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CONTRACEPTION AND HRT Cath Ann Rees (F1) and Ruth Marsden (Year 5)MENSTRUAL CYCLE NATURAL BARRIER HORMONAL LARC PERMANENT Abstinence Condoms Combined Injection Sterillisation - Male - Pills Withdrawal - Female - Patch Implant Vasectomy (usually - Ring local anaesthetic) Fertility Awareness Methods Diaphragm Coils - Cervical secretions Cap Progesterone only pill - Progesterone - Basal body temperature Sponge – ‘mini-pill’ - Copper - Calendar method Lactational Amenorrhoea CONTRACEPTION METHODSSKIP TO TALK ABOUT THE HORMONAL METHODS (SLIDE 12) NATURAL METHODS 1. Abstinence 2. Withdrawal 3. Lactational Amenorrhoea 4. Fertility AwarenessMethods (FAM) 🢝 All ways of tracking cycle and predictingfertility 🢝 Basal body temperature (see next slide) 🢝 Cervical secretion(see next slide) 🢝 Calendar method Advantages of FAM Disadvantages of FAM • No hormones – so • Need regular cycles feels ‘natural’ for • Need to be accurate women • Need to avoid UPSI during ‘high risk’ times • Does not protect against STIs • Single method not very effective (76- 80% = More effective when used together)NATURAL METHODS: TEMP AND MENSTRUAL CYCLE Tracking cycle and predicting when most fertile Temperature ↑ coincides with Progesterone ↑ Monitor temperature every day for a few cycles Predict ovulation date by tracking changes in temp More fertile few days before body temp ↑ Most fertile week before ovulation and 2 days after NATURAL METHODS: CERVICAL MUCUS most fertilele and predicting when Progesterone and Oestrogen – changes to cervical mucus By tracking cervical mucus cycle, can preduct menstrual cycle and therefore when most fertile Dry/tacky/cream/thick = Not fertile Cloudy/stretchy = semi-fertile Watery/stretchy/raw egg white = most fertile NATURAL METHODS: LACTATIONAL AMENORRHOEA METHOD Suckling → Inhibits Dopamine → Stimulates prolactin → Milk Production Suckling → Stimulates oxytocin (post pituitary) → Milk release Suckling → Inhibits Dopamine → Stimulates prolactin → Inhibits LH and FSH → Prevents ovulation → Amenorrhoea Only effective if < 6 months post-partum + fully breastfeeding + no periods 2% conception risk if all 3 LAM criteria are satisfied 🢝 < 6 months post-partum 🢝 Full lactation 🢝 No periods(amenorrhoea) BARRIER Condoms (male and female) 🢝 Advantages 🢝 Male - Only method to protect against STIs 🢝 No hormones 🢝 Disadvantages 🢝 Interrupts sex 🢝 Depends on user 🢝 Not very reliable 🢝 Costs Diaphragm, cap and sponges 🢝 Rarely used 🢝 Insert 3 hours prior to sex with spermicide 🢝 Remove 6 hours after sex 🢝 Need to be fitted by clinician and needs practice in inserting 🢝 Does not protect against STIsSee later See later See later See later See later • Put on skin for 7 days, Insert one (per vagina). Stays in change weekly, have a break for 3 weeks. Remove 4 weekh on 4 week (withdrawal (withdrawalbleed) then rest bleed) then restart • Can run patches together COCP – E.G MICROGYNON • What’s the MOA? 🢝 Inhibits ovulation due to negative feedback on HPO axis Starting the pill: 🢝 Tpenetrate (progesterone)arder for sperm to • Can start on any day of cycle 🢝 Thins endometrial lini→greduces chance of implantation • Start day 1-5 of cycle: no need for additional contraception (immediate protection) When used correctly, over 99% effective • Start after day 5 of cycle: no immediate Traditional regime: 21 days on, 7 days off protection: will need additional contraception for 🢝 Can have 7 days of ‘sugar pills’ 7 days 🢝 Withdrawal bleed – not real period Tailored regimes REMEMBER you need to have taken COCP for 7 🢝 21 days on, 4 days off consecutive days for it to be effective (think about 🢝 9 weeks on, 7 days off 🢝 21 (or more days on), 4 days off (when this when missing a pill) breakthrough bleed starts) 🢝 Continuous use with no breaks COCP – MISSED PILL When taking COCP, what is considereda ‘Missed Pill?’ OVER 24 hours late i.e 48 hours or more since last pill Actions to be taken depends on HOW LATE the drug is and WHEN IN THE CYCLE the pill was missed it to be effective (think about this when missing a pill)ys for Can direct patients to NHS website - https://www.nhs.uk/conditions/contraception/miss-combined-pill/ADVS AND DISADVS OF ‘THE PILL’ Advantages Disadvantages Helps with Menorrhagia, Hormonal s/e Dysmenorrhoea, Endometriosis • Oestrogen: nausea, breast tenderness, irregular bleeding • Progesterone: mood swings, acne, bloating, decreased libido Compared to POP, reduced risk of Small risk of • Ovarian Ca • VTE • Endometrial Ca • Cervical and breast cancer • CRC • CVA and MIs Can help with acne and hirsutism Daily medication (depending on preparation) Does not affect sex Affected by enzyme inducers • Antiepileptic drugs (carbamazepine, phenytoin, topiramate), ABx (rifampicin, rifabutin) • If on these meds, preferred methods are IUS, IUD or depot • Advised to have another highly effective contraceptive method for 4 weeks or more even after stopping enzyme-inducing drug No STI protection UKMEC4 UKMEC3 Breastfeeding < 6 weeks post partum Non-breastfeeding < 3 weeks without other RFs for VTE - Reduced lactation + increase thrombosis CONTRA- especially in first 3-6 weeks postpartum Non-breastfeeding < 3 weeks postpartum with Non breastfeeding 3-6 week with other RTs for VTE INDICATIONS other RFs for VTE Age > 35 + smoking > 15 cigs a day Age > 35yo smokes < 15 OR stopped < 1 year ago HTN of systolic > 160 and diastolic > 100 BMI > 35 OF COCP Vascular disease Multiple RFs for CVD (smoking, DM, HTN, obesity, dyslipidaemia) COCP and Postpartum Current/Hx of IHD Migraine without aura (already initiated on COCP but develop UKMEC2: Breastfeeding 6 wee(Recently changedt partum Sx during COCP use) from UKMEC 3 in 2016) Stroke, TIA Hx > 1 year ago of migraine with aura mum not breastfeeding) concerns around reduced lactation if Current or Hx of VTE Undiagnosed breast mass/Sx Major surgery with prolonged immobilization Carrier of BRCA months after birthects on lactation, avoid COCP until weaning OR for 6 Migraine with aura Hx of breast Ca Current breast Ca Gallbladder disease (current or medically treated) Severe/decompensated cirrhosis Cholestasis with past COC use Liver Ca Viral hepatitis flare full remobilisationCP 4 weeks BEFORE surgery and recommend 2 weeks after Benign hepatocellular adenoma Complicated organ transplant eg rejection, graft failure etc Thrombophilia Adequately controlled HTN or systolic > 140-159 or diastolic 90-99 Cardiomyopathy with impaired cardiac function 1 degree relative with VTE < 45 yo AF Immobility unrelated to surgery (e.g wheelchair) Antiphospholipid syndrome (+ve AP antibody) DM with nephropathy/retinopathy/neuropathy/other vasc disease PROGESTERONE ONLY PILL – MINI- PILL What is the MOA? 🢝 Thickens cervical mucus (prevents sperm entry) 🢝 Depending on preparation: suppresses ovulation (not as effective as COCP at preventing ovulation) If taken correctly, it's more than 99% effective. 🢝 Desogestrel – 12 hour window to take pill (newer) (latter is preferred) 🢝 Norethisterone or Levonogestrel – 3 hour window Take every day at the same time (stricter window than COCP) 🢝 If start day 6-28, need additionalcontraception for 2 daystion Childbirth 🢝 Can start any time up to and including 21 days post-partum without extra contraception 🢝 If start after 21 days postpartum, extra contra needed for 2 days 🢝 Safe in breastfeeding (does not affect lactation unlike oestrogen) PROGESTERONE ONLY PILL – ‘MINI- PILL’ Advantages Disadvantages No oestrogenic side effects May cause irregular bleeding (oligo-amenorrhoea) • Tends to lessen with continued use No significant increase in breast cancer risk or Progesterone side effects - mood swings, weight gain, venous disease (therefore indicated in ladies with libido and acne (no evidence for this but anecdotal) Hx