1. Hormonal Contraception and EHC Trainer’s name XX Medicines Information Service for Health Information Advisors

2. Hormonal Contraception and EHC Learning Outcomes 1.Have baseline knowledge and understanding about hormonal contraception including  Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions.  Implications and advice for missed doses and dosing errors.  Indications and limitations of Emergency Hormonal Contraception (EHC). 2.Be able to use the NHS Direct emergency contraception and missed pill algorithm.

3. Hormonal Contraception and EHC Plan for the Day 9.30 Introduction & learning outcomes Baseline knowledge for hormonal contraception  Types, action, risks, cautions, side effects, interactions.  Missed doses and dosing errors. 10.45Tea break Emergency Hormonal Contraception (EHC) Workshop 1 12.45Lunch EHC & missed OC algorithm Workshop 2 3.00Tea break Workshop 2 (continued) 4.00 Review of learning outcomes & close

4. Hormonal Contraception and EHC Contraceptive Options Hormonal Methods Combined OC pill Progestogen-only pill Patches Injections Implants Intrauterine devices Emergency Hormonal Contraception (EHC) Non-Hormonal Methods Sterilisation Abstinence Interruptus Condoms – male and female Diaphragms and Caps Spermicides Intra uterine devices Rhythm methods

5. Hormonal Contraception and EHC Contraceptive Preference

6. Hormonal Contraception and EHC Contraceptive Preference

7. Hormonal Contraception and EHC Hormonal Contraception Oral contraceptive pill Combined oral contraceptive pill (COC) Progestogen only pill (POP) Contraceptive patch Contraceptive implant Contraceptive injection Emergency Hormonal contraception (EHC)

8. Hormonal Contraception and EHC Combined Oral Contraceptive Pill Oestrogen Ethinylestradiol (EE) Mestranol Progestogen Norethisterone Desogestrel Levonorgestrel Gestodene Norgestimate Drospirenone

9. Hormonal Contraception and EHC COCs: How does it work?

10. Hormonal Contraception and EHC COCs: Monophasics Fixed amount of oestrogen & progestogen One tablet daily for 21 days then a 7 day pill free period. Every Day (ED) - One tablet daily for 21 days then 7 days of dummy tablets. > 99% effective, when used properly.

11. Hormonal Contraception and EHC COCs: Monophasics Low Strength 20 microgram EE Loestrin 20 Mercilon Femodette Standard Strength 30-35 microgram EE Microgynon 30 Loestrin 30 Marvelon Minulet Femodene

12. Hormonal Contraception and EHC COCs: Biphasics & Triphasics Varying amounts of oestrogen and progesterone according to stage of the cycle. Useful when there is breakthrough bleeding or no withdrawal bleed on monophasics.

13. Hormonal Contraception and EHC COCs: Biphasics & Triphasics Biphasics Binovum Triphasics Logynon ED Synphase Trinordial TriNovum Tri-Minulet Triadene

14. Hormonal Contraception and EHC COCs: Risks Migraine Increased stroke risk in migraine sufferers Risk my be increased in COC users Headache with aura plus neurological symptoms Cancer Very small  risk of breast cancer. Protects against ovarian and endometrial cancer.

15. Hormonal Contraception and EHC COCs: Breast Cancer Risk User Status Risk Non User <35 years~1/500 Current user+ 24 % 1-4 years post+ 16% 5 years post+ 7% 10 years or more postNot significant

16. Hormonal Contraception and EHC COCs: Risks DVT Healthy women non pregnant - 5-10 /100,000 2 nd gen pill – 15/100,000 3 rd gen pill – 25/100,000 Caution if 1, avoid if 2 of: PMH, family history, obesity, immobility. Stroke and MI Caution if 1, avoid if 2 of: PMH, family history, diabetes,  BP, smoking, >35 years, obesity, migraine.

