One-day Essentials Contraception. Dr Paula Briggs, General Practitioner, Clinical Lead Community Sexual Health, Sefton and West Lancashire

Transcription

1 One-day Essentials Contraception { Dr Paula Briggs, General Practitioner, Clinical Lead Community Sexual Health, Sefton and West Lancashire

2 80% women access contraception from their GP Therefore it is essential that primary care providers are up to date and can offer choice from the contraceptive menu, based on an individual assessment..

3 Angie needs EC Too busy to get to the doctors - ran out of pills about 1-2 weeks ago!! UPSI 3 or 4 days ago (can t be sure) 6 children Recently gave birth to twins and could not cope with another pregnancy now

4 If problems with contraception, when is EC needed? 2 or more COC missed in first week (changed missed pill rules in 2011) >3 h late POP (12h for Cerazette) IUD/IUS expelled/removed Injection >2/52 late Condom non perfect use Interacting drugs

5 FSRH Guidance 2012 Emergency Contraception Risk of ovulation 10 days after last COC CEU EC Guidance, Revised Jan 2012

6 When in the cycle is the risk highest? Max risk

7 Asking for Levonelle Had Levonelle recently No adverse effects same again please? OR Can you do better?

8 Management of a request for Emergency Contraception What do you need to know? Consider possibility of an implanted pregnancy Timing of episode(s) of UPSI? LMP or withdrawal bleed? Potential drug interactions? Medical eligibility? Explain all method options Discuss on-going contraception Discuss STIs Arrange any necessary referral/follow-up

9 CEU Emergency Contraception Guidance January /05/2012

10 Available options CHOICE Copper IUD Ulipristal Acetate (UPA) Levonorgestrel (LNG)

11 Copper IUD mode of action Emergency IUD can be fitted within 5 days of UPSI or within 5 days of earliest calculated day of ovulation If she is amenable to an IUD, is it available as an option and if not, are pathways/communication processes in place to ensure that this option can be made available to her from an alternative provider

12 Levonorgestrel (LNG)

13 Ulipristal acetate (UPA)

14 UPA - Mode of Action Primary mode of action is to inhibit or delay ovulation The probability of conception peaks just before ovulation ellaone s inhibitory effect on follicular rupture allows it to be effective in some women even when administered immediately before ovulation, even if LH levels have already begun to rise CEU EC Guidance, Revised Jan 2012

15 Effectiveness of oral EC Inhibition of follicular rupture (>18mm) at 5 days after treatment Levonorgestrel 7/ % Ulipristal Acetate 20/ % p< Does not give any protection later in cycle and may just delay ovulation Brache et al 2010

16 When in the cycle is EC effective? Ulipristal Max risk LNG IUD

17 Efficacy related to mode of action Pills delay/inhibit ovulation UPA > LNG No evidence of effect after fertilisation LNG no effect after ovulation UPA no evidence of effect after ovulation IUD may prevent fertilisation IUD inhibits implantation CEU EC Guidance, Revised Jan 2012

18 Emergency Contraception Effectiveness If 1000 women had UPSI and used. Cu IUD, ellaone, LNG, Nothing James Trussell 2011

19 Adverse events Oral (LNG, UPA) Nausea (slight) Vomiting (rare 2-3h) Some delay to cycle IUD Insertion related (discomfort/pain; infection if at risk of STI; expulsion/perforation) Heavy menstrual bleeding if long term use CEU EC Guidance, Revised Jan 2012

20 Drug Interactions UPA and Levonorgestrel concomitant use of: Liver enzyme inducers UPA Medications that raise gastric ph proton pump inhibitors, H2-receptor antagonists, antacids Levonorgestrel containing emergency contraception - discuss CEU EC Guidance, Revised Jan 2012 Summary of Product Characteristics (UPA). Revised Nov 2011

21 Contraindications & Precautions to UPA Pregnancy Hypersensitivity Asthma insufficiently controlled with oral steroids Severe hepatic or renal impairment Rare hereditary disorders: Galactose intolerance, Lapp lactase deficiency, glucose-galactose malabsorption Summary of Product Characteristics. Revised Nov 2011

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24 CEU Quick Starting Guidance September 2010 Emergency contraception alone is not enough 24 16/05/2012

25 Then what? Quick start can she have? CHC: COC? Evra? NuvaRing? POP? Nexplanon? DMPA? IUS?

26 Contraceptive use among women aged in England and Wales (2007) OC (COC or POP) 28% Male condom 24% Sterilised / partner sterilised 17% IUD 4% Injection / implant 5% IUS 3% Cap / diaphragm 0% Periodic abstinence (rhythm) 2% Contraception and Sexual Health Office for National Statistics

27 Accidental pregnancy in first year of use typical use Perfect use Typical use percent Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J et al. Contraceptive Technology, revised edition 19. NY: Ardent Media, 2007

28 FSRH CHC guidance

29 UKMEC

30 Sub-dermal implant Failure rate <0.1% at 3 years Regular follow-up not required Position of implant important for removal Counselling important for compliance

31 Depo Provera(DMPA) 150mg Depo Medroxyprogesterone Acetate Injection given i.m. every 12 weeks ( licence 12+5 days) now up to 14 weeks <4/1000 failure rate Inhibits ovulation

32 Drug interactions

33 Guidance on antibiotics and contraceptive pill interaction changed GPs have been given the goahead to prescribe almost all classes of antibiotics to women who take the contraceptive pill, in a major change to current practice prompted by new evidence on the interactions between the drugs.

34 NICE - Key Priorities for Implementation Women requiring contraception should be given information about and offered a choice of all methods, including LARCs. All IUD/IUS/depo/implant are more cost effective than the COC even at 1 year of use IUD/IUS/implants are more cost effective than depo - provera Increasing the uptake of LARCs will reduce the numbers of unintended pregnancies.

35 LARCS Depo Provera Implanon Cu IUD copper coil Mirena IUS hormone coil

36 Mirena EvoInserter advantages compared to original inserter 3 Simplified loading by pushing the slider forwards to its furthest position 2 Mirena is already in the horizontal position 1 Threads are inside the inserter handle 6 Smaller diameter insertion tube 4 More ergonomic shape of slider and handle 5 Double-sided centimetre scale

37 Improving compliance Offering choices Right product, right time Managing expectations Counselling re side effects Managing adverse effects

38 Useful websites Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Health Emergency contraception (January 2012) Quick Start, Missed pills, drug interactions All reversible methods, particular situations, FAQs Medical Eligibility Criteria for contraceptive use Selected practice recommendations for contraceptive use e-diploma from January 2010 all with NHS address via patient leaflets and information