1 / 62

Contraception Update

Contraception Update. Dr Sarah Gatiss Consultant in Obstetrics and Gynaecology Sunderland Royal Hospital. OVERVIEW. Combined Contraceptive methods New Pills Yaz & Qlaira Missed Pills Pill taking Regimes Nuvaring Nexplanon New faculty guidance Drug interactions Quick start guidance

lou
Télécharger la présentation

Contraception Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Contraception Update Dr Sarah Gatiss Consultant in Obstetrics and Gynaecology Sunderland Royal Hospital

  2. OVERVIEW • Combined Contraceptive methods • New Pills Yaz & Qlaira • Missed Pills • Pill taking Regimes • Nuvaring • Nexplanon • New faculty guidance • Drug interactions • Quick start guidance • UKMEC 2009 guidance changes from 2005 • Essure • Questions

  3. COMBINED ORAL CONTRACEPTION Yaz Qlaira Missed Pills Flexible Pill taking Regimes

  4. COCP: Yaz • 20mcg EE + 3 mg Drospirenone • New regime 24/28 • Take active Pills for 24 days then 4 day placebos • Shorter PFI is more effective • Licensed USA • Contraception, acne and PMDD • Benefits • Less Dysfunctional Bleeding • Less PMS • Less Blood loss by 50-60%

  5. COCP: Yaz • Initial efficacy data from USA • 3-5 year follow up of new starters or switchers • Prospective recruitment • 434 unplanned pregnancies • By March 2008 • Pearl Index for 24day regime 0.94 • Pearl Index for 21 day regime DRSP/EE 1.5 • Pearl Index for 21day regime other COCP 2.22

  6. COCP: Qlaira • Oestradiol Valerate+ Dienogest • Benefits • More ‘natural’,effective and safe • Cycle control like 20mcg LNG Pill • Little effect on glucose, lipids, BP, coagulation factors • Disadvantages • New so limited data on VTE / CHD risk etc • Need to take all 28 Pills in correct order (EE: Prog) • Different Missed Pills rules

  7. Qlaira regime • 26/2 • Maintain stable E2 levels, optimise cycle control, inhibit ovulation

  8. Qlaira packet

  9. Start immediately with next pack • Use barrier contraception (e.g. condoms) for the next 9 days Missed Pill Advice Missed 2 or more coloured pills or forgotten to start new pack Seek advice from your HCP YES YES Had sex in the 7 days before forgetting? day 1-9 NO • Take missed pill • Continue with pack as usual • Use a barrier contraception (e.g. condoms) for the next 9 days day 10-17 Missed only 1 pill (more than 12 hours late ) Check pill number on pack YES day 18-24 • Take missed pill • Continue with packet as usual • No additional contraception necessary day 25-28 HCP, Healthcare professional

  10. MISSED PILL RULES

  11. Missed Pills • Multiple sources of advice • FSRH guidance • SPC- leaflet in box of Pills • FPA leaflet • BNF • ALL DIFFERENT • Conflicting advice leads to confusion • Inaccurate & inconsistent Pill taking

  12. Missed Pills • MHRA decided not acceptable to have so much conflicting information • New set of missed Pill rules • Not dependant on dose • NB separate rules for • QLAIRA-Quadraphasic Pill –use SPC • Cerazette • Progestogen only Pills

  13. Missed Pill RulesCEU- May13th 2011 • 1 missed Pill ( >24 hrs late or PFI lengthened by 1 day) • Take Pill as soon as remember • Continue rest of pack • No additional contraception needed • Have 7 day break as normal

  14. Missed Pill RulesCEU- May13th 2011 • 2 missed Pills ( or PFI lengthened by 2 days) • Take Pill as soon as remember • Continue rest of pack • Use additional contraception for 7 days • EC if 2 pills are in first week of packet • No break if less than 7 Pills left in packet

