Contraception Update

To know the contraindications for each and how to identify them To know what forms of contraception are available and when they are necessary To know the contraindications for each and how to identify them What to check for on f/u consultations To know how to access information for ourselves and patients To know how to approach a consultation for : A teenager A >35 y.o The rest!

To be able to discuss the main pros and cons for different types of contraception. To know which are the most effective methods of contraception To know why some are less good for different patient groups To be aware of important issues for different age ranges

Brainstorm! What forms of contraception are there?

Quiz! If 1000 women were to use these methods of contraception…. How many pregnancies would arise in the first year of use?

Diaphragm/Spermicide <1 1-10 11-50 51-100 100+ Cocp Pop Depo IUS IUD Implant Patch Diaphragm/Spermicide Condom Female condom withdrawal Male Sterilisation Female sterilisation No method

The answers!

First year of Use Perfect Use Cocp 50 2 Pop 4 Depo 3 Ius/iud 1 implant Patch 80 Diaphragm/Spermicide 160 (nullip) 9 Condom 150 20 Female condom 210 Withdrawal 270 40 Male sterilisation Female sterilisation ~5 5 No method 850

Let’s have some cases!

Amelia

Frazer/Gillick competence <13yrs not legally capable of consenting to sexual activity 13-16 discuss and consider

Nicky

Julie Use the BNF cautions contraindications list… 2 strikes and you’re out!

Important things to worry about with the COCP? VTE Cancer Stroke

VTE with COCP Risk of VTE per 100.000 Healthy, non pregnant, no COCP Cocp with levonorgestrol Cocp with gestodene or desogestrol Pregnant

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

Other risks… Which is more likely to happen? Dying from a thrombosis from a third generation COCP Or Dying in a RTA

Cancers… Is there an increase in risk of breast cancer with the COCP? RR increased by: 0% 1-9% 10-19% 20-49% >50%

Is there an increase in risk of breast cancer with the COCP? RR increased by: 25%

What is the absolute risk increase? 0.01% 0.1% 0.5% 1% 2-10%

Absolute risk is 0.01% Actual baseline risk <30 1:1900 30-40 1:200 30-40 1:200 Risk increase is 12/100,000

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

Cerebrovascular Risk Ischaemic stroke: non smoking, normotensive women XS risk 4/100,000/yr Increased with age/smoking x 10 / migraine x 11

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

Agatha

Emergency Contraception POEC :Progesterone only Emergency contraception (Levonelle 1500) Success Rates: preventing expected pregnancy <24 hr 95% 25-48 hr 85% 49-72 hr 56% (72-120 hr ?60%)

POEC Effect on next period 87% within 7 days of expected: may be early or late Most of rest 7-14d late

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

EllaOne(Ulipristal) Inhibits/delays ovulation Good efficacy up to 120h (better than Levonelle esp after 48h) Only once in cycle Can’t rely on Hormonal contraception rest of that cycle: (Need to allow 9d for progesterone methods 14d cocp)

Pat

Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing… and you may need time recover before the menopause This is not true for implanon

June

Mirena ok for 4y for endometrial protection Menopause: amenorrhoea >2y if under 50 >1y if >50 If Mirena / Implanon FSH > 30 6w apart means likely but above applies IUD change x 1 after 40 IUS change x 1 after 45

Fran

Sophie

Missed pills New rules Can miss one anywhere in pack no prob even if extend pill free interval to 8 days

Missed pills see handout !!! 7 successive pills to inhibit ovulation Alt contraception for 7d if miss 2 for 20 or 3 for 30. Important… just keep going! Take asap then as normal If start pkt late in wk 1and sex in pfw need EC If in week 3 miss pfw , wk 1 EC

Missed pills POP Cerazette 12h, rest 3h Take and continue : need 48h continuous taking (3 pills) then ok again

New ideas All more expensive… NuvaRing: 15mg EE2/120 etonorgestel/d Sits in vagina: replace monthly As effective, ok with amoxicillin/doxycycline Store in fridge/expulsion may occur/same restrictions as patch

Nuvaring

New ideas Extended pill regimes (not available uk yet): seasonale/seasonique 4 periods/yr Anya/Lybrel 365d pill 20mcg, btb the prob. Suggest bi-cycling or tri-cycling to limit of btb tolerance of other pills

Special considerations

Women on HIV drugs Enzyme inducers+++ Best option IUD EC double levonelle

Enzyme inducers Women with epilepsy Injectable/IUD Oral contraceptives with 50mg oestrogen Tricycle with 4 days break Double emergency contraceptive dosage

When should contraception be started? IUCD within 18 days of period onset Mirena day 1-7 or if no risk preg at other time Depot-? COCP? POP?

Swapping pills/hrt Side effects can be oestrogenic/progestogenic If someone has each of the following what would you use/change to? (pill ladder) Spots, Hirsuitism Feeling depressed Nausea Bloating Breast discomfort

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