contraception for gps dr lisa jayne adams november 2007
TRANSCRIPT
CONTRACEPTIONCONTRACEPTIONfor GPsfor GPs
Dr Lisa Jayne AdamsDr Lisa Jayne Adams
November 2007November 2007
AGENDAAGENDA
Non-hormonal contraceptionNon-hormonal contraception
Hormonal contraceptionHormonal contraception
CasesCases
Contraceptive EfficacyContraceptive Efficacy
Pearl IndexPearl Index
Effectiveness rates depend on age and Effectiveness rates depend on age and motivation of usermotivation of user
Most effective? A method that stops Most effective? A method that stops ovulation and is independent of user ovulation and is independent of user compliancecompliance
WithdrawalWithdrawal
Mentioned in the BibleMentioned in the Bible
No side effectsNo side effects
Pearl index of 8Pearl index of 8
Natural Family Planning/PersonaNatural Family Planning/Persona
Complex to explainComplex to explain
Calender methodCalender method
Temperature methodTemperature method
Cervical mucusCervical mucus
Combine all three Pearl Index 8-10Combine all three Pearl Index 8-10
FPA can provide local teachersFPA can provide local teachers
PERSONAPERSONA
Pearl Index 6Pearl Index 6
BREAST FEEDINGBREAST FEEDING
Pearl Index 2Pearl Index 2
CONDOMSCONDOMS
Most commonly used Most commonly used non-hormonalnon-hormonal
Pearl Index 3-20Pearl Index 3-20
Beware certain topical Beware certain topical productsproducts
Protection against Protection against STI’sSTI’s
FEMALE BARRIER METHODSFEMALE BARRIER METHODS
FemidomFemidom
DiaphragmDiaphragm
Cervical capCervical cap
IUDsIUDs
Banded copper device Banded copper device =gold standard=gold standard
More effective in older More effective in older womenwomen
Main problemsMain problems
Duration of use 10 yearsDuration of use 10 years
Can be used for Can be used for emergency emergency contraceptioncontraception
Pearl index 1-3Pearl index 1-3
IUSIUS
Periods shorter and Periods shorter and lighterlighterLicensed for 5 yearsLicensed for 5 yearsCan cause spotting Can cause spotting and irregular bleeding and irregular bleeding for up to 6 monthsfor up to 6 monthsPearl Index < 1Pearl Index < 1(included in non-(included in non-hormonal methods as hormonal methods as effects are local)effects are local)
HORMONAL CONTRACEPTIONHORMONAL CONTRACEPTION
COCPCOCP
Pearl index 1-5Pearl index 1-5
Mode of actionMode of action
Non contraceptive Non contraceptive benefitsbenefits
Starting regimeStarting regime
Late pills/missed pillsLate pills/missed pills
Diarrhoea/vomiting/ Diarrhoea/vomiting/ antibioticsantibiotics
EVRA transdermal EVRA transdermal combined hormonal combined hormonal contraceptioncontraception
Yasmin contains Yasmin contains drospirenone, has drospirenone, has diuretic and diuretic and antiandrogen antiandrogen propertiesproperties
NuvaRingNuvaRing
Potential HarmsPotential Harms
All COCP’s increase the risk of VTE, MI, All COCP’s increase the risk of VTE, MI, ischaemic stroke, absolute risk is smallischaemic stroke, absolute risk is small
Any associated increased risk of breast Any associated increased risk of breast cancer likely to be smallcancer likely to be small
Non contraceptive BenefitsNon contraceptive Benefits
Decreased pain and blood lossDecreased pain and blood loss
Risk of ovarian and endometrial cancer Risk of ovarian and endometrial cancer decreased by at least 50% during usedecreased by at least 50% during use
Decreased risk of colorectal cancerDecreased risk of colorectal cancer
Decreased incidence functional ovarian Decreased incidence functional ovarian cystscysts
Not RecommendedNot Recommended(UKMEC category 4)(UKMEC category 4)
Smokers >35 years (>15 a day)Smokers >35 years (>15 a day)Migraine with aura at any ageMigraine with aura at any ageKnown thrombogenic mutationsKnown thrombogenic mutationsBMI >40BMI >40BP consistently > 160/100BP consistently > 160/100Current breast cancerCurrent breast cancerLiver tumoursLiver tumoursHx VTE/Stroke/MI Hx VTE/Stroke/MI Valvular and congenital heart diseaseValvular and congenital heart disease
PRESCRIBINGPRESCRIBING
Record BMI and BPRecord BMI and BP
Take a full history, check smoking statusTake a full history, check smoking status
Use a monophasic pill first line eg Use a monophasic pill first line eg microgynonmicrogynon
Counsel re risks and side effects Counsel re risks and side effects
Discuss non-contraceptive benefitsDiscuss non-contraceptive benefits
POPPOP
Thickens cervical Thickens cervical mucusmucusPearl index 0.3- 4Pearl index 0.3- 4Late pillsLate pillsCerazette (desogestrel) Cerazette (desogestrel) more effective, blocks more effective, blocks ovulation in 97% of ovulation in 97% of cyclescyclesAdvantagesAdvantagesSide effectsSide effectsStarting regimeStarting regime
