CONTRACEPTION for GPs Dr Lisa Jayne Adams November 2007.

CONTRACEPTIONCONTRACEPTIONfor GPsfor GPs

Dr Lisa Jayne AdamsDr Lisa Jayne Adams

November 2007November 2007

AGENDAAGENDA

Non-hormonal contraceptionNon-hormonal contraception

Hormonal contraceptionHormonal contraception

CasesCases

Contraceptive EfficacyContraceptive Efficacy

Pearl IndexPearl Index

Effectiveness rates depend on age and Effectiveness rates depend on age and motivation of usermotivation of user

Most effective? A method that stops Most effective? A method that stops ovulation and is independent of user ovulation and is independent of user compliancecompliance

WithdrawalWithdrawal

Mentioned in the BibleMentioned in the Bible

No side effectsNo side effects

Pearl index of 8Pearl index of 8

Natural Family Planning/PersonaNatural Family Planning/Persona

Complex to explainComplex to explain

Calender methodCalender method

Temperature methodTemperature method

Cervical mucusCervical mucus

Combine all three Pearl Index 8-10Combine all three Pearl Index 8-10

FPA can provide local teachersFPA can provide local teachers

PERSONAPERSONA

Pearl Index 6Pearl Index 6

BREAST FEEDINGBREAST FEEDING

Pearl Index 2Pearl Index 2

CONDOMSCONDOMS

Most commonly used Most commonly used non-hormonalnon-hormonal

Pearl Index 3-20Pearl Index 3-20

Beware certain topical Beware certain topical productsproducts

Protection against Protection against STI’sSTI’s

FEMALE BARRIER METHODSFEMALE BARRIER METHODS

FemidomFemidom

DiaphragmDiaphragm

Cervical capCervical cap

IUDsIUDs

Banded copper device Banded copper device =gold standard=gold standard

More effective in older More effective in older womenwomen

Main problemsMain problems

Duration of use 10 yearsDuration of use 10 years

Can be used for Can be used for emergency emergency contraceptioncontraception

Pearl index 1-3Pearl index 1-3

IUSIUS

Periods shorter and Periods shorter and lighterlighterLicensed for 5 yearsLicensed for 5 yearsCan cause spotting Can cause spotting and irregular bleeding and irregular bleeding for up to 6 monthsfor up to 6 monthsPearl Index < 1Pearl Index < 1(included in non-(included in non-hormonal methods as hormonal methods as effects are local)effects are local)

HORMONAL CONTRACEPTIONHORMONAL CONTRACEPTION

COCPCOCP

Pearl index 1-5Pearl index 1-5

Mode of actionMode of action

Non contraceptive Non contraceptive benefitsbenefits

Starting regimeStarting regime

Late pills/missed pillsLate pills/missed pills

Diarrhoea/vomiting/ Diarrhoea/vomiting/ antibioticsantibiotics

EVRA transdermal EVRA transdermal combined hormonal combined hormonal contraceptioncontraception

Yasmin contains Yasmin contains drospirenone, has drospirenone, has diuretic and diuretic and antiandrogen antiandrogen propertiesproperties

NuvaRingNuvaRing

Potential HarmsPotential Harms

All COCP’s increase the risk of VTE, MI, All COCP’s increase the risk of VTE, MI, ischaemic stroke, absolute risk is smallischaemic stroke, absolute risk is small

Any associated increased risk of breast Any associated increased risk of breast cancer likely to be smallcancer likely to be small

Non contraceptive BenefitsNon contraceptive Benefits

Decreased pain and blood lossDecreased pain and blood loss

Risk of ovarian and endometrial cancer Risk of ovarian and endometrial cancer decreased by at least 50% during usedecreased by at least 50% during use

Decreased risk of colorectal cancerDecreased risk of colorectal cancer

Decreased incidence functional ovarian Decreased incidence functional ovarian cystscysts

Not RecommendedNot Recommended(UKMEC category 4)(UKMEC category 4)

Smokers >35 years (>15 a day)Smokers >35 years (>15 a day)Migraine with aura at any ageMigraine with aura at any ageKnown thrombogenic mutationsKnown thrombogenic mutationsBMI >40BMI >40BP consistently > 160/100BP consistently > 160/100Current breast cancerCurrent breast cancerLiver tumoursLiver tumoursHx VTE/Stroke/MI Hx VTE/Stroke/MI Valvular and congenital heart diseaseValvular and congenital heart disease

PRESCRIBINGPRESCRIBING

Record BMI and BPRecord BMI and BP

Take a full history, check smoking statusTake a full history, check smoking status

Use a monophasic pill first line eg Use a monophasic pill first line eg microgynonmicrogynon

