Download Getting contraception right for women in 2012 and beyond

‘Doc I’ve had an accident’
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33 year old
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Burst condom
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BMI 35
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Wants the
morning after pill
Emergency contraception
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Cu- IUD
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Levonelle
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Ella-One
Recommendations for EC use
Situation
Indication for EC
Combined hormonal
contraceptive (CHC)
Three or more pills missed in first week of pill cycle
or >48 hrs late restarting patch or ring and UPSI in
hormone free week or in week 1
Progesterone only pill (POP)
POP taken >3 hrs late (>12 hrs with Cerazette) and
UPSI has occurred within 2 days following this
Progesterone-only injectable
Injection is late (Depo-provera >14 weeks; Noristat
>10 weeks) and UPSI has occurred
IUD/IUS
Complete or partial expulsion or mid-cycle removal
of IUD/IUS and UPSI has occurred in previous 7 days
Barrier methods
Failure of method
History for EC
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The timing of all episodes of UPSI in the current
cycle
The most likely date of ovulation based on the
date of the LMP and usual cycle length
Details of potential contraceptive failure e.g. how
many pills were missed and when
Use of medications which may affect
contraceptive efficacy
Levonelle
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Acts by inhibition of ovulation - up to 5 days
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Less effective when UPSI occurs around
time of ovulation
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Effective up to 96 hrs
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Repeat dose if vomiting within 2 hours
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Multiple doses possible in each cycle
ellaOne
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ulipristal acetate
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synthetic progesterone receptor modulator
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as effective as Levonelle and licensed for use
up to 120 hours after unprotected sex
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No reduction in efficacy over the 120 hours
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£16.95
Mode of action
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Primary mode of action is to inhibit or delay ovulation
Inhibits follicular rupture - effective in even when after
LH levels have already begun to rise
Contraindications
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Pregnancy
Asthma insufficiently controlled with oral
steroids
Hypersensitivity
Severe hepatic impairment
Rare hereditary disorders:
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Galactose intolerance, Lapp lactase deficiency, glucose-galactose
malabsorption
Issues with ellaOne
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Should only be used once per cycle
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Should NOT be used if suspicion of an implanted pregnancy
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Not to be used with enzyme inducers as they reduce efficacy
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Can NOT double the dose for any reason
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Should not be used with any drugs that increase gastric Ph
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Should avoid breast feeding for 36 hours after taking
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Use may reduce the efficacy of progesterone containing
contraceptives.
Weight and oral emergency
contraception failure
7
6
Failure %
5
4
Normal BMI
3
25-29.9
>30
2
1
0
UPA
Glasier et al. Contraception 2011
LNG
UPSI and oral emergency
contraception failure
4
3.5
Failure %
3
2.5
2
UPA
1.5
LNG
1
0.5
0
Outside fertile window
Glasier et al. Contraception 2011
Inside fertile window
Don’t forget IUDs
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> 99% effective
May be inserted within 120 hours of UPSI or within 5
days of earliest expected ovulation
Mode of action – inhibits fertilisation (+ antiimplantation)
Efficacy not affected by concomitant drug use
STI risk assessment and or prophylactic antibiotics
Know local pathway for IUD insertion
Give oral EC if delay in IUD insertion
May keep IUD for ongoing contraception
IUD myths of 20th century
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Increased risk of PID
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Increased risk of tubal infertility
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Increased risk of ectopic pregnancy
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Can’t be used in nullips
IUD myths of 20th century
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Increased risk of PID
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Increased risk of tubal infertility
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Increased risk of ectopic pregnancy
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Can’t be used in nullips
Quick Starting
Sub-dermal implant
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Failure rate <0.1% at 3 years
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Regular follow-up not required
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Position of implant important for removal
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Counselling important for compliance
SDI ‘failures’
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1.4 million users in 11 years
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600 pregnancies reported since 1999
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> 50% non-insertion
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25% using liver enzyme inducers
‘Sort me out Doc!’
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49 yr old
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IUS for 4 years
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No bleeding for 4
years
Recently started
heavy irregular
bleeding
Medical Mx of HMB
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IUS reduces MBL by 79 – 97% @ 6 months
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Local effect
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Avoids systemic effects
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High risk endometrial hyperplasia
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1st line Rx for obese women
Bleeding patterns with the IUS
%
Spotting
Abnormal Bleeding with hormonal
contraception
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30-40% new users of any type of oral contraception in first
3 months have IMB
 due to insufficient sex steroid or
 inconsistent pill-taking.
Irregular bleeding with progesterone only contraception
frequent but with persistence often subsides
Women developing problems later on need Ix to exclude
pathology
Counselling is important to prevent anxiety and improve
compliance
Abnormal Bleeding with hormonal
contraception
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Take a clinical history
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Woman’s concerns
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Correct use of method
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Other symptoms
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Exclude sexually transmitted infections
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Check the cervical screening history
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Consider the need for a pregnancy test
Bleeding problems with Nexplanon
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Pre-insertion counselling important
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Exclude pathology
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Drug treatments
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COC cyclically for 2-3 months
Progestogens –MPA 10mgs bd for 3 months
POP- Cerazette
NSAID for 5-10 days
Tranexamic acid 500mg twice daily for 5 days
Return of bleeding likely when treatment stopped
Bleeding problems with DMPA
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Pre-insertion counselling important
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Menstrual disturbance
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unpredictable 2-3months
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34% amenorrhoea at 3 months
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70.3% at 12 months
Consider giving first 2-3 injections every 8-9 weeks
Exclude pathology
Drug treatments
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COC
Oestrodiol
Female sterilisation
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Regret
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20% women <30
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6% women >30
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Reversibility
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Failure rate
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1 in 200
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1 in 130 post- LSCS
Operative risk
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1 in 1200 endoscopic injury
Menstrual problems
Hysteroscopic sterilisation
adiana
essure
Improving compliance
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Offering choices
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Right product, right time
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Managing expectations
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Counselling re side effects
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Managing adverse effects
Thank- you
Any Questions?