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CONTRACEPTON FOR GP’S Dr Mazhar Khan 7 April 2010

CONTRACEPTON FOR GP’S Dr Mazhar Khan 7 April 2010. AGENDA. Statistics Contraceptive Efficacy Non-hormonal Contraception UKMEC/ WHO criteria for safe prescribing Hormonal Contraception Cases. Statistics. UK has one of the highest rates of teenage pregnancies in the world

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CONTRACEPTON FOR GP’S Dr Mazhar Khan 7 April 2010

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  1. CONTRACEPTON FOR GP’SDr Mazhar Khan7 April 2010

  2. AGENDA • Statistics • Contraceptive Efficacy • Non-hormonal Contraception • UKMEC/ WHO criteria for safe prescribing • Hormonal Contraception • Cases

  3. Statistics • UK has one of the highest rates of teenage pregnancies in the world • UK has one of the highest levels of unintended pregnancies in the world

  4. Statistics

  5. Statistics

  6. Statistics • Approximately 200,000 women in England/ Wales seek abortion / year • 62% of these women reported using contraception at the time of getting pregnant • “Just cant remember to take the pill” • “ Didn’t think I would get pregnant while on the pill “ • “ Doc, the condom broke” • 38% of these women were not on a regular contraception or used no contraception at all • “ didn’t think at the time I needed one “ • “ didn’t think I would get pregnant at all “ • “ I was drunk ! “ • “ It was a one night stand “

  7. Contraceptive Efficacy • Pearl Index: No. of pregnancies/ 100 years of use • Contraceptive efficacy depends on: • Age • Motivation of user/ compliance/ concordance • Duration of use of contraceptive method • Pearl index • Mechanism of action: Method that stops ovulation and is independent of user compliance

  8. Contraceptive Efficacy Pearl Index

  9. Non-Hormonal Contraception Natural Family Planning • Calendar Method • BBT • Cervical Mucus Test • Billings Ovulation Method • PERSONA • Lactation • Coitus Interruptus

  10. Non-Hormonal Contraception Barrier Methods (Males) Condoms • Most commonly used NHC • Pearl Index 2 – 15 • Latex/ Polyurethane • Most come with the spermicidal, Nonoxynol-9 • Beware of certain topical products/ lubricants • Protection against STI’s • Disposable

  11. Non-Hormonal Contraception Barrier Methods (Females) Femidom (female condom) • Pearl Index 5 – 15 • Latex/ Polyurethane • Most come with the spermicidal, Nonoxynol-9 • Insertion – Prior to sexual intercourse • Removal – Does not need to be removed immediately after ejaculation • Beware of certain topical products/ lubricants • Protection against STI’s • Some evidence that polyurethane femidoms can be washed, disinfected and reused

  12. Non-Hormonal Contraception Barrier Methods (Females) Vaginal Diaphragm • Pearl Index 4 - 20 • Latex/ Silicone • 5 mls of spermicidal should be used • Insertion – Can be inserted up to 6 hrs prior to sexual intercourse • Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 30 hrs • Beware of certain topical products/ lubricants • Less protection against STI’s • Can be washed, disinfected and reused – 1 yr • Right size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgs • D. Adv – UTI’s , risk of TSS (2.4:100,000) • Contraindications – Latex allergy, H/O TSS, poor vaginal tone, prolapse (cystocele/ rectocele), HIV

  13. Non-Hormonal Contraception Barrier Methods (Females) Cervical Cap • Pearl Index 11 - 19 • Latex/ Silicone • Spermicidal should be used – fill about 1/3 rd • Insertion – Can be inserted up to 6 hrs prior to sexual intercourse • Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 48 - 72 hrs • Beware of certain topical products/ lubricants • Does not protect against all STI’s • Can be washed, disinfected and reused – 1 yr • Right size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgs • D. Adv – Can be difficult to insert, risk of UTI’s, TSS • Contraindications – Latex allergy, H/O TSS, cervical diseases (malignancy, poor smear result, cervicitis) etc), HIV

  14. Non-Hormonal Contraception Barrier Methods (Females) Contraceptive Sponge • Pearl Index 15 - 20 • Polyurethane Foam • Contains a spermicidal • Insertion – Prior to sexual intercourse. Moisten with water before insertion • Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 24 hrs • Does not protect against all STI’s • Disposable • D. Adv – Risk of UTI’s, TSS • Contraindications – Latex allergy, H/O TSS, HIV

  15. UKMEC Faculty of Sexual & Reproductive Health Care of the Royal College of Obstetricians & Gynecologists

  16. Hormonal Contraception(COC’s) • Mechanism of action: • Inhibits ovulation • Thickens cervical mucus • Renders endometrium unsuitable for implantation • Pearl Index: • 0.3 – 4 • With perfect use it is 0.1 (true pill failure)

