family planning sarah stradling gp camberley health centre

FAMILY PLANNING

Sarah Stradling

GP Camberley Health Centre

OVERVIEW

• Combined Contraception• Emergency Contraception• Gillick competence• LARC• POP• Other methods• The new kids on the block• Case studies

The perfect contraceptive?

• The perfect contraceptive would:– give total protection against pregnancy – would be ethically acceptable– cheap– require little or no medical intervention– have no unwanted side effects but perhaps some

benefits to health– fertility would return promptly and completely when

use ended

This ideal does not exist-apart from abstinence.

Efficacy

• Pearl Index- Comparing efficacy– High index; high chance of failure (no

contraception 80-90)– Low index; low risk failure (Mirena <0.5)

number of unintentional pregnancies related to 100 women years. E.g 3 pregnancies in 100 women in 1 year, pearl index is 3.0

I would like to go on the pill…

• Age

• Contraceptive hx

• Menstrual hx, LMP

• Obstetric hx- ectopic?

• Medical hx

• Medication

• Allergies

• Options• Risks/benefits• Mode of action• Side effects• Teaching about method• PILS• Follow up• Special instructions

COMBINED ORAL CONTRACEPTIVES

‘The Pill’

• Mode of action and efficacy

• First consultation

• UKMEC

• Risks

• Initiation

• Missed pill guidance

• Choice of pill and managing side effects

• Commonest hormonal

• Action- anovulatory – reduces endometrial lining

Pills 1-7 INHIBIT OVULATION

Pills 8-21 MAINTAIN ANOVULATION

Important when considering ‘missed pills’

• Pearl Index- 0.3- 4.0

• Perfect use vs. true use

• Promote safe sex- condoms– Sexual health screening– Opportunistic chlamydia (1:10 <25)

First COC consultation

• Clinical Hx- Medical conditions

Drug use prescription and OTCFamily hx

• Specific enquiries

• User preference and concerns

UkMEC(medical eligibility criteria)

• UKMEC 1- No restriction

• UKMEC 2- Advantages > theoretical proven risk

• UKMEC 3- Risk > advantages

• UKMEC 4- Unnacceptable health risk

Suggest specialist referral if 3 or above

Risks

• Age- to what age can it be safely used?

• Smoking- can the coc be used in a 30 y.o smoker?

• Obesity (BMI 30-34;2 35-39;3)

• Blood pressure

Not Recommended(UKMEC category 4)

• Smokers >35 years (>15 a day)• Migraine with aura at any age• Known thrombogenic mutations• BMI >40• BP consistently > 160/95• Current breast cancer• Liver tumours• Hx VTE/Stroke/MI • Valvular and congenital heart disease

‘The pill scare’

• VTE:

Increase five fold, remains low

No screen needed

Different progestogens associated with risk- levonorgestrel and norethisterone may counteract thrombogenic effect of EE better than desogestrel and gestodene

Greatest risk in first year

Normal within weeks of stopping

• Dianette- 35mcg EE and cyproterone acetate

Four fold increase risk vs. microgynon 30

Limit duration of use

Yasmin? Lies between the above

Risk per 100,000 women years

Non COC/not pregnant 5

Levonorgestrel/norethisteron (Microgynon, Loestrin)

15

Desogestrel/gestodene

(Marevlon, mercilon, fermodene

25

Pregnancy 60

• Migraine:

Migraine + aura (any age)

Migraine – aura

Risk of ischaemic stroke

Is it an aura??

• Breast Cancer:– No increase risk if family hx– Gene carriers– Current breast ca vs. past ca (>5yrs ago)

• Drugs-– Liver enzyme inducers reduce efficacy, 28/7 after

stopping– Non enzyme inducing antiobiotics- sept 2011

– Having reviewed the available evidence, the CEU no longer advises that additional precautions are required

to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers

with combined hormonal methods for durations of 3 weeks or less. The only proviso would

be that if the antibiotics (and/or the illness) caused vomiting or diarrhoea.

What would you do with a patient with a UKMEC 4 score and says that they are

accepting of the risk?

Risk vs. pregnancy?

Patients right to choose?

Prescribing responsibility?

