1. Contraception, Gynae emergencies and Funny Bleeding
ST1’s
Jo Swallow 2014

2. Objectives
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

3. Brainstorm!

4. What forms of contraception are there?

5. Quiz!
If 1000 women were to use these methods of contraception in real life (not perfect)…. How many pregnancies would arise in the first year of use?

6. <1 1-10 11-50 51-100 100+ Cocp Pop Depo Ius Iud Patch Condom
Diaphragm/Spermicide
Condom
Female condom
withdrawal
Male sterilisation
Female sterilisation

7. The answers!

8. First year of Use Perfect Use Cocp 50 3 Pop 20? Depo Ius/iud 1 implant
Patch 80
Diaphragm/Spermicide
160 6
Condom
150 20
Female condom
210
withdrawal
270 40
Male sterilisation
Female sterilisation ~5 5
No method
850

9. 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

10. Pros and Cons of each method
Groups/Pairs…. discuss

11. What are the benefits?

12. What are the benefits?
Any one want to fill this in?

13. What are the real risks?
VTE
Cancer
Stroke

14. 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

15. 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

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

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

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

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

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

21. Special considerations
Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing
This is not true for implanon
Consider cerazette/other pops, >70kg rule

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

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

24. Missed pills
New rules
Can miss one anywhere in pack no prob even if extend pill free interval to 8 days
Can miss one pill anywhere in pack, no cover rqd generally unless also missed earlier in pack/in last week of previous pk
If 2 or more missed see flow chart, +use condoms until 7 consequetive pills taken +/-emergency contraception depending on where in pack.

25. Special considerations
Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing
This is not true for implanon
Consider cerazette/other pops, >70kg rule

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

27. 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

28. When should contraception be started?
IUCD within 12 days of period onset
Mirena day 1-7 or if no risk preg at other time
Depot-?
COCP?

29. GP activity *** swopping pills/hrt
Side effects can be oestrogenic/progestogenic
Guillain book (pill ladder)
*******Photocopy, brainstorm complaints on the pill ******
Spots, w gain, mood swings, bleeding, migraing increased weight inc >70kg ?can have 20mcg oestrogen?
Choose an approp pill *******

30. 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

31. 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

32. 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!

33. Dianette/Yasmin Can we use for contraception? For acne?
What are the concerns?

34. 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

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

36. 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

37. 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

38. 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

39. Emerg contraception 2. 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

40. 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

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

42. Gynae emergencies
Jo Swallow 2014

43. Case yr LIF pain
Charlotte attends your mid morning surgery reporting
Feeling unwell
Stomach pains
Duration 24hrs
What else would you like to know?

44. Useful info Fever Dyspareunia (deep)
Intermenstrual bleeding for a few months
Using condoms reliably
What would you do having obtained this history?

45. Examination Chaperone issues Cervical excitation Adnexal tenderness
Take swabs for chlamydia, gonorrhoea and mc+s
What other tests would you like?

46. Invst Urinalysis Preg test MSU Bloods Viscoscity/crp
What would your immediate management plan be for this patient?

47. Treatment Ofloxacin 400mg bd 14 days +metronidazole 400mg bd 14 days
Or doxycycline +metronidazole
Admission can be rqd, safety net, rvw, rvw 4 wks ?compliant, ptner screened.
Doxycycline 200mg stat if needs top

48. Case 2- the condom split Michelle 15 yrs attends asking for ‘the pill’
What do you need to ask?
What other issues does this present?

49. 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

50. Up to 72 (120 hrs)
If >72 hrs consider copper iud
(up to 5 days or, up to 5 days> earliest ovulation)
Levonelle-2
95% - 1st 24hr, 85% 48, 70% 72
Mode of action
Vomiting
Enzyme inducing drugs
Next Period

51. FUTURE contraception,
Condoms have a 5% failure rate when used PERFECTLY

52. CASE 3 – 35 yr RIF pain Lois 35 presents with abdo pain
She has a copper iud insitu
She has not had a period for 6 weeks but ‘they are always erratic’
She has a strange pain in her right shoulder, no injury.
What diagnoses are you considering?
How could you confirm/refute these?

53. Examination RIF tender no rebound no guarding Apyrexial
Appendicectomy scar
BP 105/64 pulse 110. appears unwell.
Urinalysis, bhcg positive. Infection neg, trace blood.
PV with consent, os closed iud strings not present, small amount of brown discharge pv. Acutely tender R adnexa, cervical excitation

54. ?Now what What is your plan of action?
What may be the action in hospital

55. Pain ‘down there’
What genital conditions cause pain?

56. Name the conditions and their treatments

57. Aciclovir – doses?
Antibiotics, expression,
Marsupilisation or removal

58. Funny Bleeding objectives
To discuss
Causes of Unscheduled bleeding….
Investigation of unscheduled bleeding
Management of unscheduled bleeding

59. My periods are funny In pairs, What questions should we ask?
Unusual health beliefs which patients have asked you about?

60. Management of unscheduled bleeding?
ON COCP
ON POP
ON Depo
ON Implant
With iud/ius

61. Women bleeding on Contraception
Don’t change combined oral contraceptive pill (COC) in first 3 months
Bleeding common initial months of progestogen-only method use - may settle without treatment.
Bleeding with depo, implant or ius (a COC may be used for up to 3/12 or trial of mefenamic acid.)

62. Funny Bleeding not on contraception?
Sexually transmitted infections
Cervical cancer – up to date with smears? ?<25 ?cervirax
Pregnancy?implantation ?ectopic
uterine polyps, fibroids or ovarian cysts, endometriosis.

63. Discuss, when to do what investigations?
Speculum examination
Swabs
Smear test
Bimanual examination
Endometrial biopsy
Transvaginal ultrasound scan
Hysteroscopy

64. Gynae 2WW rules Refer urgently any women with pmb not on hrt.
Refer any women on hrt with unexplained bleeding after cessation of hrt for 6 weeks.
Consider urgent referral of patients with persistent imb and negative pelvic exam.
Refer Pt with Post coital bleeding if persists >4wks if pt is >35yrs.

65. Questions?