Contraception Update Jo Swallow ST1s October 2011.

Objectives 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 contraception request An emergency contraception request

Brainstorm! What forms of contraception are there? Rank them now in order of efficacy, (most effective at the top)

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

Case 1-Lois A Lois 15yrs attends asking to go on the pill. In groups of 3, History factors? Examination factors? ?Pill choice

COCP/POP What did you think?

A reminder, re child protection. Frazer/Gillick competence <13yrs not legally capable of consenting to sexual activity 13-16 discuss and consider

Pros/cons of cocp

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!

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

Dianette/Yasmin Heard the news?

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

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

Case 1 -Lois B Lois returns to see you with symptoms of a urine infection, She reports that although she is quite good at remembering her pills, she does forget occasionally, is this ok?

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

Missed pills New rules Can miss one anywhere in pack no prob even if extend pill free interval to 8 days If std dose 30 can miss 2/3**** If low dose oestrogen (20) can miss ***

Case 1 –Lois C Lois returns, 4 months later, she is now 16. Her parents has been complaining about her mood swings and she wonders if the pill is to blame. She hasn’t told them that she takes it. What might you consider?

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

Case 2- The condom split Michelle 15 yrs attends asking for ‘the emergency pill’ Groups of 3 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

Case 2 - Michelle B It transpires that the condom split yesterday evening around 11pm, They also had sex 3.5 days ago using the withdrawal method What is the most effective measure for her now? What other options are there?

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%