6StatisticsApproximately 200,000 women in England/ Wales seek abortion / year62% 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 “
7Contraceptive Efficacy Pearl Index: No. of pregnancies/ 100 years of useContraceptive efficacy depends on:AgeMotivation of user/ compliance/ concordanceDuration of use of contraceptive methodPearl indexMechanism of action: Method that stops ovulation and is independent of user compliance
10Non-Hormonal Contraception Barrier Methods (Males)CondomsMost commonly used NHCPearl Index 2 – 15Latex/ PolyurethaneMost come with the spermicidal, Nonoxynol-9Beware of certain topical products/ lubricantsProtection against STI’sDisposable
11Non-Hormonal Contraception Barrier Methods (Females)Femidom (female condom)Pearl Index 5 – 15Latex/ PolyurethaneMost come with the spermicidal, Nonoxynol-9Insertion – Prior to sexual intercourseRemoval – Does not need to be removed immediately after ejaculationBeware of certain topical products/ lubricantsProtection against STI’sSome evidence that polyurethane femidoms can be washed, disinfected and reused
12Non-Hormonal Contraception Barrier Methods (Females)Vaginal DiaphragmPearl IndexLatex/ Silicone5 mls of spermicidal should be usedInsertion – Can be inserted up to 6 hrs prior to sexual intercourseRemoval – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 30 hrsBeware of certain topical products/ lubricantsLess protection against STI’sCan be washed, disinfected and reused – 1 yrRight size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgsD. Adv – UTI’s , risk of TSS (2.4:100,000)Contraindications – Latex allergy, H/O TSS, poor vaginal tone, prolapse (cystocele/ rectocele), HIV
13Non-Hormonal Contraception Barrier Methods (Females)Cervical CapPearl IndexLatex/ SiliconeSpermicidal should be used – fill about 1/3 rdInsertion – Can be inserted up to 6 hrs prior to sexual intercourseRemoval – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > hrsBeware of certain topical products/ lubricantsDoes not protect against all STI’sCan be washed, disinfected and reused – 1 yrRight size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgsD. Adv – Can be difficult to insert, risk of UTI’s, TSSContraindications – Latex allergy, H/O TSS, cervical diseases (malignancy, poor smear result, cervicitis) etc), HIV
14Non-Hormonal Contraception Barrier Methods (Females)Contraceptive SpongePearl IndexPolyurethane FoamContains a spermicidalInsertion – Prior to sexual intercourse. Moisten with water before insertionRemoval – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 24 hrsDoes not protect against all STI’sDisposableD. Adv – Risk of UTI’s, TSSContraindications – Latex allergy, H/O TSS, HIV
16UKMEC Faculty of Sexual & Reproductive Health Care of the Royal College of Obstetricians & Gynecologists
17Hormonal Contraception (COC’s) Mechanism of action:Inhibits ovulationThickens cervical mucusRenders endometrium unsuitable for implantationPearl Index:0.3 – 4With perfect use it is 0.1 (true pill failure)
18Hormonal Contraception (COC’s) 1st prescription of a COC UKMEC guidance will help in safe prescription of COCAgeBreastfeedingPostpartumSmokingObesity – BMIRisk factors for CVD – old age, smoking, obesity, hypertension, diabetesBPVTE and risk factors for VTEH/O IHD, Stroke, Hyperlipidemia, PVDH/O Valvular heart diseaseHeadaches/ MigrainesBreast disease/ Family Hx/1 breast diseaseEndocrine Diseases – Diabetes (with/ without PVD)Liver/ Gall Bladder Diseases – Gall stones, Cholestasis, Hepatitis, Cirrhosis, Liver tumorsAnaemiaRaynauds Disease, SLEDrug Interactions
19Hormonal 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 pillHigh estrogen side effects: nausea, dizziness, bloating, vaginal discharge, breast problems – try a lower estrogen pill or changing the pillHigh progestogen side effects: mood swings, reduced sexual drive, vaginal dryness, breast tenderness, wt gain, acne – try a low progestogen pill or changing the pillBenefits of COC:Contraceptive benefits –Good efficacy if good compliance, reversibilityNon-contraceptive benefits - periods regular, light, painless, protection against ovarian cysts, ovarian tumors, benign breast diseases, endometrial ca, colorectal ca, few extra uterine pregnancies
