Transcript Oral Contraception and EHC

Hormonal Contraception and EHC
for Health Information Advisors
Trainer’s name
XX Medicines Information Service
Learning Outcomes
1. Have baseline knowledge and understanding about
hormonal contraception including
 Types of hormonal contraception, mode of action, risks,
cautions, side effects and drug interactions.
 Implications and advice for missed doses and dosing
errors.
 Indications and limitations of Emergency Hormonal
Contraception (EHC).
2. Be able to use the NHS Direct emergency
contraception and missed pill algorithm.
Hormonal Contraception and EHC December 2007 Version 1.0
Plan for the Day
9.30
Introduction & learning
outcomes
Baseline knowledge for
hormonal contraception
 Types, action, risks,
cautions, side effects,
interactions.
 Missed doses and dosing
errors.
12.45 Lunch
EHC & missed OC algorithm
Workshop 2
3.00 Tea break
Workshop 2 (continued)
4.00 Review of learning outcomes
& close
10.45 Tea break
Emergency Hormonal
Contraception (EHC)
Workshop 1
Hormonal Contraception and EHC December 2007 Version 1.0
Contraceptive Options
Hormonal Methods







Combined OC pill
Progestogen-only pill
Patches
Injections
Implants
Intrauterine devices
Emergency Hormonal
Contraception (EHC)
Non-Hormonal Methods








Sterilisation
Abstinence
Interruptus
Condoms – male and
female
Diaphragms and Caps
Spermicides
Intra uterine devices
Rhythm methods
Hormonal Contraception and EHC December 2007 Version 1.0
Combined Oral Contraceptive Pill
Oestrogen
Progestogen
Ethinylestradiol (EE)
Mestranol
Norethisterone
Desogestrel
Levonorgestrel
Gestodene
Norgestimate
Drospirenone
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: How does it work?
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Monophasics

Fixed amount of
oestrogen & progestogen

One tablet daily for 21
days then a 7 day pill free
period.

Every Day (ED) - One
tablet daily for 21 days
then 7 days of dummy
tablets.

> 99% effective, when
used properly.
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Monophasics
Low Strength
20 microgram EE
Standard Strength
30-35 microgram EE
Loestrin 20
Mercilon
Femodette
Microgynon 30
Loestrin 30
Marvelon
Minulet
Femodene
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Biphasics & Triphasics

Varying amounts of
oestrogen and
progesterone according
to stage of the cycle.

Useful when there is
breakthrough bleeding
or no withdrawal bleed
on monophasics.
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Biphasics & Triphasics
Biphasics
Triphasics
Binovum
Logynon ED
Synphase
Trinordial
TriNovum
Tri-Minulet
Triadene
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Risks

Migraine
Increased stroke risk in migraine sufferers
 Risk my be increased in COC users
 Headache with aura plus neurological
symptoms


Cancer
Very small  risk of breast cancer.
 Protects against ovarian and endometrial
cancer.

Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Breast Cancer Risk
User Status
Risk
Non User <35 years
~1/500
Current user
+ 24 %
1-4 years post
+ 16%
5 years post
+ 7%
10 years or more post
Hormonal Contraception and EHC December 2007 Version 1.0
Not significant
COCs: Risks

DVT



Healthy women non pregnant - 5-10 /100,000
2nd gen pill – 15/100,000 3rd gen pill – 25/100,000
Caution if 1, avoid if 2 of: PMH, family history,
obesity, immobility.
Stroke and MI

Caution if 1, avoid if 2 of: PMH, family history,
diabetes, BP, smoking, >35 years, obesity,
migraine.
Hormonal Contraception and EHC December 2007 Version 1.0
“Tricycling” Monophasics

Running three packs together
 Four Pill Free Intervals per year
 Three extra packets of hormone per year
 Reduces hormone fluctuations

Unlicensed
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Missed doses


7 days of pill taking puts
the ovaries to sleep.
NHSD CAS algorithm
Ovaries wake up if miss



Guidance
10 days of standard
strength pill.
Family Planning
Association (FPA)
Patient information leaflet
9 days of low
strength pill.
The 7 pill free days are
safe.
eBNF
Faculty of Family Planning
& Reproductive Health
(FFPRHC)
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: Missed doses
1-2 standard strength or
1 low strength
3 standard strength or
2 low strength

Take pill now and then
continue as normal.

Take pill now and then
continue as normal.

No extra precautions.


No emergency
contraception.
Extra precautions until
taken 7 pills in a row.

