1. 1 Contraception Update & New Developments – May 2008 E Stephen Searle MRCGP, MFPH, FFFP Clinical Director/Consultant in Contraception & Sexual Health, N Derbyshire

2. 2 Content of talk Yaz, Evra, NuvaRing IUDs/IUS Esure Peri-menopausal contraception Injectables, esp osteoporosis. Implant Contraception at time of TOP

3. 3 satisfaction 25% never start Rx contraception 30% discontinue within 1 month 65-80% missed 1+ pill per month Offer ‘Quick-start regime’ – start on day of presentation regardless of day of cycle. Advise back-up method x 1 wk. & return if menses late

4. 4 Future methods NuvaRing – planned Sept 2008 Yaz – planned ?Sept 2008

5. 5 NuvaRing Design, composition and use 1 ring per cycle Regimen: –3 weeks of ring-use –1 ring-free week Daily release: –15 µg ethinylestradiol –120 µg etonogestrel 1 ring per cycle Regimen: –3 weeks of ring-use –1 ring-free week Daily release: –15 µg ethinylestradiol –120 µg etonogestrel

6. 6 NuvaRing Pharmacokinetics and dynamics Based on data from various sources, no direct comparative data

7. 7 Contraceptive efficacy NuvaRing European study PregnanciesCyclesPearl Index 95% CI 612 1090.650.24–1.41 Roumen et al, Hum Reprod, 2001;16:469–75

8. 8 NuvaRing Compliance: Ring V’s COC Compliance was higher in the NuvaRing group: > 85% of women in the NuvaRing group complied to prescribed regimen 75% of women in the Microgynon group complied to prescribed regimen i Scientific communication ESC 2004

9. 9 NuvaRing Concomitant antibiotic use AmoxicillineDoxycycline Scientific communication ESC 2004

10. 10 Incidence of local adverse events (n=1145) Vaginal discharge5.3% Vaginitis5.0% Device-related events3.8% Treatment-relatedAdverse event Vaginal discomfort2.2% Roumen et al, Hum Reprod, 2001;16:469–75

11. Irregular bleeding with Nuvaring Comparison with a COC Scientific communication ESC 2004 * ** * / * * Statistically significant differences

12. 12 NuvaRing Effect of on body weight Bjarnadóttir et al, Am J Obstet Gynecol, 2003 Cycle 3 Cycle 6

13. 13 Storage Prior to dispensing to the user, store refrigerated 2–8°C (36–46°F). After dispensing to the user, NuvaRing® can be stored for up to four months at 25°C (77°F); excursions permitted to 15–30°C (59–86°F) [see USP Controlled Room Temperature]. Avoid storing NuvaRing® in direct sunlight or at temperatures above 30°C (86°F). NuvaRing® Package Insert

14. 14 Yasmin Drospirenone 3mg, EE 30mcg Good for fluid retension/bloating Acne (1 st try oestrogenic COC, tetracycline. Then Dianette x 6/12) Mild hypertension <140/90 PMS: RCT Xover v’s placebo yasmin signif better £14.70 x3 x21

15. 15 Yaz EE 20mcg 24 active pills then x4 placebo pills Launch ? Sept 2008

16. 16 IUDs Cu T 380 now approved for 12 yrs in USA Failure rate virtually stable up to 15 yrs Cu IUDs may be left in-situ x20 yrs

17. 17 IUDs & infection Single dose of doxy. prophylactically at insertion only results in signif reduction of PID in areas of high GC, Chlamydia prevalence ALOs less likely with IUS (2.9%) than IUDs (up to 20%) No link between IUD use & CIN. Even a Hx of Ca Cx is WHO 2 for continuing IUD. WHO 4 for insertion while awaiting diagnosis

18. 18 IUDs & HIV No effect on viral shedding No increased risk of transmission or other infection (still rec. condoms) WHO 2 for HIV WHO 3 for insertion with AIDS

19. 19 IUD/IUS & gynae pathology Cu IUD reduces endometrial Ca by 50%, increased protection with duration of use IUS good for endometriosis IUS may reduce fibroid related problems, surgery & size Spotting may take longer to settle in women with menorrhagia esp if also have fibroids

20. 20 HPV vaccine Catch-up vac still useful in women who’ve had HPV as only 5% of young women have had exposure to >1 type, so still get protection from other types.

21. 21 Evra = ‘cilest in a patch’ Weekly patch x 3 then PFI x 7/7 Better compliance than pills No 1 st pass through liver, consider for GI disease/malabsorption

22. 22 How do we choose?- Nottingham Evra Audit

23. 23 Should modern women accept having menstruation? ‘Menses should be optional & convenient’

24. 24 Peri-menopausal contraception Oldest reported spontaneous preg. – 57 yr old in Portland “COC & Depo are methods of choice in osteoporotic women” – combined with osteoporosis Rx Measuring FSH on COC – OK at end of PFI Can abandon contraception from 55 th year

25. 25 Progestogen-Only Injectable Contraceptives January 2003

26. 26

27. 27 What are the advantages of injectables – Depo & Noristerat?

28. 28 Advantages of DMPA Almost 100% effective, up to 14/52 Does not require day to day motivation Non intercourse related No oestrogenic side effects or health risks Protective against PID & Endometrial Ca Does not inhibit lactation Protective in sickle cell (SS) disease

29. 29 Depo Provera and Cancer Breast cancer1.2 (0.96 - 1.5) Cervical cancer1.1 (0.96 - 1.3) Ovarian cancer1.1 (0.6 - 1.8) Endometrial cancer0.2 (0.1 - 0.8) WHO studies 1991-2 RR95% CI

30. 30 Disadvantages of DMPA (Injection cannot be removed once given) Menstrual disturbance Delay in return of fertility Weight gain (Androgenic side effects eg. acne - rare) ? osteoporosis

31. 31 Depo Guidelines Contraception & Sexual Health Service Guideline for Injectable Contraception (Progestogen Only) - First Visit

32. 32 Depo & osteporosis SUMMARY Special Warnings and Precautions etc: Loss of bone mineral density, increasing with length of use. A risk: benefit assessment should be performed, especially in young or adolescent women and if use is anticipated to be long term (ie 2 years or longer). In adolescents and women with significant lifestyle and/or medical risk factors for osteoporosis, other methods of contraception should be considered before using Depo- Provera.

33. 33 Depo Provera and Arterial disease Reduction in HDL (15% approx) Impairment of arterial endothelial function Sorenson MB et al. Circulation 2002; 106: 1646-1651 WHO Epidemiological study – no increased risk WHO Contraception 1998; 57: 315-324

34. 34 Contraception at time of TOP Talk to ALL women about LARC IUD/IUS fit at time of STOP or MTOP: – WHO 1 for 1 st trimester TOP –WHO 2 for 2 nd trimester (<24/40) STOP or MTOP

35. 35 Bleeding patterns with Implanon ® All studies Br J Fam Plann 1999;24

36. 36 BODY Wt. Comparative 2 yr study N=180 METHOD CHANGE in Wt Implanon+2.6% Norplant+2.9% Cu IUD+2.4%

37. 37 Cerazette Desogestrel As effective as COC 12 hr rule No oestrogen risks or S/E Frequently used, often 1 st choice POP or even 1 st choice OC but for ?bleeding