Wednesday 30 th March
GP VTS

 What to consider with contraception
 Pills
 IUD/IUS
 Implants and injection
 Special circumstances
 QOF
 Case studies

 Surgical methods - no funding
 Natural methods
 Gillick (in too much detail)
 Infertility

 Common consultation
 Increased choice
 Benefits and risks
 Unwanted pregnancy

 Personal preference
 Lifestyle
 Medical history
 Family history
 Risk of STI

 Confirm not pregnant
 Previous methods
 Current medical problems
 BP
 Migraine?
 Smoker?
 Family history of cancers

 Vary by oestrogen content
 Vary by progesterone type
 21 pills then break

 Aged 35y + smoker
 >50y
 HTN
 IHD/CVA/PVD
 DM
 VTE
 Focal migraine

 Female malignancy
 Hormonal problems in pregnancy
 Breast feeding
 Acute hepatitis
 Porphyria

 Microgynon 30
 Ovranette
 150mcg - levonorgesterol (progesterone)
 30mcg – ethinylestradiol (oestrogen)
 £2.99
 £2.29

 Acne
 Headache
 Depression
 Weight gain
 Breast symptoms
 Decreased libido

 Desogesterel – Marvelon
 Gestodene – Femodene
 Norgestimate – Cilest
 Drospirenone - Yasmin
 £6.70
 £7.18
 £11.94
 £14.70

 Cyproterone acetate – Dianette
 £3.70
 Not licensed for contraception alone
 Used in treatment of acne

 Breast tenderness
 Nausea
 Weight gain
 Bloating
 Loestrin 20 – 20mcg ethinylestradiol
 £2.70

 First few months
 Exclude other cause
 Compliance

 New advice on antibiotics
 Enzyme inducers
 Affect all hormonal contraception

 Current advice
 Take ASAP
 2 or less
 3 or more

 Older women
 Smokers
 VTE history
 HTN, DM, Migraine
 Breastfeeding <6m post-partum

 Cerazette- desogesterel - £8.85
 Micronor/Noriday – norethisterone - £2.00
 Femulen – etynodiol - £3.31
 Norgeston – levonorgesterel - £0.98

 Start on day 1 of cycle
 Take every day – no breaks
 Missed pill
 D+V

 Higher failure rate
 Irregular bleeding
 Risk of ectopic

 LARC 23% of primary methods of contraception
 LARC methods
 intrauterine devices [IUDs]

 the intrauterine system [IUS] injectable contraceptives
 implants
 all LARCs more cost effective than the COCP even at
1 year of use
 IUDs, the IUS and implants are more cost effective than the injectable contraceptives (DMPA)

All LARC methods are suitable for:
 nulliparous women
 breastfeeding
 women who have had an abortion
 BMI > 30
 women with HIV – encourage safer sex
 women with diabetes
 women with migraine with or without aura – all progestogen-only methods may be used
 women with contraindication to oestrogen

 contraceptive efficacy
 duration of use
 risks and possible side effects
 non-contraceptive benefits
 initiation and removal/discontinuation
 when to seek help while using the method.

Copper IUDs IUS (Mirena) Progestogen-only injections
Unacceptable vaginal bleeding/pain
Ectopic pregnancy
1/20 (lower than without contraception)
Unacceptable vaginal bleeding/pain
Ectopic pregnancy
1/20
Altered bleeding pattern eg. persistent
Small loss in bone mineral density, largely recovered when stopped.
Implants
Irregular bleeding
Acne
PID <1% low risk women
PID <1% Weight gain – up to 2-3kg over a year
Uterine perforation
<1/1000
Uterine perforation
<1/1000
No evidence of effect on depression, acne or headaches
No evidence of effect on weight, mood, libido, headaches, BMD
Mood/libido change
No weight gain
Mood/libido change, acne
No weight gain

 Progestogen-only implants/DMPA may improve dysmenorrhoea and the symptoms of endometriosis.
 Up to 20% of women using a progestogenonly implant will be amenorrhoeic
 A RTC found a significant reduction in dysmenorrhoea and menorrhagia with the
LNG-IUS (Mirena) when compared to a Cu-
IUD.

Implanon/Nexplanon

 Nexplanon® is a progestogen-only subdermal implant ( non palpable ) - now replaced Implanon®.
 Nexplanon and Implanon are bioequivalent (i.e. they both contain 68 mg etonogestrel and they have the same release rate and 3-year duration of action).
 Nexplanon is radio-opaque and has a different application device and insertion technique.

When fitting:
Check the woman is not pregnant!
Nexplanon may be inserted:
 at any time
(but use barrier methods for first 7 days if the woman is amenorrhoeic or it is more than 5 days since menstrual bleeding started)

 Prevention of ovulation.
 3 years
 No delay
 20% of users - no bleeding
 50% will have infrequent, frequent or prolonged bleeding
 Bleeding patterns are likely to remain irregular.
 Not recommended for women taking enzymeinducing drugs eg. Anti-epileptics, St.Johns Wort.
 Useful if high BMI

Copper devices or Mirena coil.

 Test for:
 Chlamydia trachomatis in women at risk of
STIs
 Neisseria gonorrhoeae in women at risk of
STIs in areas where it is prevalent
 For woman at increased risk of STIs, give prophylactic antibiotics before inserting an
IUD or IUS if testing has not been completed.

 Like the implant - an IUD or IUS may be inserted:
 at any time
 If the woman has epilepsy, seizure risk may be increased at the time of fitting an IUD or
IUS.
 Women with a history of venous thromboembolism (VTE) may use the IUS.

