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FAMILY PLANNING

FAMILY PLANNING. Sarah Stradling GP Camberley Health Centre. OVERVIEW. Combined Contraception Emergency Contraception Gillick competence LARC POP Other methods Case studies. The perfect contraceptive?. The perfect contraceptive would: give total protection against pregnancy

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FAMILY PLANNING

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  1. FAMILY PLANNING Sarah Stradling GP Camberley Health Centre

  2. OVERVIEW • Combined Contraception • Emergency Contraception • Gillick competence • LARC • POP • Other methods • Case studies

  3. The perfect contraceptive? • The perfect contraceptive would: • give total protection against pregnancy • would be ethically acceptable • cheap • require little or no medical intervention • have no unwanted side effects but perhaps some benefits to health • fertility would return promptly and completely when use ended This ideal does not exist-apart from abstinence.

  4. Efficacy • Pearl Index- Comparing efficacy • High index; high chance of failure (no contraception 80-90) • Low index; low risk failure (Mirena <0.5) number of unintentional pregnancies related to 100 women years. E.g 3 pregnancies in 100 women in 1 year, pearl index is 3.0

  5. I would like to go on the pill… • Age • Contraceptive hx • Menstrual hx, LMP • Obstetric hx- ectopic? • Medical hx • Medication • Allergies

  6. Options • Risks/benefits • Mode of action • Side effects • Teaching about method • PILS • Follow up • Special instructions

  7. COMBINED ORAL CONTRACEPTIVES ‘The Pill’

  8. Mode of action and efficacy • First consultation • UKMEC • Risks • Initiation • Missed pill guidance • Choice of pill and managing side effects

  9. Commonest hormonal • Action- anovulatory • reduces endometrial lining Pills 1-7 INHIBIT OVULATION Pills 8-21 MAINTAIN ANOVULATION Important when considering ‘missed pills’

  10. Pearl Index- 0.3- 4.0 • Perfect use vs. true use • Promote safe sex- condoms • Sexual health screening • Opportunistic chlamydia (1:10 <25)

  11. First COC consultation • Clinical Hx- Medical conditions Drug use prescription and OTC Family hx • Specific enquiries • User preference and concerns

  12. UkMEC(medical eligibility criteria) • UKMEC 1- No restriction • UKMEC 2- Advantages > theoretical proven risk • UKMEC 3- Risk > advantages • UKMEC 4- Unnacceptable health risk Suggest specialist referral if 3 or above

  13. Risks • Age- to what age can it be safely used? • Smoking- can the coc be used in a 30 y.o smoker? • Obesity (BMI 30-34;2 35-39;3) • Blood pressure

  14. Not Recommended(UKMEC category 4) • Smokers >35 years (>15 a day) • Migraine with aura at any age • Known thrombogenic mutations • BMI >40 • BP consistently > 160/95 • Current breast cancer • Liver tumours • Hx VTE/Stroke/MI • Valvular and congenital heart disease

  15. ‘The pill scare’ • VTE: Increase five fold, remains low No screen needed Different progestogens associated with risk- levonorgestrel and norethisterone may counteract thrombogenic effect of EE better than desogestrel and gestodene Greatest risk in first year Normal within weeks of stopping

  16. Dianette- 35mcg EE and cyproterone acetate Four fold increase risk vs. microgynon 30 Limit duration of use Yasmin? Lies between the above

  17. Migraine: Migraine + aura (any age) Migraine – aura Risk of ischaemic stroke Is it an aura??

  18. Breast Cancer: • No increase risk if family hx • Gene carriers • Current breast ca vs. past ca (>5yrs ago)

  19. Drugs- • Liver enzyme inducers reduce efficacy, 28/7 after stopping • Non enzyme inducing antiobiotics- sept 2011 • Having reviewed the available evidence, the CEU no longer advises that additional precautions are required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less. The only proviso would be that if the antibiotics (and/or the illness) caused vomiting or diarrhoea.

  20. What would you do with a patient with a UKMEC 4 score and says that they are accepting of the risk? Risk vs. pregnancy? Patients right to choose? Prescribing responsibility?

  21. Non contraceptive benefits: • Blood loss and pain • Functional ovarian cysts • 50% reduction in ovarian and endometrial ca (15 years post) • Acne • Tricycling packets: prevent bleed, endometriosis, withdrawl headache- OUTSIDE LICENCE

  22. Initiation • Day 1-5- immediate cover • Elsewhere – COULD THEY BE PREGNANT? Alternative precautions • Chaotic recurrent EC users? Immediate start and bHCG in 3/52- Quick Start • Best method if chaotic?

