Family Planning

FAMILY PLANNING
Sarah Stradling
GP Camberley Health Centre
OVERVIEW
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Combined Contraception
Emergency Contraception
Gillick competence
LARC
POP
Other methods
The new kids on the block
Case studies
The perfect contraceptive?
• The perfect contraceptive would:
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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.
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
I would like to go on the pill…
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Age
Contraceptive hx
Menstrual hx, LMP
Obstetric hx- ectopic?
Medical hx
Medication
Allergies
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Options
Risks/benefits
Mode of action
Side effects
Teaching about method
PILS
Follow up
Special instructions
COMBINED ORAL
CONTRACEPTIVES
‘The Pill’
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Mode of action and efficacy
First consultation
UKMEC
Risks
Initiation
Missed pill guidance
Choice of pill and managing side effects
• Commonest hormonal
• Action- anovulatory
– reduces endometrial lining
Pills 1-7 INHIBIT OVULATION
Pills 8-21 MAINTAIN ANOVULATION
Important when considering ‘missed pills’
• Pearl Index- 0.3- 4.0
• Perfect use vs. true use
• Promote safe sex- condoms
– Sexual health screening
– Opportunistic chlamydia (1:10 <25)
First COC consultation
• Clinical HxMedical conditions
Drug use prescription and OTC
Family hx
• Specific enquiries
• User preference and concerns
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
Risks
• Ageto what age can it be safely used?
• Smokingcan the coc be used in a 30 y.o smoker?
• Obesity (BMI 30-34;2 35-39;3)
• Blood pressure
Not Recommended
(UKMEC category 4)
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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
‘The pill scare’
• VTE:
Increase five fold, remains low
No screen needed
Different progestogens associated with risklevonorgestrel and norethisterone may
counteract thrombogenic effect of EE better than
desogestrel and gestodene
Greatest risk in first year
Normal within weeks of stopping
• Dianette- 35mcg EE and cyproterone
acetate
Four fold increase risk vs. microgynon 30
Limit duration of use
Yasmin? Lies between the above
Non COC/not pregnant
Risk per 100,000
women years
5
Levonorgestrel/norethisteron
(Microgynon, Loestrin)
15
Desogestrel/gestodene
(Marevlon, mercilon,
fermodene
25
Pregnancy
60
• Migraine:
Migraine + aura (any age)
Migraine – aura
Risk of ischaemic stroke
Is it an aura??
• Breast Cancer:
– No increase risk if family hx
– Gene carriers
– Current breast ca vs. past ca (>5yrs ago)
• 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.
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?
• 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 headacheOUTSIDE LICENCE
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?
• Post partum- ideally day 21
• Amenorrhoea- anytime + 7day
• Post TOP- up to 7 days
‘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
If 1 pill missed at any time in packet
Take the missed pill as soon
as remembered
Continue remaining pills as normal
Emergency contraception is not usually needed but
consider if earlier pills missed
If 2 or more pills missed at anytime in packet
Take most recent missed pill
Take remaining pills as usual
Advised to use condoms/abstain until
has taken 7 pills in a row
Pills 1-7: Consider EC
Pills 8-14: Nil
Pills 15-21:Omit pill free interval (ED)
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PILS
Drug information leaflet
NHS direct
GP
OOH
Patient.co.uk
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
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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
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 pille.g. Cilest, Brevinor, Marvelon
• 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
• Changing from another form of
contraception to COC and vice versaMIMS 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
NUVARING
• Once a month intravaginal ring
• Low oestrogen (2mg ethinyloestradiol15mcg daily and etonogestrel)
• Individually packaged
• No GI absorption- malabsorptive
disorders, binge drinking, vomiting
• May view as user controlled LARC
• 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
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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
QUESTIONS?
EMERGENCY
CONTRACEPTION
Preventing pregnancy following
UPSI/contraceptive failure
1. 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
• 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
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
‘The Morning after pill’
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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
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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
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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
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
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
Other discussions
• Sexual health screening
• Ongoing contraception
• ?start alternative method before next
period
• Young people- No medical reason to avoid
– Child protection issues
GILLICK COMPETENCE
• Gillick vs. West Norfolk HA (1986)
• DOH guidance
• Law Lords Ruling (Fraser ruling)…..
“ A clinician may provide treatment to a young
person <16years, without parental consent,
provided that he/she has confirmed that they are
competent and that the Fraser criteria have
been met”
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Advice understood
Will have or continue to have sex
Advised to inform parents
In the patients best interests
• Age <13years- responsibility to inform
social services, advise patient
• Consider each case on merits
• 15 year old with a 17 year old partner
• 15 year old with a 35 year old partner
• 12 year old with a 14 year old partner
Case 1
• 20 y.o on Microgynon 30, has missed her
last 2 pills and she is in the last week of
her packet.
She had sex without a condom yesterday
and is worried about her pregnancy risk…
What would you advise her?
Case 2
• 26 y.o had a split condom 4 days ago.
She has a 28 day regular cycle and is
now day 15 of cycle. She is requesting the
morning after pill…
How do you counsel her?
