Emergency Contraception, Quick Start & a bit about LARCS Dr Jackie Abrahams jackie.abrahams@dchs.nhs.uk

Pregnancy and Emergency Contraception (EC) ‘All women of reproductive age are pregnant until proven otherwise’ Think about possibility of pregnancy or need for EC With every request for contraception With every request for a pregnancy test. With any other consultation

Emergency Contraception Remember There is a failure rate with Levonelle 1500 and EllaOne There is virtually no failure rate with postcoital (PC) Coil.  All women should be offered the option of PC Coil (especially if they are mid cycle and/or over 48 hours)

NB No evidence that either have much effect after ovulation ellaOne vs Levonelle ellaOne more effective (failure rate 1.28% compared to 2.2% with Levonelle) ellaOne can still inhibit/delay ovulation once LH surge started - ie in 48 hours pre-ovulation ellaOne licensed for use up to 120 hours post UPSI and equally effective throughout that time period ellaOne is a Progesterone Receptor Modulator and therefore interferes with ongoing hormonal contraception for the next 7 days NB No evidence that either have much effect after ovulation

ellaOne vs Levonelle ellaOne more expensive - £16.95 vs £5.20 Approved by Joint Area Prescribing Committee (JPAC) for women under 35 who are mid cycle (ovulation minus 6 days to ovulation plus 2 days) For women presenting for EC between 73 and 120 hours post UPSI

Emergency Contraception Over 72 hours? – PC Coil best option up to 5 days after earliest ovulation (i.e., day 19 of a regular 28 day cycle) – regardless of how many episodes unprotected sexual intercourse (UPSI). If beyond ovulation+5days - up to 5 days after UPSI Unlicenced Use Levonelle 1500 or EllaOne If coil not an option, can have Levonelle-2 or EllaOne as unlicensed use over same timescale as PC Coil (but much higher failure rate)

Emergency Contraception And then ?Quickstart If starting hormonal method consider immediate start oral contraception  small risk of pregnancy but ?worth it. COC - not safe for 7 days after Levonelle – 14 days after EllaOne POP – not safe for 2 days after Levonelle – 9 days after EllaOne PT with EMU in 3-5 weeks – ideally PT 3 weeks after last risk (eg 5 weeks after EllaOne and quickstart COC as not protected by COC for first 2 weeks)

Emergency Contraception Missed Pills Take Levonelle and continue with pills (don’t stop and wait for next period – it might never come!) Do Pregnancy test 3-4 weeks later (whether or not normal withdrawal bleed) NB Levonelle better than EllaOne for missed pills (because of effect on progesterone receptors with EllaOne)

Late / Missed Pills COC Latest FPA Guidance (what we teach the patients) can miss 1 pill anywhere in pack – no extra precautions needed If miss 2 or more need extra precautions and active pills for 7 days ‘pragmatic’ guidance (what we know) Need to have taken 7 active pills can miss up to 7 anywhere else in pack need 7 active pills after missed pills NB Extra precautions not needed with antibiotics POP – Only need extra precautions until normal pill taking resumed for 48 hours (Late = 12 hours for Cerazette, 3 hours for other POP’s)

Late Depo Injection Up to 14 weeks – give next Depo. No extra precautions needed 14 – 15 weeks – give next Depo. If any UPSI after 14 weeks also give PCC (Levonelle or PC IUD). Not safe for 7 days and need PT in 4 weeks Over 15 weeks – need to exclude pregnancy before rpt Depo – unless no UPSI after 14 weeks (?COC or POP for 1 month and then next Depo with neg PT) (according to most recent WHO guidelines can have repeat Depo up to 16 weeks and don’t need extra precautions for 7 days – UK Guidelines still say 14 weeks)

Quick Starting Contraception Clinical Effectiveness Unit September 2010 See Faculty website http://www.fsrh.org.uk for full guidelines

Quick Starting Contraception Key Recommendations If a health professional is reasonably sure that a woman is not pregnant or at risk of pregnancy from recent unprotected sexual intercourse (UPSI), contraception can be started immediately unless the woman prefers to wait until her next period.

Quick Starting Contraception Key Recommendations If pregnancy cannot be excluded (e.g. following administration of EC) but a woman is likely to continue to be at risk of pregnancy, immediate ‘quick starting’ of CHC, the POP or progestogen only implant may be considered. The woman should be informed of the potential risks and the need to have a pregnancy test at the appropriate time.

Quick Starting Contraception Key Recommendations Women requesting the progestogen-only injectable should ideally be offered a bridging method if pregnancy cannot be excluded, but immediate start is acceptable if other methods are not appropriate or acceptable.

Quick Starting Contraception Key Recommendations If contraception is quick started in a woman for whom pregnancy cannot be excluded, a pregnancy test should be advised no sooner than 3 weeks after the last episode of UPSI.

Quick Starting Contraception Key Recommendations If starting hormonal contraception immediately after ulipristal acetate EC, the CEU recommends condoms or avoidance of sex for 14 days (9 days if starting POP, 16 days for Qlaira)

LARC’s Long Acting Reversible Contraceptives IUD/IUS Progesterone subdermal implant (Nexplanon) Depoprovera

IUD/IUS Key Messages Just as good for Nullips as Multips No need for swabs with every fit Do STI risk assessment and decide if necessary If taking swabs only need to do 2 endocervical swabs for GC and Chlamydia (an HVS is a diagnostic test – only necessary if has abnormal discharge)

IUD vs IUS IUD IUS Less problems than IUS if normal/light periods Can be fitted up to ovulation + 5 days regardless of whether UPSI since LMP If fitted over age 40 can stay in until menopause Most effective emergency contraception IUS 1st choice if heavy periods or had heavy periods with IUD Amenorrhoea in only 25-30% Can cause significant bleeding problems for up to 6 months Other progesterone side effects Cannot be used for emergency contraception

Nexplanon Most effective contraceptive method Failure rate 1/2000 No serious risks Main challenge is management of side effects Bleeding problems Mood swings Skin problems

Bleeding Problems with Nexplanon Don’t usually need any investigation apart from STI risk assessment and/or screening Usually respond to COC or POP Often settle after 3 months of treatment If recur on stopping can continue COC or POP longterm

DCHS Sexual Health Service Clinics Central Booking Line for all Appointments Tel 01246 235792 We will accommodate requests for Emergency IUD’s at all of our clinics Contact numbers to speak to a clinician Dr Jackie Abrahams 07967 729253 Dr Stephen Searle 07774 962320

Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) Details of the training requirements for DFSRH and Letters of Competence (LoC’s) in Intrauterine Techniques and Subdermal Implants are available on the Faculty website http://www.fsrh.org/pages/Diploma_of_the_FSRH.asp DFSRH training involves three stages: e-learning for theory background; the e-SRH programme Course of 5; five hours of small group workshops Clinical experience and assessment

Course of 5 and Practical Training Locally training is organised through Course of 5 is run twice a year – next one is on 17th June 2013 Details of training elsewhere in UK is available on the Faculty website Training for Health Department Phone:       01246 868448 Email:         trainingforhealth@dchs.nhs.uk Website:    www.trainingforhealth.derbys.nhs.uk