Emergency Contraception Hormonal method PGD training Pharmacists South

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Emergency Contraception (Hormonal method) PGD training Pharmacists South Tyneside and Gateshead Dr Janet Gallagher

Emergency Contraception (Hormonal method) PGD training Pharmacists South Tyneside and Gateshead Dr Janet Gallagher Assoc. Specialist Sexual Health Services Gateshead and South Tyneside

Covering Education / knowledge Information / new information Reducing risk taking behaviour Considering the

Covering Education / knowledge Information / new information Reducing risk taking behaviour Considering the unexpected/ onward referral, physical, emotional , harassment, exploitation, abuse • Reducing the need for EHC In the future? • Testing your understanding • •

UPSI =unprotected sexual intercourse EC = emergency contraception LNG-EC= levonorgestrel 1. 5 mg QS=

UPSI =unprotected sexual intercourse EC = emergency contraception LNG-EC= levonorgestrel 1. 5 mg QS= quick start of a suitable hormonal contraception • UPA-EC= ulipristal acetate 30 mg • Cu-IUD= copper intrauterine device • •

How to decide in the pharmacy to offer EC and which is best? Is

How to decide in the pharmacy to offer EC and which is best? Is there any time E C is not necessary because there is no risk? What do you think? Why should I discuss EC IUD if I can’t fit one? What other risks are there Is it safe? Will it ever do any harm? Do I have to refer onward Should consider Ella. One and what about the price difference?

Misconceptions • • I can use EHC as a method of contraception It will

Misconceptions • • I can use EHC as a method of contraception It will cause an abortion My boyfriend can get it for me…. Alarm Bells I can take it any time It will work every time I take it I cannot take it as I have migraine I am ‘ allergic’ to hormones

Risk of Pregnancy following UPSI • 2 -4% after a single act of UPSI

Risk of Pregnancy following UPSI • 2 -4% after a single act of UPSI anytime during the cycle • Highest risk if UPSI in 5 days before ovulation and that day of ovulation • No risk if before 21 days post natal • No risk days 1 -4 after TOP, miscarriage, ectopic • More irregular cycle , greater length of risk of pregnancy but less over all. • Can you calculate exact risk, science or art? • What about their weight ( BMI)?

UPSI • • • Consensual sex Failure of a method , compliance or not

UPSI • • • Consensual sex Failure of a method , compliance or not used at all Rape /Sexual assault, non-consensual Withdrawal method Ejaculation on the genitalia

Pitfalls in calculating risk • Sure of LMP- No woman has exactly 28 day

Pitfalls in calculating risk • Sure of LMP- No woman has exactly 28 day cycle to the hour • Follicular and luteal phases are variable • Was there full ejaculation , did the condom slip of after • Has she taken hormones recently ( especially if UPA-EC considered) • How may times has she had sex • Variable natural fertility

Licensed Methods in UK • Levonelle 1500 (introduced October 2005) • Now (P) •

Licensed Methods in UK • Levonelle 1500 (introduced October 2005) • Now (P) • ella. One • Copper IUD

How effective is Levonelle • Only evidence of efficacy at 96 hours none at

How effective is Levonelle • Only evidence of efficacy at 96 hours none at 120 hours • Can be repeated in a single cycle • What are we treating, – Real risk – Anxiety • Both Levonelle and ella. One work to delay ovulation • Reduced effect if BMI >26 or Weight > 70 kg ( levonorgestrel unknown , ulipristal acetate) • No known effect after ovulation?

Caution? UKMEC 2016 category 2 These conditions benefits outweigh risks • Current VTE on

Caution? UKMEC 2016 category 2 These conditions benefits outweigh risks • Current VTE on anticoagulants • Current or Past history of breast cancer • Inflammatory bowel disease( particularly if known to have significant malabsorption or small bowel resection following Chron’s) Not affected by colectomy and ileostomy • Acute intermittent porphyria

Caution exclusions- No UKMEC 3 or 4 category • Acute intermittent porphyria may be

Caution exclusions- No UKMEC 3 or 4 category • Acute intermittent porphyria may be used • Severe liver disease No Contraindication in UKMEC 2016 • Severe malabsorption syndromes • Trophoblastic disease No Contraindication in UKMEC 2016 • Remember enzyme inducing drugs ( allows for 2 to be taken) • Previous ectopic pregnancy There is no apparent increased risk of ectopic pregnancies following use of any EC method

