FAMILY PLANNING Sarah Stradling GP Camberley Health Centre

OVERVIEW Combined Contraception Emergency Contraception Gillick competence LARC POP Other methods The new kids on the block Case studies

The perfect contraceptive? The perfect contraceptive would: –give total protection against pregnancy –would be ethically acceptable –cheap –require little or no medical intervention –have no unwanted side effects but perhaps some benefits to health –fertility would return promptly and completely when use ended This ideal does not exist-apart from abstinence.

Efficacy Pearl Index- Comparing efficacy –High index; high chance of failure (no contraception 80-90) –Low index; low risk failure (Mirena <0.5) number of unintentional pregnancies related to 100 women years. E.g 3 pregnancies in 100 women in 1 year, pearl index is 3.0

I would like to go on the pill… Age Contraceptive hx Menstrual hx, LMP Obstetric hx- ectopic? Medical hx Medication Allergies

Options Risks/benefits Mode of action Side effects Teaching about method PILS Follow up Special instructions

COMBINED ORAL CONTRACEPTIVES ‘The Pill’

Mode of action and efficacy First consultation UKMEC Risks Initiation Missed pill guidance Choice of pill and managing side effects

Commonest hormonal Action- anovulatory –reduces endometrial lining Pills 1-7 INHIBIT OVULATION Pills 8-21 MAINTAIN ANOVULATION Important when considering ‘missed pills’

Pearl Index Perfect use vs. true use Promote safe sex- condoms –Sexual health screening –Opportunistic chlamydia (1:10 <25)

First COC consultation Clinical Hx- Medical conditions Drug use prescription and OTC Family hx Specific enquiries User preference and concerns

UkMEC (medical eligibility criteria) UKMEC 1- No restriction UKMEC 2- Advantages > theoretical proven risk UKMEC 3- Risk > advantages UKMEC 4- Unnacceptable health risk Suggest specialist referral if 3 or above

Risks Age- to what age can it be safely used? Smoking- can the coc be used in a 30 y.o smoker? Obesity (BMI 30-34; ;3) Blood pressure

Not Recommended (UKMEC category 4) Smokers >35 years (>15 a day) Migraine with aura at any age Known thrombogenic mutations BMI >40 BP consistently > 160/95 Current breast cancer Liver tumours Hx VTE/Stroke/MI Valvular and congenital heart disease

‘The pill scare’ VTE: Increase five fold, remains low No screen needed Different progestogens associated with risk- levonorgestrel and norethisterone may counteract thrombogenic effect of EE better than desogestrel and gestodene Greatest risk in first year Normal within weeks of stopping

Dianette- 35mcg EE and cyproterone acetate Four fold increase risk vs. microgynon 30 Limit duration of use Yasmin? Lies between the above

Risk per 100,000 women years Non COC/not pregnant 5 Levonorgestrel/norethisteron (Microgynon, Loestrin) 15 Desogestrel/gestodene (Marevlon, mercilon, fermodene 25 Pregnancy 60

Migraine: Migraine + aura (any age) Migraine – aura Risk of ischaemic stroke Is it an aura??

Breast Cancer: –No increase risk if family hx –Gene carriers –Current breast ca vs. past ca (>5yrs ago)

Drugs- –Liver enzyme inducers reduce efficacy, 28/7 after stopping –Non enzyme inducing antiobiotics- sept 2011 –Having reviewed the available evidence, the CEU no longer advises that additional precautions are required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less. The only proviso would be that if the antibiotics (and/or the illness) caused vomiting or diarrhoea.

What would you do with a patient with a UKMEC 4 score and says that they are accepting of the risk? Risk vs. pregnancy? Patients right to choose? Prescribing responsibility?

Non contraceptive benefits: –Blood loss and pain –Functional ovarian cysts –50% reduction in ovarian and endometrial ca (15 years post) –Acne –Tricycling packets: prevent bleed, endometriosis, withdrawl headache- OUTSIDE LICENCE

Initiation Day 1-5- immediate cover Elsewhere – COULD THEY BE PREGNANT? Alternative precautions Chaotic recurrent EC users? Immediate start and bHCG in 3/52- Quick Start Best method if chaotic?