  15. FLEXIBLE PILL TAKING REGIMES

  16. COCP :Flexible regime • Tricycling • 3 packets back to back with no break • 63 continuous days • Reduce Pill free interval to 3-4 days • Reduce bleeding • Minimise risk of lengthening break • ‘Break at bleed’ • Take Pills continuously until break through bleed occurs • Break for 4 -7 days then restart

  17. When to use alternative regime? • PFI side effects • Heavy/painful bleed in PFI • Headaches/ migraines in PFI • PMS • Cyclical symptoms • Endometriosis • Previous Pill failure • Women’s Choice/ convenience

  18. NUVARING Alternative ways of delivering combined EE & Progestogen

  19. Nuva Ring • Vaginal Ring • 15µg/day EE and 120µg/day Etonogestrel • Flexible transparent ring,4mm thick x 54mm diameter • Latex free • Use • 1 Ring for 3 weeks then 7 day break • Can be used with tampons and during SI • Pharmacology • Avoids first pass metabolism& GI interference with absorption • Systemic EE is 50% of that of 30µg EE COCP • Efficacy • Pearl Index 0.64 ( perfect use) • Comparable to COCP

  20. Nuva Ring • Compliance • >85% of cycles compliant in trials • Acceptibility • Low incidence of Break through bleeding • Better than COCP for cycle control • >90% trial subjects found easy to insert and remove • Safety • Same metabolic and coagulation effects as most combined methods • Storage • 2-8°C before dispensing to patient • Cost • £27 for 3 rings ( £9 per month)

  21. Nexplanon Failure rates Management of bleeding problems

  22. Nexplanon • Subdermal implant • Etonogestrel 68mg released over 3 years • Most effective method available for women • Change insertion device • New technique • Reduced chance of leaving device in inserter • Change component • Barium Sulphate • Radio opaque

  23. Nexplanon • Pregnancies • >50% linked with non-insertion • 25% with liver enzyme inducers (carbemazepine) • Pregnancy rate • 0.049/100 implants fitted • 0.01/100 true method failure • New insertion Site • Inner side of non-dominant upper arm 8-10cm above medial epicondyle of the humerus

  24. Irregular Bleeding Patterns Median number of days bleeding /spotting in LARC users over 3 months

  25. Irregular Bleeding Patterns-Management Options • Pre-insertion/fitting/injection Counselling • Progestogen Injection • Shorten interval to 8/52 until amenorrhoeic • IUS / Nexplanon • Change earlier is bleeding starts in final year of use • Drug treatments • COCP cyclically for 2-3 months • NSAIDs/ Mefanamic Acid( little evidence) • Doxycycline (little evidence) • NET 5mg tds for 3 weeks for 2-3 cycles • Problems • Recurrence of bleeding when discontinues treatment

  26. FACULTY GUIDANCE Quick start regimes

  27. Quick start • If we can be reasonably sure that a woman is not pregnant or at risk of a pregnancy from recent UPSI, contraception can be started immediately. • Use may be out of licence • If method of choice is not available use bridging method- COCP, POP or Injectable Progestogen • IUCD can be used if meet EC criteria • IUS insertion should be delayed until pregnancy excluded

  28. Quick start • If pregnancy cannot be excluded (eg after EC administration) &women will not abstain until pregnancy is excluded or is keen to start method immediately COCP, POP, Nexplanon can be started . • Injectable progestogen should only be used if other options are not appropriate or acceptable • Follow-up with pregnancy test after 3 weeks • Use may be out of licence

  29. Quick start • Starting hormonal contraception after POEC (eg Levonelle) • Advise condom use or abstainance for • 7 days for COCP, Nexplanon, Injectable Progestogen • 2days for POP • 9days for Qlaira

  30. Quick start • Starting hormonal contraception after Ullipristal (EllaOne) • Advise condom use or abstainance for an extra week • 14 days for COCP, Nexplanon, Injectable Progestogen • 9 days for POP • 16 days for Qlaira