 Pelvic infection risk - 20 days following insertion
 risk same as non-IUD-using population thereafter
 Irregular bleeding common in the first 6 months after insertion of the LNG-IUS but by 1 year amenorrhoea or light bleeding is usual.

 Previous endocarditis
 Prosthetic heart valve
 require intravenous antibiotic prophylaxis
 Copper is toxic to ovum and sperm inhibiting fertilisation.
 In addition, the endometrial inflammatory reaction has an antiimplantation effect and alterations in the copper content of cervical mucus inhibit sperm penetration.

 A Cu-IUD inserted when a woman >40 years can be retained until the menopause is confirmed.
 >50yrs - 1 year after the last menstrual period
 <50yrs - 2 years
 Copper IUDs - 5-10 years

 Prevents implantation.
 Effects on cervical mucus reduce sperm penetration.
 Inserted >45 years and amenorrhoeic - may retain the LNG-IUS until the menopause.
 Randomised trials show that the LNG-IUS provides effective contraception for up to 7 years – licensed for 5 years .

 At first follow-up visit (after the first menses, or 3–6 weeks after insertion)
 exclude infection, perforation or expulsion.
 IUD only: For heavier and/or prolonged bleeding associated with use of an IUD:
 – treat with NSAIDs and tranexamic acid
 – or suggest changing to the IUS if the woman finds bleeding unacceptable.

Depo Provera

Depo Provera or Noristerat (short term use)
Inhibits ovulation.
Check not pregnant!
Can give:
 – up to 5 th day of the menstrual cycle without the need for additional contraceptives
 – or use barrier contraception 7 days

 Every 12 weeks
 Deep intramuscular injection
 into the gluteal or deltoid muscle or the lateral thigh
 Delay up to 1 year in the return of fertility BUT
 …no evidence of reduced fertility long term

 Amenorrhoea (14.4%)
 Infrequent bleeding (24.2%)
 Spotting (27.9%)
 Prolonged bleeding (33.5%) were all reported

 Small loss of BMD, which is usually recovered after discontinuation.
 Women should be advised that there is no available evidence on the effect of DMPA on longterm fracture risk.
 Use may continue to age 50 years.

 Can try:
 3 cycles of 20-30mcg COC, taken cyclically
– can be repeated
 If COC contraindicated: mefenamic acid
500mg BD until bleeding settles…
 Cerazette 1 tab daily for approx. 3 months

 Repeat injections may be given up to 2 weeks late.
 DMPA use >2 years, review and discuss the balance of benefits and risks again eg. BMD
 No evidence of congenital malformation to the fetus if pregnancy occurs during DMPA use.
 Good choice if on enzyme-inducing drugs

Routine follow-up
IUD/IUS
 At 3–6 weeks
 Return if problems or time for removal.
Injectable contraceptives
 Every 12 weeks; every 8 weeks for NET-EN
Implants
 No routine follow-up

Under 16s and post-partum

Fraser Guidelines and Gillick Competence

 Be aware of the law
 Duty of care and a duty of confidentiality to all patients, including under 16s.
 > 25% of young people are sexually active
<16 years.
 Least likely to use contraception.
 Confidentiality

 If considering any disclosure of information
- weigh up a right to privacy against:
 current or likely harm
 what any such disclosure is intended to achieve
 potential benefits to the young person’s well-being.
 Except in the most exceptional of circumstances consult the young person and offer to support a voluntary disclosure.

 the young person understands the health professional’s advice;
 cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice;
 the young person is very likely to begin or continue having intercourse with or without contraceptive treatment;
 unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer;
 the young person’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent .

The Act states that, a person is not guilty of aiding, abetting or counselling a sexual offence against a child where they are acting for the purpose of:
 protecting a child from pregnancy or STIs
 protecting the physical safety of a child,
 promoting a child’s emotional well-being by the giving of advice.

Choices for women post-partum, including breastfeeding
 IUD – copper: from 4 weeks after childbirth
 IUS - Mirena: from 4 weeks after childbirth
 DMPA injection: any time after childbirth, if
>21 days need additional.
 Implants - Nexplanon: any time after childbirth; if >21 days postpartum need additional

 Progestogen-only injectable contraception or implant is appropriate:
 after surgical abortion
 (second part of) medical abortion
 miscarriage.
 If DMPA or Nexplanon within 5 days
 Ideally insert IUD or IUS within the first 48 hours or delay until 4 weeks postpartum.

 Less than 72 hours – levenorgesterol - 1.5mg
 Between 72h and 120h – EllaOne
 Most effective is Copper IUD

 Advise to return if abdominal pain or next period overdue
 Advice on STI
 Plan contraceptive follow up

 Less than 24w
 Reasons
 Medical and surgical
 Marie Stopes centres
 http://www.mariestopes.org.uk

 LARC – offered and coded
 Chlamydia testing – people under 25

 17y
 Only current partner
 BMI 22
 Non-smoker
 Wants contraception

 Comes back 3m later
 Spots over face, some on back

 42y
 Finished family
 Wants something long term

 24y
 New baby
 Unplanned pregnancy

 37y
 Heavy smoker
 BMI 42
 Bed bound
 Diabetic
 Previous DVT
 BP 172/104

 Faculty of Family Planning
 Oxford handbook of General Practice
 BNF
 Marie Stopes
 Monkgate Clinic