17. Hormonal Contraception and EHC “Tricycling” Monophasics Running three packs together Four Pill Free Intervals per year Three extra packets of hormone per year Reduces hormone fluctuations Unlicensed

18. Hormonal Contraception and EHC COCs: Missed doses 7 days of pill taking puts the ovaries to sleep. Ovaries wake up if miss 10 days of standard strength pill. 9 days of low strength pill. The 7 pill free days are safe. Guidance NHSD CAS algorithm Family Planning Association (FPA) Patient information leaflet eBNF Faculty of Family Planning & Reproductive Health (FFPRHC)

19. Hormonal Contraception and EHC COCs: Missed doses 1-2 standard strength or 1 low strength Take pill now and then continue as normal. No extra precautions. No emergency contraception. 3 standard strength or 2 low strength Take pill now and then continue as normal. Extra precautions until taken 7 pills in a row. Week 1 – EC indicated. Week 2 – No EC. Week 3 – No EC, start new pack, no break.

20. Hormonal Contraception and EHC COCs: 3 standard strength or 2 low strength missed Pill free Wk 1 Wk 2 Wk 3 Pill free

21. Hormonal Contraception and EHC COCs: 3 standard strength or 2 low strength missed Pill free Wk 1 Wk 2 Wk 3 Pill free

22. Hormonal Contraception and EHC COCs: 3 standard strength or 2 low strength missed Pill free Wk 1 Wk 2 Wk 3 Pill free

23. Hormonal Contraception and EHC Progestogen Only Pill (POP) One active ingredient – progesterone. Taken continuously with no break. Alternative if COCs are contraindicated. Relies on motivation of the user.

24. Hormonal Contraception and EHC Progestogen Only Pill Benefits Well tolerated No proof of increased disease risk Useful in lactation Drawbacks Precise timing Changes in menstrual pattern Brand Names Femulen Micronor Norgeston Noriday Cerazette

25. Hormonal Contraception and EHC POP: Missed doses Less than 3 hours late Take the missed pill immediately and continue as normal. No extra precautions. No emergency contraception. More than 3 hours late Take the missed pill as soon as possible. Extra precautions until 2 further pills in a row. EC if unprotected sex before 2 further pills in a row have been taken. Cerazette: Instead of 3 hours read 12 hours

26. Hormonal Contraception and EHC POPs: More than 3 hours late Wk 1 Wk 2 Wk 3 Wk 4 Wk 1

27. Hormonal Contraception and EHC Contraceptive Patch Evra  Contains Low strength oestrogen Progestogen Dose 1 patch a week (on same day of week) for 3 weeks. One week patch free.

28. Hormonal Contraception and EHC Delayed Patch 1 Most risky time to forget to apply the patch. Apply Patch 1 as soon as remembering. This is now the beginning of the patch cycle (new start day and change day). Take extra precautions for 7 days. If the delay was for more than 48 hrs (extends patch free period) and unprotected sex - emergency contraception is indicated.

29. Hormonal Contraception and EHC Delayed Patch 1 Patch free Wk 1 Wk 2 Wk 3 Patch free

30. Hormonal Contraception and EHC Delayed Patch 2 or 3 If less than 48 hrs (Extra 48hr drugs in patch) Apply patch immediately, keep usual change day. No extra precautions. No emergency contraception. If more than 48 hrs Stop current cycle and start a new patch cycle with a new Week 1. Extra precautions for 7 days. If prolonged patch free period & unprotected sex – EC is indicated.

31. Hormonal Contraception and EHC Delayed <48hrs Patch 2 or 3 Patch free Wk 1 Wk 2 Wk 3 Patch free

32. Hormonal Contraception and EHC Delayed >48hrs Patch 2 or 3 Patch free Wk 1 Wk 2 Wk 3 Patch free

33. Hormonal Contraception and EHC Detached patch If less than 48 hrs Apply patch immediately, keep same change day. No extra precautions. No EC. If more than 48 hrs Stop current cycle and start a new patch cycle with a new start day / change day. Extra precautions for 7 days. If prolonged patch free period & unprotected sex – EC is indicated.

34. Hormonal Contraception and EHC Contraceptive Injection Long acting progestogen. Depo-Provera . IM injection every 12 weeks. Noristerat . IM injection every 8 weeks.

35. Hormonal Contraception and EHC Delayed injection Up to 14 days late World Health Organisation (WHO) states: no extra precautions needed, EC not indicated. Manufacturer states up to 5 days late but super seeded by the WHO advice. More than 14 days late Extra precautions for 7 days. Consider EC if unprotected sex.

