Slide 1

Wednesday 30 th March GP VTS Slide 2 Topics covered What to consider with contraception Pills IUD/IUS Implants and injection Special circumstances QOF Case studies Slide 3 Not covering Surgical methods - no funding Natural methods Gillick (in too much detail) Infertility Slide 4 General intro Common consultation Increased choice Benefits and risks Unwanted pregnancy Slide 5 Initial consultation Personal preference Lifestyle Medical history Family history Risk of STI Slide 6 Before starting Confirm not pregnant Previous methods Current medical problems BP Migraine? Smoker? Family history of cancers Slide 7 COCP Vary by oestrogen content Vary by progesterone type 21 pills then break Slide 8 Risk greater than benefit Aged 35y + smoker >50y HTN IHD/CVA/PVD DM VTE Focal migraine Slide 9 Risk greater than benefit Female malignancy Hormonal problems in pregnancy Breast feeding Acute hepatitis Porphyria Slide 10 Starter pills Microgynon 30 Ovranette 150mcg - levonorgesterol (progesterone) 30mcg ethinylestradiol (oestrogen) 2.99 2.29 Slide 11 Progesterone side effects Acne Headache Depression Weight gain Breast symptoms Decreased libido Slide 12 Alternate options Desogesterel Marvelon Gestodene Femodene Norgestimate Cilest Drospirenone - Yasmin 6.70 7.18 11.94 14.70 Slide 13 Alternate options Cyproterone acetate Dianette 3.70 Not licensed for contraception alone Used in treatment of acne Slide 14 Oestrogen side effects Breast tenderness Nausea Weight gain Bloating Loestrin 20 20mcg ethinylestradiol 2.70 Slide 15 Breakthrough bleeding First few months Exclude other cause Compliance Slide 16 Interactions New advice on antibiotics Enzyme inducers Affect all hormonal contraception Slide 17 Missed COC pills Current advice Take ASAP 2 or less 3 or more Slide 18 POP Older women Smokers VTE history HTN, DM, Migraine Breastfeeding Who can use LARCs? All LARC methods are suitable for: nulliparous women breastfeeding women who have had an abortion BMI > 30 women with HIV encourage safer sex women with diabetes women with migraine with or without aura all progestogen-only methods may be used women with contraindication to oestrogen Slide 25 Important points to discuss: contraceptive efficacy duration of use risks and possible side effects non-contraceptive benefits initiation and removal/discontinuation when to seek help while using the method. Slide 26 Risks and side effects Copper IUDsIUS (Mirena)Progestogen-only injections Implants Unacceptable vaginal bleeding/pain Altered bleeding pattern eg. persistent Irregular bleeding Ectopic pregnancy 1/20 (lower than without contraception) Ectopic pregnancy 1/20 Small loss in bone mineral density, largely recovered when stopped. Acne PID IUDs A Cu-IUD inserted when a woman >40 years can be retained until the menopause is confirmed. >50yrs - 1 year after the last menstrual period IUS - Mirena Prevents implantation. Effects on cervical mucus reduce sperm penetration. Inserted >45 years and amenorrhoeic - may retain the LNG-IUS until the menopause. Randomised trials show that the LNG-IUS provides effective contraception for up to 7 years licensed for 5 years. Slide 39 After fitting: At first follow-up visit (after the first menses, or 36 weeks after insertion) exclude infection, perforation or expulsion. IUD only: For heavier and/or prolonged bleeding associated with use of an IUD: treat with NSAIDs and tranexamic acid or suggest changing to the IUS if the woman finds bleeding unacceptable. Slide 40 Depo Provera Slide 41 Injectable contraceptives Depo Provera or Noristerat (short term use) Inhibits ovulation. Check not pregnant! Can give: up to 5 th day of the menstrual cycle without the need for additional contraceptives or use barrier contraception 7 days Slide 42 Every 12 weeks Deep intramuscular injection into the gluteal or deltoid muscle or the lateral thigh Delay up to 1 year in the return of fertility BUT no evidence of reduced fertility long term Slide 43 Amenorrhoea (14.4%) Infrequent bleeding (24.2%) Spotting (27.9%) Prolonged bleeding (33.5%) were all reported Slide 44 Small loss of BMD, which is usually recovered after discontinuation. Women should be advised that there is no available evidence on the effect of DMPA on longterm fracture risk. Use may continue to age 50 years. Slide 45 Managing irregular bleeding Can try: 3 cycles of 20-30mcg COC, taken cyclically can be repeated If COC contraindicated: mefenamic acid 500mg BD until bleeding settles Cerazette 1 tab daily for approx. 3 months Slide 46 Managing problems with Depo Provera Repeat injections may be given up to 2 weeks late. DMPA use >2 years, review and discuss the balance of benefits and risks again eg. BMD No evidence of congenital malformation to the fetus if pregnancy occurs during DMPA use. Good choice if on enzyme-inducing drugs Slide 47 Slide 48 Follow-up required acc. to NICE Routine follow-up IUD/IUS At 36 weeks Return if problems or time for removal. Injectable contraceptives Every 12 weeks; every 8 weeks for NET-EN Implants No routine follow-up Slide 49 Under 16s and post-partum Slide 50 Fraser Guidelines and Gillick Competence Slide 51 Under 16s and providing contraception Be aware of the law Duty of care and a duty of confidentiality to all patients, including under 16s. > 25% of young people are sexually active Choices for women post-partum, including breastfeeding IUD copper: from 4 weeks after childbirth IUS - Mirena: from 4 weeks after childbirth DMPA injection: any time after childbirth, if >21 days need additional. Implants - Nexplanon: any time after childbirth; if >21 days postpartum need additional Slide 57 Abortion/miscarriage Progestogen-only injectable contraception or implant is appropriate: after surgical abortion (second part of) medical abortion miscarriage. If DMPA or Nexplanon within 5 days Ideally insert IUD or IUS within the first 48 hours or delay until 4 weeks postpartum. Slide 58 Emergency contraception Less than 72 hours levenorgesterol - 1.5mg Between 72h and 120h EllaOne Most effective is Copper IUD Slide 59 Emergency contraception Advise to return if abdominal pain or next period overdue Advice on STI Plan contraceptive follow up Slide 60 TOP - practicalities Less than 24w Reasons Medical and surgical Marie Stopes centres http://www.mariestopes.org.uk Slide 61 QOF LARC offered and coded Chlamydia testing people under 25 Slide 62 Case study 1 17y Only current partner BMI 22 Non-smoker Wants contraception Slide 63 Case study 1 Comes back 3m later Spots over face, some on back Slide 64 Case study 2 42y Finished family Wants something long term Slide 65 Case study 3 24y New baby Unplanned pregnancy Slide 66 Case study 4 37y Heavy smoker BMI 42 Bed bound Diabetic Previous DVT BP 172/104 Slide 67 Resources Faculty of Family Planning Oxford handbook of General Practice BNF Marie Stopes Monkgate Clinic