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Contraception andSexual Health Update

Debbie SmithFebruary 2013

Areas to Cover

Missed pill advice Timing of pills Alternative Oral Contraception brands Emergency Contraception including IUDs

and ellaOne Larcs-What can Pharmacists discuss?

Chlamydia screening in under 25s

Menstrual cycle

Combined Hormonal Contraception

Can be started up to and inc day 5 ofcycle, can be started later but requireadditional precautions for 7 days

Missed pills, vomiting within 2 hours oftaking pill, severe diarrhoea requireadditional precautions for 7 days

Additional contraceptive precautions arenot required during or after courses ofantibiotics that do not induce enzymes

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FSRH CHC guidance

Extendedregimens

Reduced ‘pill-free’ interval

Alternative Brands

Rigevidon Microgynon30Millinette 30/20 Femodene/FemodetteGedarel 30/20 Marvelon/Mercilon

And now Cerelle Cerazette

Emergency Contraception Options

ORAL Levonorgestrel 1.5mg – POEC

(Levonelle) Ulipristal Acetate 30mg – UPA

(ellaOne) IUD

All copper IUDs

Efficacy related to mode ofaction

Pills delays/inhibit ovulation UPA > LNG

No evidence of effect after fertilisation LNG no effect after ovulation UPA not studied enough yet (probably not)

IUD may prevent fertilisation IUD inhibits implantation

Levonelle

Inhibits ovulation

Less effective at ovulation

Effective up to 96 hrs

Repeat dose if vomiting within 2 hours

Multiple doses possible

ellaOne

Ulipristal acetate

Synthetic progesterone receptor modulator

Licensed for use up to 120 hours after unprotectedsex

No reduction in efficacy over the 120 hours

£16.95

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Max risk

LNG

Ulipristal

IUD

When in the cycle is EC effective?

0%1%2%3%4%5%6%7%8%9%

1 4 7 10 13 16 19 22 25 28 31 34 37 40

No treatmentLNGCopper IUD

Probability of Pregnancy by Cycle DaySource: Wilcox et al. 2001

Emergency Contraception EffectivenessIf 1000 women had UPSI and used….

Cu IUD, UPA, LNG, Nothing James Trussell2011

Weight and oral emergencycontraception failure

0

1

2

3

4

5

6

7

UPA LNG

Normal BMI25-29.9>30

Failu

re %

Glasier et al. Contraception 2011

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When to prescribe UPA?

Days 4-5 post unprotected sex when IUDnot accepted

Mid-cycle / not known - when IUD notaccepted

Women with high BMI

Issues with ellaOne

Should only be used once per cycle

Should NOT use if suspicion of an implanted pregnancy

Not to be used with enzyme inducers

Can NOT double the dose for any reason

Not to be used with any drugs that increase gastric Ph

Avoid breast feeding for 36 hours after taking

Reduces the efficacy of progesterone containing

contraceptives.

Don’t forget Cu IUDs

> 99% effective

120 hours after UPSI or within 5 days of earliest

expected ovulation

Efficacy not affected by concomitant drug use

STI risk assessment +/- prophylactic antibiotics

AGREE LOCAL PATHWAYS

Give oral EC if delay in IUD insertion

Can keep IUD - LARC

LARC Counselling

Depo Provera

Nexplanon

IUD-TT380, Nova T 380,Flexi T 380

IUS-Mirena

Births per 1000 women age 16–19

0 5 10 15 20 25 30 35 40

USA

UK

New Zealand

Ireland

Portugal

Australia

Austria

Spain

Luxemberg

Finland

Greece

Norway

Germany

Belgium

Sweden

France

Switzerland

Denmark

Cyprus

Italy

Netherlands

1. United Nations Population Division 2009

Number of abortions is highestin the 20-24 age group

3,718

34,551

55,481

40,800

27,978 27,046

0

10,000

20,000

30,000

40,000

50,000

60,000

under 16 16-19 20-24 25-29 30-34 35+Age

Num

ber of

abo

rtions

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Accidental pregnancy in first yearof use – typical use

Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J et al. Contraceptive Technology, revised edition 19. NY: Ardent Media, 2007

percent

NICEGuidelines

NICE - Key Priorities forImplementation

Women requiring contraception should be giveninformation about and offered a choice of allmethods, including LARCs.All IUD/IUS/depo/implant are more cost effective

than the COC even at 1 year of use IUD/IUS/implants are more cost effective than

depo Increasing the uptake of LARCs will reduce the

numbers of unintended pregnancies.

