CONTRACEPTION UPDATE OCTOBER 2011 DR HAYLEY ALLEN GP AND LEAD FP DR

AIMS OF SESSION To be able to offer women an effective choice consultation for contraception To be able to deal with simple contraception problems To have a brief insight into what’s new in the contraception world

CONTRACEPTION – WHY BOTHER? 50% of unintended pregnancies occur in women not using any contraception in the month they conceive 4 in 10 women are using their method inconsistently/incorrectly Only 1 in 20 unintended pregnancies are attributable to method failure

GENERAL PRINCIPLES (1) Many individual factors affecting a couples choice of contraception Advice should be given on all methods that are medically eligible To be effective, contraception must be used consistently and correctly For long acting methods to be cost effective the continuation rate must be high

UKMEC ELIGIBILTY CRITERIA 1 = A condition for which there is no restriction for the use of the contraceptive method 2 = A condition where the advantages of using the method generally outweigh the theoretical or proven risks 3= A condition where the theoretical or proven risks usually outweigh the advantages of the method 4= A condition which represents an unacceptable health risk if the contraceptive method is used

COMBINED ORAL CONTRACEPTION Works primarily by inhibiting ovulation via it’s action on the hypothalamo-pituitary axis, reducing LH and FSH Additional effects on the endometrium and cervical mucus First 7 pills of a packet inhibit ovulation, the rest maintain anovulation

MISSED PILLS Current guidance is to use 7 days extra precautions if 3 or more pills are missed at any time of the packet (2 or more if on 20mcg) If in first week and UPSI has occurred need emergency contraception If in second week nothing needed unless missed more than 7 pills If in third week to omit pill free week and nothing extra needed

COMBINED ORAL CONTRACEPTION Failure rate in perfect use 0.1% but in typical use averages at 5% The most used hormonal method. Can be used from menarche to age 50 depending on risks Important potential harms which need to be assessed with all first prescriptions. Should not be given to smokers over 35 unless stop for over 1 year

COMBINED ORAL CONTRACEPTION Not recommended in women of any age if hx of migraine with aura. Not used in women >35 if migraine without aura Liver enzyme inducing drugs reduce the efficacy so consider alternatives. Not recommended if BMI >35 due to increased VTE and MI risk. Remember to ask about FH VTE in first degree relatives >45 years age

PILL PROBLEMS (1) Half of those on COCP stay on first pill prescribed but up to 10% try 4 or more Of those who stop taking the pill nearly half do so because of minor side effects such as weight gain, poor cycle control, breast tenderness, mood swings, headache Need to consider whether side effects are progestogenic, oestrogenic or both

PILL PROBLEMS (2) If progesterone side effects consider a newer generation, more oestrogenic pill such as Marvelon or Yasmin If oestrogenic side effects consider a lower dose oestrogen or move to a progesterone dominant pill such as Microgynon or Loestrin For breakthrough bleeding consider a pill with increased dose of oestrogen to 35mcg such as Norimin or Cilest

BREAK THROUGH BLEEDING Consider alternative causes of bleeding - Cervical factors, erosion, polyps, cancer, Chlamydia - Recent pregnancy, RPOC - Missed pills - Failed pills due to diarrhoea/vomiting, drug interactions

PROGESTERONE ONLY PILLS SAFE FOR THE MAJORITY ONLY UKMEC 4 IS CURRENT BREAST CANCER

MODE OF ACTION All POPs alter cervical mucus to prevent sperm penetration into the upper reproductive tract For some women ovulation is inhibited 60% on levonorgestrel, 95% on desogestrel Take same time every day with no pill-free interval. 99% effective if taken regularly, increases with age and parity

MISSED PILLS >3hrs late (12hrs with desogestrel) Take late pill when remember and next pill at usual time. Barrier methods for next 48hrs Sex before missed pill is still protected

SIDE EFFECTS Altered bleeding pattern 2 in 10 no bleeding 4 in 10 regular bleeding 4 in 10 irregular bleeding 10-25% discontinue use at 1 year due to bleeding

FINAL POINTS Can continue until 55 years of age when natural loss of fertility can be assumed No evidence to support the taking of 2 POPs a day if >70kg No delay in fertility following discontinuation of POP

DEPO - PROVERA Works primarily by inhibiting ovulation Thickening of cervical mucus inhibiting sperm penetration into the upper reproductive tract Also changes the endometrium making it unfavourable for implantation

DEPO - PROVERA Failure rates if given regularly are <4 in 1000 over 2 years No max duration of use, review every 2 years. Can continue using until age of 50 Causes a delay in fertility following discontinuation of up to 1 year, but no evidence of reduced fertility long term