20Hormonal 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 protectionCOC 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 daysWhich 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 noevidence to support the use of biphasic or triphasic pills”
21Hormonal Contraception (COC’s) 1st prescription of a COC YasminFemodetteFemodeneCilestLoestrin 20Microgynon 30Ovysmenn
22Hormonal Contraception (COC’s) 1st prescription of a COC Missed Pill Advice
23Hormonal Contraception (COC’s) Follow up prescription of a COC Pill check - initially 3 mths- then 6 months x 2- then annually if no risk factorsCheck well being/ adverse effectsNew risk factors/ contraindicationsMenstrual historyBP, Smoking, BMI, concordanceCervical smearCheck educationMissed pill adviceInteraction with drugsIntercurrent illness – D/VRisk of STI’sFuture plan of wanting to concievePrenatal advice regarding diet, exercise, smoking, OTC F acid, RubellaUnusual/ prolonged headachesAura/ visual problemsSpeech disturbanceWeakness/ paraesthesia in limbsPainful calf swellingFocal epilepsySevere abdominal pain/ jaundiceFracture/ surgery/ immobilisationHigh BPSevere skin rashNew risk factor for breast caSTOP
24Hormonal Contraception (COC’s) Estradiol Valerate + Dienogest4 sequential phasesPearl Index: 0.4 – 0.5Missed pill: may need 9 days extra precautions +/- EC
25Hormonal Contraception (Transdermal - EVRA) Failure rate <1% if used correctlyEach patch lasts a weekChange a patch every week for 3 weeks followed by a weeks breakIf the patch comes off, do not reattach it – adv to use a new one
26Hormonal Contraception (POP’s) Inhibits cervical mucus (Cerazette also inhibits ovulation)Pearl index: Micronor :- 0.3 – 4; Cerazette:- 0.17Start on day 1 of period , no PFIWindow period: Minipill :- 3 hrs; Cerazette:- 12 hrs.If missed/ delayed pill then take other pills as usual + extra precautions for 48 hrs +/- ECCan be started 3 weeks postpartumNot affected by broad spectrum antibiotics but by enzyme inducersCan be taken with HRT in perimenopausal period until menopauseRefer to UKMEC for contraindications
28LARC’SWomen requesting any contraception should be given information about and offered choice of all methods including LARCNICE LARC GUIDELINES 30, DOH: 0CT 2005QOF 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%)
29LARC’SAll currently available LARC methods (IUD, IUS, Implanon, DEPO) are most cost effective than COC even at 1 yr of ageIUD, IUS and Implanon are more cost effective than injectable contraceptionIncreased uptake of LARC methods will reduce the number of unintended pregnanciesNICE recommendations for LARCS:Provision of information and informed choice to patientsTraining of health care professionalsNICE LARC GUIDELINES 30, DOH: 0CT 2005
30LARC’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 – 2STI screen prior to insertionAdverse effects: heavy, painful bleeding likelyRisks:< 1:1000 chance of uterine perforation< 1:100 chance of PID following IUD insertion but risk increases if already has STI1:1000 in 5 yrs chance of an ectopic pregnancy but 1:20 chance of ectopic if gets pregnant while on the coil
31LARC’S (IUD’S) Contraindications: Refer to UKMEC Insertion: Anytime during periods. Anytime when not pregnant + 7 days extra precautionsImmediately post 1st/ 2nd trimester abortion4 weeks post partum irrespective of mode of deliveryFollow up – After 1st period/ 3 – 6 weeks post insertionCheck for threads, expulsion, infection, perforation.(USS if unable to locate the IUD)Heave periods while on IUD:NSAIDS/ Tx acidShort course of low estrogen COCChange to IUSCervical smear may show ActinomycosesIf IUD and pregnant, remove coil before 12 weeks
33LARC’S (IUS)Inhibits fertilisation and implantation, thickens cervical mucusLicense: 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: < 0.5STI screen prior to insertionAdverse effects:Irregular bleeding common in 1st 6 mths of insertion – oligomenorrhoea/ amenorrhoea likely by the end of 1 yr of useNo evidence of wt gain. Slight effect on mood, acne a possibilityRisks:< 1:1000 chance of uterine perforation< 1:100 chance of PID following IUD insertion but risk increases if already has STI1:1000 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
