CONTRACEPTON FOR GP’S Dr Mazhar Khan 7 April 2010

AGENDA Statistics Contraceptive Efficacy Non-hormonal Contraception UKMEC/ WHO criteria for safe prescribing Hormonal Contraception Cases

Statistics UK has one of the highest rates of teenage pregnancies in the world UK has one of the highest levels of unintended pregnancies in the world

Statistics

Statistics

Statistics Approximately 200,000 women in England/ Wales seek abortion / year 62% 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 “

Contraceptive Efficacy Pearl Index: No. of pregnancies/ 100 years of use Contraceptive efficacy depends on: Age Motivation of user/ compliance/ concordance Duration of use of contraceptive method Pearl index Mechanism of action: Method that stops ovulation and is independent of user compliance

Contraceptive Efficacy Pearl Index Method Pearl Index None (young women) 80-90 None (age 40) 40-50 None (age 45) 10-20 None (age 50) 0-20 Contraceptive Sponge 9-25 Rhythm Methods 6-25 Spermicide only 4-25 Coitus Interruptus 8-17 Persona 3-6 Male Condom (sheath) 2-15 Method Pearl Index Female Condom 5-15 Diaphragm 4-20 IUCD (coil) 0.2-2 IUS <0.5 POP 0.3-4 COC 0.1-4 Implanon 0-0.1 Depo-Provera 0-1 Sterilisation - Female 0-0.5 Sterilisation - Male 0-0.05

Non-Hormonal Contraception Natural Family Planning Calendar Method BBT Cervical Mucus Test Billings Ovulation Method PERSONA Lactation Coitus Interruptus

Non-Hormonal Contraception Barrier Methods (Males) Condoms Most commonly used NHC Pearl Index 2 – 15 Latex/ Polyurethane Most come with the spermicidal, Nonoxynol-9 Beware of certain topical products/ lubricants Protection against STI’s Disposable

Non-Hormonal Contraception Barrier Methods (Females) Femidom (female condom) Pearl Index 5 – 15 Latex/ Polyurethane Most come with the spermicidal, Nonoxynol-9 Insertion – Prior to sexual intercourse Removal – Does not need to be removed immediately after ejaculation Beware of certain topical products/ lubricants Protection against STI’s Some evidence that polyurethane femidoms can be washed, disinfected and reused

Non-Hormonal Contraception Barrier Methods (Females) Vaginal Diaphragm Pearl Index 4 - 20 Latex/ Silicone 5 mls of spermicidal should be used Insertion – Can be inserted up to 6 hrs prior to sexual intercourse Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 30 hrs Beware of certain topical products/ lubricants Less protection against STI’s Can be washed, disinfected and reused – 1 yr Right size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgs D. Adv – UTI’s , risk of TSS (2.4:100,000) Contraindications – Latex allergy, H/O TSS, poor vaginal tone, prolapse (cystocele/ rectocele), HIV

Non-Hormonal Contraception Barrier Methods (Females) Cervical Cap Pearl Index 11 - 19 Latex/ Silicone Spermicidal should be used – fill about 1/3 rd Insertion – Can be inserted up to 6 hrs prior to sexual intercourse Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 48 - 72 hrs Beware of certain topical products/ lubricants Does not protect against all STI’s Can be washed, disinfected and reused – 1 yr Right size is important – size changes post delivery/ termination/ miscarriage/ pelvic surgery/ wt change > 6.8 kgs D. Adv – Can be difficult to insert, risk of UTI’s, TSS Contraindications – Latex allergy, H/O TSS, cervical diseases (malignancy, poor smear result, cervicitis) etc), HIV

Non-Hormonal Contraception Barrier Methods (Females) Contraceptive Sponge Pearl Index 15 - 20 Polyurethane Foam Contains a spermicidal Insertion – Prior to sexual intercourse. Moisten with water before insertion Removal – Left for 6 hrs after last intra-vaginal ejaculation. Should not be left in for > 24 hrs Does not protect against all STI’s Disposable D. Adv – Risk of UTI’s, TSS Contraindications – Latex allergy, H/O TSS, HIV

UKMEC Faculty of Sexual & Reproductive Health Care of the Royal College of Obstetricians & Gynecologists

Hormonal Contraception (COC’s) Mechanism of action: Inhibits ovulation Thickens cervical mucus Renders endometrium unsuitable for implantation Pearl Index: 0.3 – 4 With perfect use it is 0.1 (true pill failure)

Hormonal Contraception (COC’s) 1st prescription of a COC UKMEC guidance will help in safe prescription of COC Age Breastfeeding Postpartum Smoking Obesity – BMI Risk factors for CVD – old age, smoking, obesity, hypertension, diabetes BP VTE and risk factors for VTE H/O IHD, Stroke, Hyperlipidemia, PVD H/O Valvular heart disease Headaches/ Migraines Breast disease/ Family Hx/1 breast disease Endocrine Diseases – Diabetes (with/ without PVD) Liver/ Gall Bladder Diseases – Gall stones, Cholestasis, Hepatitis, Cirrhosis, Liver tumors Anaemia Raynauds Disease, SLE Drug Interactions

