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Hormonal Contraception and EHC

Hormonal Contraception and EHC. for Health Information Advisors. Trainer’s name XX Medicines Information Service. Learning Outcomes. Have baseline knowledge and understanding about hormonal contraception including

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Hormonal Contraception and EHC

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  1. Hormonal Contraception and EHC for Health Information Advisors Trainer’s name XX Medicines Information Service

  2. Learning Outcomes • Have baseline knowledge and understanding about hormonal contraception including • Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions. • Implications and advice for missed doses and dosing errors. • Indications and limitations of Emergency Hormonal Contraception (EHC). • Be able to use the NHS Direct emergency contraception and missed pill algorithm.

  3. 9.30 Introduction & learning outcomes Baseline knowledge for hormonal contraception Types, action, risks, cautions, side effects, interactions. Missed doses and dosing errors. 10.45 Tea break Emergency Hormonal Contraception (EHC) Workshop 1 12.45 Lunch EHC & missed OC algorithm Workshop 2 3.00 Tea break Workshop 2 (continued) 4.00 Review of learning outcomes & close Plan for the Day

  4. Hormonal Methods Combined OC pill Progestogen-only pill Patches Injections Implants Intrauterine devices Emergency Hormonal Contraception (EHC) Non-Hormonal Methods Sterilisation Abstinence Interruptus Condoms – male and female Diaphragms and Caps Spermicides Intra uterine devices Rhythm methods Contraceptive Options

  5. Oestrogen Ethinylestradiol (EE) Mestranol Progestogen Norethisterone Desogestrel Levonorgestrel Gestodene Norgestimate Drospirenone Combined Oral Contraceptive Pill

  6. COCs: How does it work?

  7. COCs: Monophasics • Fixed amount of oestrogen & progestogen • One tablet daily for 21 days then a 7 day pill free period. • Every Day (ED) - One tablet daily for 21 days then 7 days of dummy tablets. • > 99% effective, when used properly.

  8. Low Strength 20 microgram EE Loestrin 20 Mercilon Femodette Standard Strength 30-35 microgram EE Microgynon 30 Loestrin 30 Marvelon Minulet Femodene COCs: Monophasics

  9. COCs: Biphasics & Triphasics • Varying amounts of oestrogen and progesterone according to stage of the cycle. • Useful when there is breakthrough bleeding or no withdrawal bleed on monophasics.

  10. Biphasics Binovum Triphasics Logynon ED Synphase Trinordial TriNovum Tri-Minulet Triadene COCs: Biphasics & Triphasics

  11. COCs: Risks • Migraine • Increased stroke risk in migraine sufferers • Risk my be increased in COC users • Headache with aura plus neurological symptoms • Cancer • Very small  risk of breast cancer. • Protects against ovarian and endometrial cancer.

  12. COCs: Breast Cancer Risk

  13. COCs: Risks • DVT • Healthy women non pregnant - 5-10 /100,000 2nd gen pill – 15/100,000 3rd gen pill – 25/100,000 • Caution if 1, avoid if 2 of: PMH, family history, obesity, immobility. • Stroke and MI • Caution if 1, avoid if 2 of: PMH, family history, diabetes, BP, smoking, >35 years, obesity, migraine.

  14. “Tricycling” Monophasics • Running three packs together • Four Pill Free Intervals per year • Three extra packets of hormone per year • Reduces hormone fluctuations • Unlicensed

  15. 7 days of pill taking puts the ovaries to sleep. Ovaries wake up if miss 10 days of standard strength pill. 9 days of low strength pill. The 7 pill free days are safe. Guidance NHSD CAS algorithm Family Planning Association (FPA) Patient information leaflet eBNF Faculty of Family Planning & Reproductive Health (FFPRHC) COCs: Missed doses

  16. 1-2 standard strength or 1 low strength Take pill now and then continue as normal. No extra precautions. No emergency contraception. 3 standard strength or 2 low strength Take pill now and then continue as normal. Extra precautions until taken 7 pills in a row. Week 1 – EC indicated. Week 2 – No EC. Week 3 – No EC, start new pack, no break. COCs: Missed doses

  17. COCs: 3 standard strength or 2 low strength missed

  18. COCs: 3 standard strength or 2 low strength missed

  19. COCs: 3 standard strength or 2 low strength missed

  20. Progestogen Only Pill (POP) • One active ingredient – progesterone. • Taken continuously with no break. • Alternative if COCs are contraindicated. • Relies on motivation of the user.

  21. Benefits Well tolerated No proof of increased disease risk Useful in lactation Drawbacks Precise timing Changes in menstrual pattern Brand Names Femulen Micronor Norgeston Noriday Progestogen Only Pill Cerazette

  22. Less than 3 hours late Take the missed pill immediately and continue as normal. No extra precautions. No emergency contraception. More than 3 hours late Take the missed pill as soon as possible. Extra precautions until 2 further pills in a row. EC if unprotected sex before 2 further pills in a row have been taken. POP: Missed doses Cerazette: Instead of 3 hours read 12 hours

  23. POPs: More than 3 hours late

  24. Contraceptive Patch • Evra • Contains • Low strength oestrogen • Progestogen • Dose • 1 patch a week (on same day of week) for 3 weeks. • One week patch free.