DEPOT PROVERADEPOT PROVERA
Deep IM every 12 Deep IM every 12 weeksweeks
Pearl index 0.3- 1Pearl index 0.3- 1
Preinjection Preinjection counsellingcounselling
Unwanted effectsUnwanted effects
Can lower bone Can lower bone density in long-term density in long-term usersusers
IMPLANONIMPLANON
Contraceptive implant Contraceptive implant etonogestreletonogestrel
Pearl index 0.8Pearl index 0.8
Lasts for 3 yearsLasts for 3 years
Fitting and Fitting and counsellingcounselling
Pros and consPros and cons
EMERGENCY CONTRACEPTIONEMERGENCY CONTRACEPTION
LevonelleLevonelle
Copper IUD insertionCopper IUD insertion
LEVONELLELEVONELLE
Licenced for u to 72 Licenced for u to 72 hours after UPSIhours after UPSI
Prevents 86% of Prevents 86% of pregnanciespregnancies
Levonogestrel Levonogestrel 1500ug1500ug
Contraindications and Contraindications and drug interactionsdrug interactions
EMERGENCY IUDEMERGENCY IUD
99.8% effective for postcoital use99.8% effective for postcoital use
Copper IUD most effectiveCopper IUD most effective
ContraindicationsContraindications
Insert up to 5 days after UPSIInsert up to 5 days after UPSI
If regular cycle can insert up to 5 days If regular cycle can insert up to 5 days after expected date of ovulationafter expected date of ovulation
CASE HISTORIESCASE HISTORIES
CASE ONECASE ONE
Carly is 18 years old. She has just had a Carly is 18 years old. She has just had a TOP due to ‘pill failure’. She is off to TOP due to ‘pill failure’. She is off to university soon. She is not in a regular university soon. She is not in a regular relationship. She admits that she relationship. She admits that she sometimes forgot to take her pill. She sometimes forgot to take her pill. She really wants to avoid another pregnancy. really wants to avoid another pregnancy. She wants your advice.She wants your advice.
CASE TWOCASE TWO
Linda is forty years old, married with three Linda is forty years old, married with three children. She is a non smoker and has children. She is a non smoker and has been taking the COCP for 7 years. She been taking the COCP for 7 years. She stopped taking it last week because her stopped taking it last week because her younger sister has been admitted to younger sister has been admitted to hospital with a DVT. She does not really hospital with a DVT. She does not really want any more children. What are her want any more children. What are her options?options?
CASE THREECASE THREE
Eve is 25 years old. She is in a stable Eve is 25 years old. She is in a stable relationship. She has been using condoms relationship. She has been using condoms but wants something ‘safer’. She smokes but wants something ‘safer’. She smokes 10 cigarettes a day.10 cigarettes a day.
CASE FOURCASE FOUR
Sam is 35, she has recently got divorced. Sam is 35, she has recently got divorced. She has one child. She has had a coil for She has one child. She has had a coil for the last 9 years. She knows her coil will the last 9 years. She knows her coil will need changing soon. She is not sure if she need changing soon. She is not sure if she wants another one. What is your advice?wants another one. What is your advice?
CASE FIVECASE FIVE
Pippa has come in for her 6 week Pippa has come in for her 6 week postnatal check. She is 29 years old. She postnatal check. She is 29 years old. She has a six week old baby and a fifteen has a six week old baby and a fifteen month toddler. She is mainly month toddler. She is mainly breastfeeding, but gives some formula at breastfeeding, but gives some formula at night. She feels exhausted. Although her night. She feels exhausted. Although her and her partner may want some more and her partner may want some more children they would like a ‘decent’ gap children they would like a ‘decent’ gap next time. She wants your advice.next time. She wants your advice.
Useful websitesUseful websites
Fpa.org.uk (formerly Family Planning Fpa.org.uk (formerly Family Planning Association)Association)
BNF onlineBNF online
Prescriber.comPrescriber.com
AttractAttract
Prodigy (good for guidelines)Prodigy (good for guidelines)
REFERENCESREFERENCES
Faculty of Family Planning and Faculty of Family Planning and Reproductive Health Care Clinical Reproductive Health Care Clinical Guidance: First prescription of combined Guidance: First prescription of combined oral contraception (July 2006)oral contraception (July 2006)
Guillebaud, J. Contraception Today. 5Guillebaud, J. Contraception Today. 5thth ed. ed. Martin Dunitz, 2005Martin Dunitz, 2005