UPA-EC More effective than LNG-EC Works before LH surge Up to 120 hours from

UPA-EC More effective than LNG-EC Works before LH surge Up to 120 hours from UPSI Effectiveness reduced in takers of enzyme inducing drugs ( and for 28 days after stopped taking) • Not suitable for women who have severe asthma controlled by oral steroids • Unknown significance of esomeprazole on UPA-EC. Not studies of UPA-EC used. Lower level of ulipristal (when used for other reasons at different doses) shown to be altered by esomeprazole • •

News hot off the press highlights Apr 2017 • Women not wanting to conceive

News hot off the press highlights Apr 2017 • Women not wanting to conceive should be offered EC after UPSI taken place on any day of natural cycle • EC providers who cannot offer all EC methods should give women information on other methods and signpost them to services that can provide them. If chosen CU IUD then oral EC should be given at time of referral in case IUD can not be inserted or woman changes mind or does not attend. • EC providers can offer UPA-EC or LNG-EC if she has had UPSI earlier in the same cycle as well as within the last 5 days. They will not disrupt an existing pregnancy and are not associated with fetal abnormality.

 • UPA-EC can be used again in same cycle after further UPSI •

• UPA-EC can be used again in same cycle after further UPSI • LNG-EC can be used again in same cycle after further UPSI • If already taken UPA-EC, LNG-EC should not be taken in next 5 days • If already taken LNG-EC , UPA-EC could be less effective it taken in 7 days after taking • After taking LNG-EC women should be encouraged to start contraception immediately or ASAP and use condoms or abstain until this method is effective • After taking UPA-EC women should wait 5 days before starting hormonal contraception and wait until this method is effective

 • If Cu IUD is not acceptable EC providers should consider UPA-EC as

• If Cu IUD is not acceptable EC providers should consider UPA-EC as the first ling oral EC for a woman having UPSI within last 5 days and or if likely to have occurred in 5 days prior to estimated day of ovulation • Breast feeding women should express milk and discard for a week after taking UPA-EC • Breast feeding women to be informed that limited evidence that LNG-EC has no adverse effect in breast feeding or infants • Women to be informed that possible that higher weight or BMI could reduce the effectiveness of oral EC , particularly LNG-EC

New decision making took for EC • Identifying what to use • When to

New decision making took for EC • Identifying what to use • When to refer

Fig 1 Window of action of different emergency contraceptive methods in relation to ovulation.

Fig 1 Window of action of different emergency contraceptive methods in relation to ovulation. Prabakar I , Webb A BMJ 2012; 344: bmj. e 1492 © 2012 by British Medical Journal Publishing Group

Making decisions Algorithms for Emergency Contraception FSRH guidance 2017 Copper IUCD vs Oral EC

Making decisions Algorithms for Emergency Contraception FSRH guidance 2017 Copper IUCD vs Oral EC ( adapted for pharmacists) Currently < 120 hrs since UPSI Yes Additional UPSI > 120 hours ago? Yes or unknown Currently ≤ 5 days after earliest likely date of ovulation? Yes No Offer Cu IUD If not acceptable offer EC* and discuss suitable ongoing contraception No or unknown Offer Cu IUD If not acceptable offer oral EC* and discuss suitable ongoing contraception Unknown No Currently ≤ 5 days after earliest likely date of ovulation? Yes Offer Cu IUD Oral EC* unlikely to be effective Refer onward for suitable quick start contraception Consider pregnancy test if UPSI this cycle > 21 days ago Offer oral EC* and discuss suitable on-going contraception No or unknown Cannot insert Cu IUD Oral EC unlikely to be effective Refer onward for suitable quick start contraception Currently ≤ 5 days after earliest likely date of ovulation? Yes Offer CU IUD If not acceptable offer oral EC* and discuss suitable ongoing contraception No or unknown Offer oral EC* and discuss suitable ongoing contraception See next slide for oral EC choices Note that there is no evidence that oral EC is effective if ovulation has already occurred

