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Contraception Presentedby DrJoelleElAwar,Obs andGynae Lead MTB and Subfertility ReviewedbyProfessor EmeritusSirArulkumaran SabharatnamConcepts • Contraception • Toxic Shock Syndrome • Fertility and Subfertility Contraception • Natural Method – Avoid sexual intercourse during fertile period (fertility awareness), Lactational amenorrhoea during breastfeeding, Coitus Interruptus – Unreliable • Barrier Method – Male condom, Female condom, Diaphragm, Cap + spermicide gel, sponge. • Hormonal contraception • Combined Hormonal Contraception (CHC) – COCP pill, Combined transdermal patch, Combined vaginal ring • Progestogen only – POP (pill), implant, injectable • Emergency Contraception- after unprotected sexual intercourse UPSI • Copper IUD - Gold standard • Ulipristal acetate (EllaOne) • Levonogestrel (Levonelle) • Intrauterine Contraception: Cu-IUD, LNG-IUS • Sterilization: Male (vasectomy) vs Female (tubal occlusion)Considerations • Exclude pregnancy – be reasonably certain • Identify any comorbidities • HTN, migraines, surgeries (gastric sleeve/bypass for oral medications), • Allergies (Latex..), Medications (esp liver enzyme inducing drugs, antiepileptics) • Lifestyle factors (smoking) • Reproductive history (postpartum, breastfeeding..) • Age (approaching menopause, <18 y o) • UKMEC should be applied to assess eligibility for CHC, POP of IUC • Assess risk for STIs, advice on safe sex • Risk assessment of sexual abuse, rape, non-consensual sex, <16 y o engaging in sexual intercourse (including capacity to consent, Fraser Criteria), any learning/physical disabilities.Combined Oral Contraceptive Pill • Reliable, Effective. If used correctly, 0.3% chance of pregnancy • Typical use - 9% chance of pregnancy • Modern COCP has ethinylestradiol (20,30, 25 mcg) + Progestogen, and most are monophasic (fixed dose) nd rd • Many types of progestogens : 2 gen (norethisterone, levonogestrel), 3 gen (Desogestrel, less androgenic), Yasmin (Drospirenone, antiandrogenic and weak antidiuretic), Co-cyprindiol/Dianette : Cyproterone acetate, anti androgenic (used in PCOS) • Mode of Action • Ovulation inhibition (-ve feedback on Hypothalamus and pituitary) —> Lower LH and FSH, no LH surge, no ovulation • Thickened cervical mucus, prevents sperm penetration • Thin endometrium, preventing implantation and prevent endometrial hyperplasiaContraindications - UKMEC • UKMEC 4 – Unacceptable Risk,Absolute CI • >35 y o with >15 cig/day • Migraine with aura • History of VTE/Stroke/IHD, severe diabetes, uncontrolled HTN, major surgery, prolonged immbolisation • Breastfeeding <6 weeks postpartum, known/suspected pregnancy • Current Breast Ca • UKMEC 3 – Disadvantage >> Benefits • >35 y o with <15 cig/day, BMI>35, Fam Hx VTE in 1 degree relative <45 y o , diabetes, controlled HTN, Immobility, BRCA ½ +ve, Current gallbladder disease, >6weeks postpartum • UKMEC 2 – Advantages generally outweighs disadvantages • Comorbidities, BMI 30-34 • UKMEC 1 – No restriction for usePill T each • If pill started between days 1-5 of period—> Contraception immediate • If started later, Contraception needed for 7 days • Not suitable if taking with liver enzyme-inducing medication as it decreases its efficacy • Taken at the same time every day • Either one pill daily for 21 days, then 7 pill free days. Or Continuous pills with one week being placebo pill. • After Emergency contraception, start COCP • Immediately after levonogestrel • 5 days after ulipristal acetate • Avoid intercourse or use barrier protection for the next 7 days • Golden Rule • COCP needs 7 continuous days to start protecting!! Missed Pill • If 1 pill missed: Take one ASAP + today’s one. • If <72 hrs since last pill, that’s it. No need for more precautions. • If 2 or more missed (>72 hrs) • In Week 1: Take ASAP + 7 days of barrier condoms + emergency contraception if UPSI occurred. • In Week 2 : Continue, 7 days protection, NO need for emergency pill. • In Week 3: Take & Omit pill free interval / placebo week & needednew pack, 7 days protection, no extra emergency pill • >7 pills missed —> Emergency contraception + 7 days