2. Contraception Cases From Practice Dr P Feldman

3. Contraception Major social change Major social change Reproductive self determination Reproductive self determination If, when, and if they want children If, when, and if they want children Freedom from pregnancy Freedom from pregnancy Career Career

4. The Ideal Contraceptive 100% reversible 100% reversible 100% effective 100% effective 100% convenient 100% convenient 100% free of adverse effects 100% free of adverse effects 100% protective against sexually transmitted diseases 100% protective against sexually transmitted diseases Has other non contraceptive advantages Has other non contraceptive advantages Maintenance free Maintenance free

5. Under Age Contraception 90,000 teenage conceptions/year 90,000 teenage conceptions/year 7,700 to girls < 16 7,700 to girls < 16 2,200 to girls < 14 2,200 to girls < 14 3/5 result in live births = 5,600 births/year 3/5 result in live births = 5,600 births/year 2/3 of 16 yr olds don’t have sex 2/3 of 16 yr olds don’t have sex

6. Under Age Contraception Assessment Assessment Menstrual history Menstrual history Sexual history Sexual history Contraceptive history Contraceptive history Medical history Medical history Social history Social history Family history Family history

7. Under Age Contraception Examination Examination Blood pressure Blood pressure Weight Weight Ethical concerns Ethical concerns Pregnancy Pregnancy Age Age Doctors own morals Doctors own morals

8. Fraser Guidelines Contraception may be given provided:- Contraception may be given provided:- Understands advice Understands advice Encourage to inform parents Encourage to inform parents Will have sex anyway Will have sex anyway Physical/mental health would suffer Physical/mental health would suffer Contraception is in her best interests Contraception is in her best interests

9. Under Age Contraception Management Management Combined oral contraceptive pill Combined oral contraceptive pill Progesterone only contraceptive pill Progesterone only contraceptive pill

10. Under Age Contraception Combined oral contraceptive Combined oral contraceptive Action Action –Prevents ovulation and implantation Failure rate Failure rate Age 25-34 0.38/100 woman years Age 25-34 0.38/100 woman years Age 35+0.23/100 woman years Age 35+0.23/100 woman years

11. Risk Factors

12. Risk Factors for Arterial Disease Risk factor absoluterelative FH ihd < 45 Abnormal lipids Normal lipids Smoking40+/day5-40/day Diabetesseveremild Hypertension>160/95<160/95 Obese BMI >39 BMI 30-39 Migraine Focal aura No aura

13. Risk Factors for Venous thromboembolism Risk factor absoluterelative FH vte < 45 Clotting abnormality Normal clotting factors Obese BMI > 39 BMI 30-39 immobility Confined to bed Wheelchair life Varicose veins Past thrombosis Extensive varicose veins

14. Under age contraception Risks Risks Liver benign and malignant Liver benign and malignant Cervix Cervix Breast Breast Benefits Endometrium Ovary

15. Under Age Contraception Which COC Which COC Risk of vte in healthy non pregnant women is 5/100,000 Risk of vte in users of second generation COC is15/100,000 Risk of vte in users of third generation COC is 25/100,000 Risk in pregnancy is60/100,000

16. Under Age Contraception Use of third generation COC Use of third generation COC Make a record of Make a record of Risk factor history Risk factor history Woman accepts possible increased risk Woman accepts possible increased risk –10 cases of vte per 100,000 users per year –0.2 deaths

17. Under Age Contraception Advice Advice Missed pills Missed pills Vomiting and diarrhoea Vomiting and diarrhoea Antibiotics Antibiotics

18. Under Age Contraception Progesterone only pill Progesterone only pill Failure rate Failure rate Age 25-293.1/100 woman years Age 25-293.1/100 woman years Age 35-391/100 woman years Age 35-391/100 woman years Age 40+0.3/100 woman years Age 40+0.3/100 woman years Full lactation= that of COC Full lactation= that of COC Failure rate increases with weight Failure rate increases with weight > 70 kg use 2 pills/day > 70 kg use 2 pills/day

19. Under Age Contraception Mode of action Mode of action Fertile ovulation prevented in 60% cycles Fertile ovulation prevented in 60% cycles Cervical mucous less penetrable by sperm Cervical mucous less penetrable by sperm Antinidatory action on endometrium Antinidatory action on endometrium

20. Under Age Contraception Situations where POP useful Situations where POP useful Oestrogen related contraindications to COC Oestrogen related contraindications to COC Smokers > 35yrs Smokers > 35yrs Hypertension Hypertension Migraine Migraine Diabetes Diabetes Lactation Lactation Sickle cell disease Sickle cell disease

