Presentation on theme: "Emergency Contraception, Quick Start & a bit about LARCS"— Presentation transcript:
1 Emergency Contraception, Quick Start & a bit about LARCS Dr Jackie Abrahams
2 Pregnancy and Emergency Contraception (EC) ‘All women of reproductive age are pregnant until proven otherwise’Think about possibility of pregnancy or need for ECWith every request for contraceptionWith every request for a pregnancy test.With any other consultation
3 Emergency Contraception RememberThere is a failure rate with Levonelle 1500 and EllaOneThere is virtually no failure rate with postcoital(PC) Coil. All women should be offered the option of PC Coil (especially if they are mid cycle and/or over 48 hours)
4 NB No evidence that either have much effect after ovulation ellaOne vs LevonelleellaOne more effective (failure rate 1.28% compared to 2.2% with Levonelle)ellaOne can still inhibit/delay ovulation once LH surge started - ie in 48 hours pre-ovulationellaOne licensed for use up to 120 hours post UPSI and equally effective throughout that time periodellaOne is a Progesterone Receptor Modulator and therefore interferes with ongoing hormonal contraception for the next 7 daysNB No evidence that either have much effect after ovulation
5 ellaOne vs Levonelle ellaOne more expensive - £16.95 vs £5.20 Approved by Joint Area Prescribing Committee (JPAC)for women under 35 who are mid cycle (ovulation minus 6 days to ovulation plus 2 days)For women presenting for EC between 73 and 120 hours post UPSI
6 Emergency Contraception Over 72 hours? – PC Coil best optionup to 5 days after earliest ovulation (i.e., day 19 of a regular 28 day cycle) – regardless of how many episodes unprotected sexual intercourse (UPSI).If beyond ovulation+5days - up to 5 days after UPSIUnlicenced Use Levonelle 1500 or EllaOneIf coil not an option, can have Levonelle-2 or EllaOne as unlicensed use over same timescale as PC Coil (but much higher failure rate)
7 Emergency Contraception And then ?QuickstartIf starting hormonal method consider immediate start oral contraception small risk of pregnancy but ?worth it.COC - not safe for 7 days after Levonelle – 14 days after EllaOnePOP – not safe for 2 days after Levonelle – 9 days after EllaOnePT with EMU in 3-5 weeks – ideally PT 3 weeks after last risk (eg 5 weeks after EllaOne and quickstart COC as not protected by COC for first 2 weeks)
8 Emergency Contraception Missed PillsTake Levonelle and continue with pills (don’t stop and wait for next period – it might never come!)Do Pregnancy test 3-4 weeks later (whether or not normal withdrawal bleed)NB Levonelle better than EllaOne for missed pills (because of effect on progesterone receptors with EllaOne)
9 Late / Missed PillsCOCLatest FPA Guidance (what we teach the patients)can miss 1 pill anywhere in pack – no extra precautions neededIf miss 2 or more need extra precautions and active pillsfor 7 days‘pragmatic’ guidance (what we know)Need to have taken 7 active pillscan miss up to 7 anywhere else in packneed 7 active pills after missed pillsNB Extra precautions not needed with antibioticsPOP – Only need extra precautions until normal pill taking resumed for 48 hours (Late = 12hours for Cerazette, 3 hours for other POP’s)
10 Late Depo InjectionUp to 14 weeks – give next Depo. No extra precautions needed14 – 15 weeks – give next Depo. If any UPSI after 14 weeks also give PCC (Levonelle or PC IUD). Not safe for 7 days and need PT in 4 weeksOver 15 weeks – need to exclude pregnancy before rpt Depo – unless no UPSI after 14 weeks (?COC or POP for 1 month and then next Depo with neg PT)(according to most recent WHO guidelines can have repeat Depo up to 16 weeks and don’t need extra precautions for 7 days – UK Guidelines still say 14 weeks)
12 Quick Starting Contraception Key Recommendations If a health professional is reasonably sure thata woman is not pregnant or at risk ofpregnancy from recent unprotected sexualintercourse (UPSI), contraception can bestarted immediately unless the woman prefersto wait until her next period.
13 Quick Starting Contraception Key Recommendations If pregnancy cannot be excluded (e.g. followingadministration of EC) but a woman is likely tocontinue to be at risk of pregnancy, immediate‘quick starting’ of CHC, the POP or progestogenonly implant may be considered.The woman should be informed of thepotential risks and the need to have apregnancy test at the appropriate time.
14 Quick Starting Contraception Key Recommendations Women requesting the progestogen-onlyinjectable should ideally be offered abridging method if pregnancy cannot beexcluded, but immediate start isacceptable if other methods are notappropriate or acceptable.
15 Quick Starting Contraception Key Recommendations If contraception is quick started in awoman for whom pregnancy cannot beexcluded, a pregnancy test should beadvised no sooner than 3 weeks after thelast episode of UPSI.
16 Quick Starting Contraception Key Recommendations If starting hormonal contraceptionimmediately after ulipristal acetate EC,the CEU recommends condoms oravoidance of sex for 14 days (9 days ifstarting POP, 16 days for Qlaira)
17 LARC’s Long Acting Reversible Contraceptives IUD/IUSProgesterone subdermal implant (Nexplanon)Depoprovera
18 IUD/IUS Key Messages Just as good for Nullips as Multips No need for swabs with every fitDo STI risk assessment and decide if necessaryIf taking swabs only need to do 2 endocervical swabs for GC and Chlamydia(an HVS is a diagnostic test – only necessary if has abnormal discharge)
19 IUD vs IUS IUD IUS Less problems than IUS if normal/light periods Can be fitted up to ovulation + 5 days regardless of whether UPSI since LMPIf fitted over age 40 can stay in until menopauseMost effective emergency contraceptionIUS1st choice if heavy periods or had heavy periods with IUDAmenorrhoea in only 25-30%Can cause significant bleeding problems for up to 6 monthsOther progesterone side effectsCannot be used for emergency contraception
20 Nexplanon Most effective contraceptive method Failure rate 1/2000 No serious risksMain challenge is management of side effectsBleeding problemsMood swingsSkin problems
21 Bleeding Problems with Nexplanon Don’t usually need any investigation apart from STI risk assessment and/or screeningUsually respond to COC or POPOften settle after 3 months of treatmentIf recur on stopping can continue COC or POP longterm
22 DCHS Sexual Health Service Clinics Central Booking Line for all Appointments TelWe will accommodate requests for Emergency IUD’s at all of our clinicsContact numbers to speak to a clinicianDr Jackie AbrahamsDr Stephen Searle
23 Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) Details of the training requirements for DFSRH and Letters of Competence (LoC’s) in Intrauterine Techniques and Subdermal Implants are available on the Faculty websiteDFSRH training involves three stages: e-learning for theory background; the e-SRH programmeCourse of 5; five hours of small group workshopsClinical experience and assessment
24 Course of 5 and Practical Training Locally training is organised throughCourse of 5 is run twice a year – next one is on 17th June 2013Details of training elsewhere in UK is available on the Faculty websiteTraining for Health Department Phone: Website: