FAMILY PLANNING

Sarah Stradling GP Camberley Health Centre

OVERVIEW
Combined Contraception Emergency Contraception Gillick competence LARC POP Other methods Case studies

The perfect contraceptive?

The perfect contraceptive would:
give total protection against pregnancy would be ethically acceptable cheap require little or no medical intervention have no unwanted side effects but perhaps some benefits to health fertility would return promptly and completely when use ended

This ideal does not exist-apart from abstinence.

Efficacy
Pearl Index- Comparing efficacy
High index; high chance of failure (no contraception 80-90) Low index; low risk failure (Mirena <0.5)
number of unintentional pregnancies related to 100 women years. E.g 3 pregnancies in 100 women in 1 year, pearl index is 3.0

I would like to go on the pill

Age Contraceptive hx Menstrual hx, LMP Obstetric hx- ectopic? Medical hx Medication Allergies

Options Risks/benefits Mode of action Side effects Teaching about method PILS Follow up Special instructions

COMBINED ORAL CONTRACEPTIVES

The Pill

Mode of action and efficacy First consultation UKMEC Risks Initiation Missed pill guidance Choice of pill and managing side effects

 Commonest hormonal Action- anovulatory

reduces endometrial lining Pills 1-7 INHIBIT OVULATION Pills 8-21 MAINTAIN ANOVULATION Important when considering missed pills

 Pearl Index- 0.3- 4.0 Perfect use vs. true use

Promote safe sex- condoms

Sexual health screening Opportunistic chlamydia (1:10 <25)

First COC consultation

Clinical HxMedical conditions
Drug use prescription and OTC Family hx

Specific enquiries User preference and concerns

UkMEC (medical eligibility criteria)

UKMEC 1- No restriction UKMEC 2- Advantages > theoretical proven risk UKMEC 3- Risk > advantages UKMEC 4- Unnacceptable health risk

Suggest specialist referral if 3 or above

Risks
Ageto what age can it be safely used?

Smokingcan the coc be used in a 30 y.o smoker?

Obesity (BMI 30-34;2 35-39;3)

Blood pressure

Not Recommended (UKMEC category 4)

Smokers >35 years (>15 a day) Migraine with aura at any age Known thrombogenic mutations BMI >40 BP consistently > 160/95 Current breast cancer Liver tumours Hx VTE/Stroke/MI Valvular and congenital heart disease

The pill scare

VTE:
Increase five fold, remains low No screen needed Different progestogens associated with risklevonorgestrel and norethisterone may counteract thrombogenic effect of EE better than desogestrel and gestodene Greatest risk in first year Normal within weeks of stopping

 Dianette- 35mcg EE and cyproterone acetate Four fold increase risk vs. microgynon 30 Limit duration of use

Non COC/not pregnant Levonorgestrel/norethisteron (Microgynon, Loestrin) Desogestrel/gestodene (Marevlon, mercilon, fermodene Pregnancy

Risk per 100,000 women years 5 15 25

60

 Migraine:
Migraine + aura (any age) Migraine aura (>35)
Risk of ischaemic stroke Is it an aura??

 Breast Cancer:
No increase risk if family hx Gene carriers Current breast ca vs. past ca (>5yrs ago)

 Drugs Liver enzyme inducers reduce efficacy, 28/7 after stopping Abx: short term vs. long term

What would you do with a patient with a UKMEC 4 score and says that they are accepting of the risk? Risk vs. pregnancy? Patients right to choose? Prescribing responsibility?

 Non contraceptive benefits:

Blood loss and pain Functional ovarian cysts 50% reduction in ovarian and endometrial ca (15 years post) Acne Tricycling packets: prevent bleed, endometriosis, withdrawl headacheOUTSIDE LICENCE

Initiation
Day 1-5- immediate cover Elsewhere COULD THEY BE PREGNANT? Alternative precautions Chaotic recurrent EC users? Immediate start and bHCG in 3/52 Best method if chaotic?

 Post partum- ideally day 21 Amenorrhoea- anytime + 7day Post TOP- up to 7 days

Missed Pill
HOW MANY? WHERE IN THE PACKET?
Two for Twenty Three for Thirty Day 1-7 ?Ec Day 8-21 ?condom use over cautious Day 14-21 Run packets

If 1 or 2 pills missed at any time OR 1 20mcg EE pill missed

Take the most recent missed pill as soon as remembered Continue remaining pills as normal

Will not need on emergency contraception

If 3 or more pills missed at anytime OR 2 or more 20mcg EE pills

Take most recent missed pill Take remaining pills as usual Advised to use condoms/abstain until has taken 7 pills in a row

Pills 1-7: Consider EC Pills 8-14: Nil Pills 15-21:Omit pill free interval (ED)

PILS Drug information leaflet NHS direct GP OOH Patient.co.uk

Which Pill?
Monophasic COC with 30mcg EE + Norethisterone or levonorgestrel Why?
No evidence for biphasic or triphasic Reduced VTE risk 20mcg efficacy similar but increased BTB

Note: ED pills no evidence for increased compliance

Provide written information Review at 3/12 Bp and troubleshooting May issue 12/12 supply with SOS review Encourage 3/12 trial Advise re VTE signs/sx Advise re condom use for STI protection

Side effects
Remember side effects may not be COC related Oestrogen s/e Nausea Dizziness Bloating Cyclical fluid retention Vaginal discharge Swap to a progesterone dominant pille.g. Cilest, Yasmin, Brevinor, Marvelon

 Progesterone s/e:
Vaginal dryness Weight gain Depression Low libido Breast tendernss Change to an oestrogen dominant pill e.g microgynon 30, loestrin 30/20

 Changing from another form of contraception to COC and vice versaMIMS and BNF EVRA-consistent levels of hormones, change every 7 days, patch free week, ?improve compliance, if patch no longer sticky will need a new patch

NUVARING
Once a month intravaginal ring Low oestrogen (2mg ethinyloestradiol15mcg daily and etonogestrel) Individually packaged No GI absorption- malabsorptive disorders, binge drinking, vomiting May view as user controlled LARC

 Insert and leave for 3 weeks Ring free week- withdrawl bleed Does not matter where it sits unlike diaphragm Each ring works for 5 weeks Removal to ovulation16 days

Can use tampons and spermicides <5% women report BTB 90% men found it acceptable Needs cold storage prior to dispensing, then has 4 month shelf life at room temp If taken out, 3hr window before contracptive efficacy is compromised No evidence that it effects cervical cytology

QUESTIONS?

EMERGENCY CONTRACEPTION

Preventing pregnancy following UPSI/contraceptive failure

1. Oral Hormonal - levonorgestrel (LNG)
Inhibits ovulation as primary action] - Ella One Uliprisatal acetate- Selective progesterone receptor modulator

2. Copper IUD- Minimum 380mm

Toxicity to fertilisation and inflammatory action against endometrium- anti implantation

NOT IUS

 2002 Judicial review- pregnancy starts at implantation NOT fertilisation NO time in cycle when there is NO risk following UPSI

No evidence that LNG/ulipristal will harm a fetus

Indications
COC- 3 or more (2 or more 20mcg) missed in week 1 PLUS UPSI in pill free week or week 1 POP- 1 missed pill (>3hrs late or 12hrs if cerazette) and UPSI in following 2 days IU- removal or expulsion and UPSI in previous 7 days Injectable- >14 weeks and UPSI Liver enzyme inducers- taken with COC or implant or in the following 28 days UPSI

The Morning after pill

Levonelle 1500 ASAP, within 72hrs- licence Consider up to 5 days- outside licence Consider more than once in a cycle Always give if a/w IUD No CI to EHC Liver enzyme inducing drugs, ?2 doses

Ella One Licence for 5 days (120hrs) post UPSI Acts to delay ovulation May also have effect on the endometrium At least as effective as LNG

Vomits within 2 hrs- repeat Nausea- 14% 50% period was a few days late or early 16% non menstrual bleeding in next 7 days bHCG at 3/52 Levonelle 1500 5.11 Ella One 16.95

Would you?
Should EHC be offered in advance of need?
Foreign travel Barrier methods May reduce unwanted pregnancies without increase in risky behaviour. Available OTC

IUD for emergency contraception

Up to 5 days after 1st episode UPSI Up to 5 days after calculated date of ovulation Detailed hx of normal cycle and calculate expected date of ovulation

Always give EHC whilst arranging

Other discussions
Sexual health screening Ongoing contraception ?start alternative method before next period Young people- No medical reason to avoid
Child protection issues

GILLICK COMPETENCE
Gillick vs. West Norfolk HA (1986) DOH guidance Law Lords Ruling (Fraser ruling)..

 A clinician may provide treatment to a young person <16years, without parental consent, provided that he/she has confirmed that they are competent and that the Fraser criteria have been met Advice understood Will have or continue to have sex Advised to inform parents In the patients best interests

 Age <13years- responsibility to inform social services, advise patient Consider each case on merits 15 year old with a 17 year old partner 15 year old with a 35 year old partner 12 year old with a 14 year old partner

Case 1
20 y.o on Microgynon 30, has missed 3 pills in the last week of her packet. She had sex without a condom yesterday and is worried about her pregnancy risk What would you advise her?

Case 2
26 y.o had a split condom 4 days ago. She has a 28 day regular cycle and is now day 15 of cycle. She is requesting the morning after pill How do you counsel her?

LONG ACTING REVERSIBLE CONTRACEPTION

LARC

Options
IUD IUS Injectable progestogens Implanon

 NICE- Discuss with all women-QOF Cost effectiveness at 1 year >COC use of LARC leads to unwanted pregnancies

Copper IUD
Mechanism

IUS

Injection
Prevents ovulation 12 weeks/ 8 weeks

Implants
Prevents ovulation 3 years

Fertilisation Prevents and Implant implantation 5-10yrs, unless 40+ 5 years unless 45+

Duration

Failure Rate <2/100

Bleeding Dysmen Ectopic1:20 PID Perforation

<1/100

<0.4/100

<0.1/100 Bleeding Acne

Risks

Bleeding Bleeding Ectopic Weight gain PID BMD Perforation Libido/acne

Bleeding patterns
IUD- Increased and often dysmenorrhoea IUS- 6/12 often irreg, amenorrhoea 65% after 1 year Injectable- 70% amenorrhoea at 1yr Implant- 20% amenorrheoa, 50% irregular

Fertility
No alternation with IUD/IUS/Implant Injectable- up to 1 year, detectable in serum at 9/12 No guarantee on stopping

Suitability
Nulliparous Breast feeding BMI Post TOP Diabetes Migraine + aura CI to oestrogen

IUD/IUS
Chlamydia testing Ensure not PG prior to insertion Review at 6/52, trouble shooting IUD immediate cover IUS may need alternative Advise early return if pain or discharge, remind re bleeding

 Use of tranexamic acid Systemic effects with IUS

Lost IUD/IUS? Pregnant?

Partner dissatisfaction Length of protection

 Risks
Perforation: 1:1000 Expulsion: 1:20 Ectopic: 1:20 PID: 6 times increased risk in first 20 days, then low

INJECTABLE Depo
DMPA (12/52) and NET-EN (8/52) Deep IM, well mixed 4 week window- WHO, product guidance 12+5 Emergency drug availability

 Review every 2 years re ongoing use Not affected by liver enzyme inducers

 ?EC if greater than 14/52 Up to age 50- consider change at 45+ Weight gain and elevated BMI Document date of next injection

BMD and injectables

Caution if <18 or >40 Systematic review- reduction in BMD after 1 year but recovers after stopping MHRA
If <18 consider all other options before use Revaluate every 2 years If RF for OP consider alternative

IMPLANON/NEXPLANON
Single subdermal rod Norplant- 5 rods, 1999, poor advice

No effect on BMD
Affected by liver enzyme inducing drugs ?trial of cerazette

 8-10cm above medial epicondyle Woman must palpate No routine f/u Bleeding- tranexamic acid or COC

Full assesment with IMB

If cannot palpate- USS

PROGESTERONE ONLY PILL

 Mode of action Cervical mucus Ovulation (up to 60% or 97% with desogestrel) Daily No pill free interval Takes 48hrs to thicken mucus 3Hrs- Femulen, Micronor, Noriday, Norgeston 12hrs- desogestrel (cerazette)

 Failure rate 0.3-8.0% Decreases with age

Traditionally double dose if BMI >70kg, NO evidence to support this and use of one pill is recommended
Only UKMEC 4 is breast ca

Missed Pill advice

Traditional POP

Desogestrel POP (Cerazette)

>3hr late i.e. >27hrs since last pill

>12hrs late i.e. >36hrs since last pill

1. Take the missed pill 2. Take the next pill at the usual time (this may mean 2 pills in 1 day) 3. Condoms or abstinence for the next 48 hrs 4. No need for EC if sex before the missed pill

 3 hr window may be difficult Cerazette 8.85 vs. micronor 1.69 Advise re vomiting Avoid if using liver enzyme inducers Not affected by antibiotics No effect on lactation Migraine

Bleeding Patterns
Commonest reason for stopping Good counselling may reduce 70% report prolonged, BTB or spotting General Guide
20% amenorrhoea 40% regular pattern 40% erratic

 Level of tolerance ?use of increased dose for BTB, anecdotal but poor evidence.
Remember if new bleeding pattern in previously untroubled patient ?STI, Drug interactions, compliance, pregnancy

 Commence in first 5 days- immediate cover Anywhere else extra precautions for 48hrs Can continue until the menopause

OTHER METHODS

Condoms Diaphragm LAM Sterilisation Natural family planning

CONDOMS
Male and female condoms Traditionally latex Polyurethane condoms Latex allergy- usually local but may be systemic

EU safety tested and kite mark Always look for the exp. date

 Breakage and slippage reduce with experience Avoid oil based lubricants e.g. baby oil and petroleum jelly Failure rate:
True 2% Actual up to 15%

 Latex vs. latex free- efficacy the same

Evidence supports the use of condoms to reduce the risk of STI. However, even with consistent and correct use, transmission may still occur.

 Free condoms from family planning centres No restriction on selling condoms to those under 16years

No evidence to suggest that supplying condoms encourages sexual activity

DIAPHRAGMS AND CAPS

Diaphragm lies across the cervix Perfect use failure rate 4-8% True use 10-18% Need to be used with a spermicide Needs teaching

Caps are much smaller Rarely used

 Advantages:
Non hormonal More independent of intercourse than condom Reduces the risk of HPV transmission
Disadvantages:
Messy Forward planning Low efficacy

Must apply spermicide to both sides Active for 3hrs Leave in for at least 6hrs post intercourse Top up if intercourse again Remove, wash and allow to dry

Resizing needed if >3kg weight change, TOP, miscarriage, vaginal delivery, vaginal surgery

LACTATIONAL AMENORRHOEA
No guidance provided by faculty A method of contraception?? Reported failure of 2% Criteria to be met:
No return of periods Baby is nearly or fully breastfed (4hrs in the day and 6hrs at night) The baby is less than 6 months old (i.e. pre weaning) Note: nearly fully breastfed means that the infant receives mostly breast milk but can have some alternative liquids

STERILISATION
Counselling, especially LARC, permanent Take a full contraceptive hx No absolute CI- make request themselves, sound mind and no external duress Female- Tubal occlusion, alternative method until surgery and until the next period Male- No scalpel approach with division of vas and diathermy, contraception until clearence

 Failure rate:
Women 1:200 (same as IUS) Men 1:2000 after clearance
If pregnancy occurs after female sterilisation increased risk of ectopic. Increase report of heavy periods after sterilisation.

 Persona Natural family planning- temperature, cervical mucus, avoidance of unsafe time around ovulation (days 12-16 of a 28 day cycle)

QUESTIONS??

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

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

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

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

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

CASE SIX
Gemma is 22. She has the depo injection and has attended for her next injection. Her last one was 15 weeks ago. She had sex 2 days ago. What do you do? How would this change if UPSI had occurred 6 days ago?

Useful websites
Fpa.org.uk (formerly Family Planning Association) BNF online Mims online Prodigy www.ffprhc.org.uk Contraception- John Guillebaud