1. CONTRACEPTON FOR GP’S Dr Mazhar Khan 7 April 2010

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

3. 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

4. Statistics

5. Statistics

6. 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 “

7. 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

8. 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

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

10. 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

11. 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

12. Non-Hormonal Contraception
Barrier Methods (Females)
Vaginal Diaphragm
Pearl Index
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

13. Non-Hormonal Contraception
Barrier Methods (Females)
Cervical Cap
Pearl Index
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 > 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

14. Non-Hormonal Contraception
Barrier Methods (Females)
Contraceptive Sponge
Pearl Index
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

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

17. 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)

18. 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

19. 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

20. 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”

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

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

23. 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

24. 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

25. 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

26. 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

28. 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%)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

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

40. 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)

41. 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

42. 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

43. 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

44. 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

45. Case Studies

46. 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?

47. 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?

48. 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?

49. 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?

50. 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?

51. 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?

52. 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?

53. 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?

54. 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?

55. 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?

56. 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 days.
What are your concerns?
What would you offer her?
What advice will you give her?

57. 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?

58. 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?

59. Contraception over 40

60. 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

61. 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

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