1. Consultant in Sexual and Reproductive Healthcare
Contraception Update
2018
Dr Caroline
Marfleet
Consultant in Sexual and Reproductive Healthcare

2. Contraception in 2018 Sub-dermal implants IUDs Injectables IUS
Combined hormonal contraception
Contraception in
Male and female sterilisation
Progestogen-only pills
Female barrier methods
Natural FP/withdrawal/LAM
Male barrier methods
Emergency contraception

3. Women are all different!
No one method will suit all women

4. Minimal medical interference
Choosing a method of contraception
Safe
Effective
Reliable
Easy to use
Few side effects
What’s important to women when deciding on a
method of contraception?
Easy to remember
Easy access
No effect on future
fertility
Minimal medical interference
Minimal effect
on periods

5. At the initial visit:
A full sexual, reproductive and medical history need to be taken including:
Present and past use of contraception
History of migraine & risk factors for cardiovascular disease eg smoking; previous VTE; hyperlipidaemia
Any personal medical history
Drug use (prescription, non-prescription & herbal)
Family history – VTE; stroke; arterial disease; breast cancer; diabetes; other
BP should be documented
Height, weight & BMI should be documented

6. 2018 – 3 methods of delivery of combined hormonal contraception

10. WHICH CHC? Types of OCPs – combined and progestogen-only
Ethinyl oestradiol and progestogens
Oestradiol valerate /hemihydrate(body-identical oestrogen) and progestogen
Routes of administration -pill.patch, ring
Risks and benefits to individuals
Side effects relating to oestrogens/progestogens
Which pill and managing side effects

11. COC Progestogen ladder
Cyproterone
Drospirenone
Gestodene
Desogestrel
Norgestimate
Levonorgestrel
Norethisterone
35 mcg EE
Dianette
Cilest
Brevinor
30 mcg EE
Yasmin
Femodene
Marvelon
Mic 30
Loestrin 30
20 mcg EE
Eloine (Yaz)
Femodette
Mercilon
Loestrin 20
POP
Cerazette
Norgeston
Micronor

12. Androgenicity series Norethisterone Levonorgestrel Gestodene
Desogestrel
Drospirenone
Cyproterone acetate

13. Choice of COCP by progestogen
More oestrogen dominant
Less oestrogen dominant
Drospirenone
Norgestimate
Gestodene
Desogestrel
Levonorgestrel group
Norethisterone group

14. Which COC? Oestrogen dominant COCs Cilest Marvelon Femodene Dianette
Yasmin
Progestogen dominant COCs
Microgynon 30
Loestrin 30

15. Side effects Oestrogenic Progestogenic Nausea Bloating
Weight gain (water retention)
Vaginal discharge (no infection)
Breast enlargement/tenderness
Some headaches
Chloasma
Photosensitivity
Acne
Greasy hair
Hirsutism
Weight gain (increased appetite)
Depression
Loss of libido
Vaginal dryness

16. Risks and Benefits Potential harms & benefits of CHC in non smokers
FSRH Guidance 2012 CHC
Potential harms & benefits of CHC in non smokers
RR with CHC use in non smokers
RISKS
Coronary artery disease
? V small inc risk (obesity, other risk factors)
Ischaemic stroke
2 fold inc risk (migraine)
VTE
3 fold inc risk with LNG, NET; 5 fold inc risk with DSG and GSD
Breast cancer
Any inc risk likely to be small and to vary with age. No inc risk above background 10 yrs after stopping
Cervical cancer
Small inc after 5 yrs and 2 fold inc after 10 yrs
BENEFITS
Ovarian cancer
Halving of risk lasting for > 15 yrs
Endometrial cancer

17. Risk of VTE per 200,000 wy (absolute risk)
European Pharmacovigilance working party 2011 (MHRA)
International working party Berlin 2009 (FSRH)
Women not using COC
5-10
40-50
Women using COCs with LNG or NET 20
Women using COCs with DSG or GSD 40
90-100
Pregnant women 60
290

18. COCs and risk of VTE BMI and smoking are significant risk factors
Smoking doubles the risk
BMI doubles the risk
BMI > 35 has a 4-6 fold increased risk
BMI 30-34= UKMEC 2
BMI > 35 = UKMEC 3
Smoking age < 25 yrs UKMEC 2
Smoking age > 35 yrs UKMEC 3 (<15/day) or UKMEC 4 (> 15 day)

19. Migraine and thrombotic stroke risk
Age 20
2/100,000
Age 20+COC + migraine
10/100,000
Age 20+COC + migraine + cigarettes
60/100,000
Age 40
20/100,000
Age 40+ migraine
56/100,000
100/100,000