• Non contraceptive benefits:– Blood loss and pain– Functional ovarian cysts– 50% reduction in ovarian and endometrial ca

(15 years post)– Acne

– Tricycling packets: prevent bleed, endometriosis, withdrawl headache- OUTSIDE LICENCE

Initiation

• Day 1-5- immediate cover

• Elsewhere – COULD THEY BE PREGNANT? Alternative precautions

• Chaotic recurrent EC users? Immediate start and bHCG in 3/52- Quick Start

• Best method if chaotic?

• Post partum- ideally day 21

• Amenorrhoea- anytime + 7day

• Post TOP- up to 7 days

‘Missed Pill’

• HOW MANY?• WHERE IN THE PACKET?

A missed pill is one that is more than 24hrs late.

1 active pill can be missed without the need for alternative precautions

If 1 pill missed at any time in packet

Take the missed pill as soon as remembered

Continue remaining pills as normal

Emergency contraception is not usually needed but consider if earlier pills missed

If 2 or more pills missed at anytime in packet

Take most recent missed pillTake remaining pills as usual

Advised to use condoms/abstain untilhas taken 7 pills in a row

Pills 1-7: Consider ECPills 8-14: Nil

Pills 15-21:Omit pill free interval (ED)

• PILS

• Drug information leaflet

• NHS direct

• GP

• OOH

• Patient.co.uk

Which Pill?

• Monophasic COC with 30mcg EE + Norethisterone or levonorgestrel

• Why?– No evidence for biphasic or triphasic– Reduced VTE risk– 20mcg efficacy similar but increased BTB

Note: ED pills no evidence for increased compliance

• Provide written information

• Review at 3/12

• Bp and troubleshooting

• May issue 12/12 supply with SOS review

• Encourage 3/12 trial

• Advise re VTE signs/sx

• Advise re condom use for STI protection

Side effects

• Remember ‘side effects’ may not be COC related

• Oestrogen s/e-– Nausea– Dizziness– Bloating– Cyclical fluid retention– Vaginal discharge

Swap to a progesterone dominant pill-

e.g. Cilest, Brevinor, Marvelon

• Progesterone s/e:– Vaginal dryness– Weight gain– Depression– Low libido– Breast tendernss

Change to an oestrogen dominant pill e.g microgynon 30, loestrin 30/20

• Changing from another form of contraception to COC and vice versa- MIMS and BNF

• EVRA-consistent levels of hormones, change every 7 days, ‘patch free’ week, ?improve compliance, if patch no longer sticky will need a new patch

NUVARING

• Once a month intravaginal ring

• Low oestrogen (2mg ethinyloestradiol-15mcg daily and etonogestrel)

• Individually packaged

• No GI absorption- malabsorptive disorders, binge drinking, vomiting

• May view as user controlled LARC

• Insert and leave for 3 weeks

• Ring free week- withdrawl bleed

• Does not matter where it sits unlike diaphragm

• Each ring works for 5 weeks

• Removal to ovulation→16 days

• Can use tampons and spermicides• <5% women report BTB• 90% men found it acceptable• Needs cold storage prior to dispensing,

then has 4 month shelf life at room temp• If taken out, 3hr window before

contracptive efficacy is compromised• No evidence that it effects cervical

cytology

QUESTIONS?

EMERGENCY CONTRACEPTION

Preventing pregnancy following UPSI/contraceptive failure

1. Oral Hormonal - levonorgestrel (LNG)Inhibits ovulation as primary action]

- Ella One Uliprisatal acetate- Selective progesterone receptor modulator

2. Copper IUD- Minimum 380mm²Toxicity to fertilisation and inflammatory action against endometrium- anti implantation

NOT IUS

• 2002 Judicial review- pregnancy starts at implantation NOT fertilisation

• NO time in cycle when there is NO risk following UPSI

• No evidence that LNG/ulipristal will harm a fetus

Indications

• COC- 2 or more missed in week 1 PLUS UPSI in pill free week or week 1

• POP- 1 missed pill (>3hrs late or 12hrs if cerazette) and UPSI in following 2 days

