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Transcript of Hormonal Contraception and EHC Trainer’s name XX Medicines Information Service for Health...
Hormonal Contraception and EHC
Trainer’s nameXX Medicines Information Service
for Health Information Advisors
Hormonal Contraception and EHC
Learning Outcomes
1. Have baseline knowledge and understanding about hormonal contraception including
Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions.
Implications and advice for missed doses and dosing errors.
Indications and limitations of Emergency Hormonal Contraception (EHC).
2. Be able to use the NHS Direct emergency contraception and missed pill algorithm.
Hormonal Contraception and EHC
Plan for the Day
9.30 Introduction & learning outcomes
Baseline knowledge for hormonal contraception Types, action, risks,
cautions, side effects, interactions.
Missed doses and dosing errors.
10.45 Tea break
Emergency Hormonal Contraception (EHC)
Workshop 1
12.45 Lunch
EHC & missed OC algorithm Workshop 2
3.00 Tea break
Workshop 2 (continued)
4.00 Review of learning outcomes & close
Hormonal Contraception and EHC
Contraceptive Options
Hormonal Methods
Combined OC pill Progestogen-only pill Patches Injections Implants Intrauterine devices Emergency Hormonal
Contraception (EHC)
Non-Hormonal Methods
Sterilisation Abstinence Interruptus Condoms – male and
female Diaphragms and Caps Spermicides Intra uterine devices Rhythm methods
Hormonal Contraception and EHC
Combined Oral Contraceptive Pill
Oestrogen
Ethinylestradiol (EE)
Mestranol
Progestogen
NorethisteroneDesogestrel
LevonorgestrelGestodene
NorgestimateDrospirenone
Hormonal Contraception and EHC
COCs: Monophasics
Fixed amount of oestrogen & progestogen
One tablet daily for 21 days then a 7 day pill free period.
Every Day (ED) - One tablet daily for 21 days then 7 days of dummy tablets.
> 99% effective, when used properly.
Hormonal Contraception and EHC
COCs: Monophasics
Low Strength20 microgram EE
Loestrin 20
Mercilon
Femodette
Standard Strength30-35 microgram EE
Microgynon 30
Loestrin 30
Marvelon
Minulet
Femodene
Hormonal Contraception and EHC
COCs: Biphasics & Triphasics
Varying amounts of oestrogen and progesterone according to stage of the cycle.
Useful when there is breakthrough bleeding or no withdrawal bleed on monophasics.
Hormonal Contraception and EHC
COCs: Biphasics & Triphasics
Biphasics
Binovum
Triphasics
Logynon ED
Synphase
Trinordial
TriNovum
Tri-Minulet
Triadene
Hormonal Contraception and EHC
COCs: Risks
Migraine Increased stroke risk in migraine sufferers Risk my be increased in COC users Headache with aura plus neurological
symptoms
Cancer Very small risk of breast cancer. Protects against ovarian and endometrial
cancer.
Hormonal Contraception and EHC
COCs: Breast Cancer Risk
User Status Risk
Non User <35 years ~1/500
Current user + 24 %
1-4 years post + 16%
5 years post + 7%
10 years or more post Not significant
Hormonal Contraception and EHC
COCs: Risks
DVT Healthy women non pregnant - 5-10 /100,000
2nd gen pill – 15/100,000 3rd gen pill – 25/100,000 Caution if 1, avoid if 2 of: PMH, family history,
obesity, immobility.
Stroke and MI Caution if 1, avoid if 2 of: PMH, family history,
diabetes, BP, smoking, >35 years, obesity, migraine.
Hormonal Contraception and EHC
“Tricycling” Monophasics
Running three packs together Four Pill Free Intervals per year Three extra packets of hormone per year Reduces hormone fluctuations
Unlicensed
Hormonal Contraception and EHC
COCs: Missed doses
7 days of pill taking puts the ovaries to sleep.
Ovaries wake up if miss
10 days of standard strength pill.
9 days of low strength pill.
