1. Contraception Update

2. To know the contraindications for each and how to identify them
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 teenager
A >35 y.o
The rest!

3. 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

4. Brainstorm!
What forms of contraception are there?

5. Quiz!
If 1000 women were to use these methods of contraception…. How many pregnancies would arise in the first year of use?

6. Diaphragm/Spermicide
<1
1-10
11-50
51-100
100+
Cocp
Pop
Depo
IUS
IUD
Implant
Patch
Diaphragm/Spermicide
Condom
Female condom
withdrawal
Male Sterilisation
Female sterilisation
No method

7. The answers!

8. First year of Use
Perfect Use
Cocp 50 2
Pop 4
Depo 3
Ius/iud 1
implant
Patch 80
Diaphragm/Spermicide
160 (nullip) 9
Condom
150 20
Female condom
210
Withdrawal
270 40
Male sterilisation
Female sterilisation ~5 5
No method
850

9. Let’s have some cases!

10. Amelia

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

12. Nicky

13. Julie
Use the BNF cautions contraindications list… 2 strikes and you’re out!

14. Important things to worry about with the COCP?
VTE
Cancer
Stroke

15. VTE with COCP Risk of VTE per 100.000 Healthy, non pregnant, no COCP
Cocp with levonorgestrol
Cocp with gestodene or desogestrol
Pregnant

16. 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

17. 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

18. Other risks… Which is more likely to happen?
Dying from a thrombosis from a third generation COCP Or
Dying in a RTA

19. Cancers… Is there an increase in risk of breast cancer with the COCP?
RR increased by: 0%
1-9%
10-19%
20-49%
>50%

20. Is there an increase in risk of breast cancer with the COCP?
RR increased by:
25%

21. What is the absolute risk increase?
0.01%
0.1%
0.5% 1%
2-10%

22. Absolute risk is 0.01% Actual baseline risk <30 1:1900 30-40 1:200
:200
Risk increase is 12/100,000

23. Cardiovascular Risk
Absolute risk of MI in non smoking aet <35 very low irrespective of COCP use
XS risk approx 3/1,000,000/yr
>35 XS risk approx 400/1,000,000/yr
10x risk if smoke

24. Cerebrovascular Risk
Ischaemic stroke: non smoking, normotensive women XS risk 4/100,000/yr
Increased with age/smoking x 10 / migraine x 11

25. 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

26. Agatha

27. Emergency Contraception
POEC :Progesterone only Emergency contraception (Levonelle 1500)
Success Rates: preventing expected pregnancy
<24 hr 95%
25-48 hr 85%
49-72 hr 56%
( hr ?60%)

28. POEC Effect on next period
87% within 7 days of expected: may be early or late
Most of rest 7-14d late

29. Emergency Contraception
IUCD (not IUS)
Up to 5 days after date of UPSI or expected ovulation
Failure rate <1%

30. EllaOne(Ulipristal) Inhibits/delays ovulation
Good efficacy up to 120h (better than Levonelle esp after 48h)
Only once in cycle
Can’t rely on Hormonal contraception rest of that cycle: (Need to allow 9d for progesterone methods 14d cocp)

31. Pat

32. Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing… and you may need time recover before the menopause
This is not true for implanon

33. June

34. Mirena ok for 4y for endometrial protection
Menopause: amenorrhoea >2y if under 50
>1y if >50
If Mirena / Implanon FSH > 30 6w apart means likely but above applies
IUD change x 1 after 40
IUS change x 1 after 45

35. Fran

36. Sophie

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

38. Missed pills see handout !!! 7 successive pills to inhibit ovulation
Alt contraception for 7d if miss 2 for 20 or 3 for 30.
Important… just keep going! Take asap then as normal
If start pkt late in wk 1and sex in pfw need EC
If in week 3 miss pfw , wk 1 EC

39. Missed pills POP Cerazette 12h, rest 3h
Take and continue : need 48h continuous taking (3 pills) then ok again

40. New ideas All more expensive… NuvaRing: 15mg EE2/120 etonorgestel/d
Sits in vagina: replace monthly
As effective, ok with amoxicillin/doxycycline
Store in fridge/expulsion may occur/same restrictions as patch

41. Nuvaring

42. New ideas
Extended pill regimes (not available uk yet): seasonale/seasonique 4 periods/yr
Anya/Lybrel 365d pill
20mcg, btb the prob.
Suggest bi-cycling or tri-cycling to limit of btb tolerance of other pills

43. Special considerations

44. Women on HIV drugs
Enzyme inducers+++
Best option IUD
EC double levonelle

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

46. When should contraception be started?
IUCD within 18 days of period onset
Mirena day 1-7 or if no risk preg at other time
Depot-?
COCP?
POP?

47. Swapping pills/hrt Side effects can be oestrogenic/progestogenic
If someone has each of the following what would you use/change to? (pill ladder)
Spots,
Hirsuitism
Feeling depressed
Nausea
Bloating
Breast discomfort

48. 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

49. 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