Hormonal 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 pill High estrogen side effects: nausea, dizziness, bloating, vaginal discharge, breast problems – try a lower estrogen pill or changing the pill High progestogen side effects: mood swings, reduced sexual drive, vaginal dryness, breast tenderness, wt gain, acne – try a low progestogen pill or changing the pill Benefits of COC: Contraceptive benefits –Good efficacy if good compliance, reversibility Non-contraceptive benefits - periods regular, light, painless, protection against ovarian cysts, ovarian tumors, benign breast diseases, endometrial ca, colorectal ca, few extra uterine pregnancies

Hormonal 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 protection COC 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 days Which 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 no evidence to support the use of biphasic or triphasic pills”

Hormonal Contraception (COC’s) 1st prescription of a COC Yasmin Femodette Femodene Cilest Loestrin 20 Microgynon 30 Ovysmenn

Hormonal Contraception (COC’s) 1st prescription of a COC Missed Pill Advice

Hormonal Contraception (COC’s) Follow up prescription of a COC Pill check - initially 3 mths - then 6 months x 2 - then annually if no risk factors Check well being/ adverse effects New risk factors/ contraindications Menstrual history BP, Smoking, BMI, concordance Cervical smear Check education Missed pill advice Interaction with drugs Intercurrent illness – D/V Risk of STI’s Future plan of wanting to concieve Prenatal advice regarding diet, exercise, smoking, OTC F acid, Rubella Unusual/ prolonged headaches Aura/ visual problems Speech disturbance Weakness/ paraesthesia in limbs Painful calf swelling Focal epilepsy Severe abdominal pain/ jaundice Fracture/ surgery/ immobilisation High BP Severe skin rash New risk factor for breast ca STOP

Hormonal Contraception (COC’s) Estradiol Valerate + Dienogest 4 sequential phases Pearl Index: 0.4 – 0.5 Missed pill: may need 9 days extra precautions +/- EC

Hormonal Contraception (Transdermal - EVRA) Failure rate <1% if used correctly Each patch lasts a week Change a patch every week for 3 weeks followed by a weeks break If the patch comes off, do not reattach it – adv to use a new one

Hormonal Contraception (POP’s) Inhibits cervical mucus (Cerazette also inhibits ovulation) Pearl index: Micronor :- 0.3 – 4; Cerazette:- 0.17 Start on day 1 of period , no PFI Window period: Minipill :- 3 hrs; Cerazette:- 12 hrs. If missed/ delayed pill then take other pills as usual + extra precautions for 48 hrs +/- EC Can be started 3 weeks postpartum Not affected by broad spectrum antibiotics but by enzyme inducers Can be taken with HRT in perimenopausal period until menopause Refer to UKMEC for contraindications

LARC’S Women requesting any contraception should be given information about and offered choice of all methods including LARC NICE LARC GUIDELINES 30, DOH: 0CT 2005 QOF 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%)

LARC’S All currently available LARC methods (IUD, IUS, Implanon, DEPO) are most cost effective than COC even at 1 yr of age IUD, IUS and Implanon are more cost effective than injectable contraception Increased uptake of LARC methods will reduce the number of unintended pregnancies NICE recommendations for LARCS: Provision of information and informed choice to patients Training of health care professionals NICE LARC GUIDELINES 30, DOH: 0CT 2005

LARC’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 – 2 STI screen prior to insertion Adverse effects: heavy, painful bleeding likely Risks: < 1:1000 chance of uterine perforation < 1:100 chance of PID following IUD insertion but risk increases if already has STI 1:1000 in 5 yrs chance of an ectopic pregnancy but 1:20 chance of ectopic if gets pregnant while on the coil

LARC’S (IUD’S) Contraindications: Refer to UKMEC Insertion: Anytime during periods. Anytime when not pregnant + 7 days extra precautions Immediately post 1st/ 2nd trimester abortion 4 weeks post partum irrespective of mode of delivery Follow up – After 1st period/ 3 – 6 weeks post insertion Check for threads, expulsion, infection, perforation. (USS if unable to locate the IUD) Heave periods while on IUD: NSAIDS/ Tx acid Short course of low estrogen COC Change to IUS Cervical smear may show Actinomycoses If IUD and pregnant, remove coil before 12 weeks

LARC’S (IUD’S) Flexi-T 300 I.U.D. T-safe CU380A GyneFix IUD Multi-Safe 375 IUD Multisafe 375 Short Stem IUD Nova-T 380 IUD

LARC’S (IUS) Inhibits fertilisation and implantation, thickens cervical mucus License: 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: < 0.5 STI screen prior to insertion Adverse effects: Irregular bleeding common in 1st 6 mths of insertion – oligomenorrhoea/ amenorrhoea likely by the end of 1 yr of use No evidence of wt gain. Slight effect on mood, acne a possibility Risks: < 1:1000 chance of uterine perforation < 1:100 chance of PID following IUD insertion but risk increases if already has STI 1:1000 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

