1. Dr Lisa Jayne Adams November 2007
CONTRACEPTION for GPs
Dr Lisa Jayne Adams
November 2007

2. AGENDA
Non-hormonal contraception
Hormonal contraception
Cases

3. Contraceptive Efficacy
Pearl Index
Effectiveness rates depend on age and motivation of user
Most effective? A method that stops ovulation and is independent of user compliance

4. Withdrawal
Mentioned in the Bible
No side effects
Pearl index of 8

5. Natural Family Planning/Persona
Complex to explain
Calender method
Temperature method
Cervical mucus
Combine all three Pearl Index 8-10
FPA can provide local teachers

6. PERSONA
Pearl Index 6
BREAST FEEDING
Pearl Index 2

7. CONDOMS Most commonly used non-hormonal Pearl Index 3-20
Beware certain topical products
Protection against STI’s

8. FEMALE BARRIER METHODS
Femidom
Diaphragm
Cervical cap

9. IUDs Banded copper device =gold standard More effective in older women
Main problems
Duration of use 10 years
Can be used for emergency contraception
Pearl index 1-3

10. IUS Periods shorter and lighter Licensed for 5 years
Can cause spotting and irregular bleeding for up to 6 months
Pearl Index < 1
(included in non-hormonal methods as effects are local)

11. HORMONAL CONTRACEPTION
COCP
Pearl index 1-5
Mode of action
Non contraceptive benefits
Starting regime
Late pills/missed pills
Diarrhoea/vomiting/ antibiotics

12. EVRA transdermal combined hormonal contraception
Yasmin contains drospirenone, has diuretic and antiandrogen properties
NuvaRing

13. Potential Harms
All COCP’s increase the risk of VTE, MI, ischaemic stroke, absolute risk is small
Any associated increased risk of breast cancer likely to be small

14. Non contraceptive Benefits
Decreased pain and blood loss
Risk of ovarian and endometrial cancer decreased by at least 50% during use
Decreased risk of colorectal cancer
Decreased incidence functional ovarian cysts

15. Not Recommended (UKMEC category 4)
Smokers >35 years (>15 a day)
Migraine with aura at any age
Known thrombogenic mutations
BMI >40
BP consistently > 160/100
Current breast cancer
Liver tumours
Hx VTE/Stroke/MI
Valvular and congenital heart disease

16. PRESCRIBING Record BMI and BP
Take a full history, check smoking status
Use a monophasic pill first line eg microgynon
Counsel re risks and side effects
Discuss non-contraceptive benefits

17. POP Thickens cervical mucus Pearl index 0.3- 4 Late pills
Cerazette (desogestrel) more effective, blocks ovulation in 97% of cycles
Advantages
Side effects
Starting regime

18. DEPOT PROVERA Deep IM every 12 weeks Pearl index 0.3- 1
Preinjection counselling
Unwanted effects
Can lower bone density in long-term users

19. IMPLANON Contraceptive implant etonogestrel Pearl index 0.8
Lasts for 3 years
Fitting and counselling
Pros and cons

20. EMERGENCY CONTRACEPTION
Levonelle
Copper IUD insertion

21. LEVONELLE Licenced for u to 72 hours after UPSI
Prevents 86% of pregnancies
Levonogestrel 1500ug
Contraindications and drug interactions

22. EMERGENCY IUD 99.8% effective for postcoital use
Copper IUD most effective
Contraindications
Insert up to 5 days after UPSI
If regular cycle can insert up to 5 days after expected date of ovulation

23. CASE HISTORIES

24. CASE ONE
Carly is 18 years old. She has just had a TOP due to ‘pill failure’. She is off to university soon. She is not in a regular relationship. She admits that she sometimes forgot to take her pill. She really wants to avoid another pregnancy. She wants your advice.

25. CASE TWO
Linda is forty years old, married with three children. She is a non smoker and has been taking the COCP for 7 years. She stopped taking it last week because her younger sister has been admitted to hospital with a DVT. She does not really want any more children. What are her options?

26. CASE THREE
Eve is 25 years old. She is in a stable relationship. She has been using condoms but wants something ‘safer’. She smokes 10 cigarettes a day.

27. CASE FOUR
Sam is 35, she has recently got divorced. She has one child. She has had a coil for the last 9 years. She knows her coil will need changing soon. She is not sure if she wants another one. What is your advice?

28. CASE FIVE
Pippa has come in for her 6 week postnatal check. She is 29 years old. She has a six week old baby and a fifteen month toddler. She is mainly breastfeeding, but gives some formula at night. She feels exhausted. Although her and her partner may want some more children they would like a ‘decent’ gap next time. She wants your advice.

29. Useful websites Fpa.org.uk (formerly Family Planning Association)
BNF online
Prescriber.com
Attract
Prodigy (good for guidelines)

30. REFERENCES
Faculty of Family Planning and Reproductive Health Care Clinical Guidance: First prescription of combined oral contraception (July 2006)
Guillebaud, J. Contraception Today. 5th ed. Martin Dunitz, 2005