiny parasite. It can be easily passed on through sex and most people are unaware they are infected. • In women, TV can cause a frothy yellow or watery vaginal discharge which has an unpleasant smell, soreness or itching around the vagina, and pain when passing urine. • In men, TV rarely causes symptoms. You may experience pain or burning after passing urine, a whitish discharge, or an inflamed foreskin. • TV can sometimes be difficult to diagnose and your GP may suggest you go to a specialist clinic for a urine or swab test. Once diagnosed, TV can usually be treated with antibiotics.