condoms +/- Pregnancy test + restart COCP Advantagesvs Disadvantages • Advantages • Disadvantages • Reduce menstrual blood loss & pain, regulates • Increases risk of VTE, PE, Strokes and cycle cardiovascular disease • Reduced risk of benign ovarian cysts and • Small increased risk of breast cancer tumours • No protection against STIs • Reduces incidence of PID • May be forgotten • Improves skin condition in acne vulgaris • Reduces symptoms like PMS and endometriosis • Progesterone implants/Injectables)S, • Reduces risk of colorectal cancer and ovarian cancer • More effective than barrier contraception • Easily reversible, normal fertility immediately after stoppingSide Effects • Nausea, Abdominal pain • Menstrual Irregularities • Twice increased risk of stroke (esp in diabetes, smoke..) • Cervical cancer (risk x 2 after 10 yrs, return to normal after 10 yrs of stopping) • Liver Disease • Headache • HTN • VTE (small increase) • Meningioma, Angioedema • Breast pain & tenderness • Change in lipid metabolism • Breast cancer (small, and goes back to normal after 10 yrs of stopping)Combined Transdermal Patch • Start on day 1-5 of menstrual cycle, otherwise +7days of barrier • Can start immediately after COCP, combined vaginal ring, same for switching from POP or LNG-IUS. • After emergency contraception - can start immediately after levonogestrel and 5 days after ulipristal acetate • Cu-IUD • Remove on day 1-5 of menstrual cycle, start CTP on same day. No additional contraception needed. • Can start CTP 7 days before IUD removal, no extra contraception. • If removed any other time avoid UPSI & use barrier for 7 days • Postpartum • Non-Breastfeeding – start after 21 days • Breastfeeding - start >6weeks• Evra patch – Norelgestromin (Progestogen) + Ethinylestradiol • Replaced weekly for 3 weeks + 1 patch free week (induce withdrawal bleed). Can start new patch even if still bleeding • Same mode of action, side effects, indications, contraindications and effectiveness as COCP • Minor skin irritation • Less effective if >90 kg • More convenient than a pill every day • If detached, put new one (<48 hrs). If >48 hrs, 7 days protection • Stop 4 weeks before major surgery/immobilisation, stop at 50 y oCombined V aginal Ring – Nuva Ring • Flexible, latex free, transparent, colourless • Etonogestrel and ethinyloestradiol, over 21 days, then removed for 7 days • Insert on day 1-5 of cycle, otherwise +7 days of protection • Post emergency contraception: start immediately after levonorgestrel, or 5 days after ulipristal acetate (+7 days protection) • Postpartum: On day 21 if not breastfeeding, or >6 weeks if breastfeeding • Same MOA, SE, Indication & CI & effectiveness as COCPProgesterone Only Pill • Levonorgestrel, Norethisterone, Desogestrel, Drospirenone • Mode of Action • Thickened cervical mucous, preventing sperm penetration • Delay ovum transport • Inhibit ovulation • Hostile endometrium to implantation • Perfect use: 0.3% pregnancy per year, typical use 9% • Taken daily, no pill-free interval • Ideal when COCP contraindicatedPill T each • Take pill daily, no pill free interval, at the same time every day • Forgotten, vomit within 2 hrs of ingestion or watery diarrhoea —> Missed pill rule • If taken >3 hrs late (>12 hrs for desogestrel, or >24 hrs for drospirenone) also considered mised • Take missed pill asap & subsequent pill at usual time • Take extra precaution over next 2 days • Stop if postmenopausal or >55 y oSide Effects • Following emergency contraception • Menstrual irregularities (prolonged, • Start immediately after breakthrough) – common levonorgestrel • Ectopic pregnancy • Start 5 days after ulipristal acetate • Breast tenderness • Ovarian cyst • Libido changes • Depression, mood changes • Contraindications:Active cancer, • Panic attacks pregnancy, active hepatic disease, severe arterial disease, undiagnosed • Headaches and migraines PV bleed. Caution as interacts with • Weight changes liver enzyme-inducing drugsProgesterone Only Implant • Subdermal Nexplanon (etonogestrel) • Lasts 3 years • Local anaesthetic, placed on days 1-5 of cycle. • If >day 5, use 7 days protection • Be reasonably