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Contraceptive update

Contraceptive update. Dr Christine Roke National Medical Advisor, Family Planning March 2012. Long Acting Reversible Contraception - LARC . New emphasis because: Easier to use - action less often than monthly Increased efficacy - all less than 1% failure rate.

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Contraceptive update

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  1. Contraceptive update Dr Christine Roke National Medical Advisor, Family Planning March 2012

  2. Long Acting Reversible Contraception - LARC • New emphasis because: • Easier to use - action less often than monthly • Increased efficacy - all less than 1% failure rate

  3. Long Acting Reversible Contraception - LARC • Depo Provera injection • Intrauterine contraception • Implants

  4. Longacting contraceptionWhy? • Methods that require something with every act of sexual intercourse or need to be taken every day have higher user failure rates • Combined pill has about 3% failure rate per year in every day use and 8% in first year of use • Women have first baby in NZ at about 30 • So average woman has more than 10 years contraceptive use before first baby • About 1 in 3 may therefore have an unintended conception in that time

  5. Average woman has less than 2 children • So many years of contraception required when family complete with possible contraceptive failure

  6. WHO medical eligibility criteria for contraceptive use • WHO 1: Unrestricted use • WHO 2: Advantages generally outweigh theoretical or proven risks • WHO 3: Theoretical or proven risks usually outweigh advantages • WHO 4: Do not use

  7. Depo Provera • Problem with women returning on time for subsequent injections • Now internationally recommended that “late” injection is more than 14 weeks since last injection • Still schedule next appointment for 12 weeks

  8. Possible side effects • Most don’t put on weight • Most don’t have mood changes

  9. Depo Provera and bone density • Depo Provera may reduce bone density by 5 – 7% over the first 2 years of use – it then plateaus • Caused by suppression of oestrogen • When Depo Provera discontinued, regain this loss of bone density over next few years

  10. Bone density • Maximum increase in bone mass age 11-14, some sites reach peak bone mass by 18, others later • Reduced in anorexia nervosa, exercise-induced amenorrhoea etc • Increased in Maori and Pacific nation people

  11. Depo Provera use re bone density • Can be used by adolescents if other methods unsuitable, especially if 18 or older • All ages - review at 2 years – risks and benefits • UK Faculty of Family Planning and Reproductive Health care, WHO

  12. Intrauterine contraception Action • Primarily prevention of fertilisation – copper or progestogen immobilise passage of sperm • Can prevent implantation so copper IUD can be used for emergency contraception

  13. Intrauterine contraception • Now clear that STIs cause infection not IUDs, beyond the initial insertion phase • Ideal to exclude STIs before insertion • If asymptomatic chlamydia found, can treat and insert IUD if reinfection not likely • If STI or PID diagnosed while IUD in situ, treat and only remove if not settling

  14. Intrauterine contraception • IUDs can be used by women who have not had children • No increased risk of PID or infertility unless exposed to STIs • Insertion may be more uncomfortable • Slightly higher expulsion rate

  15. Intrauterine contraception • Fertility declines in 40s • Copper IUDs – if inserted when 40 or older, can stay until postmenopausal if no problems • Mirena - if inserted when 45 or older for contraception, can stay until postmenopausal if no problems

  16. Mirena • Efficacy not statistically different from copper IUD • Special authority if menorrhagia causing anaemia and standard treatment for HMB unsatisfactory

  17. Jadelle • Progestogen-releasing rods • 2 rods of levonogestrel - lasts 5 years • inserted subdermally into upper arm under local anaesthetic by trained clinician • Subsidised • Available on individual prescription (obtain trochar from Bayer NZ)

  18. Action Slow release of progestogen which works by • Interfering with ovulation • Thickening cervical mucus • Oestrogen levels remain above threshold for loss of bone density

  19. Jadelle efficacy

  20. Side effects • Main side effect is change in bleeding pattern • Can have other hormonal side effects but lower hormonal levels than POP – headache, weight gain, mood changes, libido – randomised control trials do not confirm difference in these side effect rates • Scar for insertion and removal -occasionally local wound problem

  21. Jadelle bleeding pattern • Irregular bleeding and amenorrhoea common • Settles to long term pattern over first 3 - 6 months • Bleeding less likely to settle with time than Depo Provera or Mirena • Bleeding problems are commonest reason for discontinuation in international studies • Spotting and irregular bleeding common – 14% (1 in 7) discontinue for this reason: • 5% for prolonged episodes of vaginal bleeding and spotting • 4% for irregular bleeding • 3% for heavy bleeding

  22. Bleeding • Discussion of possible bleeding problems essential before insertion • Consider other causes of irregular bleeding • Management of irregular bleeding • COC as long as oestrogen not contraindicated • NSAIDs 5 -10 days

  23. Advantages • Efficacy • Long timeframe • Rapid return of fertility when removed • Lower PID rates • Less dysmenorrhoea

  24. Insertion • By day 7 or reliable contraception • Contraceptively effective immediately if inserted by day 5, otherwise 7 days • Contraindicated if breast cancer within last 5 years • Should not be used by those on enzyme inducing medication • Otherwise suitable for all ages provided able to manage possible bleeding problems • Superficial placement essential

  25. Removal • Do not attempt removal if implants impalpable • Refer to interventional radiologist

  26. Combined Oral ContraceptiveMajor WHO 4 categories • Past or present circulatory disease - arterial or venous • Disease of the liver – cirrhosis, jaundice • Breast cancer – current within last 5 years