34LARC’S (IUS) Contraindications: Refer to UKMEC Insertion: Anytime during periods. Anytime when not pregnant + 7 days extra precautionsImmediately post 1st/ 2nd trimester abortion4 weeks post partum irrespective of mode of deliveryFollow up – After 1st period/ 3 – 6 weeks post insertionCheck for threads, expulsion, infection, perforation(USS if unable to locate the IUS)Cervical smear may show ActinomycosesIf IUS and pregnant, remove before 12 weeks
35LARC’S (POIC’s – Depo-Provera) Inhibits ovulationPearl Index: 0 – 1Repeated every 12 weeksCould be a delay up to 1 yr in return of fertility after stoppingAdverse effects:Amenorrhoea likely but irregular/ heavy bleeding can happen (Rx with Tx acid/ add oestrogens)Wt gain: 2-3 kg in a yearReduced BMD but no increase in risk of fracturesNot associated with acne/ depression/ headachesNo evidence of congenital malformation if pregnant while on DEPOContraindications – Follow UKMECLicense: 2-3 yearsInjection: Same as IUD/IUS but can be given immediately post partum
36LARC’S (POIC’s – Depo-Provera) Timing of DEPOHas unprotected sex occurred?Can DEPO be given?Is EC indicated?Are condoms or abstinence advised?Should pregnancy test be performed?< 14 weeks since the previous injectionN/A as injection not lateYesNo> 14 weeks since the previous injectionYes, for next 7 daysYes, in the last 3 daysYes, 3 weeks laterYes, 5 days backYes, offer Cu coil as ECYes, > 5 days backYes, for 3 weeks until pregnancy test confirmed –ve and for 7 days after giving DEPOYes, initially and 3 weeks later
37LARC’S (POSDI’s - Implanon) Inhibits ovulationPearl Index: 0 – 0.1License: 3 yearsAdverse 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 yearReassurance, Tx acid, low dose COC (Mercilon) in a tricycle fashionAcne possibleNot associated with weight gain, mood swings, reduced libido, headachesContraindications – refer to UKMEC
38LARC’S (POSDI’s - Implanon) Insertion of ImplanonTiming – same as DEPOSite – Non-dominant arm, 10 cm above the medial epicondyle as opposed to bicipital groveImpalpable Implanon – deep insertion/ failed insertion/ migration. Locate with an USS. If deep insertion, referRemoval – straight switch to another Implanon/ Contraception
39Emergency Contraception Hormonal EC – Levonorgestrel (Levonelle)Non-hormonal EC – Cu IUDEC in future
40Emergency 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 daysLicense – 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 contraindicationsDrug Interactions – If on liver enzyme inducers, Cu IUD preferred. If declined then a single dose of 3 mg is given (unlicensed)
41Emergency Contraception (Hormonal EC – Levonelle) History:Assess for competence if young and document as “Fraser ruling competent”Full sexual Hx including last/ previous UPSI’sLMP (if pre-ovulatory)Assess risk of STI – offer everyone a STI screenAdvice about LARCStart a regular contraception when issuing EC if possibleCounsel about LevonelleAdverse effects:Nausea, vomiting (if vomiting within 2 hrs of taking it, repeat dose)Next period earlier/ late, lighter. If delayed/ lighter than expected – preg. testConsider advance provision of Levonelle in some cases
42Emergency Contraception (Non-hormonal EC – Cu IUD “Multiload 375”) Inhibits fertilisation; Inhibits implantationLicense – Up to 5 days post UPSI or before day 19 of a regular cycleAlways offer a emergency IUD even if presents within 72 hrs post UPSICan be removed at anytime during next period if not had UPSI since next period and alternative cover started at the right timeHistory taking vital as for levonelleIf at risk of STI (<25 yrs and > 1 sexual partner in the last 1 yr) insert EC-IUD but give prophylaxis
43Emergency Contraception (Future EC) EllaoneSelective progesterone receptor modulatorUsed up to 120 hours post UPSIDose – one dose of 30 mgExtra – precautions until next periodCannot give > 1/ monthCan cause headaches, nausea, abdominal pain
44Emergency Contraception (Future EC) MifepristoneProgesterone antagonistEffective EC when taken in a single dose up to 120 hours post UPSISingle dose – 25 – 50 mgNot licensed for EC in the UK
46Case - 1Nicola 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 normalWhat are the issues here?What contraceptives would you discuss with her?
