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ALL Y OU NEED TO KNOW ABOUT CONTRACEPTION Izzy Jackson-Brench and Maria Pisliakova 17/10/24 (Slides created by: Izzy Jackson-Brench and Maria Pisliakova) Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!Contents ■ Ethics and law ■ Regular contraception ■ Emergency contraception ■ Domestic and sexual violence ■ SBAsEthics and LawYou should be able to discuss: ■ Fraser Guidelines ■ Questions surrounding emergency contraception pills/IUD and abortionFraser Guidelines Gillick competence vs Fraser Guidelines?Fraser Guidelines Gillick competence vs Fraser Guidelines? Gillick competency refers to the assessment of whether a child is mature to make their own decisions regarding their healthcare and whether they are able to understand the implications of those decisions.Fraser Guidelines Gillick competence vs Fraser Guidelines? Gillick competency refers to the assessment of whether a child is mature to make their own decisions regarding their healthcare and whether they are able to understand the implications of those decisions. Frcontraceptive advice or treatment to under 16-year olds without parental consent.Fraser Guidelines Gillick competence vs Fraser Guidelines? Gillick competency refers to the assessment of whether a child is mature to make their own decisions regarding their healthcare and whether they are able to understand the implications of those decisions. Frcontraceptive advice or treatment to under 16-year olds without parental consent. Case 1 •You are an FY2 in A&E •You are seeing Emily, age 15, who has come in with abdominal pain, her 4th similar presentation •She has already been seen by the surgeons who ask you to take a social history to explore possible contributing factors to non-organic abdominal pain What do you want to ask Emily? Ethics and Law Paeds Lecture Current relationship details From Y5 OSCE packFrom Y5 OSCE packFrom Y5 OSCE packFrom Y5 OSCE pack Concerning Fx •a young person too immature to understand or consent •big differences in age, maturity or power between sexual partners •the sexual partner having a position of trust •force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret •drugs or alcohol used to influence a young person •a person known to the police or child protection agencies as having had abusive relationships with children or young people Ethics and Law Paeds Lecture Regular contraceptionWhat do I need to know? ■ Types of contraception – In detail: COCP, POP, IUD/IUS ■ Mechanism of action ■ Side effects and risks ■ Contraindications ■ Drug interactions ■ Missed pill rules T ypes of Contraception Hormonal Non-hormonal Short-acting Barrier Estrogen + Progesterone: COCP, patch, ring Condoms (internal and external) Progesterone: mini-pill Diaphragm +/- spermicide Long-acting Non-barrier Progesterone: Injection, implant, Mirena/IUS Natural family planning, copper coil/IUD, sterilisation T ypes of Contraception Contraception Administration COCP Every day for 21 days, followed by an optional 7 day break. POP: Desogestrel (Cerazette) Every day, continuously. 12 hour window. POP: Others 3 hour window. Patch Replace every 7 days Ring Lasts for 21 days, followed by a 7 day break. Injection Every 12-13 weeks Implant Every 3 years IUS 3-8 years IUD 5 or 10 yearsEffectivenessEffectivenessMechanism of action ■ Inhibition of ovulation ■ Thinning of the endometrium ■ Thickening of the cervical mucus ■ Reducing ciliary action in the fallopian tubes Exceptions: ■ POP - desogestrel inhibits ovulation, traditional ones less so ■ Mirena coil - inhibits ovulation in some women ■ Copper coil - toxic to gametes and induces an inflammatory response in the endometriumSide effects ■ The ‘official’ side effects do not always match up to patient’s experiences ■ Many patients will trial multiple brands and forms of contraception before finding what works for them ■ BUT ■ Side effects are often worst in the first 3-6 months before ‘settling’ ■ It can be challenging to balance patient comfort with an adequate trialSide effects General side effects: ■ Headaches ■ Breast tenderness ■ Nausea ■ Skin changes ■ Mood swings ■ Weight gain Specific