• IU- removal or expulsion and UPSI in previous 7 days

• Injectable- >14 weeks and UPSI• Liver enzyme inducers- taken with COC or

implant or in the following 28 days• UPSI

‘The Morning after pill’

• Levonelle 1500

• ASAP, within 72hrs- licence

• Consider up to 5 days- outside licence

• Consider more than once in a cycle

• Always give if a/w IUD

• No CI to EHC

• Liver enzyme inducing drugs, ?2 doses

• Ella One

• Licence for 5 days (120hrs) post UPSI

• Acts to delay ovulation

• May also have effect on the endometrium

• At least as effective as LNG

• Can only have once in a cycle

• Affects COC for 14 days, POP for 7 days

• Vomits within 2 hrs- repeat• Nausea- 14%• 50% period was a few days late or early• 16% non menstrual bleeding in next 7

days• bHCG at 3/52• Levonelle 1500 £5.11• Ella One £16.95

Would you?

• Should EHC be offered in advance of need?

– Foreign travel– Barrier methods

May reduce unwanted pregnancies without increase in risky behaviour.

Available OTC

IUD for emergency contraception

• Up to 5 days after 1st episode UPSI

• Up to 5 days after calculated date of ovulation

• Detailed hx of normal cycle and calculate expected date of ovulation

Always give EHC whilst arranging

Other discussions

• Sexual health screening

• Ongoing contraception

• ?start alternative method before next period

• Young people- No medical reason to avoid– Child protection issues

GILLICK COMPETENCE

• Gillick vs. West Norfolk HA (1986)

• DOH guidance

• Law Lords Ruling (Fraser ruling)…..

“ A clinician may provide treatment to a young person <16years, without parental consent, provided that he/she has confirmed that they are competent and that the Fraser criteria have been met”

• Advice understood• Will have or continue to have sex• Advised to inform parents• In the patients best interests

• Age <13years- responsibility to inform social services, advise patient

• Consider each case on merits

• 15 year old with a 17 year old partner

• 15 year old with a 35 year old partner

• 12 year old with a 14 year old partner

Case 1

• 20 y.o on Microgynon 30, has missed her last 2 pills and she is in the last week of her packet.

She had sex without a condom yesterday and is worried about her pregnancy risk…

What would you advise her?

Case 2

• 26 y.o had a split condom 4 days ago.

She has a 28 day regular cycle and is now day 15 of cycle. She is requesting the morning after pill…

How do you counsel her?

LONG ACTING REVERSIBLE CONTRACEPTION

LARC

Options

• IUD

• IUS

• Injectable progestogens

• Progesterone only implant

• NICE- Discuss with all women-QOF

• Cost effectiveness at 1 year >COC

• ↑ use of LARC leads to ↓unwanted pregnancies

Copper IUD

IUS Injection Implants

MechanismFertilisation and implantation

Prevents Implant

Prevents ovulation

Prevents ovulation

Duration

5-10yrs, unless 40+

5 years unless 45+

12 weeks/ 8 weeks

3 years

Failure Rate <2/100 <1/100 <0.4/100 <0.1/100

Risks

Bleeding

Dysmen

Ectopic-1:20

PID

Perforation

Bleeding

Ectopic

PID

Perforation

Libido/acne

Bleeding

Weight gain

BMD

Bleeding

Acne

Bleeding patterns

• IUD- Increased and often dysmenorrhoea

• IUS- 6/12 often irreg, amenorrhoea 65% after 1 year

• Injectable- 70% amenorrhoea at 1yr

• Implant- 20% amenorrheoa, 50% irregular

Fertility

• No alternation with IUD/IUS/Implant

• Injectable- up to 1 year, detectable in serum at 9/12

• No guarantee on stopping

Suitability

• Nulliparous

• Breast feeding

• BMI

• Post TOP

• Diabetes

• Migraine + aura

• CI to oestrogen

IUD/IUS

• Chlamydia testing

• Ensure not PG prior to insertion

• Review at 6/52, trouble shooting

• IUD immediate cover

• IUS may need alternative

• Advise early return if pain or discharge, remind re bleeding

• Use of tranexamic acid

• Systemic effects with IUS

• Lost IUD/IUS? Pregnant?

