CONTRACEPTION UPDATE 17 March 2016 Josephine Percival SRN MSc NIP PGA Med Ed FRT Nurse Consultant in Contraception East Sussex NHS Healthcare Trust

Agenda Training Methods STIs and Chlamydia Screening New contraceptives

FSRH professional qualification BASHH DFSRH – contraception LoC IUC LoC SDI STIF foundation Intermediate Advanced TRAINING

CONTRACEPTIVE METHODS  CHC - pills patch vaginal ring  POC – pills injectables implants  IUC – IUD LNG-IUD  Male & Female Sterilisation  Barrier Methods - male & female condoms diaphragms cervical caps  Spermicide  FABS Fertility Awareness Based Methods  LAM Lactational Amenorrhoea method

Family Planning Association

UKMEC Category Classification of Contraindications 1 No restrictions (always useable) 2 Advantages generally outweigh the theoretical or proven risks (broadly useable) 3 The theoretical or proven risks usually outweigh the advantages (caution/counselling) 4 Requires expert clinical judgement and /or referral to a specialist provider Unacceptable health risk (do not use)

Combined Hormonal Contraception Dosing / Delivery Regimes Standard Regimen  Monophasic pills  Multiphasic formulations  Transdermal Patch  Combined Vaginal ring

Evolution Towards Lower Doses of Hormonal Contraception MethodEstrogen Dose Delivery Mode COC Daily Oral Contraceptiv e PatchWeekly Transdermal Vaginal Ring Monthly Transvaginal

EVRA

5cm x 5cm EE 20mcg/norelgestromin 150mcg Cilest via the skin Compliance Avoids all absorption problems from GI disorders Bulimia/purging/travellers/air crew Constant hormone levels

HOW TO USE STARTING Day 1-5 – protected immediately (cycle shorter than 23/7) Day 6 onward – extra precautions for 7/7 Postnatal (if not B/F) day 21 Patch Cycle = 3 patches/7 day break New patch once a week for 3 weeks Start day & change day the same i.e. day 1, 8, 15, 22 DISLODGED PATCH Less than 48 hours – reapply same or use new patch no extra precautions needed* More than 48 hours – start whole new patch cycle, extra precautions 7/7 (EC)

HOW TO USE FORGETTING TO CHANGE Week 1 or 2 Less than 48 hours change patch no extra precautions needed More than 48 hours Start new patch cycle – extra precautions for 7/7 (EC) Week 3 Take patch off when remember, restart next cycle usual day PFI SPC states no more than 6 consecutive patches*

EVRA Apply to clean, dry, not too hairy area, buttocks, torso, abdomen or upper arm. NOT ON BREAST Change location Allergic skin reactions Reminder to change patch (company will text weekly) Dispose in sachet provided & bin Can’t be used if weight >90 kgs BTB most common in first 2 cycles

CVR - NUVARING TM

CVR Latex free flexible transparent plastic ring 4mm x 54mm Ethinylestradiol 2mg & Etonogestrel 11.7mg 15mcg/120mcg daily (Mercilon of the vagina) Releases constant dose of hormone into bloodstream through vaginal wall Good cycle control In USA since 2002 – large quantity of clinical trial data

CVR Easy to insert & remove No exact position Minimal disturbance to cervical/vaginal epithelium and flora Can use during SI Can use with tampons Women like it Avoids 1 st pass metabolism & GI interference of drug absorption

HOW TO USE START Day 1 – 5 no extra precautions needed Remove Leave in place 21 days – remove same day that it was inserted. 7 day break, reinsert same day as taken out Monthly text reminder Continuous Use Studies done – outside product licence

How to Insert NuvaRing® Positions for NuvaRing® insertion NuvaRing® Package Insert

Insertion of NuvaRing Precise position of NuvaRing in the vagina is not important Just like inserting a tampon

How to Remove NuvaRing Remove the ring three weeks after insertion on the same day of the week as it was inserted, at about the same time of day. You can remove NuvaRing® by hooking the index finger under the forward rim or by holding the rim between the index and middle finger and pulling it out. NuvaRing® Package Insert

HOW TO USE Efficacy reduced if removed for more than 3 hours (in one cycle) 1 st & 2 nd Week – Reinsert & use extra precautions for 7 days 3 rd Week - Discard & insert new ring or start 7 day break – extra precautions for 7 days Expulsion Rinse in cool or tepid water & reinsert Broken Ring Remove & reinsert new ring ASAP

CVR Dispose in sachet provided & bin Check regularly that ring still insitu (before SI) Not affected by D&V or broad spectrum antibiotics Unaffected by spermicides or antifungals (miconazole causes increased release of hormones) 40 month shelf life 36 months refrigerated (pharmacy) 4 months after dispensing (3/12 Rx)

LARC SDI - Nexplanon IUS – Mirena/Jaydess/Levosert IUD – regular & mini Injectables - DMPA & NET-EN

SUBDERMAL IMPLANT

Rate-controlling membrane (0.06 mm): 100% EVA Core: 37% ethylene vinyl acetate (EVA) 60% etonogestrel (68 mg) 3% barium sulphate (15 mg) Release rate: 60–70 µg/day initially, decreasing to 25– 30 µg/day by end of third year

SUBDERMAL IMPLANT Progestogen only Easy to fit and remove Highly effective Licensed for 3 years Very little makes it less effective Reassurance as can feel the implant under the skin Timing of fitting  Day 1-5 (inclusive)  Quick start 50% of women have it removed within the first year unacceptable  bleeding pattern  Change in mood