47Case - 2Janet, 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?
48Case - 3You 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?
49Case - 4Liz 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?
50Case - 5Maria, 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 normalWill you continue issuing her the patches?What are the alternatives?
51Case - 6Tiffany is 25 yrs old. She has 2 children. She is currently in a new relationship for the last 2 months. She has multiple sexual partners in the last 1 year. She is keen on a copper coil.What would you discuss with her?What other LARC methods will be safe and suitable for her?
52Case - 7Nicola, 25, mother of 2, recently had a normal delivery 4 weeks ago, requests a COC. Her BMI is normal, she doesn’t smoke. She is breast feeding.Is this the right time to start COC for her?What contraceptive options are you left with?Would you consider an IUD/IUS?
53Case - 8A 16 yr old girl on long term Tetracycline for her acne attends having had a UPSI last night. She is on day 12 of her cycle.What are your concerns?What would you offer her?What advice will you give her?
54Case - 9A 25 yr old attends following a burst condom 48 hrs ago. She is on day 8 of her 28 day cycle. She is taking St John’s Wort.What are your concerns?What would you offer her?What advice will you give her?
55Case - 10A 30 yr old women attends the clinic having had repeated UPSI’s since her normal period. The 1st UPSI was on day 6 of her cycle. She has a 28 day cycle. She is now day 16.What are your concerns?What would you offer her?What advice will you give her?
56Case - 11A 20 yr old attends the clinic having had 3 UPSI’s – most recent was last night and the 1st episode was 7 days back. She is now on day 25 of her cycle. Her usual cycle is days.What are your concerns?What would you offer her?What advice will you give her?
57Case - 12A 25 yr old woman telephones the clinic for advice. She uses a 30 mcg COC. She is usually a regular pill taker but has missed 3 pills. These were the 2nd week of her pill packet (pills 9,11 and 14). She had sex last night immediately following the 3rd missed pill. What do you advice?She should attend the clinic for an EC?Reassure her that EC is not needed and ask her to carry on taking the remaining pills?She should continue with her COC but use condoms until 7 concecutive pills?She should run 2 packets of pills together avoiding her next pill free week?
58Case - 13Mrs G is using a POP as contraceptive. She is now aged 49 and wonders how long she should continue with her contraception. She hasn’t had a period for 1 yr. She is getting vasomotor menopausal symptoms. She is sexually active.How long should she continue with her contraception for?Will you change her contraception?How can you be sure she is post-menopausal?How will you control her vaso-motor symptoms?
60Contraception over 40 Average age of menopause is 50.7 yrs Diagnosis of menopause –1 yr amenorrhoea if > 50 yrs or 2 yrs if < 50 yrs+Clinical symptomsBlood tests – Raised FSH (> 30 IU/L) and LH on 2 occasions done 1-2 mths apartNo single indicator is considered reliable
61Useful Websites www.ffprhc.org.uk BNF online www.mims.co.uk References Faculty of Family Planning and Reproductive Health Care Clinical GuidanceGuillebaud, J. Contraception Today. 5th ed. Martin Dunitz, 2005
62Life, why contraception is viable Please, put her out of my misery..