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Contraception – top tips

Contraception – top tips. Dr Lisa Pickles, GP Brig Royd Surgery. 11/6/13. Plan for the afternoon. 2.00-2.25pm. UKMEC, Diabetes and COC . 2.25-2.55pm. Emergency contraception including missed pills and Quickstart . 2.55-3.25pm. LARC. 3.25-3.45pm. BREAK.

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Contraception – top tips

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  1. Contraception – top tips Dr Lisa Pickles, GP Brig Royd Surgery. 11/6/13

  2. Plan for the afternoon. • 2.00-2.25pm. UKMEC, Diabetes and COC. • 2.25-2.55pm. Emergency contraception including missed pills andQuickstart. • 2.55-3.25pm. LARC. • 3.25-3.45pm. BREAK. • 3.45-4.30pm Contraception case and quiz. New points.

  3. UKMEC. • Is a system for grading safety/ contraindication for use of contraception methods when used in various medical conditions. • Tables produced by FSRH (Faculty of Sexual and Reproductive Healthcare)

  4. UKMEC. • UKMEC1. No restriction for use of the contraceptive method. • UKMEC2. Advantages outweigh risks. • UKMEC3. Risks outweigh advantages. • UKMEC4. Unacceptable risk. Generally UKMEC 3 or 4 not for general practice. Occasionally, after expert/specialist clinical judgement, could consider category 3.

  5. UKMEC – Diabetes. • Important to prevent unintended pregnancy. • NICE suggests discuss and document contraception and intentions about pregnancy at each consultation. • Compared with the general population, women with diabetes have more pregnancies age <25. Adolescents particularly important.

  6. UKMEC – Diabetes. Page 6. • What does UKMEC say?

  7. Contraception in Diabetes - summary • Women without risk factors and with uncomplicated, well controlled diabetes have the same contraception choices as women without diabetes. • Beware depo – provera and CHC if complications or RFs. • No restrictions for women with h/o gestational diabetes. • Most LARC methods can be safely used. • All 3 emergency methods can be used (though currently, only UKMEC guidance re IUD and Levonelle)

  8. Contraception in diabetes. By the way… • CHC has impact on carbohydrate metabolism (and theoretically POP) – though clinical importance uncertain. Perhaps increase glucose monitoring initially. Depo also? • Be sure to inform women re delayed return to fertility with Depo. Pregnancy at younger age is encouraged in diabetic women. Higher risk of complications when older.

  9. Quiz in groups. Assume no other risk factors unless stated. • 35 year old patient comes in for her pill check. On enquiry, she admits to smoking 20 per day. She is happy on Microgynon 30. What do you do? Page 2.

  10. Quiz. • A: Smoking < 15/day over 35 years is UKMEC 3 and >15/day is UKMEC 4. After stopping smoking for 1 year or more, risk returns to UKMEC 2.

  11. Quiz • 35 year old patient wishes to start COC.On taking a history you note that she suffered from migraine with aura in her teens, but that these have been settled for many years. Is she suitable for this method? Page 4.

  12. Quiz. • A:Unfortunately a previous history of migraine with aura is UKMEC 3, therefore it is unadvisable to use the COC in this case. Note: that non focal migraine at any age is UKMEC2 for initiation (previous 2005 guidelines suggested UKMEC 2 < 35 y and UKMEC 3 > 35 y). Of course, migraine with aura is UKMEC 4 at any age

  13. Quiz. • A 24 year old non smoker is keen to try COC . Her BMI is 36. How would you advise her? Page 2.

  14. Quiz. • A: BMI > 35 is UKMEC 3. Consider also that BMI > 30 is UKMEC 2. Cerazette ( a ‘new’ POP, with a 12 hour window, considered to be of similar efficacy to COC) is UKMEC 1. Therefore, the use of cerazette in these cases may be preferable as medically ‘safer’.

  15. Quiz. • A 19 year old patient is taking lamotrigine for her epilepsy. She wishes to start COC for contraception. How would you advise her? Page 8.

  16. Quiz. • A:Whilst certain anticonvulsants eg phenytoin, carbamazepine and topiramate are enzyme inducers and reduce serum levels of EE and progesterone in COC (UKMEC 3), Lamotrigine is not one of them. However, it is classed as UKMEC 3 because the COC can reduce the serum levels of lamotrigine and lead to loss of epileptic control.

  17. Quiz. • A 30 year old patient asks for COC. On taking a history you discover that her mother had a DVT after a long haul flight at the age of 53. Are you able to prescribe? Page 3.

