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Contraception Update . Dr Clio Timaeus Clinical Lead/Associate Specialist for Bromley Healthcare Contraception and Reproductive Health Service. Overview. Quick starting contraception Nuvaring Qlaira CHC and antibiotics Ella-one Faculty qualifications amnesty. Nuvaring .

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contraception update

Contraception Update

Dr Clio Timaeus

Clinical Lead/Associate Specialist for Bromley Healthcare Contraception and Reproductive Health Service



  • Quick starting contraception
  • Nuvaring
  • Qlaira
  • CHC and antibiotics
  • Ella-one
  • Faculty qualifications amnesty
  • Flexible transparent ring

(54mm diameter; 4mm thick)

  • Inserted vaginally
  • Combined hormonal contraception
  • 15 µg/day ethinyl estradiol (EE)

120 µg/day etonogestrel (ENG)

  • One ring every 4-week cycle

(3 weeks ring in; 1 week ring free)

useful for
Useful for
  • Once monthly dosing – not LARC, but related advantages compared to daily and weekly methods (good for women who want to remain in control of method)
  • Women who cant settle on a progestogen- only LARC method (usually due to bleeding problems) and choose not to have an IUCD
useful for1
Useful for
  • Problems with taking pills/COC:

- forgets

- changes in time zone

- difficulty swallowing pills

- nausea on taking pills

- absorption problems

  • Monthly dosing
  • Good cycle control
  • Rapid return of ovulation

(median time 19 days)

  • Easy to use
  • High user satisfaction once tried
  • Low EE dose (15 µg/day)
  • Avoids oral administration
user satisfaction study
User satisfaction study
  • 1492 women tried Nuvaring for 13 cycles:

- at baseline 66% said COC preferred method compared to Nuvaring

- after 3 Nuvaring cycles 81% said Nuvaring their preferred method

  • 9/10 women would recommend Nuvaring to a friend

Novak A et al. Contraception 2003; 67: 187-194

can use with
Can use with:
  • Tampons
  • Vaginal thrush treatments
  • Spermicides
  • Diarrhoea and vomiting
  • Antibiotics

(but still need extra precautions with liver-inducing enzymes)

  • Cost, 3-ring pack costs £27.00 (BNF)
  • Before dispensing, needs to be stored in a fridge at 2-8 ºC; once dispensed needs to be used within 4 months (so only dispense 1 pack of 3 rings at a time)
  • Still have to remember to remove and insert each month: for text or e-mail reminders
in practice
In practice
  • Easy to insert – no special technique or position; effective as long as in contact with vaginal mucosa; just ‘shove it in like a tampon’
  • Remove by hooking finger round it
  • Rarely expelled spontaneously (about 0.5% of cycles) – if comes out ok if re-inserted within 3h
  • Clients and their partners, both seem to be either unaware of or not bothered by it
in practice1
In practice

The Nuvaring is meant to be removed after 3 weeks and a new one inserted after a 7-day ring-free interval, however:

- known to be effective for upto 4 weeks if a delay in removing it (un-licensed)

- as with COC must not have more than a 7-day hormone-free interval

- no reason cant ‘run rings on’ (un-licensed)

starting schedules
Starting schedules
  • Commence on day one of menstrual cycle or use condoms for at least 7 days
  • Can commence at the end of the 7-day PFI if changing from the COC without extra precautions
  • Need extra precautions for at least 7 days if changing from the POP or starting the same day an implant or IUS is removed or contraceptive injection runs out
  • A COC available since 2009
  • A phasic pill – consisting of a 28-day cycle with a quadriphasic dosage regimen and a 2-day placebo phase
  • The resulting reducing estrogen and increasing progestogen doses are designed to optimise cycle control
  • First COC to contain estradiol valerate, which is metabolised to estradiol (that also exists naturally in women)
  • Complex regimen
  • Different (complicated) missed pill rules

Therefore need to be a good pill taker and

prepared to follow the regimen

  • Cost (£25.18 for a 3-cycle pack – BNF)
  • Has recently been licensed for heavy menstrual bleeding in women desiring contraception
  • Dienogest is a highly selective progestogen that produces good suppression of endometrial proliferation
data from bayer healthcare
Data from Bayer HealthCare
  • In 421 women with DUB, including HMB (269 Qlaira; 152 placebo)
  • 88% reduction in median menstrual loss vs. baseline at 7 cycles, compared to 24% on placebo
  • Other studies show a 96% reduction for women with an IUS at one year and
  • 35-43% for women using other COC (un-licensed use)
potential users
Potential users
  • women who have HMB and choose not to have an IUS or who it has proved difficult to fit one in and want to avoid surgery
  • women who have had problem bleeding (BTB and/or heavy menses) on various COC, as well as with any progestogen-only methods they have tried
antibiotics and chc
Antibiotics and CHC
  • Still need to use an alternative method unaffected by enzyme-inducing drugs (at the very least good condom use) if using the enzyme-inducing rifamycins (such as rifabutin and rifampicin)
antibiotics and chc1
Antibiotics and CHC