ENG implant failures  Reported post-marketing pregnancies ◦ Over 50% linked with non-insertion ◦ 25% with liver enzyme inducers (mostly carbamazepine and none with lamotrigine) ◦ No link with weight  Pregnancy rate ◦ Overall per 100 implants fitted ◦ Method failure rate 0.01 per 100 implants  11.6% of all in-treatment pregnancies were ectopic Graesslin et al Eur J Contracept Reprod Health Care 2008

LNG-IUS Average reduction of bleeding by 90% Amenorrhoea or light bleeding in 65% of women after first year of use In first 3-6 months absorb more progestogen than once lining thinned

Duration of Use  For contraceptive use 5 years  If fitted in women 45 years or older – if amenorrhoeic keep device until no longer needed (Nice Guidance 10/06 )  Prevention of endometrial hyperplasia 4 years (accepted practice to use for 5 years – off licence use)  Menorrhagia – keep as long as bleeding pattern acceptable

LNG-IUS

Jaydess ® (levonorgestrel intrauterine system) 13.5 mg intrauterine delivery system levonorgestrel Contraception for up to 3 years Local release of LNG into the intrauterine cavity allows a low daily dose, resulting in low systemic exposure. Jaydess ® offers the lowest average daily hormone dose of all long-acting reversible contraceptives (LARCs) at 6microgram/24 hours.

Jaydess ® (levonorgestrel intrauterine system)

Indications The 3-year maximum duration of use of Jaydess ® may be better suited to the changing plans of certain groups of women e.g. younger women or women who wish to space future children Upon removal of Jaydess ®, women return to their normal fertility Jaydess ® therefore offers an alternative LARC for women, extending choice and addressing unmet need.

Indicated Uses Jaydess ® may be prescribed for both parous and nulliparous women, however, it is not first choice for contraception in nulliparous women as clinical experience is limited. Ectopic pregnancy may impact future fertility so benefits and risk of use should be carefully evaluated, particularly for nulliparous women Jaydess ® is suitable for women who are considering switching from their previous contraceptive e.g. to a second oral contraceptive or a long-acting reversible method. The shorter treatment duration of 3 years as compared to 5 years with Mirena ®, provides more flexibility in order to meet the changing needs of women at different times in their lives e.g. in women not sure when/if they will start a family or in women who would like to space the time between children for up to three years.

IUD

IUD Post partum fitting up to 48 hours or after 4 weeks Gold Standard 380mm Cu banded Types T-Safe 380A QL,TT380 slimline/ mini, Nova T, UT380 standard/short Coil checking – routine checks not needed Cu IUD if fitted after 40 insertion can keep till one year after last period 50 years and over (2 years under 50) No lower age limit, no problem fitting in nullips

104mg/0.65ml suspension for injection of medroxyprogesterone acetate Licensed for self administration Given every 13 weeks +/-7 days SC pre-filled Uniject® injector given into front upper thigh or abdomen

Use if IM CI or unsafe Concerns the IM needle doesn’t reach the muscle Thin women Needle phobic Less invasive More choice Price comparable

 Theoretical concerns regarding hypo-oestrogenic effects of DMPA including whether these women will achieve appropriate peak bone mass  Limited evidence shows decreased bone density over time among adolescent DMPA users  Over 45 years - decreases bone mineral density (compared to non-users) limited evidence but gain bone mass after stopping injection (pre-men)  Post-menopausal – No difference in bone mineral density between former DMPA users & never users  No restriction on use of DMPA (including duration) women aged 18 – 55 years  For under 18’s & over 45’s the advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk DMPA & BMD LOSS

CSM circular 11/04 recommends careful evaluation after 2 years use CI – if risk factors for osteoporosis already exist Under 19 – concerns that DMPA may prevent achievement of peak bone mass Over 45 years old Low BMI R/V 2 yearly no bone scanning or blood tests needed unless clinically indicated DMPA safer overall than COC 1 st line use in under 19s only after other methods discussed & are unsuitable/unacceptable

QUICK STARTING CONTRACEPTION FFPRHC Guidance September 2010 Excluding pregnancy When pregnancy can’t be excluded Quick Start Methods  CHC  POP  Implant  DMPA

ROUTINE GUM SCREENING Self taken LVS Checks for CT and GC Text result within 2 weeks PN (partner notification) Treatment 3 month test F/U after positive CT result 2 week window period from exposure to CT to test Routine bloods STS/HIV (POC test) Other screening for BBV (Hep A, B, C)

IUB and SPHERA

The IUB™ is a revolutionary new product in the intrauterine contraception field. The IUB™ is a three-dimensional, ball-shaped device that is inserted into the uterine cavity to prevent pregnancy. Its efficacy is similar to current copper intrauterine devices (IUD), however its insertion is simpler, its improved safety profile has been demonstrated in a clinical trial and it is expected to offer a better quality of life over current devices

IUB™ 300A IUB™ 380A SPHERA™

On the way Remote control hormonal chip Low dose ulipristal acetate (oral) Ulipristal acetate vaginal ring Ulipristal acetate IUS Vasalgel Origami condom

REMOTE CONTROL CONTRACEPTIVE CHIP

RINGS Tenofovir/levonorgestrel Nomogestrelacetate/ethiny lestradiol Nesterone/ethinylestradiol

USEFUL WEBSITES