DEPO - PROVERA More cost effective than COCP after just 12 months due to reduction in number of unwanted pregnancies UKMEC 4 – CURRENT BREAST CANCER No interaction with Liver Enzyme- Inducing drugs. This is especially important in patients on anti-epileptic drugs or St. Johns wort

INITIATION Day 1-5 of cycle for immediate cover. 7 days of additional contraception if any other time of cycle Return every 12 weeks but can be given after 10 weeks if needed. Can leave up to 14 weeks without need for additional contraception

SIDE EFFECTS (1) 80% have altered bleeding pattern Up to 70% amenorrhoeic at 1 yr of use Association between depo and weight gain, mean gain 3kg at 2yrs Data varies but up to 50% discontinue at 1 yr due to bleeding or weight gain

SIDE EFFECTS (2) No proven association with mood change, libido, headache or cardiovascular disease Concerns on Bone Mineral Density if <18yrs and in older women. Recovers after discontinuation. Therefore review every 2 years and only use <18 or >40 if other methods unacceptable Reconsider use if any risks of osteoporosis

IMPLANON Single sub dermal rod, licensed for 3 years Contains 68mg etonogestrel UKMEC 4 = current breast cancer

IMPLANON Primary mode of action is inhibition of ovulation Also alters cervical mucus to prevent sperm penetration and inhibits normal endometrial development Pregnancy rate <1 in 1000 over 3yrs, very few true failures

IMPLANON No reduction in efficacy if BMI >30 so no restriction of use but manufacturers still suggest reviewing changing after 2 years No delay in fertility after removal Can use in migraine with or without aura unless develop new symptoms whilst using Efficacy affected by liver enzyme inducing drugs but not non liver enzyme inducing antibiotics

SIDE EFFECTS Altered bleeding common. 20% get no bleeding 50% infrequent, frequent or prolonged bleeding 25% discontinue at 1yr, up to 43% by 3 yrs Acne can improve or worsen No causal association with weight change, mood change, reduced libido or headache

INTRAUTERINE CONTRACEPTION Safe option for most women Need to consider STI risk and screening for Chlamydia and gonorrhoea prior to fitting UKMEC 4 = current PID, pregnancy, septic abortion, puerperal sepsis, cervical Ca, endometrial Ca, unexplained vaginal bleeding, anatomical distortion of uterine cavity e.g. Fibroids In addition IUS also CI in active liver disease/tumours, current breast cancer

INTRAUTERINE CONTRACEPTION In women who are high risk STI with no swab results antibiotic cover should be given e.g. Single dose 1g azithromycin Should be inserted by clinicians who are appropriately trained, maintained competence and attend regular updates. Appropriate resus equipment should be available

INTRAUTERINE CONTRACEPTION Efficacy determined by many factors such as sexual activity, age, parity TCU380 appears more effective than other copper IUDs At 5 years use failure rate <2% with TCU380 and <1% with IUS

INTRAUTERINE CONTRACEPTION TCU380 licensed for 10 years If inserted after age 40 can be retained until confirm menopause Mirena licensed for 5 years for contraception and menorrhagia, 4 years for endometrial protection If inserted after age 45 provides effective contraception for 7 years. Can be retained until menopause is confirmed or until contraception no longer required

COPPER IUD Copper is toxic to ovum and sperm and inhibits sperm penetration Works primarily by inhibiting fertilisation Endometrial inflammatory reaction which has an anti-implantation effect

MIRENA - IUS Effect mediated by progestogenic effect on the endometrium which prevents implantation Within 1 month of insertion high intrauterine concentrations of levonorgestrel (releases 20mcg day)induce endometrial atrophy Reduction in sperm motility and penetration through cervical mucus Has little effect on the hypothalamic-pituitary- ovarian axis so estradiol concentrations not reduced and majority continue to ovulate

MIRENA – MAIN BENEFITS Overall reduced menstrual flow Reduced No. Bleeding days Less dysmenorrhoea and premenstrual syndrome Progestogenic arm of HRT Only contraception with separate license for menorrhagia Reduced need for hysterectomy “REVERSIBLE STERILISATION”

NUVARING Combined contraceptive vaginal ring. Releases 15mcg ethinylestradiol and 120mcg etonogestrel a day. Same CI’s currently as COCP Insert for 3 weeks and then 1 week without. Excellent cycle control Change for new ring each time Costs approx £9 month Only has 4 month shelf life once out of fridge so prescribe max 3 month supply

QLAIRA New COCP with natural oestrogen Multiphasic - Different doses of hormone to mimic natural cycle so similar to old types of triphasic pill and achieve cycle control.24 day packet with 4 day withdrawal. Need to follow regimen carefully and missed pill rules will vary enormously depending on where in packet . Therefore compliance must be good