LARC’S (IUS) Contraindications: Refer to UKMEC Insertion: Anytime during periods. Anytime when not pregnant + 7 days extra precautions Immediately post 1st/ 2nd trimester abortion 4 weeks post partum irrespective of mode of delivery Follow up – After 1st period/ 3 – 6 weeks post insertion Check for threads, expulsion, infection, perforation (USS if unable to locate the IUS) Cervical smear may show Actinomycoses If IUS and pregnant, remove before 12 weeks

LARC’S (POIC’s – Depo-Provera) Inhibits ovulation Pearl Index: 0 – 1 Repeated every 12 weeks Could be a delay up to 1 yr in return of fertility after stopping Adverse effects: Amenorrhoea likely but irregular/ heavy bleeding can happen (Rx with Tx acid/ add oestrogens) Wt gain: 2-3 kg in a year Reduced BMD but no increase in risk of fractures Not associated with acne/ depression/ headaches No evidence of congenital malformation if pregnant while on DEPO Contraindications – Follow UKMEC License: 2-3 years Injection: Same as IUD/IUS but can be given immediately post partum

LARC’S (POIC’s – Depo-Provera) Timing of DEPO Has 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 injection N/A as injection not late Yes No > 14 weeks since the previous injection Yes, for next 7 days Yes, in the last 3 days Yes, 3 weeks later Yes, 5 days back Yes, offer Cu coil as EC Yes, > 5 days back Yes, for 3 weeks until pregnancy test confirmed –ve and for 7 days after giving DEPO Yes, initially and 3 weeks later

LARC’S (POSDI’s - Implanon) Inhibits ovulation Pearl Index: 0 – 0.1 License: 3 years Adverse 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 year Reassurance, Tx acid, low dose COC (Mercilon) in a tricycle fashion Acne possible Not associated with weight gain, mood swings, reduced libido, headaches Contraindications – refer to UKMEC

LARC’S (POSDI’s - Implanon) Insertion of Implanon Timing – same as DEPO Site – Non-dominant arm, 10 cm above the medial epicondyle as opposed to bicipital grove Impalpable Implanon – deep insertion/ failed insertion/ migration. Locate with an USS. If deep insertion, refer Removal – straight switch to another Implanon/ Contraception

Emergency Contraception Hormonal EC – Levonorgestrel (Levonelle) Non-hormonal EC – Cu IUD EC in future

Emergency 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 days License – 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 contraindications Drug Interactions – If on liver enzyme inducers, Cu IUD preferred. If declined then a single dose of 3 mg is given (unlicensed)

Emergency Contraception (Hormonal EC – Levonelle) History: Assess for competence if young and document as “Fraser ruling competent” Full sexual Hx including last/ previous UPSI’s LMP (if pre-ovulatory) Assess risk of STI – offer everyone a STI screen Advice about LARC Start a regular contraception when issuing EC if possible Counsel about Levonelle Adverse effects: Nausea, vomiting (if vomiting within 2 hrs of taking it, repeat dose) Next period earlier/ late, lighter. If delayed/ lighter than expected – preg. test Consider advance provision of Levonelle in some cases

Emergency Contraception (Non-hormonal EC – Cu IUD “Multiload 375”) Inhibits fertilisation; Inhibits implantation License – Up to 5 days post UPSI or before day 19 of a regular cycle Always offer a emergency IUD even if presents within 72 hrs post UPSI Can be removed at anytime during next period if not had UPSI since next period and alternative cover started at the right time History taking vital as for levonelle If at risk of STI (<25 yrs and > 1 sexual partner in the last 1 yr) insert EC-IUD but give prophylaxis

Emergency Contraception (Future EC) Ellaone Selective progesterone receptor modulator Used up to 120 hours post UPSI Dose – one dose of 30 mg Extra – precautions until next period Cannot give > 1/ month Can cause headaches, nausea, abdominal pain

Emergency Contraception (Future EC) Mifepristone Progesterone antagonist Effective EC when taken in a single dose up to 120 hours post UPSI Single dose – 25 – 50 mg Not licensed for EC in the UK

Case Studies

Case - 1 Nicola 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 normal What are the issues here? What contraceptives would you discuss with her?

Case - 2 Janet, 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?

Case - 3 You 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?

Case - 4 Liz 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?

Case - 5 Maria, 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 normal Will you continue issuing her the patches? What are the alternatives?

Case - 6 Tiffany 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?

Case - 7 Nicola, 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?

Case - 8 A 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?

Case - 9 A 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?

Case - 10 A 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?

Case - 11 A 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 28-30 days. What are your concerns? What would you offer her? What advice will you give her?

Case - 12 A 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?

Case - 13 Mrs 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?

Contraception over 40

Contraception 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 symptoms Blood tests – Raised FSH (> 30 IU/L) and LH on 2 occasions done 1-2 mths apart No single indicator is considered reliable

Useful Websites www.ffprhc.org.uk BNF online www.mims.co.uk References Faculty of Family Planning and Reproductive Health Care Clinical Guidance Guillebaud, J. Contraception Today. 5th ed. Martin Dunitz, 2005

Life, why contraception is viable Please, put her out of my misery..