Post partum- ideally day 21 Amenorrhoea- anytime + 7day Post TOP- up to 7 days

‘Missed Pill’ HOW MANY? WHERE IN THE PACKET? A missed pill is one that is more than 24hrs late. 1 active pill can be missed without the need for alternative precautions

If 1 pill missed at any time in packet Take the missed pill as soon as remembered Continue remaining pills as normal Emergency contraception is not usually needed but consider if earlier pills missed

If 2 or more pills missed at anytime in packet Take most recent missed pill Take remaining pills as usual Advised to use condoms/abstain until has taken 7 pills in a row Pills 1-7: Consider EC Pills 8-14: Nil Pills 15-21:Omit pill free interval (ED)

PILS Drug information leaflet NHS direct GP OOH Patient.co.uk

Which Pill? Monophasic COC with 30mcg EE + Norethisterone or levonorgestrel Why? –No evidence for biphasic or triphasic –Reduced VTE risk –20mcg efficacy similar but increased BTB Note: ED pills no evidence for increased compliance

Provide written information Review at 3/12 Bp and troubleshooting May issue 12/12 supply with SOS review Encourage 3/12 trial Advise re VTE signs/sx Advise re condom use for STI protection

Side effects Remember ‘side effects’ may not be COC related Oestrogen s/e- –Nausea –Dizziness –Bloating –Cyclical fluid retention –Vaginal discharge Swap to a progesterone dominant pill- e.g. Cilest, Brevinor, Marvelon

Progesterone s/e: –Vaginal dryness –Weight gain –Depression –Low libido –Breast tendernss Change to an oestrogen dominant pill e.g microgynon 30, loestrin 30/20

Changing from another form of contraception to COC and vice versa- MIMS and BNF EVRA-consistent levels of hormones, change every 7 days, ‘patch free’ week, ?improve compliance, if patch no longer sticky will need a new patch

NUVARING Once a month intravaginal ring Low oestrogen (2mg ethinyloestradiol- 15mcg daily and etonogestrel) Individually packaged No GI absorption- malabsorptive disorders, binge drinking, vomiting May view as user controlled LARC

Insert and leave for 3 weeks Ring free week- withdrawl bleed Does not matter where it sits unlike diaphragm Each ring works for 5 weeks Removal to ovulation→16 days

Can use tampons and spermicides <5% women report BTB 90% men found it acceptable Needs cold storage prior to dispensing, then has 4 month shelf life at room temp If taken out, 3hr window before contracptive efficacy is compromised No evidence that it effects cervical cytology

QUESTIONS?

EMERGENCY CONTRACEPTION

Preventing pregnancy following UPSI/contraceptive failure 1.Oral Hormonal - levonorgestrel (LNG) Inhibits ovulation as primary action] - Ella One Uliprisatal acetate- Selective progesterone receptor modulator 2. Copper IUD- Minimum 380mm² Toxicity to fertilisation and inflammatory action against endometrium- anti implantation NOT IUS

2002 Judicial review- pregnancy starts at implantation NOT fertilisation NO time in cycle when there is NO risk following UPSI No evidence that LNG/ulipristal will harm a fetus

Indications COC- 2 or more missed in week 1 PLUS UPSI in pill free week or week 1 POP- 1 missed pill (>3hrs late or 12hrs if cerazette) and UPSI in following 2 days IU- removal or expulsion and UPSI in previous 7 days Injectable- >14 weeks and UPSI Liver enzyme inducers- taken with COC or implant or in the following 28 days UPSI

‘The Morning after pill’ Levonelle 1500 ASAP, within 72hrs- licence Consider up to 5 days- outside licence Consider more than once in a cycle Always give if a/w IUD No CI to EHC Liver enzyme inducing drugs, ?2 doses

Ella One Licence for 5 days (120hrs) post UPSI Acts to delay ovulation May also have effect on the endometrium At least as effective as LNG Can only have once in a cycle Affects COC for 14 days, POP for 7 days

Vomits within 2 hrs- repeat Nausea- 14% 50% period was a few days late or early 16% non menstrual bleeding in next 7 days bHCG at 3/52 Levonelle 1500 £5.11 Ella One £16.95

Would you? Should EHC be offered in advance of need? –Foreign travel –Barrier methods May reduce unwanted pregnancies without increase in risky behaviour. Available OTC

IUD for emergency contraception Up to 5 days after 1 st episode UPSI Up to 5 days after calculated date of ovulation Detailed hx of normal cycle and calculate expected date of ovulation Always give EHC whilst arranging

Other discussions Sexual health screening Ongoing contraception ?start alternative method before next period Young people- No medical reason to avoid –Child protection issues

GILLICK COMPETENCE Gillick vs. West Norfolk HA (1986) DOH guidance Law Lords Ruling (Fraser ruling)…..

“ A clinician may provide treatment to a young person <16years, without parental consent, provided that he/she has confirmed that they are competent and that the Fraser criteria have been met” Advice understood Will have or continue to have sex Advised to inform parents In the patients best interests

Age <13years- responsibility to inform social services, advise patient Consider each case on merits 15 year old with a 17 year old partner 15 year old with a 35 year old partner 12 year old with a 14 year old partner

Case 1 20 y.o on Microgynon 30, has missed her last 2 pills and she is in the last week of her packet. She had sex without a condom yesterday and is worried about her pregnancy risk… What would you advise her?