The 7 pill free days are safe.
Guidance
NHSD CAS algorithm
Family Planning Association (FPA)
Patient information leaflet
eBNF
Faculty of Family Planning & Reproductive Health
(FFPRHC)
Hormonal Contraception and EHC
COCs: Missed doses
1-2 standard strength or1 low strength
Take pill now and then continue as normal.
No extra precautions.
No emergency contraception.
3 standard strength or2 low strength
Take pill now and then continue as normal.
Extra precautions until taken 7 pills in a row.
Week 1 – EC indicated.Week 2 – No EC.Week 3 – No EC, start new pack, no break.
Hormonal Contraception and EHC
COCs: 3 standard strength or 2 low strength missed
Pill free
Wk 1
Wk 2
Wk 3
Pill free
Hormonal Contraception and EHC
COCs: 3 standard strength or 2 low strength missed
Pill free
Wk 1
Wk 2
Wk 3
Pill free
Hormonal Contraception and EHC
COCs: 3 standard strength or 2 low strength missed
Pill free
Wk 1
Wk 2
Wk 3
Pill free
Hormonal Contraception and EHC
Progestogen Only Pill (POP)
One active ingredient – progesterone.
Taken continuously with no break.
Alternative if COCs are contraindicated.
Relies on motivation of the user.
Hormonal Contraception and EHC
Progestogen Only Pill
Benefits Well tolerated No proof of increased
disease risk Useful in lactation
Drawbacks Precise timing Changes in menstrual
pattern
Brand Names
Femulen
Micronor
Norgeston
Noriday
Cerazette
Hormonal Contraception and EHC
POP: Missed doses
Less than 3 hours late
Take the missed pill immediately and continue as normal.
No extra precautions.
No emergency contraception.
More than 3 hours late
Take the missed pill as soon as possible.
Extra precautions until 2 further pills in a row.
EC if unprotected sex before 2 further pills in a row have been taken.
Cerazette: Instead of 3 hours read 12 hours
Hormonal Contraception and EHC
Contraceptive Patch
Evra
Contains Low strength oestrogen Progestogen
Dose 1 patch a week (on
same day of week) for 3 weeks.
One week patch free.
Hormonal Contraception and EHC
Delayed Patch 1
Most risky time to forget to apply the patch.
Apply Patch 1 as soon as remembering. This is now the beginning of the patch cycle (new start day and change day).
Take extra precautions for 7 days.
If the delay was for more than 48 hrs (extends patch free period) and unprotected sex - emergency contraception is indicated.
Hormonal Contraception and EHC
Delayed Patch 2 or 3
If less than 48 hrs(Extra 48hr drugs in patch)
Apply patch immediately, keep usual change day.
No extra precautions.
No emergency contraception.
If more than 48 hrs
Stop current cycle and start a new patch cycle with a new Week 1.
Extra precautions for 7 days.
If prolonged patch free period & unprotected sex – EC is indicated.
Hormonal Contraception and EHC
Detached patch
If less than 48 hrs
Apply patch immediately, keep same change day.
No extra precautions.
No EC.
If more than 48 hrs
Stop current cycle and start a new patch cycle with a new start day / change day.
Extra precautions for 7 days.
If prolonged patch free period & unprotected sex – EC is indicated.
Hormonal Contraception and EHC
Contraceptive Injection
Long acting progestogen.
Depo-Provera. IM injection every 12
weeks.
Noristerat. IM injection every 8
weeks.
Hormonal Contraception and EHC
Delayed injection
Up to 14 days late
World Health Organisation (WHO) states: no extra precautions needed, EC not indicated.
Manufacturer states up to 5 days late but super seeded by the WHO advice.
More than 14 days late
Extra precautions for 7 days.
Consider EC if unprotected sex.
Hormonal Contraception and EHC
Contraceptive Implant
Long acting progestogen.
Implanon Subcutaneous implant
every 3 yrs.
Requires trained person to insert and remove.