of VTE, smokers above 35yo, HTN, migraines) May help dysmenorrhea and endometriosis Functional ovarian cyst formation Does not affect sex Take meds every day (every day within 3 hours) May stop menstrual bleeding (no withdrawal bleed) Affected by enzyme inducers No STI protectionWHEN YOU CAN’T HAVE COCP, YOU CAN HAVE POP HTN (POP has no effect on BP) Structural heart disease Pulmonary HTN Undergoing major or leg surgery High BMI (unless breastfeeding or over 45yo) CONTRAINDICATIONS FOR POP Absolute Recent breast cancer not yet clearly in remission Undiagnosed genital tract bleeding Acute porphyria Relative Past severe arterial disease or currently very high risk Sex-steroid dependent cancer including breast cancer Recent trophoblastic disease until hCG is undetectable in blood as well as urine Enzyme inducing drugs – although can take 2 POPs OR can also have another reliable method eg injectable, IUD or LNG-IUS Previous symptomatic (painful) functional ovarian cystMISSED POP When taking POP, what is considered a ’missed pill?’ Depends on type of POP Shorter window compared to COCP After missing a POP for more than 3 hours (or more than 12 hours for Cerazette), woman should; 🢝 Take that day’s pill immediately and the next one on time 🢝 Use added precautions for next 2 days LONG ACTING •Depo injection REVERSIBLE •Implant CONTRACEPT •Coils – IUS Mirena (progesterone) and IUD (copper) IONDEPO INJECTION •Contains medroxyprogesterone acetate 150mg •IM injection given every 12 weeks •MOA: Inhibits ovulation (also thickens cervical mucus and thins endometrial lining) •ADRs: Irregular bleeding and weight gain •Contra-indications: Current breast cancer •Disadvantages: cannot be reversed once injection has been given and there may be a delay to fertility for up to 12 months, additional contraceptive day 1-5 of menstrual periodfirst 7 days if not given onIMPLANT •Brand name: Nexplanon (was previously Implanon) •Implanted under the skin in the upper arm just overlying the tricep •Contains the progesterone hormone etonogestrel •MOA: Prevent ovulation (and thicken cervical mucus) •ADRs: Irregular bleeding (can sometimes be managed by co-prescription of COCP) – remember to do a speculum/STI check if bleeding continues to rule out other causes. •Progesterone effects – headache, nausea, breast pain •Advantages: Most effective form of contraception, long lasting (lasts for 3 years), doesn’t contain oestrogen so can be used if past history of VTE, migraine etc, can be inserted immediately following termination of pregnancy •Disadvantages: need trained professional to insert and remove, additional contraceptive methods are needed for the first 7 days if not inserted on day 1-5 of menstrual periodCOILS IUS (Mirena) •Contains progesterone levonorgestrel •MOA: Prevents endometrial proliferation and Copper IUD causes cervical mucous thickening •MOA: Prevention of fertilisation by causing •uterine perforation (2/1000), risk of PID ing, decreased sperm motility and survival first 20 days after insertion, expulsion •ADRs: Heavy, longer more painful periods, uterine perforation (2/1000), risk of PID in •to the uterus and so fewer hormonal sideonly first 20 days after insertion, expulsion effects, long lasting (5 years), after initial •Advantages: 99% effective, can be relied irregular bleeding periods tend to come upon immediately following insertion, long lighter lasting (from 5-10 years), does not contain •Can be relied upon after 7 days any hormones (so no hormonal side effects) EMERGENCY • LevonelleD CONTRACEPTION • EllaOne EMERGENCY CONTRACEPTION – COPPER COIL •The copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria •Must be inserted within 5 days of UPSI or if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date •May inhibit fertilisation or implantation •Is 99% effective regardless of where it is used in the cycle •Prophylactic antibiotics may be given if