  18. Quiz. • A: Family history of VTE in first degree relative > 45 years is UKMEC 2. Whereas, first degree relative < 45 years is UKMEC 3. It would be appropriate to supply COC in this case after explanation and discussion and considering other non EE containing methods first

  19. Quiz. • A 20 year old woman wants to start COC, however she is concerned that her mother was diagnosed with breast cancer at the age of 52. Enquiry reveals no other female members of the family affected by breast cancer. Can you safely prescribe the combined pill in this case? Page 5.

  20. Quiz. • A: FH of breast cancer is UKMEC 1. However, families affected by known gene mutations eg BRAC1 are UKMEC 3. An isolated case within a family is unlikely to be due to inherited gene mutations such as these, therefore, it is appropriate to prescribe the COC in this case. • Note: An expert speaker, Anne Szarewski at a recent update meeting, suggested a more cautious approach. Those with 1st degree relative ca breast <40 could be prescribed COC up till age 30 ( till 10 years younger than age of relative’s diagnosis), then changed to another non oestrogen method.

  21. UKMEC case history. • 31 yr old , mother of one child aged 6. Self employed business • In 2007; found to be BRCA1 positive; at the time had an implant which was removed following advice from breast surgeon who advised her that it was appropriate to use non hormonal method although “increased breast cancer risk with progesterone is not strong” • Changed method from implant to IUD. • 3 yrs; unhappy due to heavy painful bleeds, PMS symptoms; wishes to discuss alternatives. May wish to have another child . • What options are there?

  22. UKMEC case history. • UKMEC 2 – POP, depo, implant and IUS. (CHC UKMEC 3). Not depo – delayed return to fertility. Possible irregular bleeds long term with POP and implant. Implant very low serum levels. IUS – hope for reduced bleeds eventually. ? Low serum levels/absorption through endometrium.

  23. UKMEC case history. • Chose implant. Consultant happy with this. • This year, has had bilateral mastectomy and awaits laparoscopic oophorectomy.

  24. Emergency contraception. 3 options: • Levonelle (levonorgestrel 1.5mg) • ellaOne (ulipristal 30mg) • IUD

  25. Emergency contraception. Which to use? • IUD works best. 99% effective. • Levonelle up to 95% 1st 24 hours. up to 85% 25-48 hours. up to 58% 49-72 hours. (old data. Recent research suggests has effects up to 4 days, fairly constant efficacy. Then drops off to background pregnancy risk at time of the cycle) • ellaOne at least as good as Levonelle. Offer all women IUD due to efficacy.

  26. Emergency contraception – mode of action. Levonelle (LNG). Delays ovulation, no endometrium effect. Ulipristal (UPA). Delays/inhibits ovulation. Works slightly later into the LH surge. Endometrium changes seen in vitro but ? Significance. Cu IUD. Spermicidal/toxic to ovum – primarily works preventing fertilization. Also, some anti-implantation effect.

  27. Emergency contraception. • Efficacy of oral EC varies depending on day of cycle. • No clear difference in efficacy comparing LNG and UPA from research so far, but some suggestion that UPA works better. More data needed. • UPA not available OTC.

  28. Emergency contraception.True or False. A 19 year old patient attends 4 days post UPSI. You offer her a post coital IUD which she adamantly refuses. Should you offer her ellaOne?

  29. Emergency contraception. • Levonelle licensed use up to 72 hours. • ellaOne licensed use up to 120 hours. • IUD licensed use up to 120 hours ( or 120 hours from earliest predicted ovulation) ellaOne is the ORAL method of choice from 72-120 hours, so the answer is True.

  30. Emergency contraception.True or False. • A 20 year old patient is taking topiramate (enzyme inducer) for her epilepsy. She had a split condom 48 hours ago and comes to see you. She declines an IUD. Should you offer ellaOne?

  31. Emergency contraception. False. • IUD is the best method with an enzyme inducer. • Levonelle may be used at double dose (2 tabs ie. 3mg) • ellaOne not recommended.

  32. Emergency contraception.True or False. • Levonelle may be used if it has previously been prescribed in the same cycle (multiple use in same cycle) True.

  33. Emergency contraception. • ellaOne may be used if it has previously been prescribed in the same cycle. False. Levonelle may also be used for UPSI even if other UPSI has occurred in that cycle outside the treatment window. But ellaOne is not recommended here.

  34. Emergency contraception.True or False. • Levonelle should be repeated if the patient vomits within 3 hours of taking. False. Levonelle – 2 hours. ellaOne – 3 hours.

  35. Emergency contraception.True or False. • If ellaOne is used in women who are taking COC (if missed pills), additional protection is required for 14 days afterwards. True. Is progesterone receptor modulator, so thought to interact.

