1. Obs & Gynae 2015

4. Pearl Index: measures the number of pregnancies that occur for each contraceptive method if used by 100 women for one year.  Perfect use  Typical use

5.  Copper IUD  Progestogen-only IUS  Progestogen-only injectable  Progestogen-only subdermal implant  Combined vaginal rings 5

6.  All currently available LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use  – IUDs, the IUS and implants are more cost effective than the injectable contraceptives

7. 7 8 Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 18. NY: Ardent Media, 2004 % of accidental pregnancy * Norplant and Norplant 2: Data is from USA where Implanon is not available

8. 8 % Discontinuation

9. 9 7. Schering Data on File, 2006, WOMEN AGED 16 TO 44 %

10.  ‘Permanent’ but no longer the most effective  Can be reversed but no guarantee  Lifelong failure rate 5/1000 (i.e.10 times failure of vasectomy)  Requires invasive procedure  Hysteroscopic method becoming available

11.  Combined oestrogen and progestogen  Combined pill (COC)  Evra transdermal patch  Nuva-Ring vaginal ring

12.  Advantages  Suppress ovulation  High efficacy  Give predictable ‘periods’  Disadvantages  Increased risk of thrombosis  ?? Increased risk of breast cancer

13.  20, 30 or 35 micrograms of ethinyloestradiol  Different progestogens  21 day and every day formulations  Fixed dose or phasic  Combined patch – Evra  12 week withdrawal - Seasonale  Combined Ring – Nuvaring

14.  Very effective, non-intercourse related contraception  Reduction in menstrual disorders  functional ovarian cysts x 92%  menorrhagia, irregular bleeding x 50%  dysmenorrhoea x 40%  PMS   Iron deficiency anaemia x 50%   PID x 50%   Ectopic pregnancy x 90%

15.   Fibroids x 30%   Benign breast disease x 50 - 75%  Symptomatic relief / treatment of endometriosis  ?  Duodenal ulcer   Rheumatoid arthritis x 50%   Endometrial cancer x 50%   Ovarian cancer x 40%   Colorectal cancer x 20%

16.  Thrombosis  Depends on oestrogen dose  Different levels of risk with different progestogens  Benefits will always exceed risks for women major risk factors  Avoid known thrombophilias  Avoid severe obesity  Avoid with history of migraine with aura

18.  Protect against  Endometrial cancer  Ovarian cancer  ? Colorectal cancer  Increased risk of  ?? Breast cancer (?RR 1.25 for duration of use only)  Cervical cancer - ? Non-causal association  Hepatocellular carcinoma (incidence minute)

19. 20 mcg ethinyloestradiol and 150 mcg norelgestromin Apply weekly for 3 weeks Apply same day-of-the-week 1 week patch-free Sunday Patch # 1 Patch # 2 Patch # 3 28-day cycle Patch-free Sunday Start next cycle 28-day cycle Ref: Evra SmPC

20. Progestin: Etonogestrel: 120 µg/day Estrogen: Ethinyl estradiol: 15 µg/day  Worn for three out of four weeks  Self insertion & removal  Pregnancy rate 0.65 per 100 woman–years Roumen FJ, et al. Hum Reprod. 2001;16(3):469-475.

21.  Advantages  Greater safety (no oestrogen)  Variable efficacy (from extremely low to better than COC)  Some measure of loss of cycle control (varies with route, type and dose)

22.  Progestogen-only pill (POP)  Emergency contraception (Levonelle)  Injectable (Depo-Provera)  Intrauterine (Mirena)  Implant (Implanon)

23.  75 micrograms Desogestrel  Suppresses ovulation  Lower failure rate  Different rules for missed pills

25.  Products  Levonelle One Step  Ulipristal  Any copper IUD, including GyneFix  Indications  Unprotected sex  Potential barrier failures  Potential pill failure  2 missed pills in first week  4 missed pills in mid-packet  Potential IUD failure  Increased risk of ectopic in failures  Awareness of risk may not translate into action

26.  1500 micrograms levonorgestrel  Within 72 hours  Efficacy  < 24 hours95 %  24-48 hours85 %  49-72 hours58 %

27.  Progesterone receptor antagonist  Single 30 mg dose  Effective up to 5 days post UPSI  ? More effective than levonorgestrel in first 3 days  Need to consider ongoing hormonal action when starting new hormonal method

28.  Side effects  23 % nausea  6 % vomiting  Contraindications  Established pregnancy

29.  150 mg IM  Every 12 weeks  Perfect use failure rate approx 0.5%  High incidence of amenorrhoea  Long-term use associated with reduced bone density which recovers with addback or discontinuation  104 mg SC  Every 13 weeks  ?? Lower failure rate

30.  Depends on abstinence  Requires high degree of motivation  Failure rates high especially in new users  Based on a number of false premises about fertility, therefore relatively high method failure rate as well as high user failure

31.  Gold standard Copper T 380  Not user-dependant  Good efficacy (failure rate 1% or less p.a.)  Requires insertion and removal  Some increased risk of infection in first 60 days especially when cervix colonised  Periods may be heavier, longer, more painful

33.  Mirena releases 20 mcg levonorgestrel daily for 5 years  Failure rate equal to or less than female sterilisation  Reduction in menstrual loss a beneficial side- effect

34.  Good contraception  Control of menorrhagia  May help dysmenorrhoea  Effective endometrial protection  Some systemic absorption  Irregular bleeding may persist  Insertion not always easy

35.  Subdermal  Etonogestrel  Menstrual irregularity common  Failure rate far below that of sterilisation  Mode of action  Ovulation inhibition : primary effect  Effect on cervical mucus: secondary effect

36. Progestin: Etonogestrel: 120 µg/day Estrogen: Ethinyl estradiol: 15 µg/day  Worn for three out of four weeks  Self insertion & removal  Pregnancy rate 0.65 per 100 woman–years Roumen FJ, et al. Hum Reprod. 2001;16(3):469-475.