Transcript Contraception - Luton and Dunstable University Hospital

Vasanthy Ravichandran
Woodland Avenue Surgery
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Every 10 seconds 44 births and 18 deaths = net gain of 26.
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Every week extra 1.5 million people need food and
shelter
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WHO (NOV 2006): 180 million conceptions (80 million
unwanted) each year. 45 million abortions - 19 million
performed unsafely. Still 540 000 die each year!
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99% of population growth in developing world but planet
is affected everywhere- Environmental crisis due to
population explosion and no suitable second planet
available to escape
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Effective
Convenient (non-forgettable, non-coitally
related)
Reversible
Safe, minimum / no side effects
Maintenance- free (no provider/medical
intervention- pain or discomfort free)
Acceptable to culture, religion , political view
Other contraceptive benefits
Protective against STIs
Cheap and easy to distribute, store
Visible to women eg. male condom
Better deal for women
 Education and Literacy
 Availability of family planning
information and services
 Better health and fewer child
deaths
 More employment and
opportunities
 Later marriages, Migration to
Towns and cities
 Rising Living standards and
more equal distribution of
wealth
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 Age
of consent in the UK is 16.Although
mutually agreed sexual activity between
two under 16 year olds would not generally
lead to prosecution unless there is evidence
of abuse, exploitation.
 Under 13 is considered unable to legally
consent to sexual activity
 Consent, confidentiality and safeguarding
young people
 Competence to consent to treatment
should be assessed
Fraser Guidelines / Gillick competence
Contraceptive advice for young people- UPSSI
 It is considered good practice for doctors and other health professionals
to follow the criteria outlined by Lord Fraser in 1985 in the House of
Lords' ruling in the case of Victoria Gillick v West Norfolk and Wisbech
Health Authority and Department of Health and Social Security. These are
commonly known as the Fraser Guidelines:
 the young person Understands the health professional's advice.
 the health professional cannot Persuade the young person to inform his
or her parent 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 Sexual
activity 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.
UKMEC
Definition of Category
1
A condition for which there is no restriction for the
use of the contraceptive method
2
A condition where the advantages of using the
method generally outweigh the theoretical or
proven risks
3
A condition where the theoretical or proven risks
generally outweigh the advantages of using the
method. The provision of a method requires expert
clinical judgement and/or referral to a specialist
contraceptive provider, since use of the method is not
usually recommended unless other more appropriate
methods are not available or not acceptable
4
A condition which represents an unacceptable risk if
the
contraceptive method is used
History
Medical conditions and medications including OTC
Family history
Life style( sexual,work,home situation)
Cervical screening
STI risk
Examination- BMI, BP
Discussion about choices- Hormonal/Non hormonal
-Short or Long acting
- user dependent or non-user dependent
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Health professionals can be ‘reasonably certain’ that a woman is not
currently pregnant if any one or more of the following criteria are
met and there are no symptoms or signs of pregnancy:
Has not had intercourse since last normal menses.
Has been correctly and consistently using a reliable method of
contraception.
Is within the first 7 days of the onset of a normal menstrual period
Is within 4 weeks postpartum for non-lactating women
Is within the first 7 days post-abortion or miscarriage
Is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6
months postpartum.
A pregnancy test, if available, adds weight to the exclusion of
pregnancy but only if ≥3 weeks since the last episode of UPSI.
NB. Health professionals should also consider if a woman is at risk of
becoming pregnant as a result of UPSI within the last 7 days and
undertake pregnancy testing where appropriate (≥3 weeks since last
UPSI).
A
25 year old who smokes 15 cigarettes / day
with BMI 32 is requesting the combined pill?
A
35 year old smokes 15/day with BMI 33,
requesting the combined pill?
A
22 year old mother of 2 (had uneventful
pregnancies), with factor V Leiden mutation
would like to discuss her contraception?
A
22 year old suffers from acne and would
like to go on the pill?
A
20 year old with a family history of breast
cancer, has been having heavy painful
periods is requesting contraception?
A
34 year old nulliparous treated for breast
cancer five years ago, in a new relationship,
and would like a reliable contraception?
A
27 year old whose mother had DVT at 48
years, is requesting contraception?
A
woman on coc, what advice should be
given when you prescribe Amoxicillin for
chest infection?
A
young woman on the combined pill has
been diagnosed with Pulmonary TB and is
going to be started on Rifampicin, how would
you advice her?
A
26 year old on coc has been recently
diagnosed with epilepsy and the neurologist
recommends her to go on Lamotrogene. How
would you counsel her?
A
woman develops migraine with aura on
POP? What will you do?
A number of factors should be considered when
informing women about EC options. These
include:
 Medical eligibility
 Efficacy of method
 Last menstrual period and cycle length
 Number and timing of episodes of UPSI
 Previous EC use within cycle
 Need for additional precautions/ongoing
contraception
 Drug interactions
 Individual choice.
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TRADITIONAL POPs
(Micronor®, Noriday®,
Norgeston®, Femulen®)
>3 hours late
(>27 hours since the last
pill was taken)
DESOGESTREL-ONLY
(Cerazette®)
>12 hours late
(>36 hours since the last
pill was taken)
Take a pill as soon as remembered. If more than one pill has been
missed just take one pill.
Take the next pill at the usual time. This may mean taking two pills in
one day. This is not harmful.
An additional method of contraception (condoms or abstinence) is
advised for the next 2 days (48 hours after the POP has been taken).
