And the ever popular AKT crash course! Contraception Unscheduled bleeding Over 40’s And the ever popular AKT crash course! By Alice Parr

Initial management History - risk of sexually transmitted infections (i.e. those aged <25 years, or who have a new sexual partner, or more than one partner in the last year) Cervical screening A pregnancy test

EXAMINATION AND INVESTIGATION speculum examination : bleeding or a change in bleeding after at least 3 months use of a method; or failed medical treatment; or if they have not participated in a National Cervical Screening Programme. bimanual examination (in addition) unscheduled bleeding if they have other symptoms (such as pain, dyspareunia and heavy bleeding). endometrial biopsy may be considered in women aged ≥45 years (or in women aged <45 years with risk factors for endometrial cancer such as obesity, polycystic ovarian syndrome, tamoxifen use or unopposed estrogen therapy) who have persistent unscheduled bleeding 3 or more months after starting a method or who present with a change in bleeding pattern. The role of structural abnormalities (such as uterine polyps, fibroids or ovarian cysts) as a cause of unscheduled bleeding is limited. Nevertheless, for all women using hormonal contraception with unscheduled bleeding, if such a structural abnormality is suspected a transvaginal ultrasound scan and/or hysteroscopy may be indicated.

THERAPEUTIC MANAGEMENT OPTIONS Don’t change combined oral contraceptive pill (COC) in first 3 months (bleeding disturbances often settle, however can increase ethinylestradiol (EE) to a maximum of 35 μg to provide good cycle control) Bleeding common initial months of progestogen-only method use - may settle without treatment. If treatment may encourage women to continue with the method it may be considered. No evidence that changing the type and dose of progestogen-only pill will improve bleeding but this may help some individuals. For women with unscheduled bleeding using a progestogen-only injectable, implant or intrauterine system who wish to continue with the method and are medically eligible, a COC may be used for up to 3 months (this can be in the usual cyclic manner or continuously without a pill-free interval). For women using a progestogen-only injectable contraceptive with unscheduled bleeding, mefenamic acid 500 mg twice daily (or licensed up to three times daily) for 5

Questions for Management of Unscheduled Bleeding in Women Using Hormonal Contraception 1 Women aged <25 years with unscheduled bleeding on the combined pill should have a high vaginal swab performed to exclude Chlamydia trachomatis. 2 It is mandatory to perform a cervical smear in the presence of unscheduled bleeding with Implanon®. 3 Three months of a progestogen-only pill can help settle unscheduled bleeding in users of injectable progestogens. 4 There is no evidence that women taking hormonal contraception consistently and correctly have a higher risk of pregnancy if they experience unscheduled bleeding. 5 Neisseria gonorrhoeae is a common cause of unscheduled bleeding with the combined pill in the UK.

6 Abdominal ultrasound is an important tool in the detection of submucous fibroids and endometrial polyps. 7 Mefenamic acid (500 mg twice daily) was helpful in reducing bleeding episodes in women using injectable progestogens during clinical trials. 8 Biphasic and triphasic combined pills are associated with an improved bleeding pattern compared to monophasic pills. 9 The contraceptive patch is less likely to cause unscheduled bleeding than a standard combined pill preparation. 10 A pill containing 50 μg ethinylestradiol should be prescribed if a woman has persistent bleeding on a lower dose preparation and no cause for the bleeding can be found.

Sexual and Reproductive Health Issues natural decline in fertility mid-30s effective contraception is required to prevent an unintended pregnancy. Women should be informed that the risks of chromosomal abnormalities, miscarriage,pregnancy complications and of maternal morbidity and mortality increase over 40 years. Medical Eligibility Criteria No contraceptive method is contraindicated by age alone. When prescribing contraception for women aged over 40 years, health professionals should be guided by the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). Clinical judgement is also required, particularly when prescribing for women with multiple medical and social factors

