1. Contraceptive Problems Max Brinsmead MB BS PhD March 2014

2. Postnatal Consultation Elizabeth, a 40 year-old multiparous patient, visits for her 6 week check after the birth of her fourth child. The recent pregnancy occurred after a condom failure and was complicated by third trimester hypertension. She is keen to discuss her contraceptive alternatives. Elizabeth, a 40 year-old multiparous patient, visits for her 6 week check after the birth of her fourth child. The recent pregnancy occurred after a condom failure and was complicated by third trimester hypertension. She is keen to discuss her contraceptive alternatives. What further information do we require? What further information do we require? What are the contraceptive options for Elizabeth? What are the contraceptive options for Elizabeth?

3. 40 yo P 4 6w postpartum and some PIH... Does she want more children Does she want more children Is she breastfeeding Is she breastfeeding What are her periods like What are her periods like Is she likely to be a “good pill taker” Is she likely to be a “good pill taker” Any other relevant family or personal history? Any other relevant family or personal history? If the family is complete then vasectomy is the best option If the husband is unwilling then tubal ligation is next best Interim contraception is required. If she is breastfeeding a POP would suffice If she has unacceptable periods then Mirena would be better than male or female sterilisation If she is not a good pill taker then Implanon or IUD better If we elect COC, POP or IUD then we need to check personal and family contraindications to each

4. Teenage Consultation Tammy is a 15 year old mildly obese and mentally slow girl brought along by her mother “for the pill”. Her mother tells you that she herself is on Warfarin because of a previous DVT associated with homozygous Factor V Leiden. Tammy is a 15 year old mildly obese and mentally slow girl brought along by her mother “for the pill”. Her mother tells you that she herself is on Warfarin because of a previous DVT associated with homozygous Factor V Leiden. What further information do we require? What further information do we require? What are the contraceptive options for Tammy? What are the contraceptive options for Tammy?

5. 15 yo Low IQ and FH of Factor V Leiden Is it contraception, protection from STD or menstrual problems that the mother is there for Is it contraception, protection from STD or menstrual problems that the mother is there for Some cycle history Some cycle history Some sexual history Some sexual history Is this patient likely to comply with daily medication or condoms Is this patient likely to comply with daily medication or condoms A Factor V Leiden test is homozygous positive A Factor V Leiden test is homozygous positive Mirena is a better option than Depot Provera or Implanon for this patient All provide excellent contraception with no thromboembolic risk but PV bleeding can be a problem for the latter two Depot may cause osteoporosis when used long term Only condoms (male or female) will protect from STD’s Hysterectomy is often requested but problematical

6. At the Aboriginal Health Service Raquel is a 32 year old woman undergoing her 3 rd termination of pregnancy in two years. She is morbidly obese, prediabetic and she smokes 20-25/day. She has one child in the care of a former partner’s parents. She says that she “bled all the time after the needle”. Raquel is a 32 year old woman undergoing her 3 rd termination of pregnancy in two years. She is morbidly obese, prediabetic and she smokes 20-25/day. She has one child in the care of a former partner’s parents. She says that she “bled all the time after the needle”. What further information do we require? What further information do we require? What are the contraceptive options for Raquel? What are the contraceptive options for Raquel?

7. 32 yo G 4 P 1 T 3 Obese Pre-diabetic Smoker Bleeding after Depot Partner(s) relationship and wish for more children Partner(s) relationship and wish for more children Something about her spontaneous cycles Something about her spontaneous cycles More details about Depot experience. Who, where, when and how many? More details about Depot experience. Who, where, when and how many? What other methods of contraception has she used or does she know about What other methods of contraception has she used or does she know about What does she weigh What does she weigh All oral contraception is contraindicated Sterilisation may be a good option for this patient but it may be technically difficult. Essure maybe? Mirena would be a good option but she would need to be warned about the “settling in” bleeding that occurs If Implanon or a POP is elected she may require two!