20. Non contraceptive health benefits of oral contraceptives
Endometriosis; dysmenorrhoea and ovulatory pain
Menorrhagia; Fe deficiency anaemia; fibroids
Endometrial and ovarian cancer; colon cancer
Acne; hirsutism; symptoms of PCOS
Functional ovarian cysts; PID; benign breast disease; rheumatoid arthritis
PMS
RCGP study - women in the UK who have ever used the oral contraceptive pill are less likely to die from any cause, including all cancers and heart disease, compared with never users
FSRH Guidance 2012 CHC

21. Reasons to stop immediately
Serious neurological effects (prolonged headache, getting worse)
Partial or complete loss of vision
Sudden disturbance of hearing or other perceptual disorders
Dysphasia
1st epileptic seizure or weakness, motor disturbance or numbness affecting one side or part of body
Sudden chest pain
Sudden breathlessness
Haemoptysis
Severe pain in one calf
Hepatitis, jaundice, enlarged liver
Severe depression
BP > 100/160
Detection of a risk factor (UKMEC)
FSRH Guidance 2012 CHC

22. Yasmin Monophasic COC with 30 mcg EE + Drospirenone 3 mg
It acts as an anti-androgen & is therefore an alternative to Dianette for women with moderate acne or PCOS
It has diuretic properties due to antimineralocortocoid activity
It offers a useful oestrogen dominant pill for control of minor side effects such as bloating and cyclical breast enlargement
EURAS and Ingenix studies – no difference in VTE risk compared with 2nd generation OCs

23. Yasmin GPRD (UK) + Pharmetrics (US)
Both showed a 2-3 fold increase of VTE
BUT –
GPRD – low numbers, data missing (obesity), case mix not reflecting clinical practice
Pharmetrics – incomplete data on obesity, unrelaible data on duration of exposure to Ocs
Evidence for increased risk is inconclusive and absolute risk of VTE when using low dose OCs is small

24. Dianette An anti-androgen plus oestrogen combination
Licensed for acne/hirsutism – not for contraception
Data on the risk of VTE with Dianette is conflicting and has been quoted as being higher than in users of conventional COCs but other case controlled studies have shown no difference in risk
Duration of pill use does not appear to affect VTE risk
Mainly used for women with PCO-type symptoms – acne, hirsutism
PCOS – obesity, insulin resistance, dyslipidaemia, hypertension
Alternatives are an oestrogen dominant pill such as Yasmin or Marvelon

25. Qlaira COC containing estradiol valerate (E2V) and dienogest (DNG)
E2V Estradiol (E2 = natural oestrogen)
DNG offers good suppression of endometrial proliferation
The first and only COC to deliver E2
The first product in the UK to contain DNG

26. Regimen
26/2
Maintain stable E2 levels, optimise cycle control, inhibit ovulation
The first 2 pills of the Qlaira pack deliver E2 only and no progestogen, this promotes endometrial proliferation, stabilising the endometrium.
The endometrium is stabilised before the addition of the progestogen on day 3 of the cycle.
The use of DNG ensures suppression of endometrial proliferation and secretory transformation, maturing the endometrium; its stepwise increase further stabilises the endometrium.
A progressive oestrogen step-down with two oestrogen-only days at the end of the cycle avoids a rapid decline in oestrogen levels.
In the majority of women, the lack of hormones during the placebo days leads to shedding of the endometrium and a withdrawal bleed. (Note that the withdrawal bleed does not necessarily occur during the placebo day; it usually starts during the intake of the last tablets of a pack and may not have finished before the first pills of a new pack are taken).
The net result of the Qlaira regimen is a stable endometrium and a good bleeding profile.
oestrogen dominant
increasing progestogenic activity
oestrogen only

27. Summary - Qlaira Clinical studies of E2V/DNG demonstrate
Relatively stable oestrogen levels throughout the menstrual cycle
Effective inhibition of ovulation
Effective contraception
Good bleeding profile – shorter, lighter bleeding and fewer bleeding/spotting days compared with monophasic EE/LNG
An absence of all bleeding or spotting occurred in 15.4% of cycles
No discontinuations due to bleeding disorders

28. Zoely 24 active pills/ 4 placebo pills – no PFI
1.5 mg estradiol (as hemi hydrate) + Nomegestrol acetate 2.5 mg (NOMAC)
NOMAC has a strong affinity for progesterone receptor, strong antigonadotrophic activity, mild antiandrogenic activity
Shorter/lighter WTB, higher incidence of absent WTB
Acne improvement
Efficacy comparable to COC (Yasmin ethinylestradiol, drospirenone)
Faculty of SRH
Statement from CEU May 2013

29. Nuvaring – vaginal ring
A flexible transparent ring of ethylene vinyl acetate with an outer diameter of 54 mm and cross-sectional diameter of 4 mm
One size for all!
Combined hormonal contraceptive vaginal ring containing 2.7 mg ethinylestradiol and 11.7 mg etonorgestrel
It has the lowest oestrogen content of any combined hormonal contraceptive
FSRH Guidance 2012 CHC

