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Contraception – top tips. Dr Lisa Pickles 10/1/12. Plan for the afternoon. 2.00-2.15pm. COC and UKMEC . 2.15-2.55pm. Emergency contraception including missed pills. 2.55-3.25pm. LARC. 3.25-3.45pm. BREAK. 3.45-4.30pm Contraception case and quiz. UKMEC.

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contraception top tips

Contraception – top tips

Dr Lisa Pickles

10/1/12

plan for the afternoon
Plan for the afternoon.
  • 2.00-2.15pm. COC and UKMEC.
  • 2.15-2.55pm. Emergency contraception including missed pills.
  • 2.55-3.25pm. LARC.
  • 3.25-3.45pm. BREAK.
  • 3.45-4.30pm Contraception case and quiz.
ukmec
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)
coc and ukmec
COC and 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.

emergency contraception
Emergency contraception.

3 options:

  • Levonelle (levonorgestrel 1.5mg)
  • ellaOne (ulipristal 30mg)
  • IUD
emergency contraception7
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.

emergency contraception8
Emergency contraception.

Mode of action.

Levonelle (LNG).

Delays ovulation, no endometrium effect.

Ulipristal (UPA).

Delays/inhibits ovulation. Endometrium changes seen in vitro but ? Significance.

Cu IUD.

Spermicidal/toxic to ovum – primarily works preventing fertilization. Also, some anti-implantation effect.

emergency contraception9
Emergency contraception.
  • Efficacy of oral EC varies depending on day of cycle.
  • No difference in efficacy comparing LNG and UPA from research so far.
emergency contraception true or false
Emergency contraception.True or False.

A 19 year old patient attends 4 days post UPSI. You offer her a post coital coil which she adamantly refuses.

Should you offer her ellaOne?

emergency contraception11
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.

emergency contraception true or false12
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?
emergency contraception13
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.
emergency contraception true or false14
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.

emergency contraception15
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.

emergency contraception true or false16
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.

emergency contraception true or false17
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.

emergency contraception18
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.

emergency contraception true or false19
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.

emergency contraception true or false20
Emergency contraception.True or False.
  • ellaOne should not be used in patients taking omeprazole.

True.

Ulipristal should not be used if drug which increases gastric pH eg. antacid, H2blocker or PPI.

emergency contraception true or false21
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.

emergency contraception22
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.
emergency contraception23
Emergency contraception.

QOF.

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

missed pills true or false
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)

missed pills true or false26
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.

missed pills
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.

missed pills true or false28
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.

missed pills minimising the risk of pregnancy see faculty guidance re missed pills
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 pills missed.

Pills 8-14. No need for EC if UPSI.

Pills 15-21. No need for EC if UPSI, but avoid PFI.

missed pills true or false30
Missed pills.True or False.
  • Emergency contraception is needed if:

1. Pills 2 and 3 are missed and UPSI occurred on the last day of the PFI preceeding this.

True.

2. Pills 9 and 10 are missed and UPSI occurred on D11.

False.

3. Pills 19 and 20 are missed and UPSI occurred on D21.

False. Omit PFI.

late depo true or false
Late depo.True or False.
  • Currently faculty guidance recommends EC when Depo Provera is given > 13 weeks post last injection (and UPSI has occurred).

False.

Can be given up to 14 weeks with no extra precautions.

long acting reversible contraception
Long Acting Reversible contraception.
  • Implant (Nexplanon)
  • Injection (Depo Provera)
  • Intrauterine device (IUD)
  • Intrauterine system (IUS)
larc informing patients in the 10 minute consultation
LARC – informing patients in the 10 minute consultation.
  • Explain that they all have great efficacy (>99%).
  • Ask if any preferences.
  • If not, look at FPA leaflet together, but briefly highlight one or 2 pros and cons of each to try to distinguish between them.
slide35
LARC
  • Work with neighbour:

1 or 2 advantages/disadvantages only ( the most important).

Duration

Mode of action.

(note on sheets, ideas to whole group)

larc what i mention
LARC – what I mention.

ADVANTAGES.

Implant.

Quick to fit and remove.