  23. Post partum- ideally day 21 • Amenorrhoea- anytime + 7day • Post TOP- up to 7 days

  24. ‘Missed Pill’ • HOW MANY? • WHERE IN THE PACKET? A missed pill is one that is more than 24hrs late. 1 active pill can be missed without the need for alternative precautions

  25. PILS • Drug information leaflet • NHS direct • GP • OOH • Patient.co.uk

  26. Which Pill? • Monophasic COC with 30mcg EE + Norethisterone or levonorgestrel • Why? • No evidence for biphasic or triphasic • Reduced VTE risk • 20mcg efficacy similar but increased BTB Note: ED pills no evidence for increased compliance

  27. Provide written information • Review at 3/12 • Bp and troubleshooting • May issue 12/12 supply with SOS review • Encourage 3/12 trial • Advise re VTE signs/sx • Advise re condom use for STI protection

  28. Side effects • Remember ‘side effects’ may not be COC related • Oestrogen s/e- • Nausea • Dizziness • Bloating • Cyclical fluid retention • Vaginal discharge Swap to a progesterone dominant pill- e.g. Cilest, Brevinor, Marvelon

  29. Progesterone s/e: • Vaginal dryness • Weight gain • Depression • Low libido • Breast tendernss Change to an oestrogen dominant pill e.g microgynon 30, loestrin 30/20

  30. Changing from another form of contraception to COC and vice versa- MIMS and BNF • EVRA-consistent levels of hormones, change every 7 days, ‘patch free’ week, ?improve compliance, if patch no longer sticky will need a new patch

  31. NUVARING • Once a month intravaginal ring • Low oestrogen (2mg ethinyloestradiol-15mcg daily and etonogestrel) • Individually packaged • No GI absorption- malabsorptive disorders, binge drinking, vomiting • May view as user controlled LARC

  32. Insert and leave for 3 weeks • Ring free week- withdrawl bleed • Does not matter where it sits unlike diaphragm • Each ring works for 5 weeks • Removal to ovulation→16 days

  33. Can use tampons and spermicides • <5% women report BTB • 90% men found it acceptable • Needs cold storage prior to dispensing, then has 4 month shelf life at room temp • If taken out, 3hr window before contracptive efficacy is compromised • No evidence that it effects cervical cytology

  34. QUESTIONS?

  35. EMERGENCY CONTRACEPTION

  36. Preventing pregnancy following UPSI/contraceptive failure • Oral Hormonal - levonorgestrel (LNG) Inhibits ovulation as primary action] - Ella One Uliprisatal acetate- Selective progesterone receptor modulator 2. Copper IUD- Minimum 380mm² Toxicity to fertilisation and inflammatory action against endometrium- anti implantation NOT IUS

  37. 2002 Judicial review- pregnancy starts at implantation NOT fertilisation • NO time in cycle when there is NO risk following UPSI • No evidence that LNG/ulipristal will harm a fetus

  38. Indications • COC- 2 or more missed in week 1 PLUS UPSI in pill free week or week 1 • POP- 1 missed pill (>3hrs late or 12hrs if cerazette) and UPSI in following 2 days • IU- removal or expulsion and UPSI in previous 7 days • Injectable- >14 weeks and UPSI • Liver enzyme inducers- taken with COC or implant or in the following 28 days • UPSI

  39. ‘The Morning after pill’ • Levonelle 1500 • ASAP, within 72hrs- licence • Consider up to 5 days- outside licence • Consider more than once in a cycle • Always give if a/w IUD • No CI to EHC • Liver enzyme inducing drugs, ?2 doses

  40. Ella One • Licence for 5 days (120hrs) post UPSI • Acts to delay ovulation • May also have effect on the endometrium • At least as effective as LNG • Can only have once in a cycle • Affects COC for 14 days, POP for 7 days

  41. Vomits within 2 hrs- repeat • Nausea- 14% • 50% period was a few days late or early • 16% non menstrual bleeding in next 7 days • bHCG at 3/52 • Levonelle 1500 £5.11 • Ella One £16.95

  42. Would you? • Should EHC be offered in advance of need? • Foreign travel • Barrier methods May reduce unwanted pregnancies without increase in risky behaviour. Available OTC

  43. IUD for emergency contraception • Up to 5 days after 1st episode UPSI • Up to 5 days after calculated date of ovulation • Detailed hx of normal cycle and calculate expected date of ovulation Always give EHC whilst arranging

  44. Other discussions • Sexual health screening • Ongoing contraception • ?start alternative method before next period • Young people- No medical reason to avoid • Child protection issues

  45. GILLICK COMPETENCE • Gillick vs. West Norfolk HA (1986) • DOH guidance • Law Lords Ruling (Fraser ruling)…..

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