Sponsored by HRA Pharma Contraception Update Dr Tracey Dibble Associate Specialist at Sheffield Contraception & Sexual Health Service March 2012 Sponsored by HRA Pharma

“Family planning could provide more benefits to more people at less cost than any other single technology now available to the human race” James Grant, Unicef Annual Report 1992

Aims UK Picture Human Fertility History Lesson Current UK Use Contraceptive Methods LARC User Dependent EC New Developments

Why is this important in the UK? High teenage pregnancy rates in Sheffield & UK (compared to Europe) Increasing abortion rate Increasing repeat abortions

Teenage Pregnancy 2010 Figures E & W rate is 35.5 / 1000 Lowest since 1969 ↓ 9.5% since 2009 Sheffield rate is 41.4 /1000

Teenage Pregnancy Rates 1998 - 2010

Abortion 2010 Figures E & W Total numbers 189,574 (↑0.3% 2009) Rate 17.5 / 1000 women Rate 16.5 / 1000 under 18s Sheffield Total numbers 1683 Rate 13.2 / 1000 all women Rate 18 / 1000 under 18s

How fertile are human beings ? No breeding season For women maximum desire corresponds to most fertile phase 350 million sperm / ejaculate Sperm survive average 3-4 days (“super sperm” 6-7 days) Ovum needs to be fertilised within 12hrs Most fertile days are 2-3 days prior to ovulation

The menstrual cycle

Brief History Lesson

Development of Condoms 1000BC - Egyptians used linen sheath condoms for prevention of infection 1500s - linen sheaths used in European Syphilis epidemic – usefulness against pregnancy also discovered 1700s – animal intestine condoms available but expensive 1880’s – vulcanisation of rubber & mass production of rubber condoms, Goodyear & Hancock

Decline of Birth Rate in Victorian England – McLaren 1978 Years Children per marriage 1860’s 6.16 1870’s 5.8 1880’s 5.3 1890’s 4.13 1915 2.43

Consequence of birth control? -McLaren 1978 Year of birth Estimated proportion of women who control or attempt to control their fertility 1831-1845 19.5% 1861-1870 42.7% 1902-1906 72%

What methods were available? Coitus interruptus “until at least WWII the most popular form of contraception in England”-McLaren 1978 Temporary abstinence Condoms Abortion – although illegal it was common

Development of the pill Early 20th Century Feminists & Birth Control movement – Stopes, Sanger & McCormick Mexico 1950s – Marker & Djerassi 1960 1st pill marketed

Contraception in UK 2008/09, ONS Method 1997/8 2008/09 Pill 26% 25% Sterilisation 21% 17% Condom IUD/IUS 4% 6% + 2% Withdrawal Depo / Implanon 2% 3% +1% Other method 5% Pregnant No relationship 14% 13% 11% Vas & 6% female sterilisation Pill 16% coc

LARC Methods From NHS Community Contraception Clinics

Characteristics of a good contraceptive Effective Forgettable Convenient Reversible Safe Cheap Few side effects

Percentage of women pregnant in first year of use Effectiveness Spermicides Female condom Diaphragm w/spermicides Male condom Oral contraceptives DMPA IUD (TCu-380A) IUDs are among the most effective methods of contraception, with failure rates of less than 1 percent. This chart compares the pregnancy rates for the IUD with the rates for other contraceptive methods. The red rectangles show pregnancy rates for correct and consistent use, reflecting how often a contraceptive fails when it is used both correctly and consistently. The blue rectangles show pregnancy rates for typical use, reflecting how often a contraceptive fails in real-life situations, when it may not always be used correctly and consistently. In the case of the IUD, there is practically no difference between pregnancy rates for correct and consistent use and typical use. As the chart shows, other reversible contraceptive methods, such as barrier methods or oral contraceptives, may have low pregnancy rates with correct and consistent use but much higher rates with typical use. With the IUD, the woman does not need to do anything, although it is advisable to check for IUD strings once a month to make sure it is in place. Because the effectiveness of IUDs does not depend on daily user compliance, the pregnancy rates for the IUD are extremely low even with typical use. Use of the IUD results in about the same pregnancy rate as sterilization, a nonreversible method.1 █ Reference: 1. World Health Organization/Department of Reproductive Health and Research (WHO), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007. Rate during perfect use Female sterilization Rate during typical use Implants 5 10 15 20 25 30 Percentage of women pregnant in first year of use Source: CCP and WHO, 2007.

