1. Young People Postnatal women Peri-menopausal women

2.  GP  Instructing doctor  Many years interest in sexual and reproductive health

3. Contraception – to be used on every conceivable occasion

4. Information sources  Faculty Website - www.fsrh.org www.fsrh.org  UKMEC Guidelines (UK Medical Eligibility Criteria).  menopausematters.co.uk

5.  Young people  Contraceptive methods  Tea break  Postnatal women  Perimenopausal women

6.  Introductions and background

7.  Becca, aged 15, comes into surgery. It is Monday afternoon. She is unaccompanied. You ask how you can help. She says she has come for the pill, please.

8.  Safeguarding  Consent/Competence  Confidentiality  Clinical

9.  High rates of teenage pregnancy and STIs compared to other European countries.  Age of consent in UK is 16 years.  1/3 young people – approx – have had sexual intercourse before this age.

10. Safeguarding  In law sexual activity below the age of 16 is a criminal offence. However sex between two consenting 15 year olds would not lead normally to prosecution.  Is there an age gap?  Was the sex consensual?  Were alcohol/drugs involved?  Was the partner in a position of authority and the patient under 18?  Is this a looked after child?

11. What to do?  Contact your child protection nurse for advice  Contact social services  Inform the young person that you are going to do this, especially if contacting social services.  Confidentiality can be broken for third parties in child protection issues

12.  Under 13, you are not able to consent to sexual activity.  In law any COMPETENT young person can consent to medical treatment including contraception  SO – how to assess competence?

13.  Competence is demonstrated if the young person is able to:  Understand the treatment, its nature and purpose and why it is being proposed.  Understand its benefits, risks and alternatives.  Understand in broader terms what the consequences of the treatment will be.  Retain the information long enough to use it and weigh it up in order to arrive at a decision.

14. Fraser guidelines  In England Wales and Northern Ireland it is considered good practice to follow the Fraser guidelines when prescribing to under 16’s without parental consent  1995 judgement following the Gillick case

15. Fraser guidelines  The young person understands the professional’s advice  The young person cannot be persuaded to inform their parents.  The young person is likely to begin, or to continue, having sexual intercourse with or without contraceptive treatment.  Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer  The young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.

16. Confidentiality  Competence should be assessed and documented at each visit.  CONFIDENTIALITY – may only be broken in exceptional circumstances. This depends on the degree of current or potential harm, NOT THE AGE OF THE PATIENT, i.e. when the health, safety or welfare of the patient would be at grave risk.

17. Clinical  Finally………..

19. Contraceptive methods  LIST

21. Contraceptive methods  Combined pill – CHC,patch (EVRA), or NUVARING 5-8%  Progesterone only pill 8%  Depo-provera 3%  Emergency contraception – EC – variable %  Nexplanon 0.05%  Copper IUDs 0.8%  IUS (MIRENA) 0.2%  Condom 16%  Cap 8%  Sterilisation – 0.5% female 0.15% male  Natural methods

22. New developments  Jaydess – new smaller mirena, 4 mm narrower and 2 mm shorter, reliable, 3 years.  Easier to insert, less likely to get amenorrhoea. Launched April 2014.  CAYA one size fits all diaphragm launched Aug 2014.

23. Pros & Cons  Flipchart

24. Young People’s Concerns  ACNE – CHC can improve acne. Dianette can be used for severe acne unresponsive to antibiotics, nexplanon can cause improvement or worsening of acne  MOOD CHANGES - hormonal contraception can be associated with mood changes but no evidence it causes depression

25. YP concerns cont  WEIGHT – no evidence of wt gain with CHC, POP, Nexplanon, evidence of wt gain in some depot users of several pounds.  FERTILITY - no delay in return of fertility following POP/CHC/nexplanon but can be delay of up to a year following depot.  BLEEDING PATTERN – can be altered with hormonal contraception, dysmen can improve

26. Yp concerns cont  BONE HEALTH – depot is associated with small loss of BMD which usually recovers after discontinuation.  VTE – small increased risk with CHC – absolute risk very small  CANCER – with CHC may be v small increased risk of breast/cervical cancer, decreased risk of ovarian cancer

27. YP concerns cont  STI risk  Advise re use of condoms, adv testing for STIs 3 and 12 weeks after unprotected sex UPSI.

28. Becca  What do you need to cover in the consultation?

29. BECCA - aged 15  NEED TO  Establish rapport  Reassure re confidentiality  Establish competence  Check re Fraser guidelines  Establish sexual history and inc age of partner  Safeguarding  Discuss options  STI testing?  Supply contraception as appropriate (wt/BP) condoms  Arrange follow-up

30. Role Play  Becca

31. EC  Levonorgestrel – levonelle  Ullapristal ella one 30mg stat  Copper IUD

32. Levonelle  Up to 72 hours.  Can be repeated in one cycle  Good for quick start as can immediately start POP/COC

33. Ella one  Ella one – effective up to 120 hours and licenced for this.  Prevents twice as many pregnancies as levonelle  Is three times the price  Only once per cycle for one episode UPSI  Need to add an extra 7 days extra protection above usual advice

34. IUD  Can be used in good faith up to day 19 of a 28 day cycle even if multiple upsi  Over 99% effective  Can be kept for 5-10 years depending on device