8. At the Family Planning Clinic Victoria is a 29-year old business executive who has always experienced severe dysmenorrhoea with her periods. Her mother died from breast cancer. She has never been pregnant. Victoria is a 29-year old business executive who has always experienced severe dysmenorrhoea with her periods. Her mother died from breast cancer. She has never been pregnant. What further information do we require? What further information do we require? What are the contraceptive options for Victoria? What are the contraceptive options for Victoria?

9. 29 yo Nullipara Severe Dysmenorrhoea Mother breast Ca Mother’s age when she developed breast Ca Mother’s age when she developed breast Ca Any other relatives with breast, ovarian or bowel cancer Any other relatives with breast, ovarian or bowel cancer Any FH endometriosis Any FH endometriosis Any other contraindication to COC Any other contraindication to COC Is she a good pill-taker Is she a good pill-taker The COC increases a woman’s lifetime risk of 1.24- fold but the absolute risk is low If there are multiple others in the family with Ca of breast, ovary, bowel then this patient may require testing for BRAC genes COC is a reasonable option and has a good chance of reducing dysmenorrhoea and maybe endometriosis Mirena would be the next best option if compliance a problem

10. Victoria 2 Victoria is prescribed Levlen 30 ED but is experiencing break through bleeding when she returns after 6 weeks. She says that she also feels “pre menstrual” all the time and has lost interest in sex. Victoria is prescribed Levlen 30 ED but is experiencing break through bleeding when she returns after 6 weeks. She says that she also feels “pre menstrual” all the time and has lost interest in sex. What would you recommend? What would you recommend?

11. 29 yo Nullipara develops BTB on Levlen & reduced libido Breakthrough bleeding is too little oestrogen Breakthrough bleeding is too little oestrogen It’s too early to change the formulation. BTB is common for 2 – 3 cycles but may then disappear. It’s too early to change the formulation. BTB is common for 2 – 3 cycles but may then disappear. Check compliance. Check compliance. If the problem persists then switch up to 50 ug EE If the problem persists then switch up to 50 ug EE Low libido arises from the progestin Low libido arises from the progestin It may be too early to switch formulation for her other side effects as well. It may be too early to switch formulation for her other side effects as well. These problems may respond to a switch to a 3 rd or 4 th generation progestin e.g. Marvelon or Yasmin These problems may respond to a switch to a 3 rd or 4 th generation progestin e.g. Marvelon or Yasmin

12. Working at the After Hours Medical Centre Samantha is a 22 year old single receptionist who has had one previous baby. She comes after a 7-day cruise holiday and reports that, “on the first night of the cruise the condom broke” during intercourse with a new partner. Samantha is a 22 year old single receptionist who has had one previous baby. She comes after a 7-day cruise holiday and reports that, “on the first night of the cruise the condom broke” during intercourse with a new partner. What further information do we require? What further information do we require? What are the contraceptive options for Samantha? What are the contraceptive options for Samantha?

13. 22 yo P 1 7 days post-coital emergency Was she using any other method of contraception Was she using any other method of contraception Date of LNMP and usual cycle length Date of LNMP and usual cycle length Is there a need for ongoing contraception Is there a need for ongoing contraception Any contraindications to copper IUCD use? Any contraindications to copper IUCD use? Her knowledge of STDs Her knowledge of STDs Was the condom the sole means of contraception or was it for STD protection Was the condom the sole means of contraception or was it for STD protection If she was definitely post ovulatory then the risk of conception is low If she was definitely post ovulatory then the risk of conception is low This is too late for Pills (5 days) but an IUD is still an option (7 days) This is too late for Pills (5 days) but an IUD is still an option (7 days) IUD will provide ongoing contraception IUD will provide ongoing contraception Copper-containing IUD is recommended and not Mirena Copper-containing IUD is recommended and not Mirena Testing for STD is probably required Testing for STD is probably required

14. In the Antenatal Clinic Bronwyn is a 38 year old about to undergo her third and elective Caesarean section in an unplanned pregnancy that occurred whilst she was “taking the Pill”. She has a known uterine fibroid and was treated for CIN3 5 years ago. In the past she has had “very heavy and irregular periods”. Bronwyn is a 38 year old about to undergo her third and elective Caesarean section in an unplanned pregnancy that occurred whilst she was “taking the Pill”. She has a known uterine fibroid and was treated for CIN3 5 years ago. In the past she has had “very heavy and irregular periods”. What further information do we require? What further information do we require? What are the contraceptive options for Bronwyn? What are the contraceptive options for Bronwyn?