the patient is considered to be at high risk of STIs •May be left in situ to provide long term contraception however if the patient wishes for it to be removed it should be kept in until the next period EMERGENCY CONTRACEPTION- HORMONAL Levonorgestrel (Levonelle) Ulipristal acetate (EllaOne) MOA: Acts to stop ovulation and inhibit implantation MOA: inhibition of ovulation Must be taken within 72 hours of UPSI (3 days) Must be taken within 120 hours of UPSI (5 days) Can be used more than once in a menstrual cycle Can be used more than once in a menstrual cycle Hormonal contraception can be started immediately Contraception with the pill, patch or ring should be after using started or restarted 5 days after taking ulipristal with barrier methods used during this period The dose should be doubled if BMI > 26 or weight >70 Caution in patients with severe asthma kg If vomiting occurs within 3 hours then dose should be Concomitant use with levonorgestrel is not recommended repeated No restrictions for breastfeeding Breastfeeding should be delayed for one week after taking HORMONE REPLACEMENT THERAPY (HRT) Contraindications: • Current or past breast cancer • Any oestrogen sensitive cancer • Undiagnosed vaginal bleeding HRT REGIMES • Untreated endometrial hyperplasia 1. Does the woman have a uterus or not? Yes – then they will need combined HRT with oestrogen and progesterone. Oestrogen- helps with the vasomotor symptoms of menopause. Progesterone protects the uterus from endometrialcancer. However, against endometrialcancer. risk of breast cancer due to the added progesterone, but its role is to protect patients do not have a uterus.gen only HRT. No need to add progesterone to protect the uterus as these 2 . When was the patients last menstrual period? bleed, oestrogen is taken daily and there are breaks for progesteronealHRT, this produces a withdrawal >1 year ago (post-menopausal) – then they will need continuous HRT, this does not produce a bleed The aim of this is to allow for identification of patients who have irregular bleeding whilst on HRT and require HRT should not cause withdrawalbleeding and so any bleeding should be further investifated.sal. Continuous NOTE!! HRT is not licenced for contraception! Additional contraception should be offered to HRT PREPARATIONS all women up to the age of 55 years old. Only the coil can be used for both HRT and contraception. Oestrogen: Progesterone: 🢝 Tablets 🢝 Tablets 🢝 Patches 🢝 Patches 🢝 Spray 🢝 IUS coil (note only licenced for 4 years for HRT 🢝 Gel compared to 5 years for contraception but can be used off licence for HRT for 5 years) 🢝 Oestrogen increases the risk of endometrial cancer and so progesterone is required to 🢝 cancer in combined HRT although the risk of protect the uterus if the patient still has a dying from breast cancer is not raised uterus. 🢝 Oral oestrogen HRT increases the risk of VTE. 🢝 Increased risk of ovarian cancer with all HRT No increased risk with transdermal HRT.FINAL TIPS ICE – CARDIFF LOVE IT Underage relationships – safeguarding Gynae and obstetrics Hx Sexual history Safe at home? Direct patients to NHS website about contraception RECOMMENDED RESOURCES Videos on Menstrual cycle Khan Academy 🢝 The ovarian cycle | Reproductivesystemphysiology - https://www.youtube.com/watch?v=VYSFNwTUkG0&t=380s 🢝 Reproductivecycle graph-Follicularphase - https://www.youtube.com/watch?v=gmKAuceSf-s&t=293s 🢝 Reproductivecycle graph - Luteal phase - https://www.youtube.com/watch?v=uA7Xny276sk&t=9s OR Osmosis - The menstrual cycle = https://www.youtube.com/watch?v=7HlHGLr1hTA OR Armando Hasudungan = Female Reproductive System - Menstrual Cycle, Hormones and Regulation Good recap on ’ How Birth Control Pills Work’ - https://www.youtube.com/watch?v=hI2C7TsnSfk U🢝 https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/ Please can you complete the feedback form! Email us: theisceseries101@gmail.com