1. Contraception
Matthew Dowling
10/9/14

2. Contents Oral Contraceptives: Emergency Contraception Types
Method of action
Contraindications (MEC)
Emergency Contraception

3. Oral Contraceptives 2 main types: Combined oral contraceptives
(Progestogen and Oestrogen)
Progestogen-only contraceptives
(Mini-pill or POP)

4. Combined oral contraceptives
One of most commonly used methods of contraceptives
Currently available CHCs contain a synthetic oestrogen (ethinylestradiol or mestranol) and a progestogen
Eg:
Microgynon (30microg ethinylestradiol and 150mg levonogestrol)
Loestrin (20 microg ethinylestradiol and 1mg noresthisterone)
Dianette (25mcg ethinylestrodiol and 2mg cyproterone acetate)
Yasmin (30microg ethinylestradiol and 3mg drospironone)
Logynon
Binovum
Brevinor
Cilest

5. How do they work?
Primarily by preventing ovulation through inhibition of hypothalamo-ovarian-pituitary axis
Also cervical mucus
Endometrial changes

6. How are they taken? 28 pills (21 active 7 placebo)
First 7 inhibit ovulation
Next 14 maintain anovulation

7. When to start? Any time as long as sure not pregnant
Immediate contraceptive cover if started on day 1-5 of cycle
If starting after day 5, extra protection required for 7 days

8. Question
A 25 yr old woman phones for advice. She has missed two pills in a row. Today she would be taking the 19th pill of the packet. There have been no other missed pills during the packet. She has been having regular UPSI during the weekend. You have already told her to take two of her pills as soon as possible. What next?
Needs EC + use condoms for 7 days + skip the break
Use condoms for 7 days + skip the break
Needs EC + skip the 7 day break
Needs EC + use condoms for 7 days
Use condoms for next 7 days

9. What to do if you miss a pill...
1 pill missed
Take asap then carry on, no additional protection required
2 or more missed pills
Take latest missed pill then use extra protection for next 7 days
In week 1- consider EC if had UPSI in the last 7 days or pill free period
In week 2- No need for EC (as long as has had 7 consecutive pills in 1st week)
In week 3- No need for EC. Finish the pills in her current pack, skip the break

10. Question
A 25 yr old woman phones for advice. She has missed two pills in a row. Today she would be taking the 19th pill of the packet. There have been no other missed pills during the packet. She has been having regular UPSI during the weekend. You have already told her to take two of her pills as soon as possible. What next?
Needs EC + use condoms for 7 days +skip the break
Use condoms for 7 days + skip the break
Needs EC +skip the 7 day break
Needs EC + use condoms for 7 days
Use condoms for next 7 days

11. Question
A 25 yr old woman phones for advice. She has missed two pills in a row. Today she would be taking the 19th pill of the packet. There have been no other missed pills during the packet. She has been having regular UPSI during the weekend. You have already told her to take two of her pills as soon as possible. What next?
Needs EC + use condoms for 7 days +skip the break
Use condoms for 7 days + skip the break <<<<<<<<<<<<<<<<
Needs EC +skip the 7 day break
Needs EC + use condoms for 7 days
Use condoms for next 7 days

12. Who can’t have the COCP Always refer to the UKMEC guidelines:
( Available from FSRH at
All medical conditions and contraceptive options placed in a UMEC category 1 – 4 depending on their safety.

13. UKMEC definitions:
A condition for which there is no restriction for the use of the contraceptive method
A condition where the advantages of using the method generally outweigh the theoretical or proven risks
A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
A condition which represents an unacceptable health risk if the contraceptive method is used

14. Question:
Which one of the following is not an absolute contraindication to combine oral contraceptive use?
BP 165/100
Continuous use before, during and after a total knee replacement
Breastfeeding a 10 week old baby
DVT 9 years ago
A 39 yr old who smokes 20/day

15. UKMEC 3 Older than 35 and smoking <15 a day BMI>35
Migraine without aura
Family history of VTE (in a 1st degree relative <45yrs old)
Controlled hypertension
Immobility; eg wheelchair use
Breastfeeding (6 weeks- 6 month post partum)

16. UKMEC 4 Age >35 and smoking >15 cigarettes a day
Migraine with aura
History of VTE or thrombogenic mutations
History of stroke/CVA or IHD
Breastfeeding <6 weeks post partum
Uncontrolled hypertension
Breast cancer
Major surgery with prolonged immobilisation
DM diagnosed >20yrs (can be 3 or 4)

