1. ‘Doc I’ve had an accident’ 33 year old Burst condom BMI 35 Wants the morning after pill

2. Emergency contraception Cu- IUD Levonelle Ella-One

3. Recommendations for EC use SituationIndication for EC Combined hormonal contraceptive (CHC) Three or more pills missed in first week of pill cycle or >48 hrs late restarting patch or ring and UPSI in hormone free week or in week 1 Progesterone only pill (POP)POP taken >3 hrs late (>12 hrs with Cerazette) and UPSI has occurred within 2 days following this Progesterone-only injectableInjection is late (Depo-provera >14 weeks; Noristat >10 weeks) and UPSI has occurred IUD/IUSComplete or partial expulsion or mid-cycle removal of IUD/IUS and UPSI has occurred in previous 7 days Barrier methodsFailure of method

4. History for EC The timing of all episodes of UPSI in the current cycle The most likely date of ovulation based on the date of the LMP and usual cycle length Details of potential contraceptive failure e.g. how many pills were missed and when Use of medications which may affect contraceptive efficacy

5. Levonelle Acts by inhibition of ovulation - up to 5 days Less effective when UPSI occurs around time of ovulation Effective up to 96 hrs Repeat dose if vomiting within 2 hours Multiple doses possible in each cycle

6. ellaOne  ulipristal acetate  synthetic progesterone receptor modulator  as effective as Levonelle and licensed for use up to 120 hours after unprotected sex  No reduction in efficacy over the 120 hours  £16.95

7. Mode of action   Primary mode of action is to inhibit or delay ovulation   Inhibits follicular rupture - effective in even when after LH levels have already begun to rise

8. Contraindications Pregnancy Asthma insufficiently controlled with oral steroids Hypersensitivity Severe hepatic impairment Rare hereditary disorders: Galactose intolerance, Lapp lactase deficiency, glucose-galactose malabsorption

9. Issues with ellaOne Should only be used once per cycle Should NOT be used if suspicion of an implanted pregnancy Not to be used with enzyme inducers as they reduce efficacy Can NOT double the dose for any reason Should not be used with any drugs that increase gastric Ph Should avoid breast feeding for 36 hours after taking Use may reduce the efficacy of progesterone containing contraceptives.

10. Weight and oral emergency contraception failure Failure % Glasier et al. Contraception 2011

11. UPSI and oral emergency contraception failure Glasier et al. Contraception 2011 Failure %

12. Don’t forget IUDs > 99% effective May be inserted within 120 hours of UPSI or within 5 days of earliest expected ovulation Mode of action – inhibits fertilisation (+ anti- implantation) Efficacy not affected by concomitant drug use STI risk assessment and or prophylactic antibiotics Know local pathway for IUD insertion Give oral EC if delay in IUD insertion May keep IUD for ongoing contraception

13. IUD myths of 20 th century Increased risk of PID Increased risk of tubal infertility Increased risk of ectopic pregnancy Can’t be used in nullips

14. IUD myths of 20 th century Increased risk of PID Increased risk of tubal infertility Increased risk of ectopic pregnancy Can’t be used in nullips FALSE

15. Quick Starting

17. Sub-dermal implant Failure rate <0.1% at 3 years Regular follow-up not required Position of implant important for removal Counselling important for compliance

18. SDI ‘failures’ 1.4 million users in 11 years 600 pregnancies reported since 1999 > 50% non-insertion 25% using liver enzyme inducers

19. ‘Sort me out Doc!’ 49 yr old IUS for 4 years No bleeding for 4 years Recently started heavy irregular bleeding

20. Medical Mx of HMB IUS reduces MBL by 79 – 97% @ 6 months Local effect Avoids systemic effects High risk endometrial hyperplasia 1 st line Rx for obese women

21. Bleeding patterns with the IUS Spotting %

22. Abnormal Bleeding with hormonal contraception 30-40% new users of any type of oral contraception in first 3 months have IMB due to insufficient sex steroid or inconsistent pill-taking. Irregular bleeding with progesterone only contraception frequent but with persistence often subsides Women developing problems later on need Ix to exclude pathology Counselling is important to prevent anxiety and improve compliance

23. Abnormal Bleeding with hormonal contraception Take a clinical history Woman’s concerns Correct use of method Other symptoms Exclude sexually transmitted infections Check the cervical screening history Consider the need for a pregnancy test

24. Bleeding problems with Nexplanon Pre-insertion counselling important Exclude pathology Drug treatments COC cyclically for 2-3 months Progestogens –MPA 10mgs bd for 3 months POP- Cerazette NSAID for 5-10 days Tranexamic acid 500mg twice daily for 5 days Return of bleeding likely when treatment stopped

25. Bleeding problems with DMPA Pre-insertion counselling important Menstrual disturbance unpredictable 2-3months 34% amenorrhoea at 3 months 70.3% at 12 months Consider giving first 2-3 injections every 8-9 weeks Exclude pathology Drug treatments COC Oestrodiol

26. Female sterilisation Regret 20% women <30 6% women >30 Reversibility Failure rate 1 in 200 1 in 130 post- LSCS Operative risk 1 in 1200 endoscopic injury Menstrual problems

27. Hysteroscopic sterilisation adiana essure

28. Improving compliance Offering choices Right product, right time Managing expectations Counselling re side effects Managing adverse effects

29. Thank- you Any Questions?