If ONE pill has been missed (48–72
hours since last
pill in current packet or 24–48
hours late starting
first pill in new packet)
Continuing contraceptive cover
The missed pill should be taken as
soon as it is remembered. The
remaining pills should be continued
at the usual time.
Minimising the risk of pregnancy
Emergency contraception (EC) is
not usually required but may need
to be considered if pills have been
missed earlier in the packet or in
the last week of the
previous packet.
If TWO OR MORE pills have been missed
(>72 hours since last pill in current
packet or
>48 hours late starting first pill in new
packet)
Continuing contraceptive cover
The most recent missed pill should be
taken as soon as possible. The
remaining pills should be continued at
the usual time.
Condoms should be used or sex
avoided until seven consecutive active
pills have been taken. This advice may
be overcautious in the second and third
weeks, but the advice is a backup in
the event that further pills are missed.
Minimising the risk of pregnancy
If pills are
missed
in the first week
(Pills 1–7)
EC should be
considered if
unprotected sex
occurred in the
pill-free interval
or
in the first week
of
pill-taking.
If pills are missed in the
second week (Pills 8–14)
No indication for EC if
the pills in the preceding
7 days
have been taken
consistently and
correctly (assuming
the pills thereafter are
taken correctly and
additional
contraceptive
precautions are used).
If pills are missed in
the third week
(Pills 15–21)
OMIT THE PILL-FREE
INTERVAL by
finishing the pills in
the current pack (or
discarding any
placebo tablets) and
starting a new pack
the next day.
Situation
Timefram
e
Additional contraceptive protection
required?
Extension of
patch/ring-free
interval
≤48 hours
No
>48 hours
Yes (7 days). Consider EC if UPSI occurred in
patch/ring-free interval
Patch/ring
detachment/removal
≤48 hours
No (providing there has been consistent and
correct use for 7 days prior to
removal/detachment)
>48 hours
Yes (7 days). Consider EC if patch/ring was
detached/removed in Week 1 and
UPSI occurred in patch/ring-free interval or
Week 1
Extended use of
patch
Extended use of the
ring
≤9 days
No
>9 days
Yes for 7 days
≤4 weeks
No (ring-free interval can be taken)
>4 weeks
Yes. However, if the woman has worn the ring
for >4 but ≤5 weeks, efficacy could be
maintained by starting a new ring immediately
without a ring-free interval
A
woman has regular 32 days cycle presents
on day 14, following an accident with the
condom 4 days previously. How would you
advice?
A
woman using CVR (Combined vaginal ring)
has forgotten to change the ring at the end
of 3rd week and is approaching the end of
the 4th week. She had UPSI 2 days ago.
A
woman who had her first episode of UPSI 7
days ago but did not seek help, and had
another episode 50 hours ago is requesting
emergency contraception. How would you
advice? What options she has?
 She would like to go on a reliable
contraception as soon as possible Nexplanon or oral contraceptive. Would you
be happy to offer it to her?
 Woman
forgot to start the new pack of COC
> 48 hours and had UPSI during PFI (pill free
period)?
 Woman
using the CTP (combined transdermal
patch) noticed her patch detached > 48 hours
in week 2. What would you do?
 Missed
> 27 hours pop pill (Noriday) and had
UPSI? What if it was Cerezette?
 Woman
came for her DMPA. The nurse called
you to say that the lady was 2weeks and
1day overdue. What would you do?
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A 40 year old lady would like to discuss
about LARC methods in your 10 minute
consultation?
 Patient
concerned
 Clinical history- correct use, inter-current
illness, medications.
 Other symptoms (pain, dyspareunia,
abnormal discharge, PCB, HMB)
 Exclude STI
 Check cervical screening history
 Rule out pregnancy
 Manage any issues identified
COC
POP
IMPLANTS,
MDPA, IUS
Increase dose of
EE.
Try different POP.
Try COC
(continuous or
cyclical)
Try different COC
HRT (Oestrogen
only) patch.
Mefenamic acid.
Tranexamic acid.
? Doxycycline
 Receptionist
rang you to say that a lady who
had an IUD inserted the previous day is
experiencing pain and bleeding?
A
46 year old had Mirena IUD inserted 5
months ago, she is worried that she is no
longer seeing her period?
A
lady who had a sub-dermal implant
inserted 8 weeks ago, hasn’t had her period
and is now concerned?
A
25 year old would like her Implanon/
Nexplanon removed due to irregular heavy
bleeding for 4 months. How would you
manage her problem?
A
45year old with a Copper IUD inserted 2
years ago is experiencing pain and bleeding?
How would you manage her problem?
A
lady 46 years of age has a LNG-IUS for 6
months has irregular bleeding and discharge?
 An
18 year old had the first DMPA injection
and is troubled by heavy irregular bleeding?
A
50 year old who had a Copper TT 380 for 8
years and didn’t see her period for 12
months, consults you regarding the IUD?
A
50 year old had a Mirena IUS 5 years ago
for heavy periods, now amenorrhoeic for 2
years. Her husband had a vasectomy?
A healthy mother 4 weeks postpartum, fully
breast feeding would like to know her
contraceptive options.
 What if not breast feeding and would like to
go back on the coc - could she start?
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 35
year old on DMPA experiencing irregular
heavy bleeding?
 35
year old experiencing breakthrough
bleeding on Loestrin?
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13 Year old came alone to surgery to discuss
contraception, says she would soon start
sexual activity? What would you do
 Actinomyes
like organism( ALO) was reported
in routine cervical smaer in a woman has an
IUD?
 Lost
threads?
 Pregnancy
 Pelvic
with the IUD?
infection?
Any questions?