certain patient not pregnant • May need emergency contraception, pregnancy test • Start immediately post-partum if <21 days • Same MOA, Indications, CI, SE &Interactions as POP • Implant may break, migrate • Some complications during insertion & removal may occur • Also remove at 55Progesterone Only Injectable • Day 1-5 of menstrual cycle, barrier for 7 days • Same as all previous progesterone only options. • Depo Provera – Deep IM every 12 weeks • Synapress - SC every 13 weeks, Noristerat - Deep IM twice, 8 weeks apart • If UPSI > 14 weeks (or >10 for Noristerat) – consider emergency contraception, mainly Cu-IUD or Levonorgestrel • Ulipristal acetate may be less effective due to residual progestogen • SE : Menstrual irregularities, Weight gain, mood changes, injection site reaction, small loss in bone density, small increased risk in breast and cervical cancer (if used for >5 yrs) • Review every 2 yrs, review risk of osteoporotic fractures • Stop at 50 y oEmergency Contraception • Indications: UPSI, Barrier failure, patch removal, ring detachment, missed pills, late injections, expired implants… • 3 options currently (in the UK) • Copper intrauterine device (Cu-IUD) – inserted within 5 days of UPSI, or within 5 days of earliest estimated date of ovulation. Usually first line. • Not Mirena!! • Oral ulipristal acetate (30 mg) – Within 5 days after UPSI, or contraceptive failure, or within 5 days before earliest likely date of ovulation • Oral levonorgestrel (1.5 mg) - Within 72 hrs after UPSI/Contraceptive failure • If multiple UPSI or >5 days or woman unsure —> Oral Ulipristal acetate First line • There is no evidence that oral EC is effective if ovulation already occurredCopper IUD • Emergency and regular contraception • Inhibits fertilisation by direct toxicity, inhibit sperm transport, induce inflammatory reaction in endometrium • Can be removed any time, No STI protection • Be reasonably certain woman is not pregnant • Adverse effects: Painful insertion, bleeding, uterine perforation, expulsion, PID, ectopic pregnancy • Insert within 48 hrs of delivery of >4 weeks • DO NOT insert in active PID, distorted uterus, copper allergy, pregnancy and undiagnosed bleeding • Can last 5 to 10 years, but must be removed at 55 and should not be left if not neededUlipristal Acetate • Progesterone receptor modulator • Within 120 hrs of UPSI • Delays ovulation for at least 5 days, even after LH surge • May impair effectiveness of progestogen containing contraceptive for the rest of the cycle • SE: GI disturbance, menstrual irregularities, ectopic pregnancy, mood disorder, pelvic pain, breast tenderness • Delay breastfeeding for 1 week & COCP for 5 daysLevonorgestrel (LNG) • Up to 72 hrs after UPSI • Inhibits ovulation for next 5 days. If late – ineffective, & effectiveness decreases with time • SE : Headache, GI disturbance, ectopic pregnancy, breast tenderness • BMI >26 or >70kg – Double dose • Unlike Cu-UID, Ulipristal & LNG do not offer contraception for the remainder of the cycle & subsequent UPSI. They should also be used occasionally rather than regular, as they are not recommended multiple times in a cycleIntrauterine Systems • Cu-IUD (discussed in Emergency contraception) • Levonorgestrel Releasing System, Mirena IUS • Reversible, highly effective. Either on Days 1-5 for immediate protection or at any time + extra 7 days of protection • Decreases menstrual blood loss – used in management of dysmenorrhea and AUB. Periods usually lighter, shorter and less painful • Endometrial atrophy and prevents implantation • Thickens cervical mucous, inhibits sperm penetration • Ovulation usually preserved • Useful if Oestrogen CI • Postpartum within 48 hrs or >4 weeks postpartum • SE: Irregular PV bleed, hormonal symptoms, perforation & expulsionSpecial considerations in contraception • Fibroids causing uterine distortion —> No Cu-IUD & LNG-IUS • Current PID —> No Cu-IUD & LNG-IUS • High risk of VTE, CVD , HTN or migraine with aura —> Do not use combined hormonal contraception (pill, patch or ring) • Idiopathic menorrhagia —> IUS first line • If taking teratogenic drugs (Warfarin, lithium, sodium valproate) —> Use