Getting contraception right for women in 2012 and beyond
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Transcript Getting contraception right for women in 2012 and beyond
‘Doc I’ve had an accident’
33 year old
Burst condom
BMI 35
Wants the
morning after pill
Emergency contraception
Cu- IUD
Levonelle
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
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
Acts by inhibition of ovulation - up to 5 days
Less effective when UPSI occurs around
time of ovulation
Effective up to 96 hrs
Repeat dose if vomiting within 2 hours
Multiple doses possible in each cycle
ellaOne
ulipristal acetate
synthetic progesterone receptor modulator
as effective as Levonelle and licensed for use
up to 120 hours after unprotected sex
No reduction in efficacy over the 120 hours
£16.95
Mode of action
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
Pregnancy
Asthma insufficiently controlled with oral
steroids
Hypersensitivity
Severe hepatic impairment
Rare hereditary disorders:
Galactose intolerance, Lapp lactase deficiency, glucose-galactose
malabsorption
Issues with ellaOne
Should only be used once per cycle
Should NOT be used if suspicion of an implanted pregnancy
Not to be used with enzyme inducers as they reduce efficacy
Can NOT double the dose for any reason
Should not be used with any drugs that increase gastric Ph
Should avoid breast feeding for 36 hours after taking
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
> 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
Increased risk of PID
Increased risk of tubal infertility
Increased risk of ectopic pregnancy
Can’t be used in nullips
IUD myths of 20th century
Increased risk of PID
Increased risk of tubal infertility
Increased risk of ectopic pregnancy
Can’t be used in nullips
Quick Starting
Sub-dermal implant
Failure rate <0.1% at 3 years
Regular follow-up not required
Position of implant important for removal
Counselling important for compliance
SDI ‘failures’
1.4 million users in 11 years
600 pregnancies reported since 1999
> 50% non-insertion
25% using liver enzyme inducers
‘Sort me out Doc!’
49 yr old
IUS for 4 years
No bleeding for 4
years
Recently started
heavy irregular
bleeding
Medical Mx of HMB
IUS reduces MBL by 79 – 97% @ 6 months
Local effect
Avoids systemic effects
High risk endometrial hyperplasia
1st line Rx for obese women
Bleeding patterns with the IUS
%
Spotting
Abnormal Bleeding with hormonal
contraception
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
Take a clinical history
Woman’s concerns
Correct use of method
Other symptoms
Exclude sexually transmitted infections
Check the cervical screening history
Consider the need for a pregnancy test
Bleeding problems with Nexplanon
Pre-insertion counselling important
Exclude pathology
Drug treatments
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
Pre-insertion counselling important
Menstrual disturbance
unpredictable 2-3months
34% amenorrhoea at 3 months
70.3% at 12 months
Consider giving first 2-3 injections every 8-9 weeks
Exclude pathology
Drug treatments
COC
Oestrodiol
Female sterilisation
Regret
20% women <30
6% women >30
Reversibility
Failure rate
1 in 200
1 in 130 post- LSCS
Operative risk
1 in 1200 endoscopic injury
Menstrual problems
Hysteroscopic sterilisation
adiana
essure
Improving compliance
Offering choices
Right product, right time
Managing expectations
Counselling re side effects
Managing adverse effects
Thank- you
Any Questions?