  25. Delayed Patch 1 • Most risky time to forget to apply the patch. • Apply Patch 1 as soon as remembering. This is now the beginning of the patch cycle (new start day and change day). • Take extra precautions for 7 days. • If the delay was for more than 48 hrs (extends patch free period) and unprotected sex - emergency contraception is indicated.

  26. Delayed Patch 1

  27. If less than 48 hrs (Extra 48hr drugs in patch) Apply patch immediately, keep usual change day. No extra precautions. No emergency contraception. If more than 48 hrs Stop current cycle and start a new patch cycle with a new Week 1. Extra precautions for 7 days. If prolonged patch free period & unprotected sex – EC is indicated. Delayed Patch 2 or 3

  28. Delayed <48hrs Patch 2 or 3

  29. Delayed >48hrs Patch 2 or 3

  30. If less than 48 hrs Apply patch immediately, keep same change day. No extra precautions. No EC. If more than 48 hrs Stop current cycle and start a new patch cycle with a new start day / change day. Extra precautions for 7 days. If prolonged patch free period & unprotected sex – EC is indicated. Detached patch

  31. Contraceptive Injection • Long acting progestogen. • Depo-Provera. • IM injection every 12 weeks. • Noristerat. • IM injection every 8 weeks.

  32. Up to 14 days late World Health Organisation (WHO) states: no extra precautions needed, EC not indicated. Manufacturer states up to 5 days late but super seeded by the WHO advice. More than 14 days late Extra precautions for 7 days. Consider EC if unprotected sex. Delayed injection

  33. Contraceptive Implant • Long acting progestogen. • Implanon • Subcutaneous implant every 3 yrs. • Requires trained person to insert and remove. • Manufacturer and WHO do not state a safe delay for Implanon.

  34. Vomiting & Diarrhoea • If vomited within 2 hours of pill taking, its absorption will be reduced and it may be ineffective. • Diarrhoea alone without vomiting has to be severe to reduce the absorption of the pill. • Handle as a missed pill.

  35. Drug Interactions • Broad spectrum antibiotics e.g. amoxycillin, ampicillin, erythromycin. May reduce the efficacy of COCs and patch. No interaction with POPs, injection or implant. • Enzyme inducers e.g. rifampicin, ritonavir, carbamazepine, St. John’s Wort. May reduce the efficacy of COCs, patch, POPs, injection and implant. Consider referral to UKMI.

  36. Emergency Hormonal Contraception

  37. Emergency Hormonal Contraception When is EHC Indicated? • After unprotected sexual intercourse • Increased risk of contraceptive failure • Torn, leaking condom • Missed pills • Late implant or injection • Detached contraceptive patch • Dislodged IUD

  38. Levonelle 1500 “One Step” • High dose progesterone - levonorgesterel. • One 1500mcg tablet taken as soon as possible after unprotected intercourse. • Preferably within 12 hours, ideally no later than 72 hours.

  39. EHC Efficacy Rates

  40. How does EHC work? • Depends on point in the menstrual cycle. • Thought to prevent or delay ovulation, fertilisation and implantation. • Clinical opinion is that using EHC does not constitute an abortion.

  41. EHC: Cautions & Side Effects • WHO – No absolute contra-indications. • Nausea 25%, vomiting 5%. • Care with liver enzyme inducers e.g. rifampicin, St John’s Wort, ritonavir, phenytoin, carbamazepine, barbituates. • Slightly increased risk of ectopic pregnancy.

  42. Where can you get EHC? • Community Pharmacies • GP • Walk-in Centres • Family Planning Clinics • Sexual Health Clinics • A & E

  43. Tea Break

  44. 9.30 Introduction & learning outcomes Baseline knowledge for hormonal contraception Types, action, risks, cautions, side effects, interactions. Missed doses and dosing errors. 10.45 Tea break Emergency Hormonal Contraception (EHC) Workshop 1 12.45 Lunch EC & missed OC algorithm Workshop 2 3.00 Tea break Workshop 2 (continued) 4.00 Review of learning outcomes & close Plan for the Day

  45. Workshop 1: Case scenarios • What further information do you need to answer the call? • Confirm what type of contraception using the eBNF. • Refer to the NHSD algorithm rationales for an answer. What does the FPA, netdoctor & eBNF say? • What would you advise the caller?

  46. Lunch Break

  47. 9.30 Introduction & learning outcomes Baseline knowledge for hormonal contraception Types, action, risks, cautions, side effects, interactions. Missed doses and dosing errors. 10.45 Tea break Emergency Hormonal Contraception (EHC) Workshop 1 12.45 Lunch EC & missed OC algorithm Workshop 2 3.00 Tea break Workshop 2 (continued) 4.00 Review of learning outcomes & close Plan for the Day

  48. Workshop 2: EC algorithm • Repeat the case scenarios from Workshop 1 using the NHSD Emergency Contraception algorithm.

  49. Learning Outcomes • Have baseline knowledge and understanding about hormonal contraception including • Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions. • Implications and advice for missed doses and dosing errors. • Indications and limitations of Emergency Hormonal Contraception (EHC). • Be able to use the NHS Direct emergency contraception and missed pill algorithm.

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