Case 2 26 y.o had a split condom 4 days ago. She has a 28 day regular cycle and is now day 15 of cycle. She is requesting the morning after pill… How do you counsel her?

LONG ACTING REVERSIBLE CONTRACEPTION LARC

Options IUD IUS Injectable progestogens Progesterone only implant

NICE- Discuss with all women-QOF Cost effectiveness at 1 year >COC ↑ use of LARC leads to ↓unwanted pregnancies

Copper IUD IUSInjectionImplants Mechanism Fertilisation and implantation Prevents Implant Prevents ovulation Duration 5-10yrs, unless years unless weeks/ 8 weeks 3 years Failure Rate <2/100<1/100<0.4/100<0.1/100 Risks Bleeding Dysmen Ectopic- 1:20 PID Perforation Bleeding Ectopic PID Perforation Libido/acne Bleeding Weight gain BMD Bleeding Acne

Bleeding patterns IUD- Increased and often dysmenorrhoea IUS- 6/12 often irreg, amenorrhoea 65% after 1 year Injectable- 70% amenorrhoea at 1yr Implant- 20% amenorrheoa, 50% irregular

Fertility No alternation with IUD/IUS/Implant Injectable- up to 1 year, detectable in serum at 9/12 No guarantee on stopping

Suitability Nulliparous Breast feeding BMI Post TOP Diabetes Migraine + aura CI to oestrogen

IUD/IUS Chlamydia testing Ensure not PG prior to insertion Review at 6/52, trouble shooting IUD immediate cover IUS may need alternative Advise early return if pain or discharge, remind re bleeding

Use of tranexamic acid Systemic effects with IUS Lost IUD/IUS? Pregnant? Partner dissatisfaction Length of protection

Risks –Perforation: 1:1000 –Expulsion: 1:20 –Ectopic: 1:20 –PID: 6 times increased risk in first 20 days, then low

INJECTABLE ‘Depo’ DMPA (12/52) and NET-EN (8/52) Deep IM, well mixed Can safely be given up to 12+5-licence Can give up to 14 weeks-faculty guidance Emergency drug availability

Review every 2 years re ongoing use Not affected by liver enzyme inducers

?EC if greater 12+5 and upsi Up to age 50- consider change at 45+ Weight gain and elevated BMI Document date of next injection

BMD and injectables Caution if 40 Systematic review- reduction in BMD after 1 year but recovers after stopping MHRA –If <18 consider all other options before use –Revaluate every 2 years –If RF for OP consider alternative

IMPLANON/NEXPLANON Single subdermal rod Norplant- 5 rods, 1999, poor advice No effect on BMD Affected by liver enzyme inducing drugs ?trial of cerazette

8-10cm above medial epicondyle Woman must palpate No routine f/u Bleeding- tranexamic acid or COC Full assesment with IMB If cannot palpate- Xray

PROGESTERONE ONLY PILL

Mode of action- –Cervical mucus –Ovulation (up to 60% or 97% with desogestrel) Daily No pill free interval Takes 48hrs to thicken mucus 3Hrs- Femulen, Micronor, Noriday, Norgeston 12hrs- desogestrel (cerazette)

Failure rate % Decreases with age Traditionally double dose if BMI >70kg, NO evidence to support this and use of one pill is recommended Only UKMEC 4 is breast ca

Missed Pill advice…

Traditional POPDesogestrel POP (Cerazette) >3hr late i.e. >27hrs since last pill >12hrs late i.e. >36hrs since last pill 1.Take the missed pill 2.Take the next pill at the usual time (this may mean 2 pills in 1 day) 3.Condoms or abstinence for the next 48 hrs 4.No need for EC if sex before the missed pill

3 hr window may be difficult Cerazette £8.68 vs. micronor £1.80 Generic desogestrel £4.30 Advise re vomiting Avoid if using liver enzyme inducers Not affected by antibiotics No effect on lactation Migraine

Bleeding Patterns Commonest reason for stopping Good counselling may reduce 70% report prolonged, BTB or spotting General Guide –20% amenorrhoea –40% regular pattern –40% erratic

Level of tolerance ?use of increased dose for BTB, anecdotal but poor evidence. Remember if new bleeding pattern in previously untroubled patient… ?STI, Drug interactions, compliance, pregnancy

Commence in first 5 days- immediate cover Anywhere else extra precautions for 48hrs Can continue until the menopause

OTHER METHODS

Condoms Diaphragm LAM Sterilisation Natural family planning

CONDOMS Male and female condoms Traditionally latex Polyurethane condoms Latex allergy- usually local but may be systemic EU safety tested and kite mark Always look for the exp. date

Breakage and slippage reduce with experience Avoid oil based lubricants e.g. baby oil and petroleum jelly Failure rate: –True 2% –Actual up to 15%

Latex vs. latex free- efficacy the same Evidence supports the use of condoms to reduce the risk of STI. However, even with consistent and correct use, transmission may still occur.