30. Ingredients - Nuvaring
Every 24 hours the device releases:
15 mcg EE
120 mcg ENG
The hormones are absorbed into the rich supply of blood vessels within the vagina and enter the general circulation, avoiding the first-pass metabolism by the liver
Each Nuvaring is used for one monthly cycle
It stay in the vagina for 3 weeks and is then removed for a 1 week ring-free interval
The 7 days without Nuvaring allows for a withdrawal bleed

31. Nuvaring Low dose Good cycle control No daily pill to remember
No daily fluctuations in hormone levels
Easy to use
No interference with SI
Useful if GI absorption problems

32. Evra - contraceptive patch
Daily dose 20mcg EE mcg Norelgestromin (similar to Cilest)
Levels sufficient to inhibit ovulation for at least 7 days
Contraindications similar to COCs
Efficacy similar to triphasic COC (overall PI 1.24)
Probable reduced efficacy in women > 90 Kg
BTB more common in 1st 2 cycles than COC
Additional contraception advised for women on enzyme inducers
Suitable for women with absorption problems, who are forgetful or have difficulty swallowing pills
BUT – 60% more exposure to oestrogen

33. Checklist for BTB with CHC
Disease
Disorders of pregnancy
Default
Drugs
Diarrhoea and vomiting
Disturbances of absorption
Diet
Duration of use
Dose

34. CEU 2017 Drug interactions and hormonal contraception
Additional precautions NO longer required when using non- enzyme inducing antibiotics with CHC
All women on enzyme inducing drugs should be advised to use methods unaffected by those drugs – Cu-IUD; IUS; Injectables
CHC not recommended in women on Lamotrigine monotherapy (inc risk of seizures)
UPA not recommended while using enzyme inducers or within 28 days

35. Tailored regimens for use of combined hormonal contraception
Type of regimen
Suggested regimen
CHC-free interval
Extended use
Tricycling
7 days taken after finishing 3rd packet, 3rd ring or 9th patch
Shortened hormone-free interval
3 weeks of CHC use
4 days taken after each packet of pills, each ring or 3rd patch
Extended with shortened interval
Method used continuously until BTB occurs for 3-4 days
4 day interval
Extended use with regular interval
7 day interval
FSRH Clinical Guidance Combined Hormonal Contraception Oct 2011

36. UKMEC and CHC 2017
History of VTE or Current VTE (on anticoagulants) = UKMEC 4
Family Hx (1st degree relative <45 = UKMEC 3 Family Hx (1st degree relative >45 = UKMEC 2
Major surgery with prolonged immobilisation= UKMEC 4
Major surgery without prolonged immobilisation= UKMEC 2
Minor surgery without immobilisation =UKMEC 2
Immobility (in a wheelchair) = UKMEC 3

37. UKMEC and CHC 2017 Varicose veins = UKMEC 1
Superficial venous thrombosis = UKMEC 2
Known thrombotic mutations = UKMEC 4

38. Breastfeeding and CHC 2017
No differentiation between full and partial breastfeeding
<6 weeks postnatal CHC is still UKMEC4
6 weeks to 6 months postnatal CHC is UKMEC2 whether full or partial feeding
No evidence of effect on breastfeeding
Code: UKWHG
Date of prep: August 2016

39. Long Acting Reversible Contraception (LARC)

40. Intrauterine Contraception
Jaydess ▼
All long acting methods with many advantages including high efficacy – TT Cu series last 10 yrs; Cu IUDs effective for e.c.; Cu IUDs non-hormonal good for women concerned re hormone effects; Mirena IUS last 5 years and also suitable for menorrhagia and endometrial protection
Can truly fit and forget
Gynefix
TT380S
Mirena
NovaT380
MultiLoadCu385

44. Copper IUDs
Use IUDs with >300 sqmm Copper
Effective: failure rate < 2 in 100 women over 5 years
Reversible and no effect on future fertility
No systemic effects
Reduces risk of ectopic pregnancy
Can be fitted in nulliparous women (consider local anaesthesia)
Failure rate < 1% when used for post coital contraception
TT380 licensed and effective for 10 years
Cu IUDs fitted > age 40 may be left until after menopause
Is least costly LARC method

45. Nexplanon Single rod releasing 30-40 mcg etonorgestrel per day
Contains 3% barium sulphate
>99% inhibition of ovulation
Most effective LARC method
Lasts 3 years ( no need to change early if high BMI)
Not recommended for women on enzyme inducers
Does not affect bone density
20% amenorrhoea (but 47% will get bleeding by 2 years)
50% infrequent, frequent or prolonged bleeding
Not associated with weight change, mood, libido or headaches
May be associated with acne
FSRH Guidance 2014 P-O Iimplants