LARCs as most effective (IUS or implant) • >35 y o, smokes >15 cig/day —> do not use CHC. Caution in smokers in general • Lamotrigine —> Avoid CHC (reduces its effectiveness), but POP increase lamotrigine levelsT oxic Shock Syndrome • Exotoxin mediated multisystemic illness – Strep Aureus & MRSA • Leads to shock and multi organ failure • Associated with tampon use, relatively rare (3/100,000) • S&S (within hours) : Fever, N&V, Widespread rash >90% body surface with desquamation, Hypotension, multiorgan dysfunction (renal, liver, coagulopathy, ARDS), Myalgia, myositis, soft tissue necrosis • Inv: Cultures, wound swabs, FBC (Low Plt, leukocytosis), elevated CK, LFTs • Tx:As Sepsis 6 • Aggressive fluid and electrolyte resuscitation, address source of infection (abscess, tampon, wound..), • Antibiotics (Clinda + Ceph/meropenem/vancomycin), may use steroids • Surgical debridement • Complications • AKI, ARDS, Hepatic necrosis, metabolic acidosis, DIC, Encephalopathy, Rhabdomyolysis, cardiomyopathy, Recurrence (30-40%), Death (5-15%) Fertility & Subfertility • 84% of couples in the general population conceive naturally within 1 year, if they have regular (every 2-3 days) UPSI, and 92% after 2 years. • 1 in 7 couples have difficulty convceiving (in the UK) • Infertility – trying without success • Primary – never conceived, or Secondary- previously conceived • Subfertility – Reduced fertility, prolonged duration of unwanted lack of conception • Main causes: Ovulatory disorders (25%), tubal damage (20%), male infertility (30%), uterine/peritoneal disease (10%) • No identifiable cause in 25% of couples • Disorders in both man and woman – 40% of infertile couples • Other lifestyle factors (drugs, stress, obesity, smoking, alcohol), embryo defects and pelvic conditions can also be of significanceInfertility in Men • No underlying cause / idiopathic – 44% of cases • All tests normal, past medical history insignificant • Semen analysis (between 2-7 days of abstinence) • Check volume, pH, sperm concentration/motility/morphology • Decreased number of spermatozoa – oligozoospermia • Decreased sperm motility – asthenozoospermia • Many abnormal sperm morphology – teratozoospermia • Identifiable causes • Primary spermatogenic disorder, • Genetic disorders – Kallman, Klinefelter, androgen insensitivity syndrome • Obstructive azoospermia (obstructed ducts), Varicocele, Hypogonadism, Cryptorchidism (undescended testes), Vasectomy, infection, lifestyle factors, medication/drugs.. • STI screening useful (Chlamydia)Infertility in Women • Ovulatory Disorders • Group I - hypogonadotrophic hypogonadism, caused by Hypothalamic pituitary failure (10%) • Hypothalamic amenorrhoea – low body weight, excessive exercise • Congenital (Kallmann, unknown) • Present with amenorrhoea • Group II – Hypothalamic - Pituitary – Ovarian dysfunction (85%, most common) • PCOS, Hyperprolactinaemic amenorrhoea • Group III – Ovarian Failure (4-5%) • Menopausal symptoms, <40 y o • Idiopathic, post chemotherapy/radiotherapy, Post oophorectomy • High gonadotrophins, Raised FSH (>30), Low Oestradiol – Treat as menopause • Other causes: Hypo/hyperthyroid, Adrenal abnormalities (Cushing’s, Congenital adrenal hyperplasia, Cancers, AIDS, STI/PID, endometriosis, fibroids, Ashermann, Drugs, Age, lifestyle…Treatment • Full detailed history from both man and woman, examination for both • Lifestyle changes, Regular UPSI • Investigate if fail to conceive >1 year, earlier if known pathology/surgery.. • Investigations for women • Mid-luteal phase progesterone (to confirm ovulation) – 7 days before expected period, >30 Indicates ovulation • STI screen, FSH/LH, TFT, prolactin • May need tubal patency test, diagnostic laparoscopy and dye • Tx • Medical – Clomifene, Gonadotrophins, Pulsatile GnRH and dopamine agonist, PCOS tx • Surgical – Tubal Microsurgery, Ablation/excision of endometriosis • If all fails, ART – Insemination, IVF, Donor sperm/eggs, embryo donation, Surrogacy…Please fill the feedback form to get your certificate of attendance ☺ https://app.medall.org/feedback/feedback- flow?keyword=048208424eaa06be4cb1c8ef&organisation=mind-the-bleep