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Hormonal Contraception and EHC. for Health Information Advisors. Trainer’s name XX Medicines Information Service. Learning Outcomes. Have baseline knowledge and understanding about hormonal contraception including

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Hormonal contraception and ehc l.jpg

Hormonal Contraception and EHC

for Health Information Advisors

Trainer’s name

XX Medicines Information Service


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Learning Outcomes

  • Have baseline knowledge and understanding about hormonal contraception including

    • Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions.

    • Implications and advice for missed doses and dosing errors.

    • Indications and limitations of Emergency Hormonal Contraception (EHC).

  • Be able to use the NHS Direct emergency contraception and missed pill algorithm.


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9.30 Introduction & learning outcomes

Baseline knowledge for hormonal contraception

Types, action, risks, cautions, side effects, interactions.

Missed doses and dosing errors.

10.45Tea break

Emergency Hormonal Contraception (EHC)

Workshop 1

12.45Lunch

EHC & missed OC algorithm

Workshop 2

3.00Tea break

Workshop 2 (continued)

4.00 Review of learning outcomes & close

Plan for the Day


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Hormonal Methods

Combined OC pill

Progestogen-only pill

Patches

Injections

Implants

Intrauterine devices

Emergency Hormonal Contraception (EHC)

Non-Hormonal Methods

Sterilisation

Abstinence

Interruptus

Condoms – male and female

Diaphragms and Caps

Spermicides

Intra uterine devices

Rhythm methods

Contraceptive Options


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Oestrogen

Ethinylestradiol (EE)

Mestranol

Progestogen

Norethisterone

Desogestrel

Levonorgestrel

Gestodene

Norgestimate

Drospirenone

Combined Oral Contraceptive Pill


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COCs: How does it work?


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COCs: Monophasics

  • Fixed amount of oestrogen & progestogen

  • One tablet daily for 21 days then a 7 day pill free period.

  • Every Day (ED) - One tablet daily for 21 days then 7 days of dummy tablets.

  • > 99% effective, when used properly.


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Low Strength

20 microgram EE

Loestrin 20

Mercilon

Femodette

Standard Strength

30-35 microgram EE

Microgynon 30

Loestrin 30

Marvelon

Minulet

Femodene

COCs: Monophasics


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COCs: Biphasics & Triphasics

  • Varying amounts of oestrogen and progesterone according to stage of the cycle.

  • Useful when there is breakthrough bleeding or no withdrawal bleed on monophasics.


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Biphasics

Binovum

Triphasics

Logynon ED

Synphase

Trinordial

TriNovum

Tri-Minulet

Triadene

COCs: Biphasics & Triphasics


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COCs: Risks

  • Migraine

    • Increased stroke risk in migraine sufferers

    • Risk my be increased in COC users

    • Headache with aura plus neurological symptoms

  • Cancer

    • Very small  risk of breast cancer.

    • Protects against ovarian and endometrial cancer.


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COCs: Breast Cancer Risk


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COCs: Risks

  • DVT

    • Healthy women non pregnant - 5-10 /100,000

      2nd gen pill – 15/100,000 3rd gen pill – 25/100,000

    • Caution if 1, avoid if 2 of: PMH, family history, obesity, immobility.

  • Stroke and MI

    • Caution if 1, avoid if 2 of: PMH, family history, diabetes, BP, smoking, >35 years, obesity, migraine.


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“Tricycling” Monophasics

  • Running three packs together

  • Four Pill Free Intervals per year

  • Three extra packets of hormone per year

  • Reduces hormone fluctuations

  • Unlicensed


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7 days of pill taking puts the ovaries to sleep.

Ovaries wake up if miss

10 days of standard strength pill.

9 days of low strength pill.

The 7 pill free days are safe.

Guidance

NHSD CAS algorithm

Family Planning Association (FPA)

Patient information leaflet

eBNF

Faculty of Family Planning & Reproductive Health (FFPRHC)

COCs: Missed doses


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1-2 standard strength or

1 low strength

Take pill now and then continue as normal.

No extra precautions.

No emergency contraception.

3 standard strength or

2 low strength

Take pill now and then continue as normal.

Extra precautions until taken 7 pills in a row.

Week 1 – EC indicated.

Week 2 – No EC.

Week 3 – No EC, start new pack, no break.

COCs: Missed doses


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COCs: 3 standard strength or 2 low strength missed


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COCs: 3 standard strength or 2 low strength missed


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COCs: 3 standard strength or 2 low strength missed


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Progestogen Only Pill (POP)

  • One active ingredient – progesterone.

  • Taken continuously with no break.

  • Alternative if COCs are contraindicated.

  • Relies on motivation of the user.


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Benefits

Well tolerated

No proof of increased disease risk

Useful in lactation

Drawbacks

Precise timing

Changes in menstrual pattern

Brand Names

Femulen

Micronor

Norgeston

Noriday

Progestogen Only Pill

Cerazette


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Less than 3 hours late

Take the missed pill immediately and continue as normal.

No extra precautions.

No emergency contraception.

More than 3 hours late

Take the missed pill as soon as possible.

Extra precautions until 2 further pills in a row.

EC if unprotected sex before 2 further pills in a row have been taken.

POP: Missed doses

Cerazette: Instead of 3 hours read 12 hours


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POPs: More than 3 hours late


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Contraceptive Patch

  • Evra

  • Contains

    • Low strength oestrogen

    • Progestogen

  • Dose

    • 1 patch a week (on same day of week) for 3 weeks.

    • One week patch free.