side effects: ■ Continuous methods: irregular bleeding/spotting ■ Depo-provera: increased osteoporosis risk ■ Mirena coil: ovarian cysts ■ Copper coil: increased pain and heavinessComplications Procedural Cancer VTE Contraception and cancer In general (most research concerns the OCP): Breast Endometrial Cervical Ovarian ● It’s alphabetical! ● The increased risk reverts to normal after 10 years ● The decreased risk persistsContraindications ■ UKMEC grid for details ■ Think about the risks: ■ VTE – <6 weeks postpartum and/or breastfeeding – Smoking >35 years old (>15 cigarettes a day) – Significant obesity (BMI >35) – Personal or 1st degree history of VTE – Migraines with aura – Hypertension (>160/100 mmHg) ■ Cancer – Current or past breast cancer or known BRCA carrierDrug interactions ■ Hormonal contraception can be affected by liver enzyme-inducing drugs – The IUS and injection are usually unaffected ■ Be aware of: – Anti-seizures (carbamazepine, topiramate, phenytoin etc) – Antibiotics (rifampicin and rifabutin) – Anti-retrovirals (ritonavir) – St. John’s Wort ■ Consider - is the medication teratogenic?Missed pill rules: POP ■ Which pill is the patient taking - think about the window. – Most patients will be on desogestrel/Cerazette ■ Has the patient had unprotected sex? ■ If emergency contraception is not needed: – Take the missed pill ASAP, then take the next pill at the usual time – Continue with the rest of pack – Take extra precautions for 48 hours ■ Remember: apply missed pill rules when patients are experiencing D&VMissed pill rules: COCP ■ If 1 pill has been missed: – Take 1 pill immediately, and then carry on as usual ■ If 2 or more pills have been missed: – Take 1 pill immediately, and then carry on – BUT take extra precautions for 7 days PLUS ■ If week 1: consider EC if there has been UPSI in week 1 or previous pill-free interval ■ If week 2: no additional precautions ■ If week 3: omit the next pill-free interval Emergency ContraceptionWhat do I need to know? Emergency Contraception (EC): - Types/MOA - Effectiveness - Considerations when taking EC - Time frames - Potential OSCE stations – came up in Mod B Mocks last year Very high yield and very OSCE-able!EC Types and EffectivenessEC T ypes and Effectiveness 1. rateer IUD (gold standard; 99.9% effective) 1/1000 failure 2. Ulipristal (EllaOne) 14/1000 failure rate 3. Levonorgestrel (Levonelle) EC T ypes and Effectiveness 1. Copper IUD (gold standard; 99.9% effective) 1/1000 failure rate 2. Ulipristal (EllaOne) 14/1000 failure rate 3. Levonorgestrel (Levonelle) Contraceptive Mode of action Levonorgestrel Delays ovulation >5 days Ulipristal Delays ovulation > 5 days Intrauterine Prevents implantation contraceptive device EC T ypes and Effectiveness 1. Copper IUD (gold standard; 99.9% effective) 1/1000 failure rate 2. Ulipristal (EllaOne) 14/1000 failure rate 3. Levonorgestrel (Levonelle) Contraceptive Mode of action Levonorgestrel Delays ovulation >5 days Ulipristal Delays ovulation > 5 days Intrauterine Prevents implantation contraceptive device Oral EC does NOT work if ovulation has occurred!! EC T ypes and Effectiveness 1. Copper IUD (gold standard; 99.9% effective) 1/1000 failure rate 2. Ulipristal (EllaOne) 14/1000 failure rate 3. Levonorgestrel (Levonelle) “You can have unprotected sex immediately when going Contraceptive home after getting a CuIUD” Levonorgestrel Delays ovulation >5 days Ulipristal Delays ovulation > 5 days Intrauterine Prevents implantation contraceptive device Oral EC does NOT work if ovulation has occurred!!When can you give/fit EC? - Oral EC - Levonorgestrel (Levonelle) use up to 72 hours (3 days) after UPSI - Ulipristal (EllaOne) use up to 120 hours (5 days) after UPSIWhen can you give/fit EC? - Oral EC - Levonorgestrel (Levonelle) use up to 72 hours (3 days) after UPSI - Ulipristal (EllaOne) use up to 120 hours (5 days) after UPSI EllaOne → Ella is 4 letters + One = 5 daysWhen can you give/fit EC? - Oral EC - Levonorgestrel (Levonelle) use up to 72 hours (3 days) after UPSI - Ulipristal (EllaOne) use up to 120 hours (5 days) after UPSI EllaOne → Ella is 4 letters + One = 5 days - IUD can use either rule: - Up to 