The Combined Pill – the initial consultation.

1. The Combined Pill – the initial consultation. Dr Lisa Pickles. GP, Brig Royd Surgery. September 2013.

2. Overview. The aim of the presentation is to present a checklist of areas to be covered to include: • Assessing suitability • Examine • Teachand inform the patient • Prescribe • Follow up.

3. Suitability Indications • Contraception • Menses • Acne/ PCOS

4. Suitability Consider other methods/compliance • Eg. Long Acting Reversible Contraception (LARC) • Other methods already used. • Take sexual history.

5. Suitability. Contraindications. • Ask re migraine. • Ask re drugs including enzyme inducers egcarbamazepine, OTC and herbal egst John’s Wort. • Ask re CVS risk factors (smoking, obesity, hypertension, DVT, thrombophilia, hyperlipidaemia). Beware multiple risk factors. • Ask re liver disease. • Check past history egporphyria. • FH – DVT, stroke, CHD, carriers of gene mutations known to increase ca breast risk eg BRAC 1. • Check not pregnant.

6. Suitability. UKMEC (UK medical eligibility criteria). See Faculty of Reproductive and Sexual Health Care for tables. www.fsrh.org.uk November 2009. Page 4. • UKMEC 1 – unrestricted use eg non migrainous headache. • UKMEC 2 - benefits generally outweigh risks eg migraine without aura. • UKMEC 3 - risks generally outweigh benefits eg past migraine with aura. • UKMEC 4 - unacceptable health risk and should not be used eg migraine with aura.

7. UKMEC Quiz.

8. Examine. • BP • BMI

9. Teach. • How to take ( 21 day cycle, PFI 7 days). Note use of mobile phone reminders and ?avoid 1st thing in morning. • Pill is ‘missed’ if > 24 hours late • GI upset • Never increase PFI. • Menses in PFI. • Works during PFI.

10. Teach – continued. • What are the rules regarding missed pills ?

11. Teach – continued. Missed pills. Points for us to understand: • Ovaries are fully suppressed after 7 pills have been taken consecutively. • After 7 day PFI, ovarian activity may be restarting in a few women ie. the achilles heel of pill taking. Need care not to extend this. • If pills are missed D14-21, ovaries are fully suppressed, so no need for emergency contraception if UPSI has occurred, however, continue onto next pack omitting the break, to avoid extending the PFI. • If pills are missed D1-7, this may extend the PFI and emergency contraception may be advised if UPSI has occurred (even if this has been prior to the missed pills in the PFI) • However, research by WHO has demonstrated that women regularly miss pills during routine pill taking, with less detriment to efficacy than previously thought.

12. Teach – continued. Current MHRA (Medicines and Healthcare products Regulatory Agency) advice regarding missed pills. 2011. • A missed pill is one taken > 24 hours late. • One missed pill anywhere in the pack will not affect contraceptive cover. Take the last missed pill late, but no need for extra protection. • If 2 or more pills have been missed anywhere in the pack (ie. > 48 hours late), take the last missed pill, c/t pill taking, extra protection for 7 days and omit the break if there are < 7 pills left in the pack.

13. Teach – continued. MHRA and FSRH advice - continued. • Emergency contraception. Women who have UPSI during the hormone-free interval or in the first week of pill taking AND have missed 2 or more pills in that first week should seek advice about emergency contraception.

14. Teach – continued. Old missed pill advice. (still likely to be included in pill packet insert). If 1 or more pills are missed (> 12 hours late), take the last missed pill, continue with the rest of the pills at the normal time and use extra protection(condoms) or abstain from SI for 7 days. If there are fewer than 7 pills left in the pack, continue onto the next pack without a break.

15. Missed pill Quiz.

16. Teach – continued. • Timing, usually day 1 - 5 start (works straight away). Can be any day of cycle if ‘reasonably certain that patient not pregnant’ (works after 7 days). Ref: Quickstart. FSRH. • Postpartum – not BF, day 21 (works straight away). Later if amenorrhoeic and happy not pregnant(works after 7 days). • Within 7 days of TOP or miscarriage (works straight away).