Decision making for oral EC Levonorgestrel E 0 C ( LNG EC) vs Ulipristal

Decision making for oral EC Levonorgestrel E 0 C ( LNG EC) vs Ulipristal Acetated EC ( UP-A-EC The Cu IUD is the most affective form of EC. IF criteria for insertion of a Cu IUD are not met , cannot be arranged within time or a Cu IUD is not acceptable to a woman, consider Oral EC Last UPSI < 96 hours ago? Yes No or unknown UPSI likely to have taken place ≤ 5 days prior to the estimated day of ovulation? Yes or unknown Last UPSI < 120 hours ago? No BMI > 26 or weight > 70 kg Yes UPA-EC + start contraception after 5 days Reconsider Cu-IUD if all UPSI within 120 hours or if currently within 5 days after likely ovulation If UPA-EC not suitable LNG-EC + immediate QS UPA-EC + start contraception after 5 days Or Double (3 mg) LNG-EC + immediate QS Yes or unknown No No LNG-EC + immediate QS Or UPA-EC + start contracepti on after 5 days Oral EC unlikely to be effective Reconsider Cu IUD if currently within 5 days after likely ovulation Or QS contraception UPA-EC + Start contraception after 5 days LNG-EC unlikely ti be effective Reconsider Cu-IUD if all UPSI within 120 hours or if currently within 5 days after likely ovulation

Potential failure of contraceptive methods • Combined pills, late or missed pills by more

Potential failure of contraceptive methods • Combined pills, late or missed pills by more than 48 hours since should have taken. • Progesterone-only pills, late or missed pills • Depo Provera, injection over due • Nexplanon overdue to be exchanged • Interactive drugs (Liver enzyme inducers) • Enzyme inducing drugs do not reduce effectiveness of Depo provera, Intrauterine systems, IUCDs • Intrauterine contraception , being expelled fully or partially • Evra patch fallen off • Barrier method, burst / not used most common • What about Nuva. Ring • REMEMBER IF TAKEN HORMONAL METHOD LNG-EC preferred

What is a missed pill? Combined pills Missed or Late by less than 24

What is a missed pill? Combined pills Missed or Late by less than 24 hours since should have taken pill Continue as normal with pill taking Between 24 and less than 48 hours late since should have taken ONE MISSED PILL Take most recent pill now Continue take rest of pack EHC not needed unless pills missed earlier in pack or at end of last pack Current guidelines and in FPA leaflet If not complied with this advice remember EHC needs 2 or more pills missed or started new pack 2 or more days late starting your last pack Take last pill missed and continue taking rest of pack with condoms for 7 days. If you have had SI in the previous 7 days you may need Emergency contraception Remember that PIL will have conflicting advice

When EHC is needed 2 or more pills missed > 48 hours late Where

When EHC is needed 2 or more pills missed > 48 hours late Where are you in your pack of pills Days 1 -7 EC considered if UPSI in pill free interval or in this first week Days 8 -14 Days 15 -21 No need for EC if 7 pills already taken and those following pills taken correctly OMIT pill free week and once finished this pack go straight on to next pack ( consider ED pills)

Nexplanon user longer than 3 years IUD/ IUS use longer than prescribed length of

Nexplanon user longer than 3 years IUD/ IUS use longer than prescribed length of use see following IUD’s last between 5 -10 years, IUS 5 years. Age at insertion changes length of use. Copper IUD’s inserted after 40 do not need replacing. IUS, Mirena, inserted after 45, stays in until not needed if women has no periods Negligible risk between 5 -7 years of use IUS Negligible risk years 3 -4 for Nexplanon users If UPSI consider EC needs as if no method used

Late Depo Provera and had UPSI Late by up to 14 days Late by

Late Depo Provera and had UPSI Late by up to 14 days Late by > 14 days and UPSI after > 14 days since Depo due No need for EC Consider each episode of UPSI. Provide EC within 72 hours Be aware of lasting hormonal effect If multiple UPSI or > 72 hours Refer onward.