LONG ACTING REVERSIBLE
CONTRACEPTION
LARC
Options
• IUD
• IUS
• Injectable progestogens
• Progesterone only implant
• NICE- Discuss with all women-QOF
• Cost effectiveness at 1 year >COC
• ↑ use of LARC leads to ↓unwanted
pregnancies
Copper
IUD
Mechanism
Duration
Injection
Implants
Fertilisation Prevents
and
Implant
implantation
Prevents
ovulation
Prevents
ovulation
5-10yrs,
unless 40+
5 years
unless 45+
12 weeks/ 8
weeks
3 years
<1/100
<0.4/100
<0.1/100
Failure Rate <2/100
Risks
IUS
Bleeding
Dysmen
Ectopic1:20
PID
Perforation
Bleeding
Bleeding
Ectopic
Weight gain
PID
BMD
Perforation
Libido/acne
Bleeding
Acne
Bleeding patterns
• IUD- Increased and often dysmenorrhoea
• IUS- 6/12 often irreg, amenorrhoea 65%
after 1 year
• Injectable- 70% amenorrhoea at 1yr
• Implant- 20% amenorrheoa, 50% irregular
Fertility
• No alternation with IUD/IUS/Implant
• Injectable- up to 1 year, detectable in
serum at 9/12
• No guarantee on stopping
Suitability
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Nulliparous
Breast feeding
BMI
Post TOP
Diabetes
Migraine + aura
CI to oestrogen
IUD/IUS
• Chlamydia testing
• Ensure not PG prior to insertion
• Review at 6/52, trouble shooting
• IUD immediate cover
• IUS may need alternative
• Advise early return if pain or discharge, remind re
bleeding
• Use of tranexamic acid
• Systemic effects with IUS
• Lost IUD/IUS? Pregnant?
• Partner dissatisfaction
• Length of protection
• Risks
– Perforation: 1:1000
– Expulsion: 1:20
– Ectopic: 1:20
– PID: 6 times increased risk in first 20 days,
then low
INJECTABLE
‘Depo’
• DMPA (12/52) and NET-EN (8/52)
• Deep IM, well mixed
• Can safely be given up to 12+5-licence
• Can give up to 14 weeks-faculty guidance
• Emergency drug availability
• Review every 2 years re ongoing use
• Not affected by liver enzyme inducers
• ?EC if greater 12+5 and upsi
• Up to age 50- consider change at 45+
• Weight gain and elevated BMI
• Document date of next injection
BMD and injectables
• Caution if <18 or >40
• Systematic review- reduction in BMD after
1 year but recovers after stopping
• MHRA
– If <18 consider all other options before use
– Revaluate every 2 years
– If RF for OP consider alternative
IMPLANON/NEXPLANON
• Single subdermal rod
• Norplant- 5 rods, 1999, poor advice
• No effect on BMD
• Affected by liver enzyme inducing drugs
• ?trial of cerazette
• 8-10cm above medial epicondyle
• Woman must palpate
• No routine f/u
• Bleeding- tranexamic acid or COC
• Full assesment with IMB
• If cannot palpate- Xray
PROGESTERONE ONLY
PILL
• Mode of action– Cervical mucus
– Ovulation (up to 60% or 97% with desogestrel)
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Daily
No pill free interval
Takes 48hrs to thicken mucus
3Hrs- Femulen, Micronor, Noriday, Norgeston
12hrs- desogestrel (cerazette)
• Failure rate 0.3-8.0%
• Decreases with age
• Traditionally double dose if BMI >70kg,
NO evidence to support this and use of
one pill is recommended
• Only UKMEC 4 is breast ca
Missed Pill advice…
Traditional POP
Desogestrel POP (Cerazette)
>3hr late i.e.
>27hrs since last pill
>12hrs late i.e.
>36hrs since last pill
1. Take the missed pill
2. Take the next pill at the usual time (this may mean 2 pills in 1 day)
3. Condoms or abstinence for the next 48 hrs
4. No need for EC if sex before the missed pill
• 3 hr window may be difficult
• Cerazette £8.68 vs. micronor £1.80
• Generic desogestrel £4.30
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Advise re vomiting
Avoid if using liver enzyme inducers
Not affected by antibiotics
No effect on lactation
Migraine
Bleeding Patterns
• Commonest reason for stopping
• Good counselling may reduce
• 70% report prolonged, BTB or spotting
• General Guide
– 20% amenorrhoea
– 40% regular pattern
– 40% erratic
• Level of tolerance
• ?use of increased dose for BTB, anecdotal
but poor evidence.
Remember if new bleeding pattern in previously
untroubled patient…
?STI, Drug interactions, compliance, pregnancy
• Commence in first 5 days- immediate
cover
• Anywhere else extra precautions for 48hrs
• Can continue until the menopause
OTHER METHODS
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Condoms
Diaphragm
LAM
Sterilisation
Natural family planning
CONDOMS
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Male and female condoms
Traditionally latex
Polyurethane condoms
Latex allergy- usually local but may be
systemic
• EU safety tested and kite mark
• Always look for the exp. date
• Breakage and slippage reduce with
experience
• Avoid oil based lubricants e.g. baby oil and
petroleum jelly
• Failure rate:
– True 2%
– Actual up to 15%
• Latex vs. latex free- efficacy the same
Evidence supports the use of condoms to
reduce the risk of STI. However, even with
consistent and correct use, transmission may
still occur.