Manufacturer and WHO do not state a safe delay for Implanon.
Hormonal Contraception and EHC
Vomiting & Diarrhoea
If vomited within 2 hours of pill taking, its absorption will be reduced and it may be ineffective.
Diarrhoea alone without vomiting has to be severe to reduce the absorption of the pill.
Handle as a missed pill.
Hormonal Contraception and EHC
Drug Interactions
Broad spectrum antibiotics e.g. amoxycillin, ampicillin, erythromycin. May reduce the efficacy of COCs and patch.No interaction with POPs, injection or implant.
Enzyme inducers e.g. rifampicin, ritonavir, carbamazepine, St. John’s Wort.May reduce the efficacy of COCs, patch, POPs, injection and implant.Consider referral to UKMI.
Hormonal Contraception and EHC
When is EHC Indicated?
After unprotected sexual intercourse
Increased risk of contraceptive failure Torn, leaking condom Missed pills Late implant or injection Detached contraceptive patch Dislodged IUD
Emergency Hormonal Contraception
Hormonal Contraception and EHC
Levonelle 1500 “One Step”
High dose progesterone - levonorgesterel.
One 1500mcg tablet taken as soon as possible after unprotected intercourse.
Preferably within 12 hours, ideally no later than 72 hours.
Hormonal Contraception and EHC
EHC Efficacy Rates
Time EHC taken after intercourse
Proportion of pregnancies prevented
less than 24 hours 95%
25 to 48 hours 85%
49 to 72 hours 58%
Hormonal Contraception and EHC
How does EHC work?
Depends on point in the menstrual cycle.
Thought to prevent or delay ovulation, fertilisation and implantation.
Clinical opinion is that using EHC does not constitute an abortion.
Hormonal Contraception and EHC
EHC: Cautions & Side Effects
WHO – No absolute contra-indications.
Nausea 25%, vomiting 5%.
Care with liver enzyme inducers e.g. rifampicin, St John’s Wort, ritonavir, phenytoin, carbamazepine, barbituates.
Slightly increased risk of ectopic pregnancy.
Hormonal Contraception and EHC
Where can you get EHC?
Community Pharmacies GP Walk-in Centres Family Planning Clinics Sexual Health Clinics A & E
Hormonal Contraception and EHC
Plan for the Day
9.30 Introduction & learning outcomes
Baseline knowledge for hormonal contraception Types, action, risks,
cautions, side effects, interactions.
Missed doses and dosing errors.
10.45 Tea break
Emergency Hormonal Contraception (EHC)
Workshop 1
12.45 Lunch
EC & missed OC algorithm Workshop 2
3.00 Tea break
Workshop 2 (continued)
4.00 Review of learning outcomes & close
Hormonal Contraception and EHC
Workshop 1: Case scenarios
What further information do you need to answer the call?
Confirm what type of contraception using the eBNF.
Refer to the NHSD algorithm rationales for an answer. What does the FPA, netdoctor & eBNF say?
What would you advise the caller?
Hormonal Contraception and EHC
Plan for the Day
9.30 Introduction & learning outcomes
Baseline knowledge for hormonal contraception Types, action, risks,
cautions, side effects, interactions.
Missed doses and dosing errors.
10.45 Tea break
Emergency Hormonal Contraception (EHC)
Workshop 1
12.45 Lunch
EC & missed OC algorithm Workshop 2
3.00 Tea break
Workshop 2 (continued)
4.00 Review of learning outcomes & close
Hormonal Contraception and EHC
Workshop 2: EC algorithm
Repeat the case scenarios from Workshop 1 using the NHSD Emergency Contraception algorithm.
Hormonal Contraception and EHC
Learning Outcomes
1. Have baseline knowledge and understanding about hormonal contraception including
Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions.
Implications and advice for missed doses and dosing errors.
Indications and limitations of Emergency Hormonal Contraception (EHC).
2. Be able to use the NHS Direct emergency contraception and missed pill algorithm.