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Contraception, Gynae emergencies and Funny Bleeding

Contraception, Gynae emergencies and Funny Bleeding. ST1’s Jo Swallow 2014. Objectives. To be able to discuss the main pros and cons for different types of contraception. To know which are the most effective methods of contraception To know why some are less good for different patient groups

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Contraception, Gynae emergencies and Funny Bleeding

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  1. Contraception, Gynae emergencies and Funny Bleeding ST1’s Jo Swallow 2014

  2. Objectives • To be able to discuss the main pros and cons for different types of contraception. • To know which are the most effective methods of contraception • To know why some are less good for different patient groups • To be aware of important issues for different age ranges

  3. Brainstorm!

  4. What forms of contraception are there?

  5. Quiz! • If 1000 women were to use these methods of contraception in real life (not perfect)…. How many pregnancies would arise in the first year of use?

  6. The answers!

  7. Pearl index Method Failure %rates per hundred women years • Sterilisation male 0.0 to 0.2 • Sterilisation female0.0 to 0.3 (1.8% at 10 years) • Implanon0.0 • Mirena0.0 to 0.2 • Depo-Proverax0.0 to 0.2 • Combined oral contraceptive pill0.2 to 3 (3 with poor compliance) • Progestogen-only pill (second generation)0.3 to 4 (0.5 over age 35) • IUDs 0.3 to 2 • Diaphragm/cervical • Cap 5 to 20 • Condom (male, female) 5 to 15 • Coitus interruptus 8 to 17 • Natural methods 5 to 25 • Spermicides 5 to 25

  8. Pros and Cons of each method • Groups/Pairs…. discuss

  9. What are the benefits?

  10. What are the benefits? • Any one want to fill this in?

  11. What are the real risks? • VTE • Cancer • Stroke

  12. VTE with COCP

  13. VTE with COCP:Effect of weight….

  14. Other risks… • Which is more likely to happen? • Dying from a thrombosis from a third generation COCP • Or • Dying in a RTA

  15. Cancers… • Is there an increase in risk of breast cancer with the COCP? • RR increased by: • 0% • 1-9% • 10-19% • 20-49% • >50%

  16. Is there an increase in risk of breast cancer with the COCP? • RR increased by: • 25%

  17. What is the absolute risk increase? • 0.01% • 0.1% • 0.5% • 1% • 2-10%

  18. Absolute risk is 0.01% • Actual baseline risk <30 1:1900 30-40 1:200 • Risk increase is 12/100,000

  19. Special considerations • Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing • This is not true for implanon • Consider cerazette/other pops, >70kg rule

  20. Frazer/Gillick competence • <13yrs not legally capable of consenting to sexual activity • 13-16 discuss and consider

  21. Missed pills • New rules • Can miss one anywhere in pack no prob even if extend pill free interval to 8 days • See handouts

  22. Missed pills • New rules • Can miss one anywhere in pack no prob even if extend pill free interval to 8 days • Can miss one pill anywhere in pack, no cover rqd generally unless also missed earlier in pack/in last week of previous pk • If 2 or more missed see flow chart, +use condoms until 7 consequetive pills taken +/-emergency contraception depending on where in pack.

  23. Special considerations • Depot and osteoporosis, if young woman careful, depot causes bone mineral density to decrease at a time when it should be increasing • This is not true for implanon • Consider cerazette/other pops, >70kg rule

  24. Enzyme inducers • Women with epilepsy • Injectable/IUD • Oral contraceptives with 50mg oestrogen • Tricycle with 4 days break • Double emergency contraceptive dosage

  25. Migraine • Migraine with aura =absolute CI (WHO 4) • Migraine +ergots=absolute GI • Migraine +tryptan = relative CI • Migraine +1 other RF=relative CI • Migraine + No Aura +no additional stroke risk factors = OK

  26. When should contraception be started? • IUCD within 12 days of period onset • Mirena day 1-7 or if no risk preg at other time • Depot-? • COCP?