• Free condoms from family planning
centres
• No restriction on selling condoms to those
under 16years
• No evidence to suggest that supplying
condoms encourages sexual activity
DIAPHRAGMS AND CAPS
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Diaphragm lies across the cervix
Perfect use failure rate 4-8%
True use 10-18%
Need to be used with a spermicide
Needs teaching
• Caps are much smaller
• Rarely used
• Advantages:
– Non hormonal
– More independent of intercourse than condom
– Reduces the risk of HPV transmission
• Disadvantages:
• Messy
• Forward planning
• Low efficacy
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Must apply spermicide to both sides
Active for 3hrs
Leave in for at least 6hrs post intercourse
Top up if intercourse again
Remove, wash and allow to dry
• Resizing needed if >3kg weight change, TOP,
miscarriage, vaginal delivery, vaginal surgery
LACTATIONAL AMENORRHOEA
• No guidance provided by faculty
• A method of contraception??
• Reported failure of 2%
• Criteria to be met:
– No return of periods
– Baby is nearly or fully breastfed (4hrs in the day and
6hrs at night)
– The baby is less than 6 months old (i.e. pre weaning)
Note: ‘nearly fully breastfed’ means that the infant
receives mostly breast milk but can have ‘some’
alternative liquids
STERILISATION
• Counselling, especially LARC, permanent
• Take a full contraceptive hx
• No absolute CI- make request themselves,
sound mind and no external duress
• Female- Tubal occlusion, alternative method
until surgery and until the next period
• Male- No scalpel approach with division of vas
and diathermy, contraception until clearance
• Failure rate:
– Women 1:200 (same as IUS)
– Men 1:2000 after clearance
If pregnancy occurs after female sterilisation
increased risk of ectopic.
Increase report of heavy periods after
sterilisation.
• Persona
• Natural family planning- temperature,
cervical mucus, avoidance of ‘unsafe time’
around ovulation (days 12-16 of a 28 day
cycle)
The New Kids On The Block
• Zoley- Estradiol, 24 active and 4 inactive.
Good cycle control, 1 in 3 bleed free
cycles. Well tolerated
• Jaydess- IUS for 3years. Aimed at
younger women. Smaller insertion device.
Not licensed for DUB or HRT. Less
amenorrhoea, but lighter flow
• Sayana Press- s/c version of depo. Same
s/e and licence. More expensive, pt
reports more skin reactions and worse
pain at administration.
QUESTIONS??
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18 y.o off to uni, previous termination, no
regular partner but admits to having
regular one night stands. How do you
advise her?
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34 y.o smoker asking for a cocp repeatMicrogynon. What issues do you need to
consider and how do you advise her?
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28 y.o. with a young baby and a 3 year
old. Thinks that she would like more
children but with a gap. Had the depo
before and this suited her really well.
What issues do you need to consider
and how do you advise her?
4
• 32y.o would like to have a ‘coil’. Her sister
has a copper coil and she likes the idea of
no hormones. Has heavy periods with
flooding and dysmenorrhoea. How do you
advise her?
5
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23 y.o comes asking for ‘the pill’. Has
never had any contraception before other
than using condoms. How would you
approach this consultation?
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15 y.o comes with a friend asking to go
on the pill. She asks you to promise that
you won’t tell her mum- who is a regular
patient of yours. What issues does this
consultation present? Would you
prescribe to her?
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25 y.o that has been on the cocp for 5
years has recently been diagnosed with
epilepsy and started on carbamazepine.
She was advised to come by her
neurologist. What contraceptives are
available to her and where would you go
to get the information if you wanted to be
sure?
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19 y.o who has a BMI of 34 and a 5 a
day smoker comes asking for the pill.
She has had emergency contraception
twice in the last 4 months. What are her
options, how would you advise her?
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She decides on POP, how and when do
you start this?
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20 y.o had UPSI 3 days ago with her
long term partner, they usually rely on
condoms. She is on day 10 of a 28 day
cycle. What options are available to her
and what would you advise?
10
• 14 y.o. was drunk at a party last night and
thinks that something may have happened
with a ‘boy’ she barely knows. What are
the issues and how would you advise her
11
• Linda is forty years old, married with three
children. She is a non smoker and has
been taking the COCP for 7 years. She
stopped taking it last week because her
younger sister has been admitted to
hospital with a DVT. She does not really
want any more children. What are her
options?
12
• Sam is 35, she has recently got divorced.
She has one child. She has had a coil for
the last 9 years. She knows her coil will
need changing soon. She is not sure if she
wants another one. What is your advice?
13
• Gemma is 22. She has the depo injection
and has attended for her next injection.
Her last one was 15 weeks ago. She had
sex 2 days ago. What do you do?
Useful websites
• Fpa.org.uk (formerly Family Planning
Association)
• BNF online
• Mims online
• www.fsrh.org.uk
• Contraception- John Guillebaud
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