17. Question
Which one of the following is not an absolute contraindication to combine oral contraceptive use?
BP 165/100
Continuous use before, during and after a total knee replacement
Breastfeeding a 10 week old baby
DVT 9 years ago
A 39 yr old who smokes 20/day

18. Question
Which one of the following is not an absolute contraindication to combine oral contraceptive use?
BP 165/100
Continuous use before, during and after a total knee replacement
Breastfeeding a 10 week old baby <<<<<<<<<<<<
DVT 9 years ago
A 39 yr old who smokes 20/day

19. Question
A 19 yr old female has been prescribed a 7 day course of penicillin for tonsillitis. She is currently taking microgynon 30. What would you advise?
Use condoms for 7 days only if abx course overlaps with pill free period
Use condoms for 14 days
No need for extra protection
Use condoms for 21 days
Use condoms for 7 days

20. Interactions: Antibiotics: Anti-epileptics: Enzyme inducing drugs:
No problems unless an enzyme inducer (eg Rifampicin)
Anti-epileptics:
May reduce effectiveness of lamotrigine
Enzyme inducing drugs:
If very potent, cannot have COCP
May affect efficacy of COCP
Can have higher dosage regime/tricycle and have shorter break
NB St Johns Wort

21. Question
A 19 yr old female has been prescribed a 7 day course of penicillin for tonsillitis. She is currently taking microgynon 30. What would you advise?
Use condoms for 7 days only if abx course overlaps with pill free period
Use condoms for 14 days
No need for extra protection
Use condoms for 21 days
Use condoms for 7 days

22. Question
A 19 yr old female has been prescribed a 7 day course of penicillin for tonsillitis. She is currently taking microgynon 30. What would you advise?
Use condoms for 7 days only if abx course overlaps with pill free period
Use condoms for 14 days
No need for extra protection <<<<<<<<<<<<<<<<<<<<<
Use condoms for 21 days
Use condoms for 7 days

23. POP

24. Progestogen Only Pill Contains Progestogen
Works primarily on cervical mucus and endometrial factors (except Cerazette which inhibits ovulation) Eg
Cerazette (75 microg desogestrel)
Femulen
Micronor
Norgeston
Noriday

25. Who can have it? UKMEC 3: Current IHD or CVA
Headaches (migraine with aura at any age) which develop while on POP
Previous Breast Cancer
Gestational trophoblastic disease
Liver disease
UKMEC 4:
Breast cancer (current)

26. Question
A 29 yr old female presents having missed her Micronor (POP) today. She normally takes it at 0830 and it is now What advice should be given?
Take missed pill now and no further action
EC should be offered
Take missed pill now and advise condom use until pill taking reestablished for 48hr
Take missed pill now and omit pill break
Perform a pregnancy test

27. How to take it Same time every day, no pill free break
Start up to and including day 5 of cycle with no additional contraception needed
Start at any other time but use additional contraception for 48hr (if not pregnant)
Postpartum- initiate at any time, requires extra protection if after day 21
Is switching from COCP, protection is immediate if started from end of COCP packet

28. Missed pills… Classed as: Take missed pill as soon as remembered
>3hr late in traditional POP
>12hr late with Cerazette
Take missed pill as soon as remembered
Take next pill at usual time
Use additional contraception for 2 days
EC if UPSI occurs during these 2 days

29. Question
A 29 yr old female presents having missed her Micronor (POP) today. She normally takes it at 0830 and it is now What advice should be given?
Take missed pill now and no further action
EC should be offered
Take missed pill now and advise condom use until pill taking reestablished for 48hr
Take missed pill now and omit pill break
Perform a pregnancy test

30. Question
A 29 yr old female presents having missed her Micronor (POP) today. She normally takes it at 0830 and it is now What advice should be given?
Take missed pill now and no further action <<<<<<<<<<<<
EC should be offered
Take missed pill now and advise condom use until pill taking reestablished for 48hr
Take missed pill now and omit pill break
Perform a pregnancy test

31. Disadvantages? Altered bleeding patterns
Weight change (no good evidence of causal association)
Depression and mood change (no cause evidence)

32. EMERgency Contraception

33. Emergency Contraception

34. References
Passmedicine