Week 1 – EC indicated.
Week 2 – No EC.
Week 3 – No EC, start
new pack, no break.
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: 3 standard strength or 2 low
strength missed
Pill
free
Wk 1
Wk 2
Wk 3
Pill
free
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: 3 standard strength or 2 low
strength missed
Pill
free
Wk 1
Wk 2
Wk 3
Pill
free
Hormonal Contraception and EHC December 2007 Version 1.0
COCs: 3 standard strength or 2 low
strength missed
Pill
free
Wk 1
Wk 2
Wk 3
Pill
free
Hormonal Contraception and EHC December 2007 Version 1.0
Progestogen Only Pill (POP)

One active ingredient –
progesterone.

Taken continuously with
no break.

Alternative if COCs are
contraindicated.

Relies on motivation of
the user.
Hormonal Contraception and EHC December 2007 Version 1.0
Progestogen Only Pill

Benefits
Well tolerated
 No proof of increased
disease risk
 Useful in lactation
Brand Names


Drawbacks
Precise timing
 Changes in menstrual
pattern

Hormonal Contraception and EHC December 2007 Version 1.0
Femulen
Micronor
Norgeston
Noriday
Cerazette
POP: Missed doses
Less than 3 hours late

Take the missed pill
immediately and
continue as normal.

No extra precautions.

No emergency
contraception.
More than 3 hours late

Take the missed pill as
soon as possible.

Extra precautions until 2
further pills in a row.

EC if unprotected sex
before 2 further pills in a
row have been taken.
Cerazette: Instead of 3 hours read 12 hours
Hormonal Contraception and EHC December 2007 Version 1.0
POPs: More than 3 hours late
Wk 1
Wk 2
Wk 3
Wk 4
Wk 1
Hormonal Contraception and EHC December 2007 Version 1.0
Contraceptive Patch
 Evra
 Contains
 Low strength oestrogen
 Progestogen
 Dose
 1 patch a week (on
same day of week) for 3
weeks.
 One week patch free.
Hormonal Contraception and EHC December 2007 Version 1.0
Delayed Patch 1

Most risky time to forget to apply the patch.

Apply Patch 1 as soon as remembering. This is
now the beginning of the patch cycle (new start
day and change day).

Take extra precautions for 7 days.

If the delay was for more than 48 hrs (extends
patch free period) and unprotected sex emergency contraception is indicated.
Hormonal Contraception and EHC December 2007 Version 1.0
Delayed Patch 1
Patch
free
Wk 1
Wk 2
Wk 3
Patch
free
Hormonal Contraception and EHC December 2007 Version 1.0
Delayed Patch 2 or 3
If less than 48 hrs
(Extra 48hr drugs in patch)
If more than 48 hrs

Apply patch
immediately, keep usual
change day.

Stop current cycle and
start a new patch cycle
with a new Week 1.

No extra precautions.


No emergency
contraception.
Extra precautions for 7
days.

If prolonged patch free
period & unprotected
sex – EC is indicated.
Hormonal Contraception and EHC December 2007 Version 1.0
Delayed <48hrs Patch 2 or 3
Patch
free
Wk 1
Wk 2
Wk 3
Patch
free
Hormonal Contraception and EHC December 2007 Version 1.0
Delayed >48hrs Patch 2 or 3
Patch
free
Wk 1
Wk 2
Wk 3
Patch
free
Hormonal Contraception and EHC December 2007 Version 1.0
Detached patch
If less than 48 hrs

Apply patch
immediately, keep same
change day.

No extra precautions.

No EC.
If more than 48 hrs

Stop current cycle and
start a new patch cycle
with a new start day /
change day.

Extra precautions for 7
days.

If prolonged patch free
period & unprotected
sex – EC is indicated.
Hormonal Contraception and EHC December 2007 Version 1.0
Contraceptive Injection

Long acting
progestogen.

Depo-Provera.
 IM injection every 12
weeks.

Noristerat.
 IM injection every 8
weeks.
Hormonal Contraception and EHC December 2007 Version 1.0
Delayed injection
Up to 14 days late


World Health
Organisation (WHO)
states: no extra
precautions needed, EC
not indicated.
More than 14 days late

Extra precautions for 7
days.

Consider EC if
unprotected sex.
Manufacturer states up
to 5 days late but super
seeded by the WHO
advice.
Hormonal Contraception and EHC December 2007 Version 1.0
Contraceptive Implant

Long acting progestogen.

Implanon
 Subcutaneous implant
every 3 yrs.

Requires trained person
to insert and remove.

Manufacturer and WHO
do not state a safe delay
for Implanon.
Hormonal Contraception and EHC December 2007 Version 1.0
Vomiting & Diarrhoea

If vomited within 2
hours of pill taking, its
absorption will be
reduced and it may be
ineffective.