• Partner dissatisfaction

• Length of protection

• Risks– Perforation: 1:1000– Expulsion: 1:20– Ectopic: 1:20– PID: 6 times increased risk in first 20 days,

then low

INJECTABLE‘Depo’

• DMPA (12/52) and NET-EN (8/52)

• Deep IM, well mixed

• Can safely be given up to 12+5-licence• Can give up to 14 weeks-faculty guidance • Emergency drug availability

• Review every 2 years re ongoing use

• Not affected by liver enzyme inducers

• ?EC if greater 12+5 and upsi

• Up to age 50- consider change at 45+

• Weight gain and elevated BMI

• Document date of next injection

BMD and injectables

• Caution if <18 or >40

• Systematic review- reduction in BMD after 1 year but recovers after stopping

• MHRA– If <18 consider all other options before use– Revaluate every 2 years– If RF for OP consider alternative

IMPLANON/NEXPLANON

• Single subdermal rod

• Norplant- 5 rods, 1999, poor advice

• No effect on BMD

• Affected by liver enzyme inducing drugs

• ?trial of cerazette

• 8-10cm above medial epicondyle

• Woman must palpate

• No routine f/u

• Bleeding- tranexamic acid or COC

• Full assesment with IMB

• If cannot palpate- Xray

PROGESTERONE ONLY PILL

• Mode of action-– Cervical mucus– Ovulation (up to 60% or 97% with desogestrel)

• Daily• No pill free interval• Takes 48hrs to thicken mucus• 3Hrs- Femulen, Micronor, Noriday, Norgeston• 12hrs- desogestrel (cerazette)

• Failure rate 0.3-8.0%

• Decreases with age

• Traditionally double dose if BMI >70kg, NO evidence to support this and use of one pill is recommended

• Only UKMEC 4 is breast ca

Missed Pill advice…

Traditional POP Desogestrel POP (Cerazette)

>3hr late i.e.>27hrs since last pill

>12hrs late i.e.>36hrs since last pill

1. Take the missed pill2. Take the next pill at the usual time (this may mean 2 pills in 1 day)

3. Condoms or abstinence for the next 48 hrs4. No need for EC if sex before the missed pill

• 3 hr window may be difficult• Cerazette £8.68 vs. micronor £1.80 • Generic desogestrel £4.30

• Advise re vomiting• Avoid if using liver enzyme inducers• Not affected by antibiotics• No effect on lactation• Migraine

Bleeding Patterns

• Commonest reason for stopping

• Good counselling may reduce

• 70% report prolonged, BTB or spotting

• General Guide– 20% amenorrhoea– 40% regular pattern– 40% erratic

• Level of tolerance

• ?use of increased dose for BTB, anecdotal but poor evidence.

Remember if new bleeding pattern in previously untroubled patient…

?STI, Drug interactions, compliance, pregnancy

• Commence in first 5 days- immediate cover

• Anywhere else extra precautions for 48hrs

• Can continue until the menopause

OTHER METHODS

• Condoms

• Diaphragm

• LAM

• Sterilisation

• Natural family planning

CONDOMS

• Male and female condoms• Traditionally latex• Polyurethane condoms • Latex allergy- usually local but may be

systemic

• EU safety tested and kite mark• Always look for the exp. date

• Breakage and slippage reduce with experience

• Avoid oil based lubricants e.g. baby oil and petroleum jelly

• Failure rate:– True 2%– Actual up to 15%

• Latex vs. latex free- efficacy the same

Evidence supports the use of condoms to reduce the risk of STI. However, even with consistent and correct use, transmission may still occur.