Combined Hormonal Contraception CHC use in perimenopause may help to maintain bone mineral density. CHC may help to reduce menstrual pain and bleeding. CHC may reduce menopausal symptoms. Women experiencing menopausal symptoms while using CHC may wish to try an extended regimen. CHC use provides a protective effect against ovarian and endometrial cancer that continues for 15 years or more after stopping CHC. Maybe a reduction in the incidence of benign breast disease with CHC use. Reduction in the risk of colorectal cancer with CHC use. Maybe a small additional risk of breast cancer with CHC use, which reduces to no risk10 years after stopping CHC use. Women 35 years or over and smoke should be advised that the risks of using CHC usually outweigh the benefits. Maybe a very small increased risk of ischaemic stroke with CHC use. Women with cardiovascular disease, stroke or migraine with aura should be advised against the use of CHC. Consider a pill with <30 μg ethinylestradiol as a suitable first choice. Hypertension may increase the risk of stroke and myocardial infarction (MI) in those using COC. Blood pressure should be checked before and at least 6 months after initiating CHC and monitored at least annually thereafter.

Progestogen-only Contraception No conclusive evidence of a link between progestogen-only methods and breast cancer. Progestogen-only methods may help to alleviate dysmenorrhoea. Altered bleeding patterns are common with use of progestogen-only contraception. Levonorgestrel-releasing intrauterine system (LNG-IUS) can be used for the treatment of heavy menstrual bleeding once pathology has been excluded. Progestogen-only injectable is associated with a small loss of BMD, which usually recovers after discontinuation. Women who wish to continue using depot medroxyprogesterone acetate (DMPA) should be reviewed every 2 years to assess the benefits and potential risks. Users of DMPA should be supported in their choice of whether or not to continue using DMPA up to a maximum recommended age of 50 years. POC does not appear to increase the risk of stroke or MI, and there is little or no increase in venous thromboembolism risk. Caution is required when prescribing DMPA to women with cardiovascular risk factors due to the effects of progestogens on lipids.

Non-hormonal Methods of Contraception Spotting, heavier or prolonged bleeding and pain are common in the first 3–6 months of copper-bearing intrauterine device (Cu-IUD) use. Male condoms and female condoms are, respectively, up to 98% and 95% effective at preventing pregnancy. Diaphragm and caps are, respectively, estimated to be between 92% and 96% effective at preventing pregnancy (with spermicide) When using lubricant with latex condoms a non-oil-based preparation is recommended.

Stopping Contraception Stop non-hormonal contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman under 50 years. After counselling (about declining fertility, risks associated with insertion, and contraceptive efficacy), women who have a Cu-IUD containing ≥300 mm2 copper,inserted at or over the age of 40 years, can retain the device until the menopause or until contraception is no longer required. Women who continue to use their IUD until contraception is no longer required should be advised to return to have the device removed. Women using exogenous hormones should be advised that amenorrhoea is not a reliable indicator of ovarian failure. In women using contraceptive hormones, follicle-stimulating hormone (FSH) levels may be used to help diagnose the menopause, but should be restricted to women over the age of 50 years and to those using progestogen-only methods. FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free interval. Women over the age of 50 years who are amenorrhoeic and wish to stop POC can have their FSH levels checked. If the level is ≥30 IU/L the FSH should be repeated after 6 weeks. If the second FSH level is ≥30 IU/L contraception can be stopped after 1 year. Women who have their LNG-IUS inserted for contraception at the age of 45 years or over can use the device for 7 years (off licence) or if amenorrhoeic until themenopause, after which the device should be removed

Hormone Replacement Therapy and Contraception Women using hormone replacement therapy (HRT) should be advised not to rely on this as contraception. Women can be advised that a progestogen-only pill can be used with HRT to provide effective contraception but the HRT must include progestogen in addition to estrogen. Women using estrogen replacement therapy may use the LNG-IUS to provide endometrial protection. When used as the progestogen component of HRT, the LNG-IUS should be changed no later than 5 years after insertion (the licence states 4 years), irrespective of age at insertion.

Questions for Contraception for Women Aged Over 40 Years 1 No method of contraception is contraindicated on the grounds of age alone. 2 Women using combined oral contraception (COC) have a reduced incidence of ovarian cysts. 3 In women with a family history of breast cancer the use of COC increases the risk of developing breast cancer. 4 The risks of the progestogen-only pill (POP) use outweigh the benefits in women aged over 50 years. 5 A raised follicle-stimulating hormone (FSH) level is a good indicator of the perimenopause in women over 40 years.