Diarrhoea alone without
vomiting has to be
severe to reduce the
absorption of the pill.

Handle as a missed pill.
Hormonal Contraception and EHC December 2007 Version 1.0
Drug Interactions

Broad spectrum antibiotics
e.g. amoxycillin, ampicillin, erythromycin.
May reduce the efficacy of COCs and patch.
No interaction with POPs, injection or implant.

Enzyme inducers
e.g. rifampicin, ritonavir, carbamazepine, St. John’s
Wort.
May reduce the efficacy of COCs, patch, POPs,
injection and implant.
Consider referral to UKMI.
Hormonal Contraception and EHC December 2007 Version 1.0
Emergency Hormonal
Contraception
Hormonal Contraception and EHC December 2007 Version 1.0
Emergency Hormonal
Contraception
When is EHC Indicated?

After unprotected sexual intercourse

Increased risk of contraceptive failure





Torn, leaking condom
Missed pills
Late implant or injection
Detached contraceptive patch
Dislodged IUD
Hormonal Contraception and EHC December 2007 Version 1.0
Levonelle 1500 “One Step”

High dose progesterone
- levonorgesterel.

One 1500mcg tablet
taken as soon as
possible after
unprotected intercourse.

Preferably within 12
hours, ideally no later
than 72 hours.
Hormonal Contraception and EHC December 2007 Version 1.0
EHC Efficacy Rates
Time EHC taken after
intercourse
Proportion of
pregnancies prevented
less than 24 hours
95%
25 to 48 hours
85%
49 to 72 hours
58%
Hormonal Contraception and EHC December 2007 Version 1.0
How does EHC work?

Depends on point in the menstrual cycle.

Thought to prevent or delay ovulation,
fertilisation and implantation.

Clinical opinion is that using EHC does not
constitute an abortion.
Hormonal Contraception and EHC December 2007 Version 1.0
EHC: Cautions & Side Effects

WHO – No absolute contra-indications.

Nausea 25%, vomiting 5%.

Care with liver enzyme inducers
e.g. rifampicin, St John’s Wort, ritonavir, phenytoin,
carbamazepine, barbituates.

Slightly increased risk of ectopic pregnancy.
Hormonal Contraception and EHC December 2007 Version 1.0
Where can you get EHC?






Community Pharmacies
GP
Walk-in Centres
Family Planning Clinics
Sexual Health Clinics
A&E
Hormonal Contraception and EHC December 2007 Version 1.0
Tea Break
Hormonal Contraception and EHC December 2007 Version 1.0
Plan for the Day
9.30
Introduction & learning
outcomes
Baseline knowledge for
hormonal contraception
 Types, action, risks,
cautions, side effects,
interactions.
 Missed doses and dosing
errors.
12.45 Lunch
EC & missed OC algorithm
Workshop 2
3.00 Tea break
Workshop 2 (continued)
4.00 Review of learning outcomes
& close
10.45 Tea break
Emergency Hormonal
Contraception (EHC)
Workshop 1
Hormonal Contraception and EHC December 2007 Version 1.0
Workshop 1: Case scenarios

What further information do you need to
answer the call?

Confirm what type of contraception using the
eBNF.

Refer to the NHSD algorithm rationales for an
answer. What does the FPA, netdoctor &
eBNF say?

What would you advise the caller?
Hormonal Contraception and EHC December 2007 Version 1.0
Lunch Break
Hormonal Contraception and EHC December 2007 Version 1.0
Plan for the Day
9.30
Introduction & learning
outcomes
Baseline knowledge for
hormonal contraception
 Types, action, risks,
cautions, side effects,
interactions.
 Missed doses and dosing
errors.
12.45 Lunch
EC & missed OC algorithm
Workshop 2
3.00 Tea break
Workshop 2 (continued)
4.00 Review of learning outcomes
& close
10.45 Tea break
Emergency Hormonal
Contraception (EHC)
Workshop 1
Hormonal Contraception and EHC December 2007 Version 1.0
Workshop 2: EC algorithm

Repeat the case scenarios from Workshop 1
using the NHSD Emergency Contraception
algorithm.
Hormonal Contraception and EHC December 2007 Version 1.0
Learning Outcomes
1. Have baseline knowledge and understanding about
hormonal contraception including
 Types of hormonal contraception, mode of action, risks,
cautions, side effects and drug interactions.
 Implications and advice for missed doses and dosing
errors.
 Indications and limitations of Emergency Hormonal
Contraception (EHC).
2. Be able to use the NHS Direct emergency
contraception and missed pill algorithm.
Hormonal Contraception and EHC December 2007 Version 1.0