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Contraception

Contraception. Cases From Practice Dr P Feldman. Contraception. Major social change Reproductive self determination If, when, and if they want children Freedom from pregnancy Career. The Ideal Contraceptive. 100% reversible 100% effective 100% convenient 100% free of adverse effects

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Contraception

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  1. Contraception Cases From Practice Dr P Feldman

  2. Contraception • Major social change • Reproductive self determination • If, when, and if they want children • Freedom from pregnancy • Career

  3. The Ideal Contraceptive • 100% reversible • 100% effective • 100% convenient • 100% free of adverse effects • 100% protective against sexually transmitted diseases • Has other non contraceptive advantages • Maintenance free

  4. Under Age Contraception • 90,000 teenage conceptions/year • 7,700 to girls < 16 • 2,200 to girls < 14 • 3/5 result in live births = 5,600 births/year • 2/3 of 16 yr olds don’t have sex

  5. Under Age Contraception • Assessment • Menstrual history • Sexual history • Contraceptive history • Medical history • Social history • Family history

  6. Under Age Contraception • Examination • Blood pressure • Weight • Ethical concerns • Pregnancy • Age • Doctors own morals

  7. Fraser Guidelines • Contraception may be given provided:- • Understands advice • Encourage to inform parents • Will have sex anyway • Physical/mental health would suffer • Contraception is in her best interests

  8. Under Age Contraception • Management • Combined oral contraceptive pill • Progesterone only contraceptive pill

  9. Under Age Contraception • Combined oral contraceptive • Action • Prevents ovulation and implantation • Failure rate • Age 25-34 0.38/100 woman years • Age 35+ 0.23/100 woman years

  10. Risk Factors

  11. Risk Factors for Arterial Disease

  12. Risk Factors for Venous thromboembolism

  13. Risks Liver benign and malignant Cervix Breast Benefits Endometrium Ovary Under age contraception

  14. Under Age Contraception • Risk of vte in healthy non pregnant women is 5/100,000 • Risk of vte in users of second generation COC is 15/100,000 • Risk of vte in users of third generation COC is 25/100,000 • Risk in pregnancy is 60/100,000 • Which COC

  15. Under Age Contraception • Use of third generation COC • Make a record of • Risk factor history • Woman accepts possible increased risk • 10 cases of vte per 100,000 users per year • 0.2 deaths

  16. Under Age Contraception • Advice • Missed pills • Vomiting and diarrhoea • Antibiotics

  17. Under Age Contraception • Progesterone only pill • Failure rate • Age 25-29 3.1/100 woman years • Age 35-39 1/100 woman years • Age 40+ 0.3/100 woman years • Full lactation = that of COC • Failure rate increases with weight • > 70 kg use 2 pills/day

  18. Under Age Contraception • Mode of action • Fertile ovulation prevented in 60% cycles • Cervical mucous less penetrable by sperm • Antinidatory action on endometrium

  19. Under Age Contraception • Situations where POP useful • Oestrogen related contraindications to COC • Smokers > 35yrs • Hypertension • Migraine • Diabetes • Lactation • Sickle cell disease

  20. Under Age Contraception • Advice • Missed pills • No interference with antibiotics

  21. Emergency Contraception • Assesment • Menstrual history • Lmp, • Cycle • Could she already be pregnant • Previous contraceptive failures in current cycle

  22. Emergency Contraception • Assessment • Past medical history • Migraine • Venous thromboembolism • Ihd • Family history • Venous thromboembolism • ihd

  23. Schering pc4 Less effective More nausea 51% Vomiting 19% Cheaper £1.60p Levonelle 2 More effective Less nausea 23% Vomiting 6% More expensive Emergency Contraception

  24. Emergency Contraception

  25. Contraindications • Levonelle • Pregnancy • Allergy to constituent • Active acute porphyria • Active severe liver disease

  26. Emergency Contraception • Advice • Not 100% effective • Do pregnancy test if period late • Vomiting within 2 hrs • Risk of teratogenicity