Cost Contraceptive Cost / year Nuvaring £108 Evra patches £65.04 Yasmin £58.80 Cerazette £35.40 Implanon £27 Marvelon £20.10 Depo Provera £18.03 Mirena £16.63 Microgynon £11.96 Noriday £8.40 T Safe Cu 380 £1.00

Forgettable ! User Dependent Methods Condoms Pills Unfortunately are very forgettable!! Success depends upon excellent compliance

Forgettable User Independent Methods LARC methods Sterilisation Cannot be forgotten therefore woman can relax - she is not going to get pregnant

Consequences of forgetting Audit of contraception use in 200 vulnerable women at Sheffield TOP clinic, 2008 Contraception being used before pregnancy None 39% Condoms 35% Pill methods 27% No LARC failures

What is LARC? Long Acting Reversible Contraceptives are methods of contraception which are administered less than once / month

Depo Provera Pros Effective High dose progestogen im injection Inhibits ovulation Every 12 weeks Doesn’t interfere with sex More under patient control Often causes amenorrhoea

Depo Provera Cons Can be forgotten Osteopenia / osteoporosis Irregular / heavy bleeding Weight gain Low mood Delay in fertility return – average 1yr

Nexplanon Replaced Implanon in Oct 2010 Small rod in upper arm - inhibits ovulation Pros Very effective (0 – 0.07% ) Lasts 3 yrs Forgettable Doesn’t interfere with sex Very safe Cost effective

Nexplanon Cons Needs to be fitted & removed by Dr or nurse Some people don’t like idea of foreign body in arm Irregular or heavy bleeding Amenorrhoea Weight gain??

IUDs Pros Effective Forgettable Doesn’t interfere with sex Long lasting up to 10yrs Good safety record No hormones

IUDs Cons Needs fitting / removal by Dr or nurse Some patients do not like idea of IUD inside them Heavy bleeding Risk of perforation/ expulsion/ infection Not always tolerated esp by nullips

Mirena IUS Pros Very effective Forgettable Doesn’t interfere with sex Long lasting –5yrs Treatment of menorrhagia Used as part of HRT

Mirena IUS Cons Needs fitting / removal by Dr or nurse Some patients do not like idea of IUD inside them Irregular bleeding / spotting Risk of perforation/ expulsion/ infection Not always tolerated esp by nullips

Sterilisation Female Sterilisation Vasectomy Irreversible Under GA Filshie Clips on Fallopian tubes Failure rate 1 in 200 Immediately effective Irreversible Under LA Dissect Vas deferens & remove a small piece Failure rate 1 in 2000 Not immediately effective

User Dependent Methods Oral Contraceptives COC POP & Cerazette Barrier Methods Condoms Diaphragms Natural Family Planning

Combined Oral Contraceptive Pill Combines Oestrogen & Progestogen Very effective 0.2 – 3% Good menstrual cycle control Not related to sexual intercourse Helps heavy / painful periods

COC Cons Complicated pill rules Difficult to remember Minor side effects – nausea, breast tenderness Increased venous thrombosis, heart disease, stroke but only if have pre-existing risk factors (e.g. obesity , smoking) Small increased risk of breast cancer

How safe is the pill? Comparative Risks /100,000 women (Yr 2000) Taking pill = 1 death Home accidents = 3 deaths Having a baby, UK = 6 deaths Road accidents = 8 deaths Smoking at age 35yr = 167 deaths, next yr Having a baby, Rural Africa = 600-1000 deaths

Evra COC in patch form Efficacy 0.99-1.24% failure rate 20 cm patch 4.6% patch detachment Worn for 3 weeks with 1 week break Each patch lasts 7 days If forget to change patch - ok up to 2 days late Expensive £7.74 / month ( Compared to COC £0.50 / month

Progestogen Only Pill Pros Very safe Less effective (0.3 – 4%) Relies on thickening cervical mucus Inhibits ovulation in some women OK if oestrogen is contraindicated OK if breastfeeding

POP Cons Difficult to remember Only 3 hour window Higher failure rate Poor cycle control – irregular bleeding

Cerazette New POP Higher dose Inhibits ovulation in 97% of cycles Still very safe More effective (0.7 – 1.1%) 12hr window Poor cycle control for some women – irregular bleeding

Condoms Still best protection against STIs Good for additional protection alongside another contraceptive User failure rates are high Non latex versions available

Diaphragms Not very effective Perfect Use 6% Typical Use 16% Useful to space children Use in 40s Irritation from spermicide

Emergency Contraception Copper IUD Most effective Can be fitted up to 5 days after sex Levonelle High dose progestogen Can be used up to 3 days after sex Available OTC Delays ovulation Safe

ellaOne Licensed in Autumn 2009 Progestogen blocker Inhibits ovulation More effective than Levonelle Works up to 5 days after sex Must not be used more than once in cycle or if any earlier risk of pregnancy May effect ongoing contraception Expensive £ 16.95

New Developments New Methods Nuvaring Qlaira New Ways of Using Old Methods Tricycling COC & reducing PFI

Nuvaring Vaginal ring containing hormones Wear for 3 weeks, 1 week off – withdrawal bleed Stops ovulation <1% failure rate Well tolerated Can be worn during sex Periods lighter, regular, shorter Expensive

Tailored Pill Regimes Pill Free Interval is cause of high failure rate of COC Now out dated Who needs a period? Options Reduce PFI to 4 days Reduce frequency of PFI – only every 3 months