Contraception Update To know what forms of contraception

Contraception Update

• 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 teenager – A >35 y. o – The rest!

• To be able to discuss the main pros and cons for different types of contraception. • To know which are the most effective methods of contraception • To know why some are less good for different patient groups • To be aware of important issues for different age ranges

Brainstorm! • What forms of contraception are there?

Quiz! • If 1000 women were to use these methods of contraception…. How many pregnancies would arise in the first year of use?

First year of Use Perfect Use Cocp 50 2 Pop 50 4 Depo 3 3 Ius/iud 1 1 implant 1 1 Patch 80 3 Diaphragm/Spermicide 160 (nullip) 9 Condom 150 20 Female condom 210 50 Withdrawal 270 40 Male sterilisation 1 1 Female sterilisation ~5 5 No method 850

Frazer/Gillick competence • <13 yrs not legally capable of consenting to sexual activity • 13 -16 discuss and consider

• Use the BNF cautions contraindications list… 2 strikes and you’re out!

Important things to worry about with the COCP? • VTE • Cancer • Stroke

VTE with COCP Risk of VTE per 100. 000 Healthy, non pregnant, no COCP Cocp with levonorgestrol 5 per yr Cocp with gestodene or desogestrol Pregnant 25 per year 15 per year 60 per year

VTE with COCP: Effect of weight…. BMI>30 2 x risk 10 BMI >39 4 x risk 20 15 30 60 25 50 100 60 120 240 Healthy, no COCP 5 Cocp with levonorgestrol Cocp with gestodene or desogestrol Pregnant

Other risks… • Which is more likely to happen? – Dying from a thrombosis from a third generation COCP – Or – Dying in a RTA

Cancers… • Is there an increase in risk of breast cancer with the COCP? • RR increased by: – 0% – 1 -9% – 10 -19% – 20 -49% – >50%

• Is there an increase in risk of breast cancer with the COCP? • RR increased by: • 25%

• What is the absolute risk increase? – 0. 01% – 0. 5% – 1% – 2 -10%

• Absolute risk is 0. 01% – Actual baseline risk <30 1: 1900 30 -40 1: 200 – Risk increase is 12/100, 000

Cardiovascular Risk • Absolute risk of MI in non smoking aet <35 very low irrespective of COCP use • XS risk approx 3/1, 000/yr • >35 XS risk approx 400/1, 000/yr • 10 x risk if smoke

Cardiovascular Risk • Ischaemic stroke: non smoking, normotensive women XS risk 4/100, 000/yr • Increased with age/smoking x 10 / migraine x 11

Migraine • • • Migraine with aura =absolute CI (WHO 4) Migraine +ergots=absolute GI Migraine +tryptan = relative CI Migraine +1 other RF=relative CI Migraine + No Aura +no additional stroke risk factors = OK

Emergency Contraception • POEC : Progesterone only Emergency contraception • Success Rates: preventing expected pregnancy • <24 hr 95% • 25 -48 hr 85% • 49 -72 hr 56% • (72 -120 hr ? 60%)

POEC • Effect on next period • 87% within 7 days of expected: may be early or late • Most of rest 7 -14 d late

Emergency Contraception • IUCD (not IUS) • Up to 5 days after date of UPSI or expected ovulation • Failure rate <1%

• Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing… and you may need time recover before the menopause • This is not true for implanon

• • Mirena ok for 4 y for endometrial protection Menopause: amenorrhoea >2 y if under 50 >1 y if >50 If Mirena / Implanon FSH > 30 6 w apart means likely but above applies • IUD change x 1 after 40 • IUS change x 1 after 45

Missed pills • New rules • Can miss one anywhere in pack no prob even if extend pill free interval to 8 days

Missed pills • see handout COCP • Important… just keep going! Take asap then as normal • If in week 3 miss pfw , wk 1 EC • Alt contraception for 7 d if miss 2 for 20 or 3 for 30. • 7 successive pills to inhibit ovulation

Missed pills • POP • Cerazette 12 h, rest 3 h • Take and continue : need 48 h continuous taking (3 pills) then ok again

Special considerations

Enzyme inducers • • • Women with epilepsy Injectable/IUD Oral contraceptives with 50 mg oestrogen Tricycle with 4 days break Double emergency contraceptive dosage

When should contraception be started? • IUCD within 18 days of period onset • Mirena day 1 -7 or if no risk preg at other time • Depot-? • COCP? • POP?

Swapping pills/hrt • Side effects can be oestrogenic/progestogenic • If someone has each of the following what would you use/change to? (pill ladder) • Spots, • Hirsuitism • Feeling depressed • Nausea • Bloating • Breast discomfort

Progestogens • C 19 derivatives • C 21 derivatives • E. g Norethisterone • E. g Medroxyprogestogen acetate • Dydrogesterone – Levonorgestorel – More androgenic – More likely to cause side effects • Less androgenic

Side Effects(HRT/Contraception) • • 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 c 19/21 derivatives, delivery