Wednesday 30 th March GP VTS

Topics covered What to consider with contraception Pills IUD/IUS Implants and injection Special circumstances QOF Case studies

Not covering Surgical methods - no funding Natural methods Gillick (in too much detail) Infertility

General intro Common consultation Increased choice Benefits and risks Unwanted pregnancy

Initial consultation Personal preference Lifestyle Medical history Family history Risk of STI

Before starting Confirm not pregnant Previous methods Current medical problems BP Migraine? Smoker? Family history of cancers

COCP Vary by oestrogen content Vary by progesterone type 21 pills then break

Risk greater than benefit Aged 35y + smoker >50y HTN IHD/CVA/PVD DM VTE Focal migraine

Risk greater than benefit Female malignancy Hormonal problems in pregnancy Breast feeding Acute hepatitis Porphyria

Starter pills Microgynon 30 Ovranette 150mcg - levonorgesterol (progesterone) 30mcg – ethinylestradiol (oestrogen) £2.99 £2.29

Progesterone side effects Acne Headache Depression Weight gain Breast symptoms Decreased libido

Alternate options Desogesterel – Marvelon Gestodene – Femodene Norgestimate – Cilest Drospirenone - Yasmin £6.70 £7.18 £11.94 £14.70

Alternate options Cyproterone acetate – Dianette £3.70 Not licensed for contraception alone Used in treatment of acne

Oestrogen side effects Breast tenderness Nausea Weight gain Bloating Loestrin 20 – 20mcg ethinylestradiol £2.70

Breakthrough bleeding First few months Exclude other cause Compliance

Interactions New advice on antibiotics Enzyme inducers Affect all hormonal contraception

Missed COC pills Current advice Take ASAP 2 or less 3 or more

POP Older women Smokers VTE history HTN, DM, Migraine Breastfeeding <6m post-partum

Types Cerazette- desogesterel - £8.85 Micronor/Noriday – norethisterone - £2.00 Femulen – etynodiol - £3.31 Norgeston – levonorgesterel - £0.98

Starting Start on day 1 of cycle Take every day – no breaks Missed pill D+V

Side effects Higher failure rate Irregular bleeding Risk of ectopic

In summary… LARC 23% of primary methods of contraception LARC methods intrauterine devices [IUDs] the intrauterine system [IUS] injectable contraceptives implants all LARCs more cost effective than the COCP even at 1 year of use IUDs, the IUS and implants are more cost effective than the injectable contraceptives (DMPA)

Who can use LARCs? All LARC methods are suitable for: nulliparous women breastfeeding women who have had an abortion BMI > 30 women with HIV – encourage safer sex women with diabetes women with migraine with or without aura – all progestogen-only methods may be used women with contraindication to oestrogen

Important points to discuss: contraceptive efficacy duration of use risks and possible side effects non-contraceptive benefits initiation and removal/discontinuation when to seek help while using the method.

Risks and side effects Copper IUDsIUS (Mirena)Progestogen-only injections Implants Unacceptable vaginal bleeding/pain Altered bleeding pattern eg. persistent Irregular bleeding Ectopic pregnancy 1/20 (lower than without contraception) Ectopic pregnancy 1/20 Small loss in bone mineral density, largely recovered when stopped. Acne PID <1% low risk women PID <1%Weight gain – up to 2-3kg over a year Uterine perforation <1/1000 No evidence of effect on depression, acne or headaches No evidence of effect on weight, mood, libido, headaches, BMD Mood/libido change Mood/libido change, acne No weight gain

Benefits – non contraceptive Progestogen-only implants/DMPA may improve dysmenorrhoea and the symptoms of endometriosis. Up to 20% of women using a progestogen- only implant will be amenorrhoeic A RTC found a significant reduction in dysmenorrhoea and menorrhagia with the LNG-IUS (Mirena) when compared to a Cu- IUD.

Implanon/Nexplanon

Implants - update Nexplanon® is a progestogen-only subdermal implant (non palpable) - now replaced Implanon®. Nexplanon and Implanon are bioequivalent (i.e. they both contain 68 mg etonogestrel and they have the same release rate and 3-year duration of action). Nexplanon is radio-opaque and has a different application device and insertion technique.

Implants When fitting: Check the woman is not pregnant! Nexplanon may be inserted: at any time (but use barrier methods for first 7 days if the woman is amenorrhoeic or it is more than 5 days since menstrual bleeding started)

Implants Prevention of ovulation. 3 years No delay 20% of users - no bleeding 50% will have infrequent, frequent or prolonged bleeding Bleeding patterns are likely to remain irregular. Not recommended for women taking enzyme- inducing drugs eg. Anti-epileptics, St.Johns Wort. Useful if high BMI

Copper devices or Mirena coil.

Before inserting an IUD or IUS: Test for: Chlamydia trachomatis in women at risk of STIs Neisseria gonorrhoeae in women at risk of STIs in areas where it is prevalent For woman at increased risk of STIs, give prophylactic antibiotics before inserting an IUD or IUS if testing has not been completed.

Like the implant - an IUD or IUS may be inserted: at any time If the woman has epilepsy, seizure risk may be increased at the time of fitting an IUD or IUS. Women with a history of venous thromboembolism (VTE) may use the IUS.