  27. GP activity *** swopping pills/hrt • Side effects can be oestrogenic/progestogenic • Guillain book (pill ladder) • *******Photocopy, brainstorm complaints on the pill ****** • Spots, w gain, mood swings, bleeding, migraing increased weight inc >70kg ?can have 20mcg oestrogen? • Choose an approp pill *******

  28. C19 derivatives E.g Norethisterone Levonorgestorel More androgenic More likely to cause side effects C21 derivatives E.g Medroxyprogestogen acetate Dydrogesterone Less androgenic Progestogens

  29. Oestrogenic Fluid retention Bloating Breast tenderness Nausea Headache Dyspepsia (take with food) Consider changing dose, changing oestrogen or changing delivery Progestogenic (In a cyclical pattern) Fluid retention Breast tenderness Mood swings Depression Acne Backache Reduce progestogen duration to 10 days per cycle, change progestogen c19/21 derivatives, delivery Side Effects

  30. Important things to worry about with the COCP? • VTE • Cancer –breast/ovarian • Stroke • Use the BNF cautions contraindications list… 2 strikes and you’re out!

  31. Dianette/Yasmin • Can we use for contraception? • For acne? • What are the concerns?

  32. Cardiovascular Risk • Absolute risk of MI in non smoking age <35 very low irrespective of COCP use • Excess risk <35 approx 3/1,000,000/yr • >35 Excess risk approx 400/1,000,000/yr • 10x risk if smoke

  33. Antibiotics and the pill • But ILL rules, (D/V still apply, and abx can induce these!)

  34. C19 derivatives E.g Norethisterone Levonorgestorel More androgenic More likely to cause side effects C21 derivatives E.g Medroxyprogestogen acetate Dydrogesterone Less androgenic Progestogens

  35. Oestrogenic Fluid retention Bloating Breast tenderness Nausea Headache Dyspepsia (take with food) Consider changing dose, changing oestrogen or changing delivery Progestogenic (In a cyclical pattern) Fluid retention Breast tenderness Mood swings Depression Acne Backache Reduce progestogen duration to 10 days per cycle, change progestogen c19/21 derivatives, delivery Side Effects

  36. Emergency contraception • What actually happened? • ?regular partner or one off • STI risk? • Menstrual cycle and current position, other contraception? (?earliest ovulation) • When was the accident? • Any other upsi in this cycle • ?used before • ?consensual, age of partner, ?Frazer competant

  37. Emerg contraception 2. • Levonelle is effective up to 72 (120 hrs) • If >48-72 hrs consider Ella One, (ullipristal) • Always consider copper iud (up to 5 days or, up to 5 days> earliest ovulation) • Levonelle efficacy: • 95% - 1st 24hr, 85% 48, 70% 72 • Ella one efficacy: • ….. • Remember pt’s on enzyme inducers may require double dosing of MAP

  38. Things to discuss: • Mode of action • Vomiting • Enzyme inducing drugs • Next Period -87% within 7 days of expected: may be early or late, Most of rest 7-14d late • ?Preg test • ? Quickstart FUTURE contraception, • Condoms have a 5% failure rate when used PERFECTLY

  39. Emergency Contraception • IUCD (not IUS) • Up to 5 days after date of UPSI or expected ovulation • Failure rate <1%

  40. Gynae emergencies Jo Swallow 2014

  41. Case 1- 24 yr LIF pain • Charlotte attends your mid morning surgery reporting • Feeling unwell • Stomach pains • Duration 24hrs • What else would you like to know?

  42. Useful info • Fever • Dyspareunia (deep) • Intermenstrual bleeding for a few months • Using condoms reliably • What would you do having obtained this history?

  43. Examination • Chaperone issues • Cervical excitation • Adnexal tenderness • Take swabs for chlamydia, gonorrhoea and mc+s • What other tests would you like?

  44. Invst • Urinalysis • Preg test • MSU • Bloods Viscoscity/crp • What would your immediate management plan be for this patient?

  45. Treatment • Ofloxacin 400mg bd 14 days +metronidazole 400mg bd 14 days • Or doxycycline +metronidazole • Admission can be rqd, safety net, rvw, rvw 4 wks ?compliant, ptner screened. • Doxycycline 200mg stat if needs top

  46. Case 2- the condom split • Michelle 15 yrs attends asking for ‘the pill’ • What do you need to ask? • What other issues does this present?

  47. Emergency contraception • What actually happened? • ?regular partner or one off • STI risk? • Menstrual cycle and current position, other contraception? (?earliest ovulation) • When was the accident? • Any other upsi in this cycle • ?used before • ?consensual, age of partner, ?Frazer competant

  48. Up to 72 (120 hrs) • If >72 hrs consider copper iud • (up to 5 days or, up to 5 days> earliest ovulation) • Levonelle-2 • 95% - 1st 24hr, 85% 48, 70% 72 • Mode of action • Vomiting • Enzyme inducing drugs • Next Period

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