Contraception, Gynae emergencies and Funny Bleeding ST1’s Jo Swallow 2014

Objectives 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 in real life (not perfect)…. How many pregnancies would arise in the first year of use?

<1 1-10 11-50 51-100 100+ Cocp Pop Depo Ius Iud Patch Condom Diaphragm/Spermicide Condom Female condom withdrawal Male sterilisation Female sterilisation

The answers!

First year of Use Perfect Use Cocp 50 3 Pop 20? Depo Ius/iud 1 implant Patch 80 Diaphragm/Spermicide 160 6 Condom 150 20 Female condom 210 withdrawal 270 40 Male sterilisation Female sterilisation ~5 5 No method 850

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

Pros and Cons of each method Groups/Pairs…. discuss

What are the benefits?

What are the benefits? Any one want to fill this in?

What are the real risks? VTE Cancer Stroke

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

Special considerations Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing This is not true for implanon Consider cerazette/other pops, >70kg rule

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

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

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.

Special considerations Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing This is not true for implanon Consider cerazette/other pops, >70kg rule

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

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

When should contraception be started? IUCD within 12 days of period onset Mirena day 1-7 or if no risk preg at other time Depot-? COCP?

GP activity *** swopping pills/hrt Side effects can be oestrogenic/progestogenic Guillain book (pill ladder) *******Photocopy, brainstorm complaints on the pill ****** Spots, w gain, mood swings, bleeding, migraing increased weight inc >70kg ?can have 20mcg oestrogen? Choose an approp pill *******

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

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!

Dianette/Yasmin Can we use for contraception? For acne? What are the concerns?

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

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

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%

Gynae emergencies Jo Swallow 2014

Case 1- 24 yr LIF pain Charlotte attends your mid morning surgery reporting Feeling unwell Stomach pains Duration 24hrs What else would you like to know?

Useful info Fever Dyspareunia (deep) Intermenstrual bleeding for a few months Using condoms reliably What would you do having obtained this history?

Examination Chaperone issues Cervical excitation Adnexal tenderness Take swabs for chlamydia, gonorrhoea and mc+s What other tests would you like?

Invst Urinalysis Preg test MSU Bloods Viscoscity/crp What would your immediate management plan be for this patient?

Treatment Ofloxacin 400mg bd 14 days +metronidazole 400mg bd 14 days Or doxycycline +metronidazole Admission can be rqd, safety net, rvw, rvw 4 wks ?compliant, ptner screened. Doxycycline 200mg stat if needs top

Case 2- the condom split Michelle 15 yrs attends asking for ‘the pill’ What do you need to ask? What other issues does this present?

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

Up to 72 (120 hrs) If >72 hrs consider copper iud (up to 5 days or, up to 5 days> earliest ovulation) Levonelle-2 95% - 1st 24hr, 85% 48, 70% 72 Mode of action Vomiting Enzyme inducing drugs Next Period

FUTURE contraception, Condoms have a 5% failure rate when used PERFECTLY

CASE 3 – 35 yr RIF pain Lois 35 presents with abdo pain She has a copper iud insitu She has not had a period for 6 weeks but ‘they are always erratic’ She has a strange pain in her right shoulder, no injury. What diagnoses are you considering? How could you confirm/refute these?

Examination RIF tender no rebound no guarding Apyrexial Appendicectomy scar BP 105/64 pulse 110. appears unwell. Urinalysis, bhcg positive. Infection neg, trace blood. PV with consent, os closed iud strings not present, small amount of brown discharge pv. Acutely tender R adnexa, cervical excitation

?Now what What is your plan of action? What may be the action in hospital

Pain ‘down there’ What genital conditions cause pain?

Name the conditions and their treatments

Aciclovir – doses? Antibiotics, expression, Marsupilisation or removal

Funny Bleeding objectives To discuss Causes of Unscheduled bleeding…. Investigation of unscheduled bleeding Management of unscheduled bleeding

My periods are funny In pairs, What questions should we ask? Unusual health beliefs which patients have asked you about?

Management of unscheduled bleeding? ON COCP ON POP ON Depo ON Implant With iud/ius

Women bleeding on Contraception Don’t change combined oral contraceptive pill (COC) in first 3 months Bleeding common initial months of progestogen-only method use - may settle without treatment. Bleeding with depo, implant or ius (a COC may be used for up to 3/12 or trial of mefenamic acid.)

Funny Bleeding not on contraception? Sexually transmitted infections Cervical cancer – up to date with smears? ?<25 ?cervirax Pregnancy?implantation ?ectopic uterine polyps, fibroids or ovarian cysts, endometriosis.

Discuss, when to do what investigations? Speculum examination Swabs Smear test Bimanual examination Endometrial biopsy Transvaginal ultrasound scan Hysteroscopy

Gynae 2WW rules Refer urgently any women with pmb not on hrt. Refer any women on hrt with unexplained bleeding after cessation of hrt for 6 weeks. Consider urgent referral of patients with persistent imb and negative pelvic exam. Refer Pt with Post coital bleeding if persists >4wks if pt is >35yrs.

Questions?