46. Management of women taking anticoagulants or anti platelet medications who request IUC or SDI
Insertion of IUC and SDI in women using Warfarin is unlikely to be associated with a risk of significant bleeding
From clinical experience, DOAC use with these procedures carries a low bleeding risk
FSRH CEU Guidance March 2017

47. Assessment of women with bleeding risks
What anticoagulant is she taking and why?
Is she highly anticoagulated?
Expected duration of therapy?
Previous bleeding problems with procedures? (e.g. dental work)
Other medical conditions or medications that may increase the risk of bleeding further (e.g. dual anti platelet therapy, liver disease)
Result and date of most recent INR if on Warfarin
Is she postnatal/breastfeeding? Increased risk of perforation in 1st 36 weeks postnatal and if breast feeding
Previous difficult/failed IUC insertions
FSRH CEU Guidance March 2017

48. Management of women with bleeding risks
IUC and SDI insertions should be performed by clinicians with the relevant LOC and who are specialist contraceptive providers
Women who are anticoagulated can have their SDI or IUC fitted within the GP or C&SH clinic
Ideally, procedure should take place within office hours
Patients using LMWHs should have their device fitted to coincide with the lowest anticoagulant effect
Avoid fitting IUC or SDI in the first 2 weeks of Apixaban use
Women who have a target INR > 3.5 or who are on higher than standard doses of LMWH should have their IUC fitted in a hospital setting but could have an SDI fitted in the community
If LMWH taken in evening, fit device in afternoon
FSRH CEU Guidance March 2017

49. Injectables Depoprovera Sayana-Press Medroxyprogesterone acetate
150 mg/ml every 13 weeks by deep i.m. injection
If necessary, can be given from 10 weeks
CEU guidance states it can be given up to 7 days late without need for additional precautions
Cost: £6.01
Annual cost: £26.11
Medroxyprogesterone acetate
104 mg in 0.65 ml suspension every 13 weeks s.c. into upper thigh or lower abdomen
Can be given up to 7 days early or late without need for additional precautions
Cost: £6.90
Annual cost: £27.68
FSRH CEU New Product Review 2013
FSRH Clinical Guidance Progestogen-only Injectables March 2015

50. UKMEC Injectables History of VTE = UKMEC 2
Current VTE (on anticoagulants) = UKMEC 2
Family Hx of VTE (any age) = UKMEC 1
Major surgery with prolonged immobilisation = UKMEC 2
Major surgery without prolonged immobilisation or immobility = UKMEC 1
Known thrombotic mutations = UKMEC 2

51. 4 unique aspects! Cannot be speedily reversed
Can cause delayed return of (but no loss of) fertility
Can truly cause weight gain (mean of 3 kg in 2 years)
Excellent choice for women on EIDs so no change in usual injection frequency during EID use
Essential counselling points: The liver’s clearance of the progestogen equated to total hepatic blood flow so good choice for women on EIDs since they will not increase this 100% clearance
FSRH CEU Guidance Progestogen-only Injectables Nov 2008

52. MHRA Guidance 2004
Women < 18 yrs – DMPA may be used as 1st line contraception after all options have been discussed and are considered unsuitable or unacceptable
A re-evaluation of the risks and benefits of treatment should be carried out every 2 years in those who wish to continue use
Women with considerable life style and/or medical risk factors for osteoporosis should consider other methods of contraception

53. Quick starting contraception!!!
Criteria for excluding pregnancy:
No SI since last menses
Is correctly and consistently using a reliable method
Is within 7 days of onset of menses
Is within 4 weeks postpartum and not breast feeding
Is fully or nearly fully breast feeding, amenorrhoeic and < 6 months postpartum

58. What drug interactions are relevant to e.c.use?
Women using EIDs should be advised that the efficacy of UPA-ec and LNG-ec could be reduced
Women using EIDs should be offered a Cu-IUD
Women using EIDs can be offered 3 mg LNG-ec but the efficacy is not known. A double dose of UPA-ec is not recommended
The efficacy of UPA-ec could be reduced if progestogens are taken in 5 days after UPA-ec
The efficacy of UPA-ec could be reduced if progestogens in 7 days prior to UPA-ec

59. Contraception following UPA e. c
Contraception following UPA e.c. CEU advises that women should not start a hormonal method for 5 days after UPA
UPA= day 0
Methods (day UPA + 5)
Requirement for additional contraception
UPA then wait at least 5 days
CHC (except Qlaira)
7 days
Qlaira
9 days
POP (traditional and DSG)
2 days
POI or Implant

60. Intrauterine methods injectables implants pills Vaginal rings patches
2018 -
different routes,
new hormones,
more choice
Vaginal rings
patches
barriers
Natural methods
Surgical methods