  36. Emergency contraception. ellaOne interaction with the pill contd: COC – extra precns 14 days POP – extra precns 9 days Qlaira(complicated, quadriphasic pill) – 16 days. Consider Levonelle as 1st choice if on pill.

  37. Emergency contraception.True or False. • A 38 year old lady with menorrhagia presents 4 days post UPSI. A mirena IUS is the most suitable option for her. False. The IUS is not licensed as an emergency contraceptive, only copper IUDs.

  38. Emergency contraception.True or False. • ellaOne should not be used in patients taking omeprazole. True. Ulipristal should not be used with drug which increases gastric pH eg. antacid, H2blocker or PPI.

  39. Emergency contraception.True or False. • It is good practice to warn patients after an IUD that their next period may come on time OR earlier or later than expected. False. This may happen with the oral methods. Offer pregnancy testing if period abnormally light or late. Note:LNG/UPA don’t increase the risk of ectopic. Previous ectopic is not a CI to use.

  40. Emergency contraception. • Remember, offer STI testing and • Consider antibioticseg. azithromycin 1g to cover emergency IUD, and • Sort out future contraception. • FPA leaflets, including LARC. • And, consider timing in the cycle when assessing risk of pregnancy and choice of method. • And, if bringing back later for emergency IUD, offer oral method immediately, in case insertion not successful.

  41. Emergency contraception. QOF. • Need to code LARC advice given (verbal and written) after prescribing emergency pills ( or routine oral contraception).

  42. Emergency contraception – summary. Offer CuIUDand promote efficacy. If oral method chosen: • Levonelle still first line, unless 72-120 hours post UPSI, or UPSI close to predicted ovulation – in which case use UPA. • Levonelle is the choice over UPA if emergency pill already taken in the cycle, or other UPSI in the cycle, or on enzyme inducer (then double the Levonelle dose) or on hormonal contraception. • UPA causes more delay/alteration of next bleed. Warn. Need to stop BF for 1week post UPA. Not available OTC.

  43. Emergency contraception – summary of consultation. • History – time since UPSI, LMP, prev. UPSI or emergency contraception this cycle, usual cycle length. - risk of STI? Offer screening if relevant. - Coercion? Age? Risk behaviour eg. alcohol. • Choices – CuIUD (works best:offer/document), Levonelle, EllaOne. • Prescribe and teach. • Future contraception? Quickstart? • Issue leaflets. • LARC advice and code. • Safer sex advice and issue condoms. • Consider Fraser Guidelines, if <16 • FU. Advpreg test if menses light, late. At least 3w later.

  44. Emergency contraception – handy tip. • If bringing patient back for Cu IUD (can be inserted during 5 days after earliest predicted ovulation), I tend to prescribe an oral choice to take now , in case unable to insert Cu IUD (eg. cervical spasm). By this time, the ‘window’ for appropriate oral method may have passed. • Some patients are unsure re Cu IUD. I give them the opportunity of an oral method now, then returning for the Cu IUD insertion if they decide to go ahead. Leaflet.

  45. Quickstart. • Post EC ( or at any other time), if at risk of pregnancy from future UPSI, consider starting COC, POP or implant straight away (or IUD if it fits the criteria as EC). Not IUS or dianette. Takes 7 days (COC, implant) or 2 days (POP) to work. Counsel re theoretical/unproven risk & record. Arrange pregnancy testing 3 weeks later. (see Faculty guidance)

  46. Missed pills.True or False. • A missed (combined) pill is defined as a pill taken > 12 hours late. False. >24 hours late. (Faculty guidance May 2011)

  47. Missed pills.True or False. If one combined pill is missed in the last week of the pack, then the current 2 packs should be run together, avoiding the pill free interval (PFI). False.

  48. Missed pills. • May 2011 guidance. Regardless of whether 20 or 30mcg pill: 1 pill can be missed anywhere in the pill pack with no need for extra protection. If 2 pills or more are missed, then extra protection should be used for 7 days. If these pills are missed in the last week of pill taking, then the usual PFI should be omitted.

  49. Missed pills.True or False. • A 20 year old patient is taking microgynon 30. She missed her D18-21 pills, then has UPSI on D 22. She needs emergency contraception. False. She has taken 7 consecutive pills prior to missing, therefore ovulation is suppressed. However, she needs to omit the PFI.

  50. Missed pills – minimising the risk of pregnancy. See faculty guidance re missed pills. Need to think hard about pills missed in week 1 and week 3… Pills 1-7. Consider EC if UPSI (including in PFI) if 2 pills missed. Pills 8-14. No need for EC if UPSI. Pills 15-21. No need for EC if UPSI, but avoid PFI.

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