1. Contraception GP update
Dr Sue Mann
Consultant Homerton Hospital
28th September 2018

2. Today’s audience GPs/practice nurses/other
At individual and practice level, who prescribes…?
only oral methods
only non-LARC methods
all except IUD
all contraception

3. Overview of session Background Non LARC methods LARC methods Training
Resources and contacts

4. Methods of contraception

5. Accidental pregnancy in first year of use
percent
Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 17. NY: Ardent Media, 2004

6. Long acting reversible
Accidental pregnancy in first year of use
percent
LARC
Long acting reversible
contraceptives
Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 17. NY: Ardent Media, 2004

7. Prescribing - UK medical eligibility criteria
Category 1: can be used by all
Category 2: advantages generally outweigh risks
Category 3: risks generally outweigh advantages
Category 4: use represents unacceptable health risks

9. Non LARC hormonal – principles
Ensure aware LARC most effective – non-perfect use is main reason for difference
Hormones very safe in low risk women (P>E)
Unplanned pregnancy is almost always the greater risk – make it work for woman
Tailored regimes for CHC
Low threshold for quick-start (NB DMPA) – with EC if needed
Make follow-up easy - 12/12 supplies
Bridging supplies if no appointments/EC

10. Drug interactions
Non-enzyme inducing antibiotics – NO additional precautions
Enzyme inducers – IUS, IUD, DMPA, (CHC extended cycle, reduced PFI)
Lamotrigine
CHC reduces Lamotrigine levels by increasing clearance - UKMEC 3
CHC does not have this effect when lamotrigine plus sodium valproate
Progestogen-only methods do not seem to affect Lamotrigine levels
Sodium valproate

11. Combined methods

12. VTE risk

13. Cardiovascular disease and stroke
Older women – risk factors as increased baseline risk
Small increased risk in MI and stroke – rare events
VTE, Stroke and MI risk likely to be E2 dose related – lower in 20 mcg pills.
Evidence for effect of P is conflicting

14. Mood and hormonal contraception
No evidence that causes or worsens or improves
Women report mood changes with and without
Women who report mood changes with one method will not necessarily report problems on another
Worly BL, et al. The relationship between progestin hormonal contraception and
depression: a systematic review. Contraception 2018.

15. COC and cancer 12% decrease in the risk of developing cancer overall
Reduction large bowel, uterus and ovaries
Small increase in breast for current and recent users (RR 1.24) up to 5 years after stopping. No differences between ever and never users
Small increased risk in cervical cancer in women using OC for 8 years (rate 38 per 100,000 woman years)

16. Missed pills Missed if >24 hrs late Just keep going
If missed 2 or more pills
use condoms or abstain until taken 7 pills in a row
Missed pills in week 1: consider EC
Missed pills in week 3: omit PFI
Missed pill recommendations May 2011 FSRH

17. Case study 1
Mary attends on Monday morning asking for emergency contraception. She went away at the weekend and forgot to take her Microgynon 30 packet. The last pill she took was on Thursday. She was mid way through her pill packet, having taken 10 pills correctly before she went away. She had intercourse on Saturday night without a condom.
What would you advise about when to restart her COC?
Does she need emergency contraception?

18. Case study 2
Fiona attends on Friday afternoon to get more supplies of Microgynon 30. She was supposed to restart her pills on Wednesday, after her 7 day pill-free interval. She had sex on Thursday night; she did not use a condom.
What would you advise about when to restart her COC?
Does she need emergency contraception?
What would you advise if she attended on the following Monday (day 13 of her extended pill free interval) having had intercourse on Thursday night?
What would you advise if she attended on the following Thursday (day 16 of her extended pill free interval) having had intercourse on the previous Thursday night?

19. DMPA: Late attenders
Up to 14 weeks – WHO & FSRH ; 12 weeks plus 5 days – manufacturers
Over 14 weeks, consider giving DMPA at same time as emergency contraception
Enzyme inducers – still give every 12 weeks
Missed pill recommendations May 2011 FSRH

20. Newer products

21. Contraceptive vaginal ring - NuvaRing®
Similar to COC – one ring per cycle
Over 99 % effective
Low dose - 50% less systemic oestrogen exposure than COC
Etonorgestrel and ethinyl estradiol
Left in the vagina for three weeks
Seven-day ring-free interval
Side effects:
expulsion (0.5% cycles):
Partner feels device 32%
Vaginitis/discomfort due to device 6%
Vaginal discharge 5%
Storage:
36 months under refrigeration
4 months after dispensing