15. 38 yo P2 for CS. Failed COC. Fibroid. CIN3 5 yrs ago. Menorrhagia Any more pregnancies wanted Any more pregnancies wanted Is her CIN cured Is her CIN cured Location of the fibroid Location of the fibroid Tubal ligation at the time of her CS is simple but will not control her menorrhagia and has a 1% risk of failure Tubal ligation at the time of her CS is simple but will not control her menorrhagia and has a 1% risk of failure If the HPV test for high risk subtypes is negative then the CIN is inconsequential If the HPV test for high risk subtypes is negative then the CIN is inconsequential Besides, hysterectomy or even myomectomy at the time of CS is not a good idea Besides, hysterectomy or even myomectomy at the time of CS is not a good idea Mirena may be a better option unless the fibroid is submucosal Mirena may be a better option unless the fibroid is submucosal Or even tubal ligation plus a trial of the Mirena Or even tubal ligation plus a trial of the Mirena

16. A GP Consultation Robin and Mia come to talk to you about a vasectomy. Mia is 34 and Robin is 28. They have been married for 5 years and do not want any children. Three years before she met Robin Mia had a son, currently 8 years of age and a handful because of ADD. Mia has a Implanon but is experiencing frequent vaginal bleeding. Robin and Mia come to talk to you about a vasectomy. Mia is 34 and Robin is 28. They have been married for 5 years and do not want any children. Three years before she met Robin Mia had a son, currently 8 years of age and a handful because of ADD. Mia has a Implanon but is experiencing frequent vaginal bleeding. What further information do we require? What further information do we require? What are the contraceptive options for Robin and Mia? What are the contraceptive options for Robin and Mia?

17. F34 & M28. One child with ADD. Implanon but bleeding What if something were to happen to the child or the relationship What if something were to happen to the child or the relationship Are there any contraindications to COC use Are there any contraindications to COC use Or contraindications to IUCD use Or contraindications to IUCD use Vasectomy is not a good option because this male is likely to regret it if there is a relationship failure Vasectomy is not a good option because this male is likely to regret it if there is a relationship failure If Mia is unwilling or unrelaible or unsuitable for long term COC use then If Mia is unwilling or unrelaible or unsuitable for long term COC use then Mirena or Mirena or Tubal ligation are better options Tubal ligation are better options

18. A Question of Drug Interaction Cindy is an 18 year old who takes Logynon for contraception. She has moderately severe pustular acne and a dermatologist has recommended that she goes on Vibramycin 100 mg daily for 6-12 months. The dermatologist has recommended that she consults you about her current COC formulation. Cindy is an 18 year old who takes Logynon for contraception. She has moderately severe pustular acne and a dermatologist has recommended that she goes on Vibramycin 100 mg daily for 6-12 months. The dermatologist has recommended that she consults you about her current COC formulation. Why is the dermatologist concerned? Why is the dermatologist concerned? What would you recommend? What would you recommend?

19. 18 yo on Logynon (20 ug EE) about top start Doxycline long term There is a small risk that the antibiotic may alter bowel flora and the enterohepatic recirculation of oestrogen required for ovulation suppression There is a small risk that the antibiotic may alter bowel flora and the enterohepatic recirculation of oestrogen required for ovulation suppression May be heralded by break through bleeding May be heralded by break through bleeding Step up the dose of EE to 30 or 50 ug Step up the dose of EE to 30 or 50 ug Consider lengthening cycles to 3 months and Consider lengthening cycles to 3 months and Shortening the placebo period to 4 or 5 days Shortening the placebo period to 4 or 5 days Or just add a POP and take pills morning and night Or just add a POP and take pills morning and night

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