Consideration for use of Mirena after 5 years…. Do they need EHC • Women

Consideration for use of Mirena after 5 years…. Do they need EHC • Women who were under the age of 45 years at the time of Mirena insertion and who present for replacement of the device between 5 and 7 years after insertion may have immediate replacement if a pregnancy test is negative and another pregnancy test is advised no sooner than 3 weeks after the last episode of UPSI… • Means… they do not need EHC between 5 -7 years use. They can have it replaced so long as the Preg test is neg and repeated at 3 weeks after the device is exchanged

Mirena And Jaydess • If a woman is under 45 years at the time

Mirena And Jaydess • If a woman is under 45 years at the time of Mirena insertion and more than 7 years have elapsed since insertion, replacement should be delayed until the woman has a negative pregnancy test at least 3 weeks after the last UPSI. May need EHC depending on when UPSI has occurred. Level of Levonorgestrel twice as high at 5 years than Jaydess at 3 • Women who retain their 13. 5 mg LNG-IUS for more than 3 years should be advised to use additional precautions until pregnancy can be excluded, after which time a replacement device can be inserted ( Jaydess). They may need EHC

Who is it for? • Women / girls 14 and over • Confirm Fraser

Who is it for? • Women / girls 14 and over • Confirm Fraser competencies for 14, 15 year olds • Consider Women 16 years and older with learning difficulties or mental capacity problems • Consider child protection concerns • Domestic or emotional abuse • Child sexual exploitation • Remember professional curiosity

Confidential interview and advice • However……. . • Inform carefully that any information causes

Confidential interview and advice • However……. . • Inform carefully that any information causes concerns about their safely or the safely of others as a consequence of their actions would limit the confidentiality. You may therefore have to contact someone else and give them some information. • Aware that sex under 13 is a sexual offence and has to be reported, Sex under 16 is currently illegal however this is judged as confidential if there are no features that cause concern.

Fraser checks for under 16’s • Is a parent or guardian present? • If

Fraser checks for under 16’s • Is a parent or guardian present? • If no parent/ guardian present, check who is with the under 16. • Are they mature enough to Understand the advice given and its implications • Try to Persuade them to talk to a parent or guardian about relationship and sexual health advice. • They are likely to continue being Sexually active with or without the advice • Without this advice or treatment their physical or mental Health would suffer • It is in their best Interest that treatment of advice is given without parental consent. • Remember UPSHI

After care and follow up Give written and verbal information on: • Efficacy •

After care and follow up Give written and verbal information on: • Efficacy • Side-effects • Future contraception choices • STI screening where appropriate • Pregnancy test if > 5 days delay in period or lighter than usual, or no withdrawal bleed in Pill free week • Chlamydia screening…. . Available NOW from all C&SH services for under 25’s and some GP’s and for yourselves • Taking tests only Urine for male and Female………… Risks Missing diagnoses

Timing of next menstruation • The next period after taking EHC may be early,

Timing of next menstruation • The next period after taking EHC may be early, on time, or delayed. Most women will start their next period within 3 days of the expected date • Women should be advised that menstrual irregularity can occur within the cycle after EHC use • If taken more than once in any cycle there will be greater disruption of menses and less effectiveness of subsequent EHC

Future contraception • Abstinence or Effective contraception for the rest of the cycle •

Future contraception • Abstinence or Effective contraception for the rest of the cycle • REMEMBER LASTING AND REVERSIBLE CONTRACEPTION LARC • EC use after “Missed pills” resume pills within 12 hours of taking EC ( not UPA-EC) • Discuss initiating a regular method of contraception • Refer to a service that provides all methods for choice • Quick start of methods after emergency contraception except Depo Provera

Management of a request for Emergency Contraception Where does it take place? Confidentiality to

Management of a request for Emergency Contraception Where does it take place? Confidentiality to be ensured ? ? ? ? No conversations overheard No added embarrassment Privacy and dignity

What and why do we ask? - AIMS • To determine: - if they

What and why do we ask? - AIMS • To determine: - if they may be already pregnant • To estimate the level of risk of pregnancy, drugs or conditions that make EC less effective or increase health risks • Explore previous contraceptive use and plans for the future • Determine risk of STI, (especially if under 25’s recent partner changes) • Consider any issues of non- consensual SI • Legal guidance for Under 16’s • Consider child protection referral needs • Consider CSE

Summary …Assessment to identify inclusion and exclusion criteria • • • Accurate menstrual, medical

Summary …Assessment to identify inclusion and exclusion criteria • • • Accurate menstrual, medical and sexual history ( vague history) Current drug / medication use (interacting drugs) Consensual sex (potential rape/ abuse) Current method of contraception (unknown type of pills) and future use Fraser competency for under 16’s Age of patient. (potentially younger than states, potentially looks older than is) Behaviour of patient (sexualised behaviour, know all about SI and not worried, recording consultation, declining consultation) Refer onward if any concerns KNOW your local networks, telephone contacts, availability