21. Under Age Contraception Advice Advice Missed pills Missed pills No interference with antibiotics No interference with antibiotics

22. Emergency Contraception Assesment Assesment Menstrual history Menstrual history Lmp, Lmp, Cycle Cycle Could she already be pregnant Could she already be pregnant Previous contraceptive failures in current cycle Previous contraceptive failures in current cycle

23. Emergency Contraception Assessment Assessment Past medical history Past medical history Migraine Migraine Venous thromboembolism Venous thromboembolism Ihd Ihd Family history Family history Venous thromboembolism Venous thromboembolism ihd ihd

24. Emergency Contraception Schering pc4 Schering pc4 Less effective Less effective More nausea51% More nausea51% Vomiting19% Vomiting19% Cheaper£1.60p Cheaper£1.60p Levonelle 2 More effective Less nausea23% Vomiting6% More expensive

25. Emergency Contraception Time from coitus Levonelle failure Rate % PregnancypreventedPc4 Failure rate % Pregnancy prevented < 24 hrs 0.495%277% 25-48 hrs 1.285%4.136% 49-72 hrs 2.758%4.731%

26. Contraindications Levonelle Levonelle Pregnancy Pregnancy Allergy to constituent Allergy to constituent Active acute porphyria Active acute porphyria Active severe liver disease Active severe liver disease

27. Emergency Contraception Advice Advice Not 100% effective Not 100% effective Do pregnancy test if period late Do pregnancy test if period late Vomiting within 2 hrs Vomiting within 2 hrs Risk of teratogenicity Risk of teratogenicity

28. Emergency Contraception Indications for copper IUCD Indications for copper IUCD When max efficacy is required When max efficacy is required Exposure > 72 hrs or multiple exposure Exposure > 72 hrs or multiple exposure Continued as long term contraception Continued as long term contraception Absolute contraindications to hormonal methods Absolute contraindications to hormonal methods After vomiting of either dose within 2 hrs After vomiting of either dose within 2 hrs 

29. Emergency Contraception Absolute contraindications to copper IUCD Absolute contraindications to copper IUCD Suspected pregnancy Suspected pregnancy Unexplained uterine bleeding Unexplained uterine bleeding Current or recent pelvic infection/sti Current or recent pelvic infection/sti Significant immunosupression Significant immunosupression Malignant trophoblastic disease Malignant trophoblastic disease Distorted uterine cavity Distorted uterine cavity Heart valve prosthesis or previous SBE Heart valve prosthesis or previous SBE

30. Emergency Contraception Adverse effects of IUCD Adverse effects of IUCD Intra uterine pregnancy Intra uterine pregnancy Extra uterine pregnancy Extra uterine pregnancy Expulsion Expulsion Perforation Perforation Infection Infection

31. Emergency Contraception Advantages of copper IUCD Advantages of copper IUCD Safemortality 1:500,000 Safemortality 1:500,000 Effective immediately Effective immediately Cumulative failure rate at 5yrs = 1.4/100 women Cumulative failure rate at 5yrs = 1.4/100 women Nothing to remember Nothing to remember Reversible Reversible

32. Emergency Contraception Action Action Prevention of fertilisation Prevention of fertilisation Block implantation Block implantation

33. Emergency Contraception Assessment Assessment History History Menstrual Menstrual Social Social Examination Examination Options Options

34. Emergency Contraception Assessment Assessment Position in packet Position in packet Previous missed pills Previous missed pills Did they use condom Did they use condom ? Last period normal ? Last period normal

35. Emergency Contraception Emergency contraception on COC Emergency contraception on COC Unprotected sex within 7 days of Unprotected sex within 7 days of 2 missed pills from first 7 in packet 2 missed pills from first 7 in packet 4 missed pills from mid packet 4 missed pills from mid packet

36. Contraception in the 40-50’s Assessment Assessment Personal history Personal history Age Age Smoking Smoking Weight Weight Mobility Mobility Previous pill history Previous pill history

37. Contraception in the 40-50’s Assessment Assessment Past medical history Past medical history Venous thromboembolism Venous thromboembolism Ihd Ihd Migraine Migraine Diabetes Diabetes Epilepsy Epilepsy Varicose veins Varicose veins

38. Contraception in the 40-50’s Assessment Assessment Family history Family history Venous thromboembolism Venous thromboembolism Ihd Ihd Examination Examination Blood pressure Blood pressure Weight Weight

