emergency contraception, quick start & a bit about larcs dr jackie abrahams...
TRANSCRIPT
Pregnancy and Emergency Contraception (EC)
‘All women of reproductive age are pregnant until proven otherwise’
Think about possibility of pregnancy or need for EC
With every request for contraception With every request for a pregnancy
test. With any other consultation
Emergency Contraception
Remember
There is a failure rate with Levonelle 1500 and EllaOne
There is virtually no failure rate with postcoital
(PC) Coil.
All women should be offered the option of PC Coil (especially if they are mid cycle and/or over 48 hours)
4
ellaOne vs Levonelle
ellaOne more effective (failure rate 1.28% compared to 2.2% with Levonelle)
ellaOne can still inhibit/delay ovulation once LH surge started - ie in 48 hours pre-ovulation
ellaOne licensed for use up to 120 hours post UPSI and equally effective throughout that time period
ellaOne is a Progesterone Receptor Modulator and therefore interferes with ongoing hormonal contraception for the next 7 days
NB No evidence that either have much effect after ovulation
ellaOne vs Levonelle
ellaOne more expensive - £16.95 vs £5.20 Approved by Joint Area Prescribing Committee
(JPAC) for women under 35 who are mid cycle
(ovulation minus 6 days to ovulation plus 2 days)
For women presenting for EC between 73 and 120 hours post UPSI
Emergency Contraception
Over 72 hours? – PC Coil best option- up to 5 days after earliest ovulation (i.e., day 19
of a regular 28 day cycle) – regardless of how many episodes unprotected sexual intercourse (UPSI).
- If beyond ovulation+5days - up to 5 days after UPSI
Unlicenced Use Levonelle 1500 or EllaOneIf coil not an option, can have Levonelle-2 or EllaOne as unlicensed use over same timescale as PC Coil (but much higher failure rate)
Emergency Contraception
And then ?QuickstartIf starting hormonal method consider
immediate start oral contraception small risk of pregnancy but ?worth it.
- COC - not safe for 7 days after Levonelle – 14 days after EllaOne
- POP – not safe for 2 days after Levonelle – 9 days after EllaOne
- PT with EMU in 3-5 weeks – ideally PT 3 weeks after last risk (eg 5 weeks after EllaOne and quickstart COC as not protected by COC for first 2 weeks)
Emergency Contraception
Missed Pills Take Levonelle and continue with pills
(don’t stop and wait for next period – it might never come!)
Do Pregnancy test 3-4 weeks later (whether or not normal withdrawal bleed)
NB Levonelle better than EllaOne for missed pills (because of effect on progesterone receptors with EllaOne)
Late / Missed Pills
COC Latest FPA Guidance (what we teach the patients)
can miss 1 pill anywhere in pack – no extra precautions needed
If miss 2 or more need extra precautions and active pills for 7 days
‘pragmatic’ guidance (what we know) Need to have taken 7 active pills can miss up to 7 anywhere else in pack need 7 active pills after missed pills
NB Extra precautions not needed with antibiotics
POP – Only need extra precautions until normal pill taking resumed for 48 hours (Late = 12
hours for Cerazette, 3 hours for other POP’s)
Late Depo Injection
Up to 14 weeks – give next Depo. No extra precautions needed
14 – 15 weeks – give next Depo. If any UPSI after 14 weeks also give PCC (Levonelle or PC IUD). Not safe for 7 days and need PT in 4 weeks
Over 15 weeks – need to exclude pregnancy before rpt Depo – unless no UPSI after 14 weeks (?COC or POP for 1 month and then next Depo with neg PT)(according to most recent WHO guidelines can have repeat Depo up to 16 weeks and don’t need extra precautions for 7 days – UK Guidelines still say 14 weeks)
Quick Starting Contraception
Clinical Effectiveness Unit September 2010
See Faculty website http://www.fsrh.org.uk for full
guidelines
Quick Starting Contraception Key Recommendations
If a health professional is reasonably sure that
a woman is not pregnant or at risk ofpregnancy from recent unprotected sexual intercourse (UPSI), contraception can bestarted immediately unless the woman
prefersto wait until her next period.
Quick Starting Contraception Key Recommendations
If pregnancy cannot be excluded (e.g. following administration of EC) but a woman is likely tocontinue to be at risk of pregnancy, immediate‘quick starting’ of CHC, the POP or progestogenonly implant may be considered. The woman should be informed of thepotential risks and the need to have apregnancy test at the appropriate time.
Quick Starting Contraception Key Recommendations
Women requesting the progestogen-only
injectable should ideally be offered abridging method if pregnancy cannot
beexcluded, but immediate start isacceptable if other methods are notappropriate or acceptable.
Quick Starting Contraception Key Recommendations
If contraception is quick started in awoman for whom pregnancy cannot beexcluded, a pregnancy test should be advised no sooner than 3 weeks after
thelast episode of UPSI.
Quick Starting Contraception Key Recommendations
If starting hormonal contraception immediately after ulipristal acetate
EC,the CEU recommends condoms oravoidance of sex for 14 days (9 days ifstarting POP, 16 days for Qlaira)
LARC’sLong Acting Reversible
Contraceptives
IUD/IUS Progesterone subdermal
implant (Nexplanon) Depoprovera
IUD/IUS
Key MessagesJust as good for Nullips as MultipsNo need for swabs with every fit
Do STI risk assessment and decide if necessary
If taking swabs only need to do 2 endocervical swabs for GC and Chlamydia
(an HVS is a diagnostic test – only necessary if has abnormal discharge)
IUD vs IUSIUD
Less problems than IUS if normal/light periods
Can be fitted up to ovulation + 5 days regardless of whether UPSI since LMP
If fitted over age 40 can stay in until menopause
Most effective emergency contraception
IUS 1st choice if heavy
periods or had heavy periods with IUD
Amenorrhoea in only 25-30%
Can cause significant bleeding problems for up to 6 months
Other progesterone side effects
Cannot be used for emergency contraception
Nexplanon
Most effective contraceptive method Failure rate 1/2000 No serious risks Main challenge is management of
side effects Bleeding problems Mood swings Skin problems
Bleeding Problems with Nexplanon
Don’t usually need any investigation apart from STI risk assessment and/or screening
Usually respond to COC or POP Often settle after 3 months of
treatment If recur on stopping can continue COC
or POP longterm
DCHS Sexual Health Service Clinics
Central Booking Line for all Appointments Tel 01246 235792
We will accommodate requests for Emergency IUD’s at all of our clinics
Contact numbers to speak to a clinician Dr Jackie Abrahams 07967 729253 Dr Stephen Searle 07774 962320
Diploma of the Faculty of Sexual and Reproductive Healthcare
(DFSRH)
Details of the training requirements for DFSRH and Letters of Competence (LoC’s) in Intrauterine Techniques and Subdermal Implants are available on the Faculty website http://www.fsrh.org/pages/Diploma_of_the_FSRH.asp
DFSRH training involves three stages: e-learning for theory background; the e-SRH programme Course of 5; five hours of small group workshops Clinical experience and assessment
Course of 5 and Practical Training
Locally training is organised through
Course of 5 is run twice a year – next one is on 17th June 2013
Details of training elsewhere in UK is available on the Faculty website
Training for Health Department Phone: 01246 868448Email: [email protected]: www.trainingforhealth.derbys.nhs.uk