Depo Provera(DMPA)

150mg Depo MedroxyprogesteroneAcetate

Injection given i.m. every 12 weeks (licence 12+5 days) now up to 14 weeks

<4/1000 failure rate

Inhibits ovulation

Side effects

Bleeding disruption-70% amenorrheic after 1year

Weight gain-2kg/year Acne Possible loss of Bone Mineral Density Delay in return of fertility

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Bone Mineral density

CSM has advised In adolescents(12-18years)DMPA should only

be used when other methods are inappropriate In all women benefits of using DMPA beyond 2

years should be evaluated against risk In women with risk factors for osteoporosis an

alternative method of contraception instead ofDMPA should be considered

Nexplanon

4cm long 2mm in diameter

68mg etonorgestrel

Rate controlling membrane

Practical Benefits and Advantages

3 years of almost 100% contraception (methodfailure 1 in 10,000)

More cost-effective than the pill even at 12months usage

May be used when oestrogens contraindicated Compliance free-fit and forget Rapid return to previous fertility

Disadvantages/side effects

Bleeding- Nexplanon will disruptmenstrual cycle1/3rd no or light bleeding1/3rd erratic but manageable bleeding1/3rd heavy and/or very frequent bleeding

Disadvantages/side effects

Progestogenic effects-acne, breasttenderness, weight gain, mood swings

Local reaction at site of insertion

Summary of Copper IUDs in UK

TT380 Slimline® 380 10yrsMiniTT® 380 Slimline® 380 5yrsFlexi-T® 380 5 yrsMultiload® 375 5yrsNova-T® 380 5yrs

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IUSMirenaPlastic device20mcg levonorgestrel/24hrs5yr licenceAlteration in bleeding patternNon-contraceptive benefits

Non-contraceptive benefits of IUS

Reduction in menstrual blood loss –up to 90 %DysmenorrhoeaMenorrhagiaEndometriosisEndometrial protection

COUNSELLING

Essential if going to achieve good continuation FPA leaflets Practice/Local Leaflets Internet Chlamydia +/- gonorrhoea at the start

Time well spent!

All LARC methods are suitable for:

• nulliparous women• women who are breastfeeding• women who have had an abortion – at time ofabortion or later• women with BMI > 30• women with HIV – encourage safer sex• women with diabetes• women with migraine with or without aura – allprogestogen-only methods may be used• women with contraindication to oestrogen

New England Journal of Medicine May 242012

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Conclusion

The effectiveness of LARC is superior tothat of contraceptive pills, patch or ringand is not altered in adolescents andyoung women.

N ENGL J MED May 24 2012

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Chlamydia trachomatis

Commonest bacterial STI in the UK

Intracellular bacteria

Symptoms and signs

Up to 50% of males and 70% femalesinfected are asymptomatic

Untreated pool most likely responsible foronward transmission in the community

Role for universal screening

Complicated chlamydialinfection

PID Ectopic pregnancy/tubal factor

infertility/chronic pelvic pain/perihepatitis Vertical transmission-neonatal

conjunctivitis Adult conjunctivitis Epididimo-orchitis Sexually acquired reactive arthritis (SARA

formerly known as Reiters syndrome)

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Resources

www.fsrh.orgwww.fpa.orgwww.BASHH.orgwww.leedssexualhealth.com

ICSH-Introductory Certificate In SexualHealth-RCGP

Thank youDeborah.smith@nhs.net