17. Teach – continued. Switch from other method. • Other COC – start at end of current pack, no break, no extra protection • POP or IUS – start straight away (if used correctly). Extra protection 7d. • Depo, Implant, Cerazette- start straight away if used correctly/before runs out. No extra protection (they are anovulatory). • IUD – up to D5 of menses, no extra protection. Any other time of cycle, extra protection 7 days.

18. Inform Efficacy > 99% if taken properly.

19. Inform. • Safer sex/condoms also. • Consider chlamydia screening (CHLASP) if age 16-25.

20. Inform. Side effects – what would you mention?

21. Inform. Side effects. I mention: • Weight gain. No effect. May be some appetite stimulation? • Initial irregular bleeding. Should settle, so don’t stop COC if it happens. • Headaches. Report migraine immediately. • Other ‘hormonal’/non harmful effects eg. Bloating, moody, sore breasts, acne. May settle. Minor.

22. Inform. Risks. What would you mention?

23. Inform. I mention small increased (relative)risk of the following (bearing in mind that for most women of contraception age that the actual risk of all of these conditions is very small anyway, hence also low absolute risk): • VTE • Stroke (and maybe, MI) • Ca cervix • Ca breast.

24. Inform. Consider communicating stats, eg. VTE VTE risk per 100,000 women yrs. -Not on coc 5 -On LNG or norethisterone COC egmicrogynon (2nd gen.) 15 -On Desogestrel or gestodene pill Egfemodene (3rd gen) or Yasmin 25 In pregnancy 60

25. COC – patient decision aid.

26. Inform. Benefits. Reduced risk of ca ovary ca endometrium (both halved, lasts for 15 years) and, colorectal ca. (also, reduced menorrhagia, dysmenorrhoea)

27. Inform. NPC leaflet (patient decision aid) FPA leaflet.

28. Prescribe. • Issue 3 months supply, if all well after this, can issue 12 months supply. Practice nurse can carry out pill checks after initial consultation (at Brig Royd).

29. Prescribe. Which preparation? Ist line is 2nd generation ,monophasic, norethisterone or levonorgestrel containing, 30mcg EE pill egMicrogynon 30. Rationale: -not phasic (simple to take). -lower VTE risk than 3rd gen pills. -equal efficacy to 20mcg pill, but less unscheduled bleeding. Note: 3rd generation pills are acceptable, however, for 1st line use if wished because ACTUAL risk of VTE is still very small.

30. Prescribe - summary. • 2nd generation pill 1st line. (Levonorgestrel or norethisterone): – microgynon 30/ovranette, loestrin 20/30.

31. Prescribe – summary. • 3rdgeneration pill 1st or 2nd line. Newer progesterones, fewer SE, ? heart disease friendly eg. desogestrel, norgestimate, gestodene: - marvelon and femodene . Good cycle control, well tolerated, relatively acne friendly (mercilon and femodette / minulet are the 20mcg versions if OE2 side effects). -cilest. Sold as relatively acne friendly.

32. Prescribe- summary. Other options: • Dianette (co-cyprindiol)/Yasmin – good for acne treatment. Former licensed for treatment of moderate/ severe acne (after topical rx and systemic antibx have been tried) and should not be used solely for this reason - and latter, for acne treatment and as a contraceptive. Stop dianette 3-6m after acne controlled. Change to other acne friendly pill. Can have repeat courses of dianette.

33. Prescribe- summary. • Phasic pills eg. logynon. Varying dose in 2 or 3 steps throughout the 21 days. Need to be in correct order, more complicated. Good for cycle control. • ED pills. 21 active and 7 dummy pills. • Qlaira. New pill. Different oestrogen (oestradiolvalerate rather than ethinyloestradiol). Complicated quadriphasic/26 day regime. Is another option. Marketed as more ‘natural’ – is same oestrogen as used in HRT. And even newer… Zoely, also contains oestradiolvalerate – but is monophasic. Note: generally higher cost of newer pills.