- No longer advised to use extra precautions (e.g. condoms) when using CHC with antibiotics that are not enzyme-inducers, even if broad spectrum

- Only proviso if antibiotics or illness cause significant vomiting and/or diarrhoea

antibiotics and chc2
Antibiotics and CHC

- World Health Organisation Medical Eligibility Criteria for Contraceptive Use (WHOMEC, 2009/10)

- US Medical Eligibility Criteria for Contraceptive Use (USMEC, 2010)

- FSRH Clinical Effectiveness Unit (CEU)

- (UK Medical Eligibility Criteria for Contraceptive Use, UKMEC 2009)

antibiotics and chc3
Antibiotics and CHC
  • WHOMEC states that there is intermediate level evidence that the contraceptive effectiveness of COCs is not affected by co-administration of most broad-spectrum antibiotics and advises no restriction on use (WHOMEC Category 1) of CHC with antibiotics
antibiotics and chc4
Antibiotics and CHC
  • FSRH CEU Clinical Guidance – Drug Interactions with Hormonal Contraception (January 2011)
  • On web-site:

- as are UKMEC guidelines 2009

  • New (2009) oral post coital/emergency contraceptive
  • 30mg ulipristal acetate (one tablet to be taken as soon as possible after UPSI)
  • Prescription only (i.e. no direct provision available by pharmacists)
Levonelle is a progestogen (1500 µg levenorgestrel)
  • ellaOne is a selective progesterone modulator, i.e. acts on the progesterone receptor (tissue-selective) but is not a progestogen

Both primarily work by inhibiting/delaying ovulation, but may also effect endometrium – inhibiting implantation if fertilisation has occured

Levonelle licensed for use up to 72 hours post UPSI, but in practice used up to 120 hours (supported by FSRH)
  • ellaOne licensed for use up to 120 hours post UPSI
ellaOne appears to be marginally more effective than Levonelle, this superior efficacy increasing the longer the time since UPSI
  • Would need to treat about 120 women with ellaOne rather than Levonelle to prevent one pregnancy
  • If the client wants the most effective method available to prevent pregnancy, she should have a copper IUD fitted (which can be removed at the next menses or kept as a long term method)
ellaone concerns
ellaOne concerns
  • Effects of ellaOne on any subsequent pregnancy or current pregnancy unknown
  • May reduce the efficacy of any ongoing hormonal contraception use or any hormonal contraception started immediate;y after its use
Costs from current BNF
  • Levonelle 1500 - £5.20
  • Levonelle OneStep - £13.83
  • ellOne - £16.95
Bromley Contraception &RH service don’t provide ellaOne
  • We issue Levonelle 1500 up to 120 hours post UPSI (and will also consider more than once in a cycle and more than 120 hours post UPSI if before the earliest expected date of ovulation – Dr only)
  • Always offer emergency Cu-IUD fit as an alternative if fit parameters – not necessarily at same visit (when give Levonelle as well)
  • Dedicated LARC clinics on Tuesday a.m. and Thursday p.m. and can also usually fit on a Monday and Thursday evening
faculty of sexual and reproductive healthcare qualification amnesty
Faculty of Sexual and Reproductive Healthcare qualification amnesty
  • Until 31st July 2011
  • For people who have already held the qualification in the past and continue to utilise the relevant skills, but for whatever reason have not re-certified, or experienced IUCD/implant fitters and removers
  • Diploma (DFSRH) – necessary for LoC
  • LoC SDI (sub-dermal implants)
  • LoC IUT (intrauterine techniques)
diploma dfsrh
Diploma (DFSRH)
  • Experienced practitioner currently providing contraceptive and sexual healthcare
  • Previously held DFSRH/DFFP or JCC
  • Completed 15 hours of relevant CPD in last 5 years (meetings/reading/discussions/audit/etc)
  • Above to include completion of module 8 (Contraceptive Methods) of the e-SRH programme on website (1-2 hours of updating)
loc iut intra uterine techniques
LoC IUT (intra-uterine techniques)
  • Experienced IUCD fitters, who have not re-certified or never obtained qualification
  • Have the Diploma (DFSRH)
  • Self-certify to fitting at least 12 devices per year and to be auditing results
  • Have 2 fittings observed by a Faculty Registerd Trainer or a GP trainer who holds LoC IUT
  • Have completed module 18 (IUTs) of e-SRH on e-learning for healthcare website
loc sdi sub dermal implants
LoC SDI (sub-dermal implants)
  • Experienced in SDIs, but

- not re-certified or

- originally trained in a non-Faculty LoC programme as did not have DFSRH

  • Need DFSRH now to take advantage of amnesty
  • Provide details of original training and if >5 years ago complete module 17 (SDIs) of e-lfh
  • Received Nexplanon training/updating
  • Self-certify doing at least 6 procedures a year (at least one a removal and one an insertion)
e learning for healthcare e lfh
e-learning for Healthcare (e-lfh)
  • Free to everyone working in NHS
  • Can access with GMC number – need to register
  • Access the e-SRH package (sexual and reproductive health); different to SRH overview in GP training package