EMERGENCY CONTRACEPTION

Emergency contraception Levonelle can be given up to 72 hours post UPSI. It can be given after this time but patients need to know it is unlikely to be effective There is no limit to how many times a patient can have Levonelle in any one cycle Copper IUD can be inserted up to 5 days post UPSI, or 5 days after expected date of ovulation

ELLA ONE New emergency contraception soon to be launched in UK Will have a licence for use up to 5 days after UPSI Currently data states it is as effective as levonelle in first 72 hours and more effective than levonelle from 4-5 days. Still not as effective as emergency IUD

CONTRACEPTION AND BLEEDING PROBLEMS

Bleeding problems Exogenous administration of hormone contraception will dramatically influence the endometrial histology The exact mechanism of unscheduled bleeding is not fully understood but it may be due to blood vessel fragility within the endometrium Pre method counselling about the risk of bleeding may reduce concerns and encourage the continued use of the contraception

Bleeding problems the figures COCP = 20% irregular bleeding in fIrst 3 months, usually settles, ovarian activity suppressed POP = 1/3 experience a change in bleeding and 10% have frequent bleeding in first 3 months. Bleeding may not settle and ovarian activity is not always suppressed. 10-15% amenorrhoea Depo = bleeding disturbances common initially but 70% amenorrhoea by 1 year

Bleeding problems the figures Implanon = Bleeding problems common in first 3 months and at 6 months 30% still have irregular bleeding. Overall 20% end up with amenorrhoea and 50% have infrequent, frequent or prolonged bleeding which may not settle Mirena = Irregular bleeding common in first 3 months and can be light or heavy. 65% have reduced or no bleeding by 1 year and a 90% reduction in menstrual blood loss seen over 12 months

Clinical history When reviewing patients with unscheduled bleeding need to address: Patients concerns How using current method Medications that might interact Cervical screening history Risk of STI Any other associated symptoms e.g. pelvic pain, dyspareunia, PCB The possibility of pregnancy

Examination If there has been correct and consistent use of hormonal contraception a speculum examination should be performed if there is a persistent change in bleeding after at least 3 months of use, if medical treatment has failed, if they are not up to date with cervical screening, or of they have other associated symptoms Consider endometrial biopsy in women over 45 years or <45 with risk factors for endometrial ca

Medical options for bleeding If on COCP continue same pill for at least 3 months If bleeding problems on COCP consider increasing the strength to a 35mcg preparation such as Cilest or Norimin No evidence that changing the progesterone changes the bleeding risk If on POP can try a different one eg cerazette although no real evidence it makes a difference. No longer support the use of 2 POPs day to improve bleeding

Medical options for bleeding Bleeding with Depo, IUS or Implanon: A first line COCP with EE 30-35mcg and levonorgestrel or norethisterone may be used for 3 months, either cyclically or continuously (good practice point) Depo injections can be given up to 2 weeks earlier than due if bleeding occurs Mefenamic acid 500mg BD/TDS for 5 days to reduce duration of bleeding, limited effect

Medical options for bleeding Research suggests that doxycycline and mifepristone may also be beneficial but there is limited evidence to support their routine use in clinical practice If a patient has prolonged bleeding with implanon could also consider a single depo injection, especially if patient plans to move onto depo as alternative. “Try before you Buy “ theory (off licence use)

CASE 1 26 year old girl on COCP Missed two of her pills in third week of her packet, due her next pill now and asking for advice Had intercourse last night Does she need EC? What advice will we give her?

Case 2 41 year old patient comes to see you to discuss her heavy, painful periods but also requires contraception She is a non smoker, BMI 24, BP 130/80 What other information do you need to know? What are her options at this stage?

Case 3 30 year old patient currently taking cocp Recently diagnosed with epilepsy and started on carbemazepine Advised to come and discuss alternative contraception Has 2 children, no plans for any more in near future What are her options?

Case 4 18 year old on cocp. Very happy but getting headaches in her pill free week Not keen to change methods What other information do we need to know What are her options?

Case 5 16 year old girl with implanon for 18 months Just started to get break through bleeding for past 6 weeks continuously In her second relationship, been with current partner 3 months What investigations does she need? If all investigations are normal what are the options for treating her bleeding?

CASE 6 38 year old woman, been on depo for 12 years, very happy and no wish to change Has had 2 wrist fractures in past 2 years, awaiting bone scan What do we do if the bone scan is clear? What do we do if the bone scan show osteoporosis?

Case 6 Osteoporosis is not listed in UKMEC guidelines but if you consult WHO criteria then proven osteoporosis would be given a category 4 (contraindication) If bone scan is normal she is at no further risk than the average 38 year old so could continue as long as risk of long term use on bones is discussed

CASE 6 This patient was adamant she wanted to continue despite any risk and was willing to sign a letter saying so What else could we do in the event of osteoporosis to allow her to continue the depo? Consider use of adjuvant oestrogen, can use once daily gel or oral therapy