  31. Pregnancy after quickstart • If pregnancy is diagnosed after quick starting contraception • Stop or remove method • Do not remove IU contraceptives • after 12 weeks gestation • if threads not visible

  32. FACULTY GUIDANCE Drug interactions

  33. Drug interactions- Antibiotics • CEU no longer advises that additional precautions are required when using CHC with non-enzyme inducing antibiotics • EVIDENCE in line with • World Health Organisation • US Medical eligibility Criteria for Contraceptive Use

  34. Drug interactions- Antibiotics • EVIDENCE • Several studies show no decrease in EE levels with antibiotic use • Small non randomised trials no effect on pharmacokinectocs of EE/ progestogen when used with tetracyclinc/amoxicillin/doxycycline • Small non randomised trials failed to show that ampicillin has any effect on gonadotrophin conc or progesterone levels in women using >30µg COCP • Small RCTs showed Ofloxacin & Ciprofloxacin may not affect COC efficacy ( no ovulation)

  35. Drug interactions-Enzyme inducers • Rifampicin-like drugs are enzyme inducers and are the only antibiotics that have been shown to reduce EE levels • Methods unaffected • IUCD • IUS • Injectable progestogen

  36. Drug interactions-Enzyme inducers • Combined Pill • Change method(or long term 2 x50µg COC) • Patch/ Ring • Change method(2Patches/ 2Rings not recommended) • POP/Nexplanon • Change method • POEC- Levonelle • Use 3mg LNG asap • Ullipristal Acetate- EllaOne • Ella One contraindicated • Use IUCD if enzyme-inducers in last 28days

  37. Drug interactions- no longer included • Warfarin • Increase or decrease of anticoagulant effect with hormonal contraception • Lack of consistant evidence therefore no longer included • Griseofulvin • Not a clinically important enzyme inducer • Lanzoprazole • No longer listed as an enzyme inducer

  38. Drug interactions- Lamotrigine • CHC not recommended in women on Lamotrigine monotherapy ( UKMEC3) • Risk of reduced seizure control • Potential for toxicity in the CHC free interval • Progestogens • Levels of some progestogens may be reduced • May increase levels of Lamotrigine • Need more evidence (still UKMEC1 for PO methods)

  39. UKMEC RECENT CHANGES UKMEC 1 Unrestricted Use UKMEC2 Benefits outweigh Risks UKMEC 3 Risks outweigh Benefits UKMEC4 Contraindicated

  40. UKMEC New changes • Obesity • >30-34kg/m2 BMI UKMEC 2 for CHC • > 35kg/m2 BMI UKMEC 3 for CHC • Previous >40kg/m2 UKMEC4no longer included • Current VTE On anticoagulants • CHC UKMEC 4 • All other methods UKMEC 2 • Previously UKMEC 3 except POP

  41. UKMEC New changes • Gestational trophoblastic disease • Decreasing or undetectable levels • All methods (UKMEC 1) • Persistant elevated βhcg levels/malignant disease • All methods ( UKMEC 1) except IUS/IUD( UKMEC4) • Distorted cavity insertion of IUS/IUD (UKMEC 3) • Chlamydia or GC positive • Initiation of IUS/IUD ( UKMEC 4) • Continuation of IUS/IUD ( UKMEC 2) previously 1

  42. UKMEC New changes- Liver disease • Hepatitis • Cirrhosis

  43. UKMEC New changes- Liver disease • Liver tumours

  44. UKMEC New changes- SLE • SLE

  45. UKMEC New changes • Lamotrigine • CHC (UKMEC 3) • All other methods (UKMEC 1) • Broad spectrum Antibiotics • All methods ( UKMEC 1) • Antiretroviral therapy

  46. Essure • Permanent contraception • Implant placed into each tube which involves an occlusion • Hysteroscopic approach • Without General Anesthesia • No scar, no incision

More Related