Depo.

Frequently amenorrhoeic.

IUD.

Longest duration.

IUS.

Often amenorrhoea/ lighter bleeding.

larc what i mention38
LARC – what I mention.

DISADVANTAGES.

Implant.

Irregular, may be prolonged bleeding.

Depo.

Weight gain. Delayed return to fertility.

IUD.

Menorrhagia/dysmenorrhoea. Invasive insertion.

IUS.

Initial irregular bleeding. Invasive insertion.

larc what i mention39
LARC – what I mention.

DURATION.

Implant.

3 years.

Depo.

12 weeks.

IUD.

10 years.

IUS.

5 years.

larc what i mention40
LARC – what I mention.

MODE OF ACTION.

Implant.

Stops ovulation + cervical mucus effect + thinned endometrium.

Depo.

Stops ovulation + cervical mucus effect + thinned endometrium.

larc what i mention41
LARC – what I mention.

MODE OF ACTION, contd:

IUD.

Copper is spermicidal + ? Prevents implantation.

IUS.

Cervical mucus effect + preventsimplantation (direct effect on endometrium) + ? stops ovulation.

larc true or false
LARC.True or False.
  • Depo provera can be Quickstarted.

True.

So long as pregnancy can be reliably excluded. However, it may not be ideal eg.after EC. A bridging method should be Quickstarted until pregnancy is excluded. If there are no other options, it may be used in this way.

larc true or false43
LARC.True or False.
  • IUD/IUS can be removed at any time of the cycle.

True.

However, ensure that condoms have been used for any SI in the week prior to removal . These methods are not anovulatory and ovulation may have occurred during this time.

larc true or false44
LARC.True or False.
  • 1st choice IUDs should contain 300mm2 copper.

False.

380mm2.

larc true or false45
Larc.True or False.
  • A patient with IUD or IUS who is asymptomatic who has actinomyces on her smear should have the device removed.

False.

Is a commensal. Only remove if eg. pelvic pain or bleeding problems (unlikely).

larc true or false46
LARC.True or False.
  • Prior to insertion all women should be screened for STIs.

False.

Only high risk women need screening ie. Age < 25 years, or new partner, or more than one partner in past year, or partner has more than one partner.

larc true or false47
LARC.True or False.
  • Prior to changing from IUD to IUS, the patient should abstain for 7 days.

True.

In case reinsertion is not possible eg. due to cervical spasm.

larc true or false48
LARC.True or False.
  • IUS is unsuitable for patients taking an enzyme inducer.

False.

larc true or false49
LARC.True or False.
  • 30% of patients discontinue the implant due to non bleeding SE.

False.

Research has suggested up to 30% discontinue due to bleeding SE. Need careful preinsertion counselling.

larc true or false50
LARC.True or False.
  • Enzyme inducers reduce the efficacy of Nexplanon.

True.

Serum progesterone levels are important.

larc true or false51
LARC.True or False.
  • Implant is UKMEC1 in breastfeeding women.

True.

larc true or false52
LARC.True or False.
  • The combined pill is useful with problematic bleeding due to the implant.

True.

Can be tried for 3 cycles initially, but consider long term if needs be.

larc true or false53
LARC.True or False.
  • The upper age limit for use of Depo is 50.

True.

larc true or false54
LARC.True or False.
  • Average weight gain after 2 years’ Depo use is 3kg.

True.

larc true or false55
LARC.True or False.
  • Depo should be given 10 weekly in patients taking enzyme inducers.

False.

Normal 12 weekly administration.

larc other points
LARC – other points.
  • Some patients dislike the reliance on HCP to fit/remove.
  • Practice income.

LES/NES for implant and IUD/IUS insertions and removals. Practices need to claim for work done.

  • Show patients an IUD/IUS. They are often surprised by how small they are.
references
References.
  • Faculty of Sexual and Reproductive Healthcare.

www.FSRH.org (see clinical guidance)

  • BNF
  • National prescribing centre.

www.npc.nhs.uk (see e-learning : quizzes, patient decision aids etc)

  • Family Planning Association. Leaflets.

www.fpa.org.uk