Counsel re risks and side effects Counsel re risks and side effects

Discuss non-contraceptive benefitsDiscuss non-contraceptive benefits

POPPOP

Thickens cervical Thickens cervical mucusmucusPearl index 0.3- 4Pearl index 0.3- 4Late pillsLate pillsCerazette (desogestrel) Cerazette (desogestrel) more effective, blocks more effective, blocks ovulation in 97% of ovulation in 97% of cyclescyclesAdvantagesAdvantagesSide effectsSide effectsStarting regimeStarting regime

DEPOT PROVERADEPOT PROVERA

Deep IM every 12 Deep IM every 12 weeksweeks

Pearl index 0.3- 1Pearl index 0.3- 1

Preinjection Preinjection counsellingcounselling

Unwanted effectsUnwanted effects

Can lower bone Can lower bone density in long-term density in long-term usersusers

IMPLANONIMPLANON

Contraceptive implant Contraceptive implant etonogestreletonogestrel

Pearl index 0.8Pearl index 0.8

Lasts for 3 yearsLasts for 3 years

Fitting and Fitting and counsellingcounselling

Pros and consPros and cons

EMERGENCY CONTRACEPTIONEMERGENCY CONTRACEPTION

LevonelleLevonelle

Copper IUD insertionCopper IUD insertion

LEVONELLELEVONELLE

Licenced for u to 72 Licenced for u to 72 hours after UPSIhours after UPSI

Prevents 86% of Prevents 86% of pregnanciespregnancies

Levonogestrel Levonogestrel 1500ug1500ug

Contraindications and Contraindications and drug interactionsdrug interactions

EMERGENCY IUDEMERGENCY IUD

99.8% effective for postcoital use99.8% effective for postcoital use

Copper IUD most effectiveCopper IUD most effective

ContraindicationsContraindications

Insert up to 5 days after UPSIInsert up to 5 days after UPSI

If regular cycle can insert up to 5 days If regular cycle can insert up to 5 days after expected date of ovulationafter expected date of ovulation

CASE HISTORIESCASE HISTORIES

CASE ONECASE ONE

Carly is 18 years old. She has just had a Carly is 18 years old. She has just had a TOP due to ‘pill failure’. She is off to TOP due to ‘pill failure’. She is off to university soon. She is not in a regular university soon. She is not in a regular relationship. She admits that she relationship. She admits that she sometimes forgot to take her pill. She sometimes forgot to take her pill. She really wants to avoid another pregnancy. really wants to avoid another pregnancy. She wants your advice.She wants your advice.

CASE TWOCASE TWO

Linda is forty years old, married with three Linda is forty years old, married with three children. She is a non smoker and has children. She is a non smoker and has been taking the COCP for 7 years. She been taking the COCP for 7 years. She stopped taking it last week because her stopped taking it last week because her younger sister has been admitted to younger sister has been admitted to hospital with a DVT. She does not really hospital with a DVT. She does not really want any more children. What are her want any more children. What are her options?options?

CASE THREECASE THREE

Eve is 25 years old. She is in a stable Eve is 25 years old. She is in a stable relationship. She has been using condoms relationship. She has been using condoms but wants something ‘safer’. She smokes but wants something ‘safer’. She smokes 10 cigarettes a day.10 cigarettes a day.

CASE FOURCASE FOUR

Sam is 35, she has recently got divorced. Sam is 35, she has recently got divorced. She has one child. She has had a coil for She has one child. She has had a coil for the last 9 years. She knows her coil will the last 9 years. She knows her coil will need changing soon. She is not sure if she need changing soon. She is not sure if she wants another one. What is your advice?wants another one. What is your advice?

CASE FIVECASE FIVE

Pippa has come in for her 6 week Pippa has come in for her 6 week postnatal check. She is 29 years old. She postnatal check. She is 29 years old. She has a six week old baby and a fifteen has a six week old baby and a fifteen month toddler. She is mainly month toddler. She is mainly breastfeeding, but gives some formula at breastfeeding, but gives some formula at night. She feels exhausted. Although her night. She feels exhausted. Although her and her partner may want some more and her partner may want some more children they would like a ‘decent’ gap children they would like a ‘decent’ gap next time. She wants your advice.next time. She wants your advice.

Useful websitesUseful websites

Fpa.org.uk (formerly Family Planning Fpa.org.uk (formerly Family Planning Association)Association)

BNF onlineBNF online

Prescriber.comPrescriber.com

AttractAttract

Prodigy (good for guidelines)Prodigy (good for guidelines)

REFERENCESREFERENCES

Faculty of Family Planning and Faculty of Family Planning and Reproductive Health Care Clinical Reproductive Health Care Clinical Guidance: First prescription of combined Guidance: First prescription of combined oral contraception (July 2006)oral contraception (July 2006)

Guillebaud, J. Contraception Today. 5Guillebaud, J. Contraception Today. 5thth ed. ed. Martin Dunitz, 2005Martin Dunitz, 2005