  27. COC and arterial disease (MI, CVA) • Not an independent risk factor • Amplifies other risk factors - smoking - obesity - hypertension - diabetes - hyperlipidaemia : ↑ cholesterol : family history of MI and/or CVA

  28. Migraine Simple migraines present with: • Throbbing or pulsating unilateral or bilateral pain • Nausea, vomiting, anorexia • Sensitivity to light or sound • Severe and not easily relieved by aspirin or paracetamol

  29. Visual symptoms in migraine with aura • In 99% migraines with aura – usually before headache • Usually symmetrical, affecting one hemifield of both eyes, although subjectively, they may appear to affect only one eye • Typically begins with small bright blind spot which gradually increases in size to assume a C shape • Often develop scintillating edges round blind spot which appear as zigzags • May include flashing lights

  30. Neurological symptoms and signs of focal migraine • Less common • Unilateral sensory disturbance typically pins and needles, spreading up one arm or affecting one side of the face or tongue – the leg is rarely affected • Disturbance of speech – usually nominal dysphasia • Loss of motor function is very unusual • These symptoms usually follow one another – visual, then sensory, then dysphasia

  31. Headaches • Migraines (without aura) - COC OK if no other risk • COC contraindicated - migraine with aura - migraine without aura plus additional risk factor for stroke including age over 35 Past history of migraine with aura and no other risk factors – WHO 3

  32. Risk of venous thrombosis (DVT/PE) RISK: for non pregnant woman between 15-44 yr olds - 5-10 per 100,000 • for pregnant woman - up to 10 times risk • on low dose second generation pills - 3-4 times risk • on other combined pills - 6 times risk or more Fatality rate 3%

  33. Risk factors for venous disease

  34. First line COCs – second generation pills * Government subsidised pills

  35. Other combined pillsHigher VTE risk

  36. Side effects • Irregular bleeding and chloasma are linked to COC use • Randomised control trials do not show that COC causes weight gain, headaches, breast tenderness, nausea or change in libido • Nocebo effect – experience symptoms because aware they are possible

  37. Starting instructions for COC If starting with a hormone pill: • Day 1 - 5 of cycle safe = straight away • Any other time not safe until 7 hormone pills have been taken (one each day)

  38. Missing COC pills • WHO: additional precautions required only if: • Miss 3 x 30mcg pills in a row • Miss 2 x 20mcg pills in a row • UK FFPRHC: 2 missed pills in a row • Data sheets still recommend additional precautions if 12 hours late • NZ Family Planning teach missing any 2 pills within a week

  39. Missed pills • One missed pill, take it as soon as remembered, taking the next pill at the usual time – this may mean taking 2 hormone pills together • Any 2 pills missed within a week of each other, follow the 7 day rule.

  40. 7 day rule • Not contraceptively safe until 7 hormone pills have been taken in a row • Use another method of contraception such as condoms or do not have sexual intercourse while taking the 7 hormone pills • If during this time a condom breaks or slips off, the emergency contraceptive pill (ECP) is indicated. If there are less than 7 hormone pills left in the pack, finish the hormone pills and start the new pack immediately (miss the 7 inactive pills or the 7 day break)

  41. Vomiting, diarrhoea and other medications • Vomiting or severe diarrhoea for more than 24 hours, follow the 7 day rule and miss the 7 inactive pills (or 7 day break) if necessary • Enzyme inducing medications reduce efficacy – need to use higher dose COCs and shorten break between hormone pills of each packet • Antibiotics no longer thought to cause significant interaction

  42. Missed pills FIRST WEEK: • Danger of ovulation following pill free week • 7 day rule essential • Emergency contraception required if additional precautions not taken • If any UPSI during the 7 days before missed pills, client needs ECP (may be > 72 hours) SECOND WEEK: • No additional precautions required THIRD WEEK: • Miss pill free week, no additional precautions required • If pill free week taken, emergency contraception may be required.

  43. New ways of taking COC • Tricycling = taking 3 packets of pills in a row without a break • Continuous = no breaks • Less risk of contraceptive failure • Less breakthrough bleeding with time but some women will find this spotting a problem – take 7 day break • No known medical concerns

  44. Continuous pill taking • Family Planning is offering as a choice • Should be better efficacy • With 21 hormone pill regimen, missing more than 1 pill prejudices efficacy • With continuous pill regimen, need to miss more than 8 pills before efficacy prejudiced

  45. Mortality associated with COC • 39 year follow up of cohort of 46000 women from Royal College of General Practitioners Oral Contraception Study • Pill users had a lower mortality rate than non users • Increase in cervical cancer and cerebrovascular deaths balanced by decrease in ovarian cancer deaths BMJ 2010

  46. Causes of breakthrough bleeding • Late or missed pill • Diarrhoea or vomiting • Medications - enzyme inducers, antibiotics • Infection - chlamydia • Abnormal cervix – ectropion, cancer • Pregnancy • First few months of new pill • Hormone dose too low • Running packets together

  47. Progestogen only pills • Use when oestrogen contraindicated or side effects with COC • No increased risk of arterial or venous disease or cancer

  48. Progestogen only pills • Noriday and Microlut work mainly by altering cervical mucus • Variable suppression of ovulation • Cerazette reliably suppresses ovulation

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