What do you do if you are concerned • • Concerned about age they

What do you do if you are concerned • • Concerned about age they look Concerned about behaviour Concerned about associates Concerned about capacity to understand Concerned they may be in danger Concerned and need advice Concerned if pressured into having SI by texting bullying, Sexting ( This is a criminal offence)

Keeping it simple Contact numbers ST office hours 0191 424 5010 ST out of

Keeping it simple Contact numbers ST office hours 0191 424 5010 ST out of office ours 0191 4562093 During office hours (Monday - Thursday, 8: 30 am-5 pm and Friday, 8: 30 am-4: 30 pm) (0191) 433 2653 or R&ADuty@gateshead. gov. uk • Gateshead out of hours call emergency Duty team 0191 4770844 • •

Marac assessments • MARAC Multi Agency Risk Assessment Conferences • Who to Contact for

Marac assessments • MARAC Multi Agency Risk Assessment Conferences • Who to Contact for further enquiries? • • • MARAC Coordinator for South Tyneside Northumbria Police Public Protection Unit [PPU] NE 33 1 RR Phone Number: 01915636223 • south-tyneside. marac@northumbria. pnn. police. uk. • Marac coordinator Gateshead 0191 2219324 • Northumbria Area Command 08456043043

Worried about something else • • • Gut feelings Think < 13 ( statuary

Worried about something else • • • Gut feelings Think < 13 ( statuary rape, cannot consent) Signs of self harm Seen them before Remember girls or women of any age may be affected by domestic abuse or violence.

Some Signs, What may raise suspicions May smell of alcohol Lack of eye contact

Some Signs, What may raise suspicions May smell of alcohol Lack of eye contact and engagement Unexplained bruising, scalds, marks Display knowledge or interest in sex inappropriate to age • Using sexualised language or have sexual knowledge you wouldn’t expect them to have • Have expensive phones, gifts , new possessions • •

Some more • • • Have older boyfriend or girlfriend or associate Missing from

Some more • • • Have older boyfriend or girlfriend or associate Missing from home regularly Staying with friends, sleeping on sofas Missing school regularly Behaving aggressively Demanding inappropriately • Spotting the signs

Child sexual Exploitation • • • Missing from home or care Involved in offending

Child sexual Exploitation • • • Missing from home or care Involved in offending Drug/alcohol abuse Repeat STI, pregnancies, TOPS Mental health problems, self harm, physical injuries Gifts from unknown source Changes or inappropriate appearance or behaviour Evidence of bullying Estranged from family Recruiting others into exploitative situations

Contact CSE or Child protection • If under 13 legally cannot consent to SI

Contact CSE or Child protection • If under 13 legally cannot consent to SI so is classed as sexual offence. • Ring 999 • What time of day and who is available

Immediate Safeguarding concerns Inform Police and Children & Families’ Social Care Refer to specialist

Immediate Safeguarding concerns Inform Police and Children & Families’ Social Care Refer to specialist service/s for appropriate intervention Disclosure of direct victim domestic abuse from a young person Age 13 -17 years Complete Young Peoples DASH Risk Identification Checklist (RIC) This will indicate risk levels Immediate Safeguarding concerns Low-med risk (Low-High) Hi Consider early help framework- if appropriate gh ris k Refer to Children & Families Social Care and YPVA Service - and MARAC (if victim and perpetrator are both aged 16+) YPVA Service to be contacted for advice and guidance MARAC Conference is arranged from MARAC referral Social Worker allocated and YPVA service contacted by Children and Families Social Care Case to be co-worked by Social Worker and the YPVA Service Children & Families Social Care/YPVA engage young person and complete full needs assessment/DV safety plan Children & Families Social Care assessment completed MARAC YPVA represents young person, at MARAC Conference supported by Children & Families Social care (if involved) multi agency response Multi agency planning meeting held Plan implemented by social worker and supported by YPVA Service South Tyneside Local Authority

Referral Pathway South Tyneside onward contraception. Emergency IUCD or advice South Tyneside 0191 4028191

