1. Contraception Update
Jo Swallow
ST1s October 2011.

2. Objectives
To know what forms of contraception are available and when they are necessary
To know the contraindications for each and how to identify them
What to check for on f/u consultations
To know how to access information for ourselves and patients
To know how to approach a consultation for :
A contraception request
An emergency contraception request

3. Brainstorm! What forms of contraception are there?
Rank them now in order of efficacy,
(most effective at the top)

4. Pearl index Method Failure %rates per hundred women years
Sterilisation male 0.0 to 0.2
Sterilisation female0.0 to 0.3 (1.8% at 10 years)
Implanon0.0
Mirena0.0 to 0.2
Depo-Proverax0.0 to 0.2
Combined oral contraceptive pill0.2 to 3 (3 with poor compliance)
Progestogen-only pill (second generation)0.3 to 4 (0.5 over age 35)
IUDs 0.3 to 2
Diaphragm/cervical
Cap 5 to 20
Condom (male, female) 5 to 15
Coitus interruptus 8 to 17
Natural methods 5 to 25
Spermicides 5 to 25

5. Case 1-Lois A Lois 15yrs attends asking to go on the pill.
In groups of 3,
History factors? Examination factors?
?Pill choice

6. COCP/POP
What did you think?

7. A reminder, re child protection. Frazer/Gillick competence
<13yrs not legally capable of consenting to sexual activity
13-16 discuss and consider

8. Pros/cons of cocp

9. Important things to worry about with the COCP?
VTE
Cancer –breast/ovarian
Stroke
Use the BNF cautions contraindications list… 2 strikes and you’re out!

10. VTE with COCP Risk of VTE per 100.000 Healthy, non pregnant, no COCP
5 per yr
Cocp with levonorgestrol
15 per year
Cocp with gestodene or desogestrol
25 per year
Pregnant
60 per year

11. VTE with COCP:Effect of weight….
BMI>30
2 x risk
BMI >39
4 x risk
Healthy,no COCP 5 10 20
Cocp with levonorgestrol 15 30 60
Cocp with gestodene or desogestrol 25 50
100
Pregnant
120
240

12. Dianette/Yasmin
Heard the news?

13. Cardiovascular Risk
Absolute risk of MI in non smoking age <35 very low irrespective of COCP use
Excess risk <35 approx 3/1,000,000/yr
>35 Excess risk approx 400/1,000,000/yr
10x risk if smoke

14. Migraine Migraine with aura =absolute CI (WHO 4)
Migraine +ergots=absolute CI
Migraine +tryptan = relative CI
Migraine +1 other RF=relative CI
Migraine + No Aura +no additional stroke risk factors = OK

15. Case 1 -Lois B
Lois returns to see you with symptoms of a urine infection,
She reports that although she is quite good at remembering her pills, she does forget occasionally, is this ok?

16. Antibiotics and the pill
But ILL rules, (D/V still apply, and abx can induce these!)

17. Missed pills
New rules
Can miss one anywhere in pack no prob even if extend pill free interval to 8 days
If std dose 30 can miss 2/3****
If low dose oestrogen (20) can miss ***

18. Case 1 –Lois C Lois returns, 4 months later, she is now 16.
Her parents has been complaining about her mood swings and she wonders if the pill is to blame. She hasn’t told them that she takes it.
What might you consider?

19. Progestogens C19 derivatives E.g Norethisterone C21 derivatives
Levonorgestorel
More androgenic
More likely to cause side effects
C21 derivatives
E.g Medroxyprogestogen acetate
Dydrogesterone
Less androgenic

20. Side Effects Oestrogenic Fluid retention Bloating Breast tenderness
Nausea
Headache
Dyspepsia (take with food)
Consider changing dose, changing oestrogen or changing delivery
Progestogenic
(In a cyclical pattern)
Fluid retention
Breast tenderness
Mood swings
Depression
Acne
Backache
Reduce progestogen duration to 10 days per cycle, change progestogen c19/21 derivatives, delivery

21. Case 2- The condom split
Michelle 15 yrs attends asking for ‘the emergency pill’
Groups of 3
What do you need to ask?
What other issues does this present?

22. Emergency contraception
What actually happened?
?regular partner or one off
STI risk?
Menstrual cycle and current position, other contraception? (?earliest ovulation)
When was the accident?
Any other upsi in this cycle
?used before
?consensual, age of partner, ?Frazer competant

23. Case 2 - Michelle B
It transpires that the condom split yesterday evening around 11pm,
They also had sex 3.5 days ago using the withdrawal method
What is the most effective measure for her now?
What other options are there?

24. Levonelle is effective up to 72 (120 hrs)
If >48-72 hrs consider Ella One, (ullipristal)
Always consider copper iud
(up to 5 days or, up to 5 days> earliest ovulation)
Levonelle efficacy:
95% - 1st 24hr, 85% 48, 70% 72
Ella one efficacy:
…..
Remember pt’s on enzyme inducers may require double dosing of MAP

25. Things to discuss: Mode of action Vomiting Enzyme inducing drugs
Next Period -87% within 7 days of expected: may be early or late, Most of rest 7-14d late
?Preg test
? Quickstart FUTURE contraception,
Condoms have a 5% failure rate when used PERFECTLY

26. Emergency Contraception
IUCD (not IUS)
Up to 5 days after date of UPSI or expected ovulation
Failure rate <1%