5 days after earliest ovulation - Up to 5 days after UPSIWhen can you give/fit EC? - Oral EC - Levonorgestrel (Levonelle) use up to 72 hours (3 days) after UPSI - Ulipristal (EllaOne) use up to 120 hours (5 days) after UPSI EllaOne → Ella is 4 letters + One = 5 days - IUD can use either rule: - Up to 5 days after earliest ovulation - Up to 5 days after UPSI Earliest predicted ovulation date = LMP - 14 days Implantation takes 5 daysSpecial considerations Levonelle (Levonorgestrel) EllaOne (Ulipristal) No medical considerations Do not use if taking enzyme inducers; if asthmatic Can breastfeed Discard breast milk Can start hormonal contraception immediately Not to be taken if hormonal contraception used in the previous 2x dose if taking enzyme inducers or if over 70kg 1/52Special considerations Levonelle (Levonorgestrel) EllaOne (Ulipristal) No medical considerations Do not use if taking enzyme inducers; if asthmatic Can breastfeed Discard breast milk Can start hormonal contraception immediately Not to be taken if hormonal contraception used in the previous 2x dose if taking enzyme inducers or if over 70kg 1/52Special considerations Levonelle (Levonorgestrel) EllaOne (Ulipristal) No medical considerations Do not use if taking enzyme inducers; if asthmatic Can breastfeed Discard breast milk Can start hormonal contraception immediately Not to be taken if hormonal contraception used in the previous 2x dose if taking enzyme inducers or if over 70kg 1/52 SCARS (Inducers) Smoking Chronic EtOH Anti-epileptics Rifampicin St John’s WortSpecial considerations Levonelle (Levonorgestrel) EllaOne (Ulipristal) No medical considerations Do not use if taking enzyme inducers; if asthmatic Can breastfeed Discard breast milk Can start hormonal contraception immediately Not to be taken if hormonal contraception used in the previous 2x dose if taking enzyme inducers or if over 70kg 1/52 SCARS (Inducers) Smoking Chronic EtOH Anti-epileptics Rifampicin St John’s Wort Oral EC can be taken more than once per cycleSpecial considerations - IUD is the most effective and therefore is thegold standard (99.9%) Oral EC IUD One off tablet, easy to take Most effective form of EC No procedure Provides contraception for 10 years Less effective Medical procedure Does not provide ongoing contraception Comes with side effects which Izzy will cover… Risk of infection (<1/1000) Risk of expulsion (<1/100) Risk of perforation (<1/1000) Risk of ectopic (<1/2000)Special considerations - IUD is the most effective and therefore is thegold standard (99.9%) Oral EC IUD One off tablet, easy to take Most effective form of EC No procedure Provides contraception for 10 years Less effective Medical procedure Does not provide ongoing contraception Comes with side effects which Izzy will cover… Risk of infection (<1/1000) Risk of expulsion (<1/100) Risk of perforation (<1/1000) Risk of ectopic (<1/2000) 🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩 🚩🚩🚩 - Assess STI risk - Assess risk at homeA recipe for pregnancyA recipe for pregnancyA recipe for pregnancy Sperm can survive for 5 days in the uterusA recipe for pregnancy Sperm can survive for 5 days in the uterus Unfertilised egg can survive 24 hoursA recipe for pregnancy Sperm can survive for 5 days in the uterus Ovulation occurs at LMP - 14 days Unfertilised egg can survive 24 hoursWhat would you like to know?What would you like to know? 1) Are you on any contraception currently? 2) Date of LMP = first day of bleed a) Cycle length b) Regular c) Usual length 3) UPSI (this cycle) 4) Date todayWhat would you like to know? 1) Are you on any contraception currently? 2) Date of LMP = first day of bleed a) Cycle length b) Regular c) Usual length 3) UPSI (this cycle) 4) Date today 14 Today 1 (LMP) 28What would you like to know? 🚩🚩🚩🚩🚩🚩🚩🚩🚩 🚩🚩 1) Are you on any contraception currently? - Intermenstrual 2) Date of LMP = first day of bleed a) Cycle length bleeding - Heavier bleeding/pain b) Regular - Postcoital c) Usual length bleeding/pain 3) UPSI (this cycle) - Smears 3x qns 4) Date today - Risk assessment 14 Today 1 (LMP) 28What would you like to know? 