Referral Pathway South Tyneside onward contraception. Emergency IUCD or advice South Tyneside 0191 4028191 Reception open in clinic times C&SH service provides all methods. Some GP surgeries insert IUD’s (5) South Tyneside ( May not have appointment for emergency IUCD) • Some GP surgeries insert Nexplanon (5) • C&SH service open 6 days each week with • Emergency IUD insertion available each day Mon - Fri • •

Referral Pathway Gateshead for onward contraception and Emergency IUCD Gateshead 0191 2831575 clinic reception

Referral Pathway Gateshead for onward contraception and Emergency IUCD Gateshead 0191 2831575 clinic reception Emergency IUCD Mon- Fri C&SH service open 6 days per week GP surgeries inserting IUD and inter-practice referrals but may not have appointment for emergency • C&SH service provides all methods. • Some GP surgeries insert Nexplanon • C&SH service open 6 days each week • •

Documentation Locally defined On line pharmoutcomes. Transferring data ? ? How do you do

Documentation Locally defined On line pharmoutcomes. Transferring data ? ? How do you do it

Advantages of hormonal EC summary • • Effective Easily available Easy to administer Can

Advantages of hormonal EC summary • • Effective Easily available Easy to administer Can be taken up to 72+ hours of UPSI Can be repeated in same cycle Fewer side effects Safe with no reported long term side-effects No evidence of teratogenicity

Disadvantages of hormonal EHC summary • Licensed for only 72 (120) hours after UPSI

Disadvantages of hormonal EHC summary • Licensed for only 72 (120) hours after UPSI • No evidence of effectiveness of Levonelle > 96 hours and after ovulation • Less effective than IUD • Nausea (14%) & Vomiting (1%) • Other side effects • Can disturb menstruation • Does not protect against STI • Not a substitute for lasting and reversible contraception methods or any other method used reliably

Normally takes Combined pills 9 am Monday Tuesday Wednesday 9 am takes pill Thursday

Normally takes Combined pills 9 am Monday Tuesday Wednesday 9 am takes pill Thursday Friday Saturday Sunday 9 am takes pill 9 pm takes pill A Monday is first pill in pack B Monday is 10 th pill in pack no previous missed pills C Monday is 16 th pill in pack no previous missed pills When is Emergency Contraception needed A, B or C What advice would you given after A, B and C

For each case study • 5 consideration for each case. • Discuss in 2’s

For each case study • 5 consideration for each case. • Discuss in 2’s or 3’s • Each case discussed

Case 1 • • • Age 15 Taking COC Hasn’t taken COC for 10

Case 1 • • • Age 15 Taking COC Hasn’t taken COC for 10 days Was away at friends party UPSI last night What can you offer and what will you do?

Case 2 • • • Aged 47 LMP 5 weeks ago UPSI 3 days

Case 2 • • • Aged 47 LMP 5 weeks ago UPSI 3 days ago Has been using POP but not a very good taker Risk of pregnancy? What can you offer or advise.

Case 3 • • • Aged 16 LMP 12 days ago Cycle 27 days

Case 3 • • • Aged 16 LMP 12 days ago Cycle 27 days UPSI day 11 What can she have?

Case 4 • • Aged 16 LMP 7 days ago Cycle 28 days UPSI

Case 4 • • Aged 16 LMP 7 days ago Cycle 28 days UPSI days 2 and 5 seen on Day 7 Given Levonelle and Nexplanon inserted QS Seen again day 12 Had UPSI day 11 What can you offer

Case 5 • • • Aged 16 LMP 17 days ago Cycle 30 days

Case 5 • • • Aged 16 LMP 17 days ago Cycle 30 days UPSI days 10 and 13 Risk of pregnancy? What do you advise

Case 6 • • • Aged 40 LMP 20 days ago Cycle 28 days

Case 6 • • • Aged 40 LMP 20 days ago Cycle 28 days UPSI day 16 Risk of pregnancy? What do you advise

Case 7 • • • Aged 18 On Depo no periods Last injection 14

Case 7 • • • Aged 18 On Depo no periods Last injection 14 weeks and 4 days ago UPSI 24 hours ago Pregnancy risk What can you offer and what advice

Case 8 • • • Aged 51 Asks for pregnancy test LMP 3 months

Case 8 • • • Aged 51 Asks for pregnancy test LMP 3 months ago UPSI 48 hours ago What questions Can you offer anything