Contraception Update

1. Contraception Update

2. To know what forms of contraception are available and when they are necessary • To know the contraindications for each and how to identify them • What to check for on f/u consultations • To know how to access information for ourselves and patients • To know how to approach a consultation for : • A teenager • A >35 y.o • The rest!

3. To be able to discuss the main pros and cons for different types of contraception. • To know which are the most effective methods of contraception • To know why some are less good for different patient groups • To be aware of important issues for different age ranges

4. Brainstorm! • What forms of contraception are there?

5. Quiz! • If 1000 women were to use these methods of contraception…. How many pregnancies would arise in the first year of use?

7. The answers!

9. Let’s have some cases!

10. Amelia

11. Frazer/Gillick competence • <13yrs not legally capable of consenting to sexual activity • 13-16 discuss and consider

12. Nicky

13. Julie • Use the BNF cautions contraindications list… 2 strikes and you’re out!

14. Important things to worry about with the COCP? • VTE • Cancer • Stroke

15. VTE with COCP

16. VTE with COCP

17. VTE with COCP:Effect of weight….

18. Other risks… • Which is more likely to happen? • Dying from a thrombosis from a third generation COCP • Or • Dying in a RTA

19. Cancers… • Is there an increase in risk of breast cancer with the COCP? • RR increased by: • 0% • 1-9% • 10-19% • 20-49% • >50%

20. Is there an increase in risk of breast cancer with the COCP? • RR increased by: • 25%

21. What is the absolute risk increase? • 0.01% • 0.1% • 0.5% • 1% • 2-10%

22. Absolute risk is 0.01% • Actual baseline risk <30 1:1900 30-40 1:200 • Risk increase is 12/100,000

23. Cardiovascular Risk • Absolute risk of MI in non smoking aet <35 very low irrespective of COCP use • XS risk approx 3/1,000,000/yr • >35 XS risk approx 400/1,000,000/yr • 10x risk if smoke

24. Cerebrovascular Risk • Ischaemic stroke: non smoking, normotensive women XS risk 4/100,000/yr • Increased with age/smoking x 10 / migraine x 11

25. Migraine • Migraine with aura =absolute CI (WHO 4) • Migraine +ergots=absolute GI • Migraine +tryptan = relative CI • Migraine +1 other RF=relative CI • Migraine + No Aura +no additional stroke risk factors = OK

26. Agatha

27. Emergency Contraception • POEC :Progesterone only Emergency contraception (Levonelle 1500) • Success Rates: preventing expected pregnancy • <24 hr 95% • 25-48 hr 85% • 49-72 hr 56% • (72-120 hr ?60%)

28. POEC • Effect on next period • 87% within 7 days of expected: may be early or late • Most of rest 7-14d late

29. Emergency Contraception • IUCD (not IUS) • Up to 5 days after date of UPSI or expected ovulation • Failure rate <1%

30. EllaOne(Ulipristal) • Inhibits/delays ovulation • Good efficacy up to 120h (better than Levonelle esp after 48h) • Only once in cycle • Can’t rely on Hormonal contraception rest of that cycle: (Need to allow 9d for progesterone methods 14d cocp)

31. Pat

32. Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing… and you may need time recover before the menopause • This is not true for implanon

33. June

34. Mirena ok for 4y for endometrial protection • Menopause: amenorrhoea >2y if under 50 • >1y if >50 • If Mirena / Implanon FSH > 30 6w apart means likely but above applies • IUD change x 1 after 40 • IUS change x 1 after 45

35. Fran

36. Sophie

37. Missed pills • New rules • Can miss one anywhere in pack no prob even if extend pill free interval to 8 days

38. Missed pills • see handout !!! • 7 successive pills to inhibit ovulation • Alt contraception for 7d if miss 2 for 20 or 3 for 30. • Important… just keep going! Take asap then as normal • If start pkt late in wk 1and sex in pfw need EC • If in week 3 miss pfw , wk 1 EC

39. Missed pills • POP • Cerazette 12h, rest 3h • Take and continue : need 48h continuous taking (3 pills) then ok again

40. New ideas • All more expensive… • NuvaRing: 15mg EE2/120 etonorgestel/d • Sits in vagina: replace monthly • As effective, ok with amoxicillin/doxycycline • Store in fridge/expulsion may occur/same restrictions as patch

41. Nuvaring

42. New ideas • Extended pill regimes (not available uk yet): seasonale/seasonique 4 periods/yr • Anya/Lybrel 365d pill • 20mcg, btb the prob. • Suggest bi-cycling or tri-cycling to limit of btb tolerance of other pills

43. Special considerations

44. Women on HIV drugs • Enzyme inducers+++ • Best option IUD • EC double levonelle

45. Enzyme inducers • Women with epilepsy • Injectable/IUD • Oral contraceptives with 50mg oestrogen • Tricycle with 4 days break • Double emergency contraceptive dosage

46. When should contraception be started? • IUCD within 18 days of period onset • Mirena day 1-7 or if no risk preg at other time • Depot-? • COCP? • POP?

47. Swapping pills/hrt • Side effects can be oestrogenic/progestogenic • If someone has each of the following what would you use/change to? (pill ladder) • Spots, • Hirsuitism • Feeling depressed • Nausea • Bloating • Breast discomfort

48. C19 derivatives E.g Norethisterone Levonorgestorel More androgenic More likely to cause side effects C21 derivatives E.g Medroxyprogestogen acetate Dydrogesterone Less androgenic Progestogens

49. Oestrogenic Fluid retention Bloating Breast tenderness Nausea Headache Dyspepsia (take with food) Consider changing dose, changing oestrogen or changing delivery Progestogenic (In a cyclical pattern) Fluid retention Breast tenderness Mood swings Depression Acne Backache Reduce progestogen duration to 10 days per cycle, change progestogen c19/21 derivatives, delivery Side Effects