  17. Hormonal Contraception(COC’s)1st prescription of a COC UKMEC guidance will help in safe prescription of COC • Age • Breastfeeding • Postpartum • Smoking • Obesity – BMI • Risk factors for CVD – old age, smoking, obesity, hypertension, diabetes • BP • VTE and risk factors for VTE • H/O IHD, Stroke, Hyperlipidemia, PVD • H/O Valvular heart disease • Headaches/ Migraines • Breast disease/ Family Hx/1 breast disease • Endocrine Diseases – Diabetes (with/ without PVD) • Liver/ Gall Bladder Diseases – Gall stones, Cholestasis, Hepatitis, Cirrhosis, Liver tumors • Anaemia • Raynauds Disease, SLE • Drug Interactions

  18. Hormonal Contraception(COC’s)1st prescription of a COC • Adverse Effects: • Low estrogen side effects: BTB (check compliance, drug interactions, D/V or malabsorption, rule out pregnancy, infection, gyn. Problems) – increase estrogen component or try changing the pill • High estrogen side effects: nausea, dizziness, bloating, vaginal discharge, breast problems – try a lower estrogen pill or changing the pill • High progestogen side effects: mood swings, reduced sexual drive, vaginal dryness, breast tenderness, wt gain, acne – try a low progestogen pill or changing the pill • Benefits of COC: • Contraceptive benefits –Good efficacy if good compliance, reversibility • Non-contraceptive benefits - periods regular, light, painless, protection against ovarian cysts, ovarian tumors, benign breast diseases, endometrial ca, colorectal ca, few extra uterine pregnancies

  19. Hormonal Contraception(COC’s)1st prescription of a COC • When to start the COC? • Ideally COC should be started on 1st 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 contraceptive protection • 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 1st 7 days • Which pill is suitable for women being given a 1st prescription of COC? • Monophasic (containing 30 mcg is the 1st option) • Biphasic (Logynon, Binovum) • Triphasic (Trinovum) “very few direct comparative data available to identify the best, 1st line COC’s and no evidence to support the use of biphasic or triphasic pills”

  20. Hormonal Contraception(COC’s)1st prescription of a COC

  21. Hormonal Contraception(COC’s)1st prescription of a COC Missed Pill Advice

  22. Hormonal Contraception(COC’s)Follow up prescription of a COC • Pill check - initially 3 mths - then 6 months x 2 - then annually if no risk factors • Check well being/ adverse effects • New risk factors/ contraindications • Menstrual history • BP, Smoking, BMI, concordance • Cervical smear • Check education • Missed pill advice • Interaction with drugs • Intercurrent illness – D/V • Risk of STI’s • Future plan of wanting to concieve • Prenatal 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

  23. Hormonal Contraception(COC’s) • Estradiol Valerate + Dienogest • 4 sequential phases • Pearl Index: 0.4 – 0.5 • Missed pill: may need 9 days extra precautions +/- EC

  24. Hormonal Contraception(Transdermal - EVRA) • Failure rate <1% if used correctly • Each patch lasts a week • Change a patch every week for 3 weeks followed by a weeks break • If the patch comes off, do not reattach it – adv to use a new one

  25. Hormonal Contraception(POP’s) • Inhibits cervical mucus (Cerazette also inhibits ovulation) • Pearl index: Micronor :- 0.3 – 4; Cerazette:- 0.17 • Start on day 1 of period , no PFI • Window period: Minipill :- 3 hrs; Cerazette:- 12 hrs. • If missed/ delayed pill then take other pills as usual + extra precautions for 48 hrs +/- EC • Can be started 3 weeks postpartum • Not affected by broad spectrum antibiotics but by enzyme inducers • Can be taken with HRT in perimenopausal period until menopause • Refer to UKMEC for contraindications

  26. LARC’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%)

  27. LARC’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

  28. LARC’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

  29. LARC’S(IUD’S) • 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

  30. LARC’S(IUD’S) Flexi-T 300 I.U.D. T-safe CU380A GyneFix IUD Multi-Safe 375 IUD Multisafe 375 Short Stem IUD Nova-T 380 IUD

  31. LARC’S(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

  32. LARC’S(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

  33. LARC’S(POIC’s – Depo-Provera) • Inhibits ovulation • Pearl Index: 0 – 1 • Repeated every 12 weeks • Could be a delay up to 1 yr in return of fertility after stopping • Adverse effects: • Amenorrhoea likely but irregular/ heavy bleeding can happen (Rx with Tx acid/ add oestrogens) • Wt gain: 2-3 kg in a year • Reduced BMD but no increase in risk of fractures • Not associated with acne/ depression/ headaches • No evidence of congenital malformation if pregnant while on DEPO • Contraindications – Follow UKMEC • License: 2-3 years • Injection: Same as IUD/IUS but can be given immediately post partum