36. Hormonal Contraception and EHC Contraceptive Implant Long acting progestogen. Implanon  Subcutaneous implant every 3 yrs. Requires trained person to insert and remove. Manufacturer and WHO do not state a safe delay for Implanon .

37. Hormonal Contraception and EHC Vomiting & Diarrhoea If vomited within 2 hours of pill taking, its absorption will be reduced and it may be ineffective. Diarrhoea alone without vomiting has to be severe to reduce the absorption of the pill. Handle as a missed pill.

38. Hormonal Contraception and EHC Drug Interactions Broad spectrum antibiotics e.g. amoxycillin, ampicillin, erythromycin. May reduce the efficacy of COCs and patch. No interaction with POPs, injection or implant. Enzyme inducers e.g. rifampicin, ritonavir, carbamazepine, St. John’s Wort. May reduce the efficacy of COCs, patch, POPs, injection and implant. Consider referral to UKMI.

39. Hormonal Contraception and EHC Emergency Hormonal Contraception

40. Hormonal Contraception and EHC When is EHC Indicated? After unprotected sexual intercourse Increased risk of contraceptive failure Torn, leaking condom Missed pills Late implant or injection Detached contraceptive patch Dislodged IUD Emergency Hormonal Contraception

41. Hormonal Contraception and EHC Levonelle 1500 “One Step” High dose progesterone - levonorgesterel. One 1500mcg tablet taken as soon as possible after unprotected intercourse. Preferably within 12 hours, ideally no later than 72 hours.

42. Hormonal Contraception and EHC EHC Efficacy Rates Time EHC taken after intercourse Proportion of pregnancies prevented less than 24 hours95% 25 to 48 hours85% 49 to 72 hours58%

43. Hormonal Contraception and EHC How does EHC work? Depends on point in the menstrual cycle. Thought to prevent or delay ovulation, fertilisation and implantation. Clinical opinion is that using EHC does not constitute an abortion.

44. Hormonal Contraception and EHC EHC: Cautions & Side Effects WHO – No absolute contra-indications. Nausea 25%, vomiting 5%. Care with liver enzyme inducers e.g. rifampicin, St John’s Wort, ritonavir, phenytoin, carbamazepine, barbituates. Slightly increased risk of ectopic pregnancy.

45. Hormonal Contraception and EHC Where can you get EHC? Community Pharmacies GP Walk-in Centres Family Planning Clinics Sexual Health Clinics A & E

46. Hormonal Contraception and EHC Tea Break

47. Hormonal Contraception and EHC Plan for the Day 9.30 Introduction & learning outcomes Baseline knowledge for hormonal contraception  Types, action, risks, cautions, side effects, interactions.  Missed doses and dosing errors. 10.45Tea break Emergency Hormonal Contraception (EHC) Workshop 1 12.45Lunch EC & missed OC algorithm Workshop 2 3.00Tea break Workshop 2 (continued) 4.00 Review of learning outcomes & close

48. Hormonal Contraception and EHC Workshop 1: Case scenarios What further information do you need to answer the call? Confirm what type of contraception using the eBNF. Refer to the NHSD algorithm rationales for an answer. What does the FPA, netdoctor & eBNF say? What would you advise the caller?

49. Hormonal Contraception and EHC Lunch Break

50. Hormonal Contraception and EHC Plan for the Day 9.30 Introduction & learning outcomes Baseline knowledge for hormonal contraception  Types, action, risks, cautions, side effects, interactions.  Missed doses and dosing errors. 10.45Tea break Emergency Hormonal Contraception (EHC) Workshop 1 12.45Lunch EC & missed OC algorithm Workshop 2 3.00Tea break Workshop 2 (continued) 4.00 Review of learning outcomes & close

51. Hormonal Contraception and EHC Workshop 2: EC algorithm Repeat the case scenarios from Workshop 1 using the NHSD Emergency Contraception algorithm.

52. Hormonal Contraception and EHC Learning Outcomes 1.Have baseline knowledge and understanding about hormonal contraception including  Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions.  Implications and advice for missed doses and dosing errors.  Indications and limitations of Emergency Hormonal Contraception (EHC). 2.Be able to use the NHS Direct emergency contraception and missed pill algorithm.