Free condoms from family planning centres No restriction on selling condoms to those under 16years No evidence to suggest that supplying condoms encourages sexual activity

DIAPHRAGMS AND CAPS Diaphragm lies across the cervix Perfect use failure rate 4-8% True use 10-18% Need to be used with a spermicide Needs teaching Caps are much smaller Rarely used

Advantages: –Non hormonal –More independent of intercourse than condom –Reduces the risk of HPV transmission Disadvantages: Messy Forward planning Low efficacy

Must apply spermicide to both sides Active for 3hrs Leave in for at least 6hrs post intercourse Top up if intercourse again Remove, wash and allow to dry Resizing needed if >3kg weight change, TOP, miscarriage, vaginal delivery, vaginal surgery

LACTATIONAL AMENORRHOEA No guidance provided by faculty A method of contraception?? Reported failure of 2% Criteria to be met: –No return of periods –Baby is nearly or fully breastfed (4hrs in the day and 6hrs at night) –The baby is less than 6 months old (i.e. pre weaning) Note: ‘nearly fully breastfed’ means that the infant receives mostly breast milk but can have ‘some’ alternative liquids

STERILISATION Counselling, especially LARC, permanent Take a full contraceptive hx No absolute CI- make request themselves, sound mind and no external duress Female- Tubal occlusion, alternative method until surgery and until the next period Male- No scalpel approach with division of vas and diathermy, contraception until clearance

Failure rate: –Women 1:200 (same as IUS) –Men 1:2000 after clearance If pregnancy occurs after female sterilisation increased risk of ectopic. Increase report of heavy periods after sterilisation.

Persona Natural family planning- temperature, cervical mucus, avoidance of ‘unsafe time’ around ovulation (days of a 28 day cycle)

The New Kids On The Block Zoley- Estradiol, 24 active and 4 inactive. Good cycle control, 1 in 3 bleed free cycles. Well tolerated Jaydess- IUS for 3years. Aimed at younger women. Smaller insertion device. Not licensed for DUB or HRT. Less amenorrhoea, but lighter flow

Sayana Press- s/c version of depo. Same s/e and licence. More expensive, pt reports more skin reactions and worse pain at administration.

QUESTIONS??

1 18 y.o off to uni, previous termination, no regular partner but admits to having regular one night stands. How do you advise her?

2 34 y.o smoker asking for a cocp repeat- Microgynon. What issues do you need to consider and how do you advise her?

3 28 y.o. with a young baby and a 3 year old. Thinks that she would like more children but with a gap. Had the depo before and this suited her really well. What issues do you need to consider and how do you advise her?

4 32y.o would like to have a ‘coil’. Her sister has a copper coil and she likes the idea of no hormones. Has heavy periods with flooding and dysmenorrhoea. How do you advise her?

5 23 y.o comes asking for ‘the pill’. Has never had any contraception before other than using condoms. How would you approach this consultation?

6 15 y.o comes with a friend asking to go on the pill. She asks you to promise that you won’t tell her mum- who is a regular patient of yours. What issues does this consultation present? Would you prescribe to her?

7 25 y.o that has been on the cocp for 5 years has recently been diagnosed with epilepsy and started on carbamazepine. She was advised to come by her neurologist. What contraceptives are available to her and where would you go to get the information if you wanted to be sure?

8 19 y.o who has a BMI of 34 and a 5 a day smoker comes asking for the pill. She has had emergency contraception twice in the last 4 months. What are her options, how would you advise her? She decides on POP, how and when do you start this?

9 20 y.o had UPSI 3 days ago with her long term partner, they usually rely on condoms. She is on day 10 of a 28 day cycle. What options are available to her and what would you advise?

10 14 y.o. was drunk at a party last night and thinks that something may have happened with a ‘boy’ she barely knows. What are the issues and how would you advise her

11 Linda is forty years old, married with three children. She is a non smoker and has been taking the COCP for 7 years. She stopped taking it last week because her younger sister has been admitted to hospital with a DVT. She does not really want any more children. What are her options?

12 Sam is 35, she has recently got divorced. She has one child. She has had a coil for the last 9 years. She knows her coil will need changing soon. She is not sure if she wants another one. What is your advice?

13 Gemma is 22. She has the depo injection and has attended for her next injection. Her last one was 15 weeks ago. She had sex 2 days ago. What do you do?

Useful websites Fpa.org.uk (formerly Family Planning Association) BNF online Mims online Contraception- John Guillebaud