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Delayed Patch 1

  • Most risky time to forget to apply the patch.

  • Apply Patch 1 as soon as remembering. This is now the beginning of the patch cycle (new start day and change day).

  • Take extra precautions for 7 days.

  • If the delay was for more than 48 hrs (extends patch free period) and unprotected sex - emergency contraception is indicated.


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Delayed Patch 1


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If less than 48 hrs

(Extra 48hr drugs in patch)

Apply patch immediately, keep usual change day.

No extra precautions.

No emergency contraception.

If more than 48 hrs

Stop current cycle and start a new patch cycle with a new Week 1.

Extra precautions for 7 days.

If prolonged patch free period & unprotected sex – EC is indicated.

Delayed Patch 2 or 3


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Delayed <48hrs Patch 2 or 3


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Delayed >48hrs Patch 2 or 3


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If less than 48 hrs

Apply patch immediately, keep same change day.

No extra precautions.

No EC.

If more than 48 hrs

Stop current cycle and start a new patch cycle with a new start day / change day.

Extra precautions for 7 days.

If prolonged patch free period & unprotected sex – EC is indicated.

Detached patch


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Contraceptive Injection

  • Long acting progestogen.

  • Depo-Provera.

    • IM injection every 12 weeks.

  • Noristerat.

    • IM injection every 8 weeks.


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Up to 14 days late

World Health Organisation (WHO) states: no extra precautions needed, EC not indicated.

Manufacturer states up to 5 days late but super seeded by the WHO advice.

More than 14 days late

Extra precautions for 7 days.

Consider EC if unprotected sex.

Delayed injection


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Contraceptive Implant

  • Long acting progestogen.

  • Implanon

    • Subcutaneous implant every 3 yrs.

  • Requires trained person to insert and remove.

  • Manufacturer and WHO do not state a safe delay for Implanon.


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Vomiting & Diarrhoea

  • If vomited within 2 hours of pill taking, its absorption will be reduced and it may be ineffective.

  • Diarrhoea alone without vomiting has to be severe to reduce the absorption of the pill.

  • Handle as a missed pill.


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Drug Interactions

  • Broad spectrum antibiotics

    e.g. amoxycillin, ampicillin, erythromycin.

    May reduce the efficacy of COCs and patch.

    No interaction with POPs, injection or implant.

  • Enzyme inducers

    e.g. rifampicin, ritonavir, carbamazepine, St. John’s Wort.

    May reduce the efficacy of COCs, patch, POPs, injection and implant.

    Consider referral to UKMI.


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Emergency Hormonal Contraception


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Emergency Hormonal Contraception

When is EHC Indicated?

  • After unprotected sexual intercourse

  • Increased risk of contraceptive failure

    • Torn, leaking condom

    • Missed pills

    • Late implant or injection

    • Detached contraceptive patch

    • Dislodged IUD


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Levonelle 1500 “One Step”

  • High dose progesterone - levonorgesterel.

  • One 1500mcg tablet taken as soon as possible after unprotected intercourse.

  • Preferably within 12 hours, ideally no later than 72 hours.


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EHC Efficacy Rates


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How does EHC work?

  • Depends on point in the menstrual cycle.

  • Thought to prevent or delay ovulation, fertilisation and implantation.

  • Clinical opinion is that using EHC does not constitute an abortion.


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EHC: Cautions & Side Effects

  • WHO – No absolute contra-indications.

  • Nausea 25%, vomiting 5%.

  • Care with liver enzyme inducers

    e.g. rifampicin, St John’s Wort, ritonavir, phenytoin, carbamazepine, barbituates.

  • Slightly increased risk of ectopic pregnancy.


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Where can you get EHC?

  • Community Pharmacies

  • GP

  • Walk-in Centres

  • Family Planning Clinics

  • Sexual Health Clinics

  • A & E


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Tea Break


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9.30 Introduction & learning outcomes

Baseline knowledge for hormonal contraception

Types, action, risks, cautions, side effects, interactions.

Missed doses and dosing errors.

10.45Tea break

Emergency Hormonal Contraception (EHC)

Workshop 1

12.45Lunch

EC & missed OC algorithm

Workshop 2

3.00Tea break

Workshop 2 (continued)

4.00 Review of learning outcomes & close

Plan for the Day


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Workshop 1: Case scenarios

  • What further information do you need to answer the call?

  • Confirm what type of contraception using the eBNF.

  • Refer to the NHSD algorithm rationales for an answer. What does the FPA, netdoctor & eBNF say?

  • What would you advise the caller?


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Lunch Break


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9.30 Introduction & learning outcomes

Baseline knowledge for hormonal contraception

Types, action, risks, cautions, side effects, interactions.

Missed doses and dosing errors.

10.45Tea break

Emergency Hormonal Contraception (EHC)

Workshop 1

12.45Lunch

EC & missed OC algorithm

Workshop 2

3.00Tea break

Workshop 2 (continued)

4.00 Review of learning outcomes & close

Plan for the Day


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Workshop 2: EC algorithm

  • Repeat the case scenarios from Workshop 1 using the NHSD Emergency Contraception algorithm.


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Learning Outcomes

  • Have baseline knowledge and understanding about hormonal contraception including

    • Types of hormonal contraception, mode of action, risks, cautions, side effects and drug interactions.

    • Implications and advice for missed doses and dosing errors.

    • Indications and limitations of Emergency Hormonal Contraception (EHC).

  • Be able to use the NHS Direct emergency contraception and missed pill algorithm.


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