  34. LARC’S(POIC’s – Depo-Provera)

  35. LARC’S(POSDI’s - Implanon) • Inhibits ovulation • Pearl Index: 0 – 0.1 • License: 3 years • Adverse effects: • Irregular/ frequent/ prolonged bleeding 1st 6 months in about 50 % (33% stop using 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 fashion • Acne possible • Not associated with weight gain, mood swings, reduced libido, headaches • Contraindications – refer to UKMEC

  36. LARC’S(POSDI’s - Implanon) Insertion of Implanon • Timing – same as DEPO • Site – Non-dominant arm, 10 cm above the medial epicondyle as opposed to bicipital grove • Impalpable Implanon – deep insertion/ failed insertion/ migration. Locate with an USS. If deep insertion, refer • Removal – straight switch to another Implanon/ Contraception

  37. Emergency Contraception • Hormonal EC – Levonorgestrel (Levonelle) • Non-hormonal EC – Cu IUD • EC in future

  38. Emergency Contraception(Hormonal EC – Levonelle) • Inhibits ovulation – hence works best when given in pre-ovulatory stage. If taken before ovulation, it can inhibit ovulation for 5-7 days • 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 declined (unlicensed) • Contraindications: UKMEC says no absolute contraindications • Drug Interactions – If on liver enzyme inducers, Cu IUD preferred. If declined then a single dose of 3 mg is given (unlicensed)

  39. Emergency Contraception(Hormonal EC – Levonelle) • History: • Assess for competence if young and document as “Fraser ruling competent” • Full sexual Hx including last/ previous UPSI’s • LMP (if pre-ovulatory) • Assess risk of STI – offer everyone a STI screen • Advice about LARC • Start a regular contraception when issuing EC if possible • Counsel about Levonelle • Adverse effects: • Nausea, vomiting (if vomiting within 2 hrs of taking it, repeat dose) • Next period earlier/ late, lighter. If delayed/ lighter than expected – preg. test • Consider advance provision of Levonelle in some cases

  40. Emergency Contraception(Non-hormonal EC – Cu IUD “Multiload 375”) • Inhibits fertilisation; Inhibits implantation • License – Up to 5 days post UPSI or before day 19 of a regular cycle • Always offer a emergency IUD even if presents within 72 hrs post UPSI • Can be removed at anytime during next period if not had UPSI since next period and alternative cover started at the right time • History taking vital as for levonelle • If at risk of STI (<25 yrs and > 1 sexual partner in the last 1 yr) insert EC-IUD but give prophylaxis

  41. Emergency Contraception(Future EC) Ellaone • Selective progesterone receptor modulator • Used up to 120 hours post UPSI • Dose – one dose of 30 mg • Extra – precautions until next period • Cannot give > 1/ month • Can cause headaches, nausea, abdominal pain

  42. Emergency Contraception(Future EC) Mifepristone • Progesterone antagonist • Effective EC when taken in a single dose up to 120 hours post UPSI • Single dose – 25 – 50 mg • Not licensed for EC in the UK

  43. Case Studies

  44. Case - 1 • Nicola Peel is a 35 yr old P4+2 recently has a TOP. She came to discuss about contraception. Her periods are heavy but regular. Her BMI is 35 and she takes Metformin for diabetes. She is a non smoker and her BP is normal • What are the issues here? • What contraceptives would you discuss with her?

  45. Case - 2 • Janet, 36 yr old requesting a COC. She smokes 20 cigarettes/ day, BMI – 35. • What are the issues in her case? • What contraceptive methods would you discuss with her? She promised to stop smoking and returned 6 months later requesting a COC. • Will you issue it? What will you discuss with her?

  46. Case - 3 • You see Linda, mother of 3, who is requesting a COC. Her BP is 140/ 90. She is not on any anti-hypertensive. She is 35 yr old. Her mother had a thrombosis in the past. • What are the things you will discuss with her? • What contraceptive will you offer her?

  47. Case - 4 • Liz is 19 yrs old. She attends surgery to discuss contraception. She is an epileptic and currently on Valproate. A letter from hospital advices you to change it to Lamotrigine as her epilepsy wasn’t under control. She wishes to start Microgynon. She also suffers from depression. • Would you offer her CHC? • What are your thoughts? • Which contraception would be safe for her?

  48. Case - 5 • Maria, 21, a Spanish student has been using Evra patches for 2 years. She came to see you for repeat prescription. She informs you of she suffers from severe headaches at times, mainly during her periods and sees flashing lights in her Lt eye associated with numbness in her Lt arm before headaches start. She takes Atenolol and 5HT agonist for her headaches. She does not smoke. Her BMI and BP are normal • Will you continue issuing her the patches? • What are the alternatives?

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