34. Prescribe. If compliance is a problem, consider: • Combined contraceptive patch , Evra (apply weekly x3, then patch free week). There is a 48 hour ‘window’ in which to remember patch application (COC missed pill rules are now similar, but no need to take daily pill). • Combined contraceptive ring, Nuvaring (insert vaginally, leave in situ for 3 weeks, then remove for 1 week). It can be left in for up to 4 weeks before efficacy may be lost. • LARC

35. Leaflet. • Issue FPA leaflet. • NPC pda leaflet, if relevant. • Other, eg CKS, patient.co.uk

36. Follow up. • Prescription for 3 months. • Is free from chemist. • Consider issuing condoms. • See nurse for FU if all is well. See GP if any problems. Note: plan for FU may be different at other practices!

37. QOF. • The percentage of women prescribed an oral or patch contraceptive method who have also received information from the practice about long acting reversible methods of contraception in the preceding 15 months. • Code LARC advice given (leaflet) and Verbal LARC advice given.

38. Fraser Guidelines. • If the patient is under 16 and unaccompanied, be happy that the patient fulfills the criteria. Remember to encourage her to involve a parent in her decision. And ensure that she is having consensual sex, not being coerced. Record in the notes. Safeguarding. (see below for full guidelines)

39. Fraser Guidelines. • The young person will understand the professional’s advice. • The young person cannot be persuaded to inform their parents. • The young person is likely to begin, or continue having, sexual intercourse with or without contraceptive treatment. • Unless the young person receives contraceptive treatment, their physical or mental health, or both, is likely to suffer. • The young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.

40. Summary/checklist COC - new start 1.Indication – menses, contraception, PCOS/acne. 2.Consider other methods eg LARC/suitability /previous methods used/sexual history. 3.Contraindications – focal migraine, DVT, other eg active liver disease, ca breast, pregnant. -FH: cabreast,DVT, stroke (relative CI) -check history screen for rarer entries eg. Porphyria. - other drugs inc. OTC eg. St John’s Wort. 4.Smoker? 5.Check BP and BMI. 6. Teach – 21 days on, 7 days off (pill free interval) - missed pills (>24 hours late), GI upset, enzyme inducers. - never increase PFI. - timing, usually D1 start, works straight away (remember Quickstart, 7d extra precns) -remember mobile phone reminder to aid compliance, ? Not 1st thing if young. 7. Efficacy - > 99% when taken properly. 8.Safer sex advice/condoms/sexual history.

41. Summary/checklist – contd. 9.SE– initial irregular bleeding - reassure re weight. - headaches (need to report migraine) - other ‘hormonal’/minor egmastalgia, moody, bloating, nausea, acne. 10.Risks – small actual numbers. DVT, ca cervix, ca breast, stroke . 11. Benefits – ca ovary, ca endometrium, ca bowel. - improved periods. - good contraceptive. 12. Issue prescription and ? condoms. Initially 3 months’ supply. If all well, 12 months after that. 13. Give FPA leaflet. 14. Follow up. Inform re need to be seen in 3 months for next prescription. Also, advise that the prescription is free. 15. Fraser Guideline. If under 16 ensure that she fits the criteria and record in the notes. Safeguarding. 16. Offer chlamydia screening (CHLASP programme) if aged 16-25. 17. QOF. Code LARC advice.

42. References. • Faculty of Sexual and Reproductive Healthcare (FSRH). www.fsrh.org.uk Go to Publications on the site, many useful documents inc. COC – First prescription, CEU guidance: missed pills, quickstart contraception, drug interactions w hormonal contraception, emergency contraception and UKMEC summary sheets. • Family Planning Association (FPA). www.fpa.org.uk • National Prescribing Centre(NPC). www.npc.nhs.uk Patient decision aids. • Other GP education sites, eg GP notebook, CKS, webmentor. • Other patient information sites eg. CKS and patient.co.uk. • This presentation will be found on the Pennine website for a few weeks! www.pennine-gp-training.co.uk AND … (next slide)

43. Training video. • YouTube. Search: new pill start. Simulated consultation of 1st pill prescription in detail. 18 minutes long. Includes the steps in this presentation in ‘real life’. May need to split the consultation if short of time.