Dr K Dissanayake Bute House Medical Centre Contraception Dr K Dissanayake Bute House Medical Centre

Different Methods Hormonal Barrier methods IUD Natural methods Sterilisation

Things to consider Age, consider whether Fraser competent in <16 yrs Medical History – UKMEC / WHOMEC Current medications Menstrual cycle Patient preference – previous experience, hormonal/non-hormonal, amenorrhoea Efficacy Quick starting Medical history – CV risk factors, diabetes, epilepsy, headache/migraine, hypertension, Uterine anomalies, weight, smoker, VTE Current medications – Antibiotics that induce liver enzymes (rifamipicin/Rifabutin),

Table 4: Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (modified from Trussell et al.) Method Typical use (%) Perfect use (%) Fertility awareness-based methods 24 0.4–5 Male condom 18 2 Combined hormonal contraception (CHC) Progestogen only pill (POP) 9 0.3 Implant 0.05 DMPA 6 0.2 Cu-IUD LNG- IUS 0.8 0.6 Female sterilisation Vasectomy 0.5 0.15 0.1

UKMEC criteria Provides guidance who can use the contraceptive methods safely – related to safety not efficacy UKMEC Definition 1 A condition for which there is no restriction of use of the method 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks 3 A condition where the theoretical or proven risks usually outweigh the advantages. Expert clinical judgement or referral advised 4 A condition which represents and unacceptable health risk if the method is used

Emergency Contraception Levonorgestrel (Levonelle) Ulipristal (Ella One) Copper IUD

Considarations Persistently elevated b-HCG levels (category4) or decreasing levels (Cat. 3) for Cu-IUD Post partum < 4 week and distorted uterus are category 3 for Cu-IUD

Hormonal contraception Combined hormonal contraception COC First line - Ethinylestradiol 30mcg +levonorgestrel or Norethisterone – eg Microgynon, Rigevidon. Higher risk of VTE if the progestogen is Drospirenone (Yasmin), Gestodene (Femodene) and Desogestrel (Marvelon/Gedarel) Transdermal patches –eg Evra Vaginal ring - NuvaRing

CHC Mechanism of action – Inhibition of ovulation, some effect on the cervical mucus and endometrium. When to start Missed pills One missed pill 2 or more missed pills Diarrhoea and vomiting

CHC and UKMEC Postpartum (0-<6 weeks) and breastfeeding – category 4 Post partum (3-6 weeks) and non breast feeding With other risk factors for VTE – category 3 Without other risk factors for VTE – category2 Age and smoking <35 yrs – category2 >35 yrs - <15 cigarettes – cat. 3 and >15 cig cat. 4

CHC and UKMEC Obesity Hx of or current VTE – Cat. 4 BMI >= 30-34 Cat.2 BMI>= 35 Cat.3 Hx of or current VTE – Cat. 4

Progestogen only contraception POP Depo injections Subdermal implant UKMEC Current breast cancer Cat 4, past breast cancer Cat 3 Check if hx of stroke and IHD IUS

POP Mechanism of action – changes to cervical mucus, suppression of ovulation(Desogestrel>norgeston), suppression of midcycle peaks of LH and FSH, hostile endometrium, reduced activity of cilia in the fallopian tube When to start Delayed or missed pills Vomiting and diarrhoea

LARC Progestogen only injections Subdermal implant IUS IUD Depot medroxyprogesterone acetate 150mg deep IM(depo-provera) Depot medroxyprogesterone acetate 104mg SC (Sayana Press) Norethisterone enantate 200mg deep IM (Noristerat) Subdermal implant IUS IUD

Progestogen only injectables

Progestogen only injectables Mechanism of Action – Inhibition of ovulation and thickening of cervical mucus When to start Depo Provera – every 12 weeks and Sayana Presss – every 13 weeks Loss of bone mineral density

Progestogen only implant Nexplanon – Etonogestrel 68mg

Nexplanon Mechanism of Action – Inhibition of ovulation, some changes to cervical mucus When to start 3 years Menstrual irregularities Liver enzyme inducing drugs are likely to reduce efficacy Deep implants/migration of implant

IUS Levonorgestrel intrauterine systems Mirena Levosert Jaydess Dose 52mg 13.5mg Contraception 5 yrs 3 yrs Endometrial protection 4yrs - Menorrhagia size 32mm(h) 32mm(w) 32mm(h) 32mm(w) 30mm(h) 28mm(w)

Mirena

IUS Mechanism of Action – prevents implantation of the fertilised ovum and changes to cervical mucus When to start

IUD Copper containing devices Most effective devices contain at least 380mm 2 of copper and have copper bands on the transverse arms.

IUD TT380 Slimline – 10 years MiniTT380 Slimline – 5 years T-Safe 380A QL – 10 years

IUD Mechanism of Action When to start Heavier and more painful periods Toxic to the sperm and ovum thereby preventing fertilisation Alteration in the copper content of the cervical mucus – inhibits penetration Inflammatory reactions within endometrium – prevents implantation When to start Heavier and more painful periods

IUS/IUD Risk of Uterine Perforation – 1/1000 Risk of PID – related to insertion and background risk of STI Educate patient to feel for threads Risk of ectopic pregnancy Actinomyces like organisms on smear

Permanent methods Sterilisation Vasectomy Tubal Occlusion

Vasectomy Minor surgical procedure Small risk of haematoma and infection Potentially irreverisible Need to use contraception for 12 weeks post procedure until azoospermia in confirmed Risk of testicular/scrotal pain post vasectomy – can develop months or years later. 1-14%

Vasectomy

Tubal Occlusion Surgical procedure Potentially irreversible If tubal occlusion fails the resulting the pregnancy might be ectopic Filshie clips and modified Pomeroy technique – contraception for 4 weeks following the procedure Hysteroscopic sterilisation – need contraception for 3 months until confirmation of occlusion

Tubal Occlusion