Pelvic infection risk - 20 days following insertion risk same as non-IUD-using population thereafter Irregular bleeding common in the first 6 months after insertion of the LNG-IUS but by 1 year amenorrhoea or light bleeding is usual.

IUDs Previous endocarditis Prosthetic heart valve require intravenous antibiotic prophylaxis Copper is toxic to ovum and sperm inhibiting fertilisation. In addition, the endometrial inflammatory reaction has an antiimplantation effect and alterations in the copper content of cervical mucus inhibit sperm penetration.

IUDs A Cu-IUD inserted when a woman >40 years can be retained until the menopause is confirmed. >50yrs - 1 year after the last menstrual period <50yrs - 2 years Copper IUDs years

IUS - Mirena Prevents implantation. Effects on cervical mucus reduce sperm penetration. Inserted >45 years and amenorrhoeic - may retain the LNG-IUS until the menopause. Randomised trials show that the LNG-IUS provides effective contraception for up to 7 years – licensed for 5 years.

After fitting: At first follow-up visit (after the first menses, or 3–6 weeks after insertion) exclude infection, perforation or expulsion. IUD only: For heavier and/or prolonged bleeding associated with use of an IUD: – treat with NSAIDs and tranexamic acid – or suggest changing to the IUS if the woman finds bleeding unacceptable.

Depo Provera

Injectable contraceptives Depo Provera or Noristerat (short term use) Inhibits ovulation. Check not pregnant! Can give: – up to 5 th day of the menstrual cycle without the need for additional contraceptives – or use barrier contraception 7 days

Every 12 weeks Deep intramuscular injection into the gluteal or deltoid muscle or the lateral thigh Delay up to 1 year in the return of fertility BUT …no evidence of reduced fertility long term

Amenorrhoea (14.4%) Infrequent bleeding (24.2%) Spotting (27.9%) Prolonged bleeding (33.5%) were all reported

Small loss of BMD, which is usually recovered after discontinuation. Women should be advised that there is no available evidence on the effect of DMPA on longterm fracture risk. Use may continue to age 50 years.

Managing irregular bleeding Can try: 3 cycles of 20-30mcg COC, taken cyclically – can be repeated If COC contraindicated: mefenamic acid 500mg BD until bleeding settles… Cerazette 1 tab daily for approx. 3 months

Managing problems with Depo Provera Repeat injections may be given up to 2 weeks late. DMPA use >2 years, review and discuss the balance of benefits and risks again eg. BMD No evidence of congenital malformation to the fetus if pregnancy occurs during DMPA use. Good choice if on enzyme-inducing drugs

Follow-up required acc. to NICE Routine follow-up IUD/IUS At 3–6 weeks Return if problems or time for removal. Injectable contraceptives Every 12 weeks; every 8 weeks for NET-EN Implants No routine follow-up

Under 16s and post-partum

Fraser Guidelines and Gillick Competence

Under 16s and providing contraception Be aware of the law Duty of care and a duty of confidentiality to all patients, including under 16s. > 25% of young people are sexually active <16 years. Least likely to use contraception. Confidentiality

If considering any disclosure of information - weigh up a right to privacy against: current or likely harm what any such disclosure is intended to achieve potential benefits to the young person’s well-being. Except in the most exceptional of circumstances - consult the young person and offer to support a voluntary disclosure.

The Fraser Guidelines: the young person understands the health professional’s advice; cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice; the young person is very likely to begin or continue having intercourse with or without contraceptive treatment; unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer; the young person’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent.

The Sexual Offences Act 2003 The Act states that, a person is not guilty of aiding, abetting or counselling a sexual offence against a child where they are acting for the purpose of: protecting a child from pregnancy or STIs protecting the physical safety of a child, promoting a child’s emotional well-being by the giving of advice.

Choices for women post-partum, including breastfeeding IUD – copper: from 4 weeks after childbirth IUS - Mirena: from 4 weeks after childbirth DMPA injection: any time after childbirth, if >21 days need additional. Implants - Nexplanon: any time after childbirth; if >21 days postpartum need additional

Abortion/miscarriage Progestogen-only injectable contraception or implant is appropriate: after surgical abortion (second part of) medical abortion miscarriage. If DMPA or Nexplanon within 5 days Ideally insert IUD or IUS within the first 48 hours or delay until 4 weeks postpartum.

Emergency contraception Less than 72 hours – levenorgesterol - 1.5mg Between 72h and 120h – EllaOne Most effective is Copper IUD

Emergency contraception Advise to return if abdominal pain or next period overdue Advice on STI Plan contraceptive follow up

TOP - practicalities Less than 24w Reasons Medical and surgical Marie Stopes centres

QOF LARC – offered and coded Chlamydia testing – people under 25

Case study 1 17y Only current partner BMI 22 Non-smoker Wants contraception

Case study 1 Comes back 3m later Spots over face, some on back

Case study 2 42y Finished family Wants something long term

Case study 3 24y New baby Unplanned pregnancy

Case study 4 37y Heavy smoker BMI 42 Bed bound Diabetic Previous DVT BP 172/104

Resources Faculty of Family Planning Oxford handbook of General Practice BNF Marie Stopes Monkgate Clinic