  27. Emergency Contraception • Indications for copper IUCD • When max efficacy is required • Exposure > 72 hrs or multiple exposure • Continued as long term contraception • Absolute contraindications to hormonal methods • After vomiting of either dose within 2 hrs • ·

  28. Emergency Contraception • Absolute contraindications to copper IUCD • Suspected pregnancy • Unexplained uterine bleeding • Current or recent pelvic infection/sti • Significant immunosupression • Malignant trophoblastic disease • Distorted uterine cavity • Heart valve prosthesis or previous SBE

  29. Emergency Contraception • Adverse effects of IUCD • Intra uterine pregnancy • Extra uterine pregnancy • Expulsion • Perforation • Infection

  30. Emergency Contraception • Advantages of copper IUCD • Safe mortality 1:500,000 • Effective immediately • Cumulative failure rate at 5yrs = 1.4/100 women • Nothing to remember • Reversible

  31. Emergency Contraception • Action • Prevention of fertilisation • Block implantation

  32. Emergency Contraception • Assessment • History • Menstrual • Social • Examination • Options

  33. Emergency Contraception • Assessment • Position in packet • Previous missed pills • Did they use condom • ? Last period normal

  34. Emergency Contraception • Emergency contraception on COC • Unprotected sex within 7 days of • 2 missed pills from first 7 in packet • 4 missed pills from mid packet

  35. Contraception in the 40-50’s • Assessment • Personal history • Age • Smoking • Weight • Mobility • Previous pill history

  36. Contraception in the 40-50’s • Assessment • Past medical history • Venous thromboembolism • Ihd • Migraine • Diabetes • Epilepsy • Varicose veins

  37. Contraception in the 40-50’s • Assessment • Family history • Venous thromboembolism • Ihd • Examination • Blood pressure • Weight

  38. Contraception in the 40-50’s • Copper IUCD • If implanted after 40 can be left for 10 yrs but off license • Infection risk is less because of different lifestyle • Loss of fertility not a problem as family completed • Pain and heavier bleeding could be controlled by drugs

  39. Contraception in the 40-50’s • Products used off license • Professional opinion must endorse use • Tell patient it is unlicensed • Mention risks and benefits • Obtain informed consent • Keep separate record

  40. Contraception in the 40-50’s • Mirena • Action • Changes cervical mucus • Impedes implantation • Failure rate • 0.1 0.2/100 woman years

  41. Advantages Ovulation continues Fertility returns quickly Lighter periods Pms improved HRT Default contraception Disadvantages Expulsion Perforation Bleeding Amenorrhoea PID Contraception in the 40-50’s

  42. Contraception in the 40-50’s • Contraindications • As for copper IUCD • Hypersensitivity to levonorgestrel • Postcoital contraception • High failure rate

  43. Contraception in the 40-50’s • Fertility per 100 woman years • No method young women 80-90 • No method at age 40 40-50 • No method at age 50 0-5

  44. Contraception in the 40-50’s • When to stop contraception • Age < 50 2 yrs after last period • Age > 50 1 yr after last period

  45. Contraception in the 40-50’s • The menopause • Periods alter • Hot flushes • Raised FSH • COC suppresses FSH • POP does not suppress FSH

  46. Contraception in the 40-50’s • Contraceptive failure rate age >35 • Pop 0.5 • Diaphragm 2.8 • Male condom 2.9

  47. Contraception in the 40-50’s • Other methods • Copper IUCD • Mirena • Barrier methods • Male condom • Diaphragm • Vaginal foam

  48. Contraception in the 40-50’s • Male condom • Second most popular form of contraception • Failure rate related to correct application • Only proven method of preventing HIV transmission • Not available on FP10

  49. Contraception in the 40-50’s • Diaphragm • Requires • Individual fitting • Checking correct fit • Used with spermicide • Inserted before intercourse • Not removed till 6 hours later

  50. Contraception in the 40-50’s • Oddities • Femidom • Personna • Vaginal foam

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