Hormonal Contraception and EHC Trainer’s name XX Medicines Information Service for Health Information Advisors.

Hormonal Contraception and EHC

Trainer’s nameXX Medicines Information Service

for Health Information Advisors


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.


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.

10.45 Tea break

Emergency Hormonal Contraception (EHC)

Workshop 1

12.45 Lunch

EHC & missed OC algorithm Workshop 2

3.00 Tea break

Workshop 2 (continued)

4.00 Review of learning outcomes & close


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


Combined Oral Contraceptive Pill

Oestrogen

Ethinylestradiol (EE)

Mestranol

Progestogen

NorethisteroneDesogestrel

LevonorgestrelGestodene

NorgestimateDrospirenone


COCs: How does it work?


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.


COCs: Monophasics

Low Strength20 microgram EE

Loestrin 20

Mercilon

Femodette

Standard Strength30-35 microgram EE

Microgynon 30

Loestrin 30

Marvelon

Minulet

Femodene


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.


COCs: Biphasics & Triphasics

Biphasics

Binovum

Triphasics

Logynon ED

Synphase

Trinordial

TriNovum

Tri-Minulet

Triadene


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.


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 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.


“Tricycling” Monophasics

Running three packs together Four Pill Free Intervals per year Three extra packets of hormone per year Reduces hormone fluctuations

Unlicensed


COCs: Missed doses

7 days of pill taking puts the ovaries to sleep.

Ovaries wake up if miss

10 days of standard strength pill.

9 days of low strength pill.

The 7 pill free days are safe.

Guidance

NHSD CAS algorithm

Family Planning Association (FPA)

Patient information leaflet

eBNF

Faculty of Family Planning & Reproductive Health

(FFPRHC)


COCs: Missed doses

1-2 standard strength or1 low strength

Take pill now and then continue as normal.

No extra precautions.

No emergency contraception.

3 standard strength or2 low strength

Take pill now and then continue as normal.

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.


COCs: 3 standard strength or 2 low strength missed

Pill free

Wk 1

Wk 2

Wk 3

Pill free



Pill free

Wk 1

Wk 2

Wk 3

Pill free



Pill free

Wk 1

Wk 2

Wk 3

Pill free


Progestogen Only Pill (POP)

One active ingredient – progesterone.

Taken continuously with no break.

Alternative if COCs are contraindicated.

Relies on motivation of the user.


Progestogen Only Pill

Benefits Well tolerated No proof of increased

disease risk Useful in lactation

Drawbacks Precise timing Changes in menstrual

pattern

Brand Names

Femulen

Micronor

Norgeston

Noriday

Cerazette


POP: Missed doses

Less than 3 hours late

Take the missed pill immediately and continue as normal.



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


POPs: More than 3 hours late

Wk 1

Wk 2

Wk 3

Wk 4

Wk 1


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.


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.


Delayed Patch 1

Patch free

Wk 1

Wk 2

Wk 3

Patch free


Delayed Patch 2 or 3

If less than 48 hrs(Extra 48hr drugs in patch)

Apply patch immediately, keep usual change day.



If more than 48 hrs

Stop current cycle and start a new patch cycle with a new Week 1.

Extra precautions for 7 days.

If prolonged patch free period & unprotected sex – EC is indicated.


Delayed <48hrs Patch 2 or 3

Patch free

Wk 1

Wk 2

Wk 3

Patch free


Delayed >48hrs Patch 2 or 3

Patch free

Wk 1

Wk 2

Wk 3

Patch free


Detached patch

If less than 48 hrs

Apply patch immediately, keep same change day.


No EC.

If more than 48 hrs

Stop current cycle and start a new patch cycle with a new start day / change day.


If prolonged patch free period & unprotected sex – EC is indicated.


Contraceptive Injection

Long acting progestogen.

Depo-Provera. IM injection every 12

weeks.

Noristerat. IM injection every 8

weeks.


Delayed injection

Up to 14 days late

World Health Organisation (WHO) states: no extra precautions needed, EC not indicated.

Manufacturer states up to 5 days late but super seeded by the WHO advice.

More than 14 days late


Consider EC if unprotected sex.


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.


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.


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.


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

Emergency Hormonal Contraception


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.


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%


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.


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.


Where can you get EHC?

Community Pharmacies GP Walk-in Centres Family Planning Clinics Sexual Health Clinics A & E


Tea Break


Plan for the Day





10.45 Tea break


Workshop 1

12.45 Lunch

EC & missed OC algorithm Workshop 2

3.00 Tea break




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?


Lunch Break


Plan for the Day





10.45 Tea break


Workshop 1

12.45 Lunch

EC & missed OC algorithm Workshop 2

3.00 Tea break




Workshop 2: EC algorithm

Repeat the case scenarios from Workshop 1 using the NHSD Emergency Contraception algorithm.


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 Trainer’s name XX Medicines Information Service for Health Information Advisors.

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