Jo Swallow ST2’s December 2011. Contraception Update Jo Swallow ST2’s December 2011.

Pearl index Method Failure %rates per hundred women years Sterilisation male 0.0 to 0.2 Sterilisation female0.0 to 0.3 (1.8% at 10 years) Implanon0.0 Mirena0.0 to 0.2 Depo-Proverax0.0 to 0.2 Combined oral contraceptive pill0.2 to 3 (3 with poor compliance) Progestogen-only pill (second generation)0.3 to 4 (0.5 over age 35) IUDs 0.3 to 2 Diaphragm/cervical Cap 5 to 20 Condom (male, female) 5 to 15 Coitus interruptus 8 to 17 Natural methods 5 to 25 Spermicides 5 to 25

A reminder, re child protection. Frazer/Gillick competence <13yrs not legally capable of consenting to sexual activity 13-16 discuss and consider

Important things to worry about with the COCP? VTE Cancer –breast/ovarian Stroke Use the BNF cautions contraindications list… 2 strikes and you’re out!

VTE with COCP Risk of VTE per 100.000 Healthy, non pregnant, no COCP 5 per yr Cocp with levonorgestrol 15 per year Cocp with gestodene or desogestrol 25 per year Pregnant 60 per year

VTE with COCP:Effect of weight…. BMI>30 2 x risk BMI >39 4 x risk Healthy,no COCP 5 10 20 Cocp with levonorgestrol 15 30 60 Cocp with gestodene or desogestrol 25 50 100 Pregnant 120 240

Dianette/Yasmin Heard the news?

Cardiovascular Risk Absolute risk of MI in non smoking age <35 very low irrespective of COCP use Excess risk <35 approx 3/1,000,000/yr >35 Excess risk approx 400/1,000,000/yr 10x risk if smoke

Migraine Migraine with aura =absolute CI (WHO 4) Migraine +ergots=absolute CI Migraine +tryptan = relative CI Migraine +1 other RF=relative CI Migraine + No Aura +no additional stroke risk factors = OK

Antibiotics and the pill But ILL rules, (D/V still apply, and abx can induce these!)

Missed pills New rules Can miss one anywhere in pack no prob even if extend pill free interval to 8 days Can miss one pill anywhere in pack, no cover rqd generally unless also missed earlier in pack/in last week of previous pk If 2 or more missed see flow chart, +use condoms until 7 consequetive pills taken +/-emergency contraception depending on where in pack.

Progestogens C19 derivatives E.g Norethisterone C21 derivatives Levonorgestorel More androgenic More likely to cause side effects C21 derivatives E.g Medroxyprogestogen acetate Dydrogesterone Less androgenic

Side Effects Oestrogenic Fluid retention Bloating Breast tenderness Nausea Headache Dyspepsia (take with food) Consider changing dose, changing oestrogen or changing delivery Progestogenic (In a cyclical pattern) Fluid retention Breast tenderness Mood swings Depression Acne Backache Reduce progestogen duration to 10 days per cycle, change progestogen c19/21 derivatives, delivery

Emergency contraception What actually happened? ?regular partner or one off STI risk? Menstrual cycle and current position, other contraception? (?earliest ovulation) When was the accident? Any other upsi in this cycle ?used before ?consensual, age of partner, ?Frazer competant

Emerg contraception 2. Levonelle is effective up to 72 (120 hrs) If >48-72 hrs consider Ella One, (ullipristal) Always consider copper iud (up to 5 days or, up to 5 days> earliest ovulation) Levonelle efficacy: 95% - 1st 24hr, 85% 48, 70% 72 Ella one efficacy: ….. Remember pt’s on enzyme inducers may require double dosing of MAP

Things to discuss: Mode of action Vomiting Enzyme inducing drugs Next Period -87% within 7 days of expected: may be early or late, Most of rest 7-14d late ?Preg test ? Quickstart FUTURE contraception, Condoms have a 5% failure rate when used PERFECTLY

Emergency Contraception IUCD (not IUS) Up to 5 days after date of UPSI or expected ovulation Failure rate <1%