35. COC  Contraindications – UKMEC guidelines  Exam – weight and height  Record smoking status  Counsel re method  Remember LARCS are best  Remember patch and ring also an option  Supply leaflet.  Follow up

36. Missed pills  Being late with one pill is OK up to 24 hours – take the late pill and the next one on time  More than 24 hours, use condoms for 7 days as well.  If end of pack run on and if beginning consider EC

37. LARCS – long acting  Nexplanon – low dose, safe, unforgettable for 3 years. Irregular bleeding main problem  Depot – injection, 12 weekly, safe UKMEC 2 for young people.  IUDS – copper and IUS – less popular with young people but are an option.  Condoms – for STI risk

39. TEA http://www.youtube.com/watch?v=CIrd34d QTzY

40. Postnatal Women  Issues?

41. Postnatal Women  Sarah, aged 35, attends for 6 week baby check. She had a section for failure to progress and is fully breast-feeding. Her BMI is 30, she has never smoked, She previously used COC/condoms. She would like something easier. She is planning a second child in a couple of years.

42. Postnatal Women  Rachel, aged 27. She also attends her post- natal check up at 6 weeks. She has children aged 7 and 5 from a previous relationship. She is bottle-feeding having given up breastfeeding at 2 weeks. She smokes 5 cigs a day. Her BMI is 34. She asks for the pill as she had it before and found it easy.

43. Postnatal Women  Contraceptive needs  Sexual activity and function  Attitudes beliefs and personal preferences  Cultural practices  Breast or bottle  Ovulation – likelihood of resumption  Possibility of pregnancy  Social factors – i.e. how likely is she to be able to attend subsequent appts  Medical hx  STI risk

44. Postnatal Women  Earliest ovulation is approx day 28 in a bottle- feeding woman  COC – bottle-feeding – do not start before day 21 as inc VTE risk  COC – breast-feeding – ideally not before 1 st 6 weeks, and if possible not before 6/12 if continuing full breastfeeding  POP – evidence is that it does not affect infant growth/breast milk volume – start any time

45. Postnatal Women  Lactational Amenorrhoea  Failure rate 2% in first 6 months if round the clock breast feeding and amenorrhoea

46. Postnatal Women  DEPOT – bottle feeding – can start any time –  Breast feeding – not before day 21- and advise that troublesome bleeding can start in early puerperium  NEXPLANON – can fit before day 21 if wish – outside licence

47. Postnatal Women  IUDS – copper – unless within first 48 hours delay until day 28 however feeding – if fit on day 28 no additional precautions needed  IUS – from day 28 – however feeding – 7 days additional contraception required

48. Postnatal Women  CAP/DIAPHRAGM  Wait until at least 6 weeks post-partum  STERILISATION – CAREFUL COUNSELLING  UPSI – if before day 21 no need PCC  If after day 21 need PCC – or copper IUD up to day 28

49. Role play/cases

50. Contraception in the Peri-menopause  Quiz

52. Peri menopause  CASE – Susan aged 47, comes into surgery. Her cycle is 4-5/21-56. She is having sweats and flushes++. She was divorced 5 years ago and is in a new relationship so has come for contraception, but also mentions that she is exhausted due to the night sweats which are really getting her down.

54. Notes on peri- menopause  NO CONTRACEPTIVE METHODS ARE CONTRA-INDICATED BY AGE ALONE.  UKMEC GUIDELINES ARE HELPFUL – NOTE APPLY CRITERIA1-4 – WHERE  1= unrestricted use  2=benefits outweigh risks  3=risks generally outweigh benefits – consider specialist advice  4=unacceptable risk

55. Peri-menopause  COC  Can use to age 50 in absence of any risk factors.  May help menstrual sx and to maintain bone density  Protects against ovarian and endometrial cancer and colo-rectal cancer  May be small additional risk breast cancer  Not usually advised for smokers aged 35+  Small inc risk VTE/stroke  Consider 20microgramme pill  BP checking

56. Peri-menopause  POP  No conclusive link to VTE /Ca breast  Safe for most women – can use into 50’s  IUS  Can help with heavy menstrual bleeding

57. Peri-menopause  Depot - Caution in women who have CVS risk factors as depot adversely affect lipids  Inform women that is assoc with small BMD loss  CU –IUD –  Can cause heavier bleeding/spotting/pain in first 3-6 months of use

58. Peri-menopause  Condoms  Caps  EC  Think STI risk

59. When to stop contraception

60.  If not on hormonal contraception  After 1 year of amenorrhoea if >50  After 2 years amenorrhoea if <50  Keep cu iud in until after the menopause of fitted over 40.  Keep IUS for up to 7 years if fitted aged 45 plus ? Longer if amenorrhoea

61. Stopping  IF USING PROGESTERONE METHODS AND OVER 50 FSH CAN HELP DIAGNOSE OVARIAN FAILURE  If amenorrhoea on POP /implanon/IUS  Check FSH – if over 30iu/l rpt after 6 weeks, if still over 30iu/l can abandon contraception after one year.

62. HRT  Is not contraceptive (even if it should be!)  But can add POP or use IUS as part of HRT – for 4/5 years to protect endometrium, irrespective of age at insertion

64. Role play/cases  Thank you