22. Emergency contraception
Timing (IUD and oral)
After pregnancy – abortion D5, pregnancy D21
Ineffective after ovulation
Ella one > levonelle
Reduced effectiveness – P in last 7/7; enzyme inducers; weight
Repeat doses but not UPA before or after levonelle
Costs IUD; Levonelle; ullipristal

24. Non hormonal methods
Barriers
Natural methods – Natural Cycles App

25. Cost comparisons for 3 months supply
NuvaRing £ X 3
Evra £19.51
Daylette £14.70
Yasmin £14.70
Mercilon £5.08
Microgynon £2.82
Cerazette £2.38
IM DMPA £6.01
Sayana press £6.90
per month of use

26. LARC Methods
If 7% of women switched from the pill to LARC methods (doubling current usage to 15%) the NHS could save approx £100 million each year by reducing unplanned pregnancies by 73,000

27. 3% LARC use in England 11% Overall, the total use of LARC rate
has decreased by 3% a year since
2014
Between rates of G P
prescribed LARC (implants and IUDs)
decreased by 1 1%
While rates of SRHS prescribed
LARC excluding injections has
remained relatively constant
32.3
28.8
17.8
17.6
2016
General Practice
Sexual Reproductive Health Services 3%
11%
Sexual and Reproductive Health Profiles. Public Health England; 2017.
NHS Digital. Sexual and Reproductive Health Services - England, 2016/17 - Data Tables. In: editor. 2017
Note: 1. Age range chosen for the rate denominator resident population to match that used by the Department of Health for abortion rates
Reproductive Health i a Public Health Issue: What does the data tell us?

28. SRH services

29. General Practice

30. LARC provision in Hackney
Overall increased by 3% per year since 2014
But has fallen by almost 40% in GP practices
Has risen by almost 30% in secondary care

31. Contraception attendances in SH
New
OHC+STI
OHC NO STI
LARC+STI
LARC NO STI
TOTAL+STI
TOTAL NO STI
TOTAL
345
418
780
690
1198
1888
305
340
324
1036
629
1376
2005
Follow up
OHC+STI
OHC NO STI
LARC+STI
LARC NO STI
TOTAL+STI
TOTAL NO STI
TOTAL
378
846
260
665
638
1511
2149
692
1525
428
1255
1120
2780
3900

32. Nexplanon

33. Nexplanon: Bleeding patterns10 20 30 40 50 60 1 2 3 4 5 6 7 8
Three-monthly assessments
Percentage
Amenorrhoea
Infrequent bleeding
Frequent bleeding
Prolonged bleeding

34. Deep implant

35. Banded device containing 380mm2 copper
IUDs
10 year licence:
T-Safe Cu 380 A
SlimlineTT380
Banded device containing 380mm2 copper
Until no longer required > 40s
Emergency contraception

36. When to fit I________________I_________________I 0 14 28 day ovulation19
I___________I_________________I
day 14

37. IUS Effective & safe Long lasting (5 years) & cheap
7 years in over 45s (unlicensed)
Beneficial effect on menstruation
Progestogen component of HRT
Not EC
Cumulative failure rate %. Statistically no significant difference between the efficacy of the LNG IUS and CuT380 at 7 years.
Reversible - Conception is possible in the cycle following removal. One year after removal the gross cumulative conception rate is 79.1%, and after 2 years 86.6%, which is comparable to normal conception rates in non-contraceptive users (80-90%).
Reduction in blood loss is a benign end organ response to intrauterine levonorgestrel. Circulating plasma estradiol levels remain normal.
Reduction in anaemia secondary to decrease in menstrual blood loss.
Less dysmenorrhoea than with copper devices.
Incidence of ectopic pregnancy 0.02 per 100 woman years. This represents an 80-90% reduction in risk compared with women not using contraception. Approximately 20% of conceptions with the LNG IUS are ectopic.
Thickening of cervical mucus plug may reduce the incidence of pelvic infection.

38. New products £66 4 years Wider 52mg No Em protection £69.22 3 years
Narrower and smaller
13.5mg
19.5mg

39. FSRH Training
Essentials
DFSRH/NDFSRH
LoC SDI and IUT

40. Complex contraception and community gynaecology
Every week at Ivy, St Leonard’s
GP Referral
ERS – triage within a week – wait time 6/52
Complex contraception
Women with complex medical problems
IUD problems – difficult, non visible threads
Non palpable implants

41. National clinical guidance
SPC
BNF
NICE
LARC
Guidance products
New method reviews
Clinical enquiries
UK MEC Guidelines

42. Sexwise video: https://youtu.be/LkCQYaFlPzY