39. Contraception in the 40-50’s Copper IUCD Copper IUCD If implanted after 40 can be left for 10 yrs but off license If implanted after 40 can be left for 10 yrs but off license Infection risk is less because of different lifestyle Infection risk is less because of different lifestyle Loss of fertility not a problem as family completed Loss of fertility not a problem as family completed Pain and heavier bleeding could be controlled by drugs Pain and heavier bleeding could be controlled by drugs

40. Contraception in the 40-50’s Products used off license Products used off license Professional opinion must endorse use Professional opinion must endorse use Tell patient it is unlicensed Tell patient it is unlicensed Mention risks and benefits Mention risks and benefits Obtain informed consent Obtain informed consent Keep separate record Keep separate record

41. Contraception in the 40-50’s Mirena Mirena Action Action Changes cervical mucus Changes cervical mucus Impedes implantation Impedes implantation Failure rate Failure rate 0.1 0.2/100 woman years 0.1 0.2/100 woman years

42. Contraception in the 40-50’s Advantages Advantages Ovulation continues Ovulation continues Fertility returns quickly Fertility returns quickly Lighter periods Lighter periods Pms improved Pms improved HRT HRT Default contraception Default contraception Disadvantages Expulsion Perforation Bleeding Amenorrhoea PID

43. Contraception in the 40-50’s Contraindications Contraindications As for copper IUCD As for copper IUCD Hypersensitivity to levonorgestrel Hypersensitivity to levonorgestrel Postcoital contraception Postcoital contraception High failure rate High failure rate

44. Contraception in the 40-50’s Fertility per 100 woman years Fertility per 100 woman years No method young women80-90 No method young women80-90 No method at age 4040-50 No method at age 4040-50 No method at age 500-5 No method at age 500-5

45. Contraception in the 40-50’s When to stop contraception When to stop contraception Age < 502 yrs after last period Age < 502 yrs after last period Age > 501 yr after last period Age > 501 yr after last period

46. Contraception in the 40-50’s The menopause The menopause Periods alter Periods alter Hot flushes Hot flushes Raised FSH Raised FSH COC suppresses FSH COC suppresses FSH POP does not suppress FSH POP does not suppress FSH

47. Contraception in the 40-50’s Contraceptive failure rate age >35 Contraceptive failure rate age >35 Pop0.5 Pop0.5 Diaphragm2.8 Diaphragm2.8 Male condom2.9 Male condom2.9

48. Contraception in the 40-50’s Other methods Other methods Copper IUCD Copper IUCD Mirena Mirena Barrier methods Barrier methods Male condom Male condom Diaphragm Diaphragm Vaginal foam Vaginal foam

49. Contraception in the 40-50’s Male condom Male condom Second most popular form of contraception Second most popular form of contraception Failure rate related to correct application Failure rate related to correct application Only proven method of preventing HIV transmission Only proven method of preventing HIV transmission Not available on FP10 Not available on FP10

50. Contraception in the 40-50’s Diaphragm Diaphragm Requires Requires Individual fitting Individual fitting Checking correct fit Checking correct fit Used with spermicide Used with spermicide Inserted before intercourse Inserted before intercourse Not removed till 6 hours later Not removed till 6 hours later

51. Contraception in the 40-50’s Oddities Oddities Femidom Femidom Personna Personna Vaginal foam Vaginal foam

52. Medical Problems Epilepsy Epilepsy Enzyme inducing drugs Enzyme inducing drugs Carbamazepine Carbamazepine Phenytoin Phenytoin Phenobarbitone Phenobarbitone Primidone Primidone Topiramate Topiramate

53. Medical Problems COC COC Metabolism increased, loss of efficacy Metabolism increased, loss of efficacy Increase dose – 50 micrograms Increase dose – 50 micrograms Decrease pill free interval Decrease pill free interval Consider tricycling Consider tricycling Break through bleeding Break through bleeding –? 90 microgram pill

54. Medical Problems Enzyme inducers – what contraceptive? Enzyme inducers – what contraceptive? Copper IUCD - most reliable Copper IUCD - most reliable Depot provera - increase injection frequency Depot provera - increase injection frequency Mirena - local action only Mirena - local action only

55. Medical Problems Other methods Other methods Barrier methods Barrier methods Femidom Femidom Diaphragm Diaphragm Condom Condom POPavoid ? effective at higher doses POPavoid ? effective at higher doses

56. Medical Problems Diabetes Diabetes POP POP Copper IUCD Copper IUCD Mirena Mirena Sterilisation Sterilisation