• Free condoms from family planning centres

• No restriction on selling condoms to those under 16years

• No evidence to suggest that supplying condoms encourages sexual activity

DIAPHRAGMS AND CAPS

• Diaphragm lies across the cervix• Perfect use failure rate 4-8%• True use 10-18%• Need to be used with a spermicide • Needs teaching

• Caps are much smaller• Rarely used

• Advantages:– Non hormonal– More independent of intercourse than condom– Reduces the risk of HPV transmission

• Disadvantages:• Messy• Forward planning• Low efficacy

• Must apply spermicide to both sides• Active for 3hrs• Leave in for at least 6hrs post intercourse• Top up if intercourse again• Remove, wash and allow to dry

• Resizing needed if >3kg weight change, TOP, miscarriage, vaginal delivery, vaginal surgery

LACTATIONAL AMENORRHOEA

• No guidance provided by faculty• A method of contraception??• Reported failure of 2%

• Criteria to be met:– No return of periods– Baby is nearly or fully breastfed (4hrs in the day and

6hrs at night)– The baby is less than 6 months old (i.e. pre weaning)Note: ‘nearly fully breastfed’ means that the infant

receives mostly breast milk but can have ‘some’ alternative liquids

STERILISATION

• Counselling, especially LARC, permanent• Take a full contraceptive hx• No absolute CI- make request themselves,

sound mind and no external duress

• Female- Tubal occlusion, alternative method until surgery and until the next period

• Male- No scalpel approach with division of vas and diathermy, contraception until clearance

• Failure rate:– Women 1:200 (same as IUS)– Men 1:2000 after clearance

If pregnancy occurs after female sterilisation increased risk of ectopic.

Increase report of heavy periods after sterilisation.

• Persona

• Natural family planning- temperature, cervical mucus, avoidance of ‘unsafe time’ around ovulation (days 12-16 of a 28 day cycle)

The New Kids On The Block

• Zoley- Estradiol, 24 active and 4 inactive. Good cycle control, 1 in 3 bleed free cycles. Well tolerated

• Jaydess- IUS for 3years. Aimed at younger women. Smaller insertion device. Not licensed for DUB or HRT. Less amenorrhoea, but lighter flow

• Sayana Press- s/c version of depo. Same s/e and licence. More expensive, pt reports more skin reactions and worse pain at administration.

QUESTIONS??

1

• 18 y.o off to uni, previous termination, no regular partner but admits to having regular one night stands. How do you advise her?

2

• 34 y.o smoker asking for a cocp repeat- Microgynon. What issues do you need to consider and how do you advise her?

3

• 28 y.o. with a young baby and a 3 year old. Thinks that she would like more children but with a gap. Had the depo before and this suited her really well. What issues do you need to consider and how do you advise her?

4

• 32y.o would like to have a ‘coil’. Her sister has a copper coil and she likes the idea of no hormones. Has heavy periods with flooding and dysmenorrhoea. How do you advise her?

5

• 23 y.o comes asking for ‘the pill’. Has never had any contraception before other than using condoms. How would you approach this consultation?

6

• 15 y.o comes with a friend asking to go on the pill. She asks you to promise that you won’t tell her mum- who is a regular patient of yours. What issues does this consultation present? Would you prescribe to her?

7

• 25 y.o that has been on the cocp for 5 years has recently been diagnosed with epilepsy and started on carbamazepine. She was advised to come by her neurologist. What contraceptives are available to her and where would you go to get the information if you wanted to be sure?

8

• 19 y.o who has a BMI of 34 and a 5 a day smoker comes asking for the pill. She has had emergency contraception twice in the last 4 months. What are her options, how would you advise her?

• She decides on POP, how and when do you start this?

9

• 20 y.o had UPSI 3 days ago with her long term partner, they usually rely on condoms. She is on day 10 of a 28 day cycle. What options are available to her and what would you advise?

10

• 14 y.o. was drunk at a party last night and thinks that something may have happened with a ‘boy’ she barely knows. What are the issues and how would you advise her

11

• Linda is forty years old, married with three children. She is a non smoker and has been taking the COCP for 7 years. She stopped taking it last week because her younger sister has been admitted to hospital with a DVT. She does not really want any more children. What are her options?

12

• Sam is 35, she has recently got divorced. She has one child. She has had a coil for the last 9 years. She knows her coil will need changing soon. She is not sure if she wants another one. What is your advice?

13

• Gemma is 22. She has the depo injection and has attended for her next injection. Her last one was 15 weeks ago. She had sex 2 days ago. What do you do?

Useful websites

• Fpa.org.uk (formerly Family Planning Association)

• BNF online

• Mims online

• www.fsrh.org.uk

• Contraception- John Guillebaud