Contraception Update

Jo Swallow

ST1s October 2011.

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

Brainstorm!

What forms of contraception are there?

Rank them now in order of efficacy,

(most effective at the top)

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

Case 1-Lois A

Lois 15yrs attends asking to go on the pill.

In groups of 3,

History factors? Examination factors?

?Pill choice

COCP/POP

What did you think?

A reminder, re child protection.Frazer/Gillick competence

<13yrs not legally capable of consenting to sexual activity

13-16 discuss and consider

Pros/cons of cocp

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!

VTE with COCPRisk 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

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 60 120 240

Dianette/Yasmin

Heard the news?

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

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

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?

Antibiotics and the pill

But ILL rules, (D/V still apply, and abx can induce these!)

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 ***

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?

Progestogens

C19 derivatives

E.g Norethisterone Levonorgestorel

More androgenic More likely to cause

side effects

C21 derivatives

E.g Medroxyprogestogen acetate

Dydrogesterone

Less androgenic

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

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?

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

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?

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

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

Emergency Contraception

IUCD (not IUS) Up to 5 days after date of UPSI or

expected ovulation Failure rate <1%