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Contraception Update & New Developments – May 2008

Contraception Update & New Developments – May 2008. E Stephen Searle MRCGP, MFPH, FFFP Clinical Director/Consultant in Contraception & Sexual Health, N Derbyshire. Content of talk. Yaz, Evra, NuvaRing IUDs/IUS Esure Peri-menopausal contraception Injectables, esp osteoporosis. Implant

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Contraception Update & New Developments – May 2008

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  1. Contraception Update & New Developments – May 2008 E Stephen Searle MRCGP, MFPH, FFFP Clinical Director/Consultant in Contraception & Sexual Health, N Derbyshire

  2. Content of talk • Yaz, Evra, NuvaRing • IUDs/IUS • Esure • Peri-menopausal contraception • Injectables, esp osteoporosis. Implant • Contraception at time of TOP

  3. satisfaction • 25% never start Rx contraception • 30% discontinue within 1 month • 65-80% missed 1+ pill per month • Offer ‘Quick-start regime’ – start on day of presentation regardless of day of cycle. Advise back-up method x 1 wk. & return if menses late

  4. Future methods • NuvaRing – planned Sept 2008 • Yaz – planned ?Sept 2008

  5. NuvaRingDesign, composition and use • 1 ring per cycle • Regimen: • 3 weeks of ring-use • 1 ring-free week • Daily release: • 15 µg ethinylestradiol • 120 µg etonogestrel

  6. NuvaRingPharmacokinetics and dynamics Based on data from various sources, no direct comparative data

  7. Contraceptive efficacyNuvaRing European study Pregnancies Cycles Pearl Index 95% CI 6 12 109 0.65 0.24–1.41 Roumen et al, Hum Reprod, 2001;16:469–75

  8. NuvaRingCompliance: Ring V’s COC • Compliance was higher in the NuvaRing group: • > 85% of women in the NuvaRing group complied to prescribed regimen • 75% of women in the Microgynon group complied to prescribed regimen i Scientific communication ESC 2004

  9. NuvaRingConcomitant antibiotic use Amoxicilline Doxycycline Scientific communication ESC 2004

  10. Incidence of local adverse events(n=1145) Adverse event Treatment-related Vaginal discharge 5.3% Vaginitis 5.0% Device-related events 3.8% Vaginal discomfort 2.2% Roumen et al, Hum Reprod, 2001;16:469–75

  11. Irregular bleeding with Nuvaring Comparison with a COC * * * * / * * Statistically significant differences Scientific communication ESC 2004

  12. NuvaRing Effect of on body weight Cycle 3 Cycle 6 Cycle 6 Cycle 3 Bjarnadóttir et al, Am J Obstet Gynecol, 2003

  13. Storage Prior to dispensing to the user, store refrigerated 2–8°C (36–46°F). After dispensing to the user, NuvaRing® can be stored for up to four months at 25°C (77°F); excursions permitted to 15–30°C (59–86°F) [see USP Controlled Room Temperature]. Avoid storing NuvaRing® in direct sunlight or at temperatures above 30°C (86°F). NuvaRing® Package Insert

  14. Yasmin • Drospirenone 3mg, EE 30mcg • Good for fluid retension/bloating • Acne (1st try oestrogenic COC, tetracycline. Then Dianette x 6/12) • Mild hypertension <140/90 • PMS: RCT Xover v’s placebo yasmin signif better • £14.70 x3 x21

  15. Yaz • EE 20mcg • 24 active pills then x4 placebo pills • Launch ? Sept 2008

  16. IUDs • Cu T 380 now approved for 12 yrs in USA • Failure rate virtually stable up to 15 yrs • Cu IUDs may be left in-situ x20 yrs

  17. IUDs & infection • Single dose of doxy. prophylactically at insertion only results in signif reduction of PID in areas of high GC, Chlamydia prevalence • ALOs less likely with IUS (2.9%) than IUDs (up to 20%) • No link between IUD use & CIN. Even a Hx of Ca Cx is WHO 2 for continuing IUD. WHO 4 for insertion while awaiting diagnosis

  18. IUDs & HIV • No effect on viral shedding • No increased risk of transmission or other infection (still rec. condoms) • WHO 2 for HIV • WHO 3 for insertion with AIDS

  19. IUD/IUS & gynae pathology • Cu IUD reduces endometrial Ca by 50%, increased protection with duration of use • IUS good for endometriosis • IUS may reduce fibroid related problems, surgery & size • Spotting may take longer to settle in women with menorrhagia esp if also have fibroids

  20. HPV vaccine • Catch-up vac still useful in women who’ve had HPV as only 5% of young women have had exposure to >1 type, so still get protection from other types.

  21. Evra • = ‘cilest in a patch’ • Weekly patch x 3 then PFI x 7/7 • Better compliance than pills • No 1st pass through liver, consider for GI disease/malabsorption

  22. How do we choose?- Nottingham Evra Audit

  23. Should modern women accept having menstruation? • ‘Menses should be optional & convenient’

  24. Peri-menopausal contraception • Oldest reported spontaneous preg. – 57 yr old in Portland • “COC & Depo are methods of choice in osteoporotic women” – combined with osteoporosis Rx • Measuring FSH on COC – OK at end of PFI • Can abandon contraception from 55th year

  25. Progestogen-Only Injectable Contraceptives January 2003

  26. What are the advantages of injectables – Depo & Noristerat?

  27. Advantages of DMPA • Almost 100% effective, up to 14/52 • Does not require day to day motivation • Non intercourse related • No oestrogenic side effects or health risks • Protective against PID & Endometrial Ca • Does not inhibit lactation • Protective in sickle cell (SS) disease

  28. Breast cancer 1.2 (0.96 - 1.5) Cervical cancer 1.1 (0.96 - 1.3) Ovarian cancer 1.1 (0.6 - 1.8) Endometrial cancer 0.2 (0.1 - 0.8) Depo Provera and Cancer RR 95% CI WHO studies 1991-2

  29. Disadvantages of DMPA • (Injection cannot be removed once given) • Menstrual disturbance • Delay in return of fertility • Weight gain • (Androgenic side effects eg. acne - rare) • ? osteoporosis

  30. Depo Guidelines Contraception & Sexual Health Service Guideline for Injectable Contraception (Progestogen Only) - First Visit

  31. Depo & osteporosis SUMMARY • Special Warnings and Precautions etc: Loss of bone mineral density, increasing with length of use. A risk: benefit assessment should be performed, especially in young or adolescent women and if use is anticipated to be long term (ie 2 years or longer). In adolescents and women with significant lifestyle and/or medical risk factors for osteoporosis, other methods of contraception should be considered before using Depo-Provera.

  32. Depo Provera and Arterial disease • Reduction in HDL (15% approx) • Impairment of arterial endothelial function • Sorenson MB et al. Circulation 2002; 106: 1646-1651 • WHO Epidemiological study – no increased risk • WHO Contraception 1998; 57: 315-324

  33. Contraception at time of TOP • Talk to ALL women about LARC • IUD/IUS fit at time of STOP or MTOP: • WHO 1 for 1st trimester TOP • WHO 2 for 2nd trimester (<24/40) STOP or MTOP

  34. Bleeding patterns with Implanon®All studies Br J Fam Plann 1999;24

  35. BODY Wt. Comparative 2 yr study N=180 • METHOD CHANGE in Wt • Implanon +2.6% • Norplant +2.9% • Cu IUD +2.4%

  36. Cerazette • Desogestrel • As effective as COC • 12 hr rule • No oestrogen risks or S/E • Frequently used, often 1st choice POP or even 1st choice OC but for ?bleeding

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