6 All women can be advised to stop contraception at age 55 years. 7 A woman who has an intrauterine system (IUS) inserted at or after the age 45 years and is amenorrhoeic may retain the device until she is postmenopausal. 8 The IUS may be used as the progestogen component of hormone replacement therapy (HRT) for 5 years. 9 A POP can be used with HRT to provide effective contraception in women aged over 40 years. 10 The intrauterine device (IUD) should be removed 1 year after the last menstrual period in women aged over 50 years.

A 19-year-old female is prescribed a 7 day course of amoxicillin for a lower respiratory tract infection. She is currently taking Cerazette (desogestrel). What is the most appropriate advice regarding contraception? A Use condoms for 14 days B. Use condoms for 21 days  C. Use condoms for 7 days D There is no need for extra protection E. Use condoms for 7 days, only antibiotic course overlaps with pill free interval

What is the failure rate of male sterilisation? A.1 in 100 B.1 in 200 C.1 in 300 D.1 in 400 E.1 in 2,000

A 19-year-old woman is seen the day after being discharged from hospital following a termination of pregnancy at 14 weeks. She is keen to start the combined oral contraceptive (COC) pill despite discussing long acting reversible contraceptives. What is the most appropriate action? A.Start COC immediately  B.Start COC after 7 days C.Refuse to prescribe a contraceptive unless she chooses a long acting reversible contraceptive D.Start COC on first day of next period  E.Start COC after 21 daysia

A 25-year-old female presents to her GP as she has missed two consecutive Microgynon 30 pills. She has taken the Microgynon for the past 5 years and is currently 11 days into a packet of pills. Last night she had sexual intercourse with a new partner but unfortunately the condom split. What is the correct management? A.Perform a pregnancy test B.No action needed C.Advise condom use for next 7 days D.Emergency contraception should be offered E.Omit pill break at end of pack

A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception? A.Immediately B.2 days C.5 days D.7 days E.Until first day of next period

Which one of the following is an absolute contraindication to combined oral contraceptive pill use? A.Controlled hypertension B.History of cholestasis C.36-year-old woman smoking 20 cigarettes/day D.BMI of 38 kg/m^2 E.Migraine without aura

A 22-year-old woman presents for her Depo-provera injection A 22-year-old woman presents for her Depo-provera injection. She apologises as she forgot about her appointment last week. You calculate she received her last injection 12 weeks and 4 day ago. What is the most appropriate course of action? A.Do a pregnancy test today + give injection if negative B.Give injection today and no further action C.Give injection today + use condoms for 7 days + pregnancy test in 21 days D.Do not give injection + do pregnancy test in 21 days E.Give injection today + use condoms for 7 days

A female patient asks for advice about having an intrauterine device inserted (a TT380 Slimline). What advice should be given regarding the likely effect on her periods? A.Periods will tend to be longer, heavier and more painful B.They will stop after 6 months in > 50% of users C.Periods will tend to be lighter, shorter and less painful D.Continual, light bleeding is seen in 50% E.They will stop after 6 months in > 90% of users

A 33-year-old woman is reviewed following a routine cervical smear A 33-year-old woman is reviewed following a routine cervical smear. She had an intrauterine device (IUD) inserted for contraception 2 years ago. She is currently well and reports no new problems. The smear report shows no evidence of dyskaryosis but states that Actinomyces-like organisms had been identified. What is the most appropriate management? A.Remove IUD + high vaginal swab in 1 month B.No action needed C.Remove IUD + oral doxycycline D.Oral metronidazole E.Remove IUD + oral metronidazole

A 44-year-old man attends for counselling with regards to a vasectomy A 44-year-old man attends for counselling with regards to a vasectomy. Which one of the following statements is true regarding vasectomy? A.Vasectomy is effective immediately B.Female sterilisation is more effective C.Two negative semen samples should be obtained at 2 and 4 weeks before other contraceptive methods are stopped D.Chronic testicular pain is seen in more than 5% of patients E.Sexual intercourse should be avoided for one month to reduce the chance of a sperm granuloma

References http://www.fsrh.org/pdfs/ContraceptionOver40July10.pdf http://www.fsrh.org/pdfs/UnscheduledBleedingMay09.pdf Passtest http://www.fsrh.org/pages/clinical_guidance.asp