🚩🚩🚩🚩🚩🚩🚩🚩🚩 🚩🚩 1) Are you on any contraception currently? - Intermenstrual 2) Date of LMP = first day of bleed a) Cycle length bleeding - Heavier bleeding/pain b) Regular - Postcoital c) Usual length bleeding/pain 3) UPSI (this cycle) - Smears 3x qns 4) Date today - Risk assessment 14 Today 1 (LMP) 28 Always consider long-term contraceptive discussionsCuIUD rules – remember, irrespective of where in cycle 14 1 (LMP) 28CuIUD rules – remember, irrespective of where in cycle 14 1 (LMP) 28CuIUD rules – remember, irrespective of where in cycle 14 1 (LMP) 28 5 daysCuIUD rules – remember, irrespective of where in cycle UPSI 1 (LMP) 14 28 5 days 5 daysCuIUD rules – remember, irrespective of where in cycle UPSI UPSI 1 (LMP) 14 28 5 days 5 days 5 daysCase 1: What would you do here with re to CuIUD? UPSI (Day 3) 14 Today (Day 26) 1 (LMP) 28Case 1: What would you do here with re to CuIUD? UPSI (Day 3) 14 Today (Day 26) 1 (LMP) 28Case 1: What would you do here with re to CuIUD? UPSI (Day 3) 1 (LMP) 14 Today (Day 26) 28 5 days 5 daysCase 1: What would you do here? ● Don’t give EC + ask to do a pregnancy test in 3 weeks ● Implantation has already occured UPSI (Day 3) 14 Today (Day 26) 1 (LMP) 28 5 days 5 daysCase 2: What would you do here? UPSI (Day 6) Today (Day 8) 14 1 (LMP) 28Case 2: What would you do here? UPSI (Day 6) Today (Day 8) 14 1 (LMP) 28 5 days 5 daysCase 2: What would you do here? UPSI (Day 6) Oral EC delays ovulation by 5 days) Today (Day 8) 14 1 (LMP) 28 5 daysCase 2: What would you do here? UPSI (Day 6) Oral EC delays ovulation by 5 days) Today (Day 8) 14 1 (LMP) 28 5 days What if they presented Day 10?Case 2: What would you do here? UPSI (Day 6) Oral EC delays ovulation by 5 days) Today (Day 8) 14 1 (LMP) 28 5 days What if they had a PMHx of asthma?SBA 1 Hana usually uses condoms for contraception. She had UPSI on days 7 and 13 of a 28-31 day cycle. She is day 18 of her cycle now. What emergency contraception options does Hana have? 1. Do a pregnancy test. 2. Don’t give her EC, ask her to do a pregnancy test in 3 weeks. 3. Fit an IUD. 4. Give her EllaOne (UPA). 5. Give her Levonelle (LNG).SBA 1 Hana usually uses condoms for contraception. She had UPSI on days 7 and 13 of a 28-31 day cycle. She is day 18 of her cycle now. What emergency contraception options does Hana have? 1. Do a pregnancy test. 2. Don’t give her EC, ask her to do a pregnancy test in 3 weeks. 3. Fit an IUD. 4. Give her EllaOne (UPA). 5. Give her Levonelle (LNG). 7 1314 Today (Day 18) 1 (LMP) 28-31 5 days 5 daysSBA 1 Hana usually uses condoms for contraception. She had UPSI on days 7 and 13 of a 28-31 day cycle. She is day 18 of her cycle now. What emergency contraception options does Hana have? 1. Do a pregnancy test. 2. Don’t give her EC, ask her to do a pregnancy test in 3 weeks. 3. Fit an IUD. 4. Give her EllaOne (UPA). 5. Give her Levonelle (LNG). 7 1314 Today (Day 18) 1 (LMP) 28-31 5 days 5 daysCase 1SBA 5SBA 5 Today (Day 14) 10 1 (LMP) 14 28 5 days 5 days “ I really don’t want to get pregnant. The nurse said you’d be able to discuss options I have.” UCL Year 5 Mock 23/24 “ I really don’t want to get pregnant. The nurse said you’d be able to discuss options I have.” “ I would like to know more about the most effective method.” UCL Year 5 Mock 23/24 “ I really don’t want to get pregnant. The nurse said you’d be able to discuss options I have.” “ I would like to know more about the most effective method.” “Can you tell me more about the coil please?” “ Are there any side effects with it?” UCL Year 5 Mock 23/24 “ I really don’t want to get pregnant. The nurse said you’d be able to discuss options I have.” “ I would like to know more about the most effective method.” “Can you tell me more about the coil please?” “ Are there any side effects with it?” “Thanks for all of that. Isn’t having a coil fitted the same as abortion?” “Can I come get it fitted the next day?” UCL Year 5 Mock 23/24 “ I really don’t want to get pregnant. The nurse said you’d be able to discuss options I have.” “ I would like to know more about the most effective method.” “Can you tell me more about the coil please?” “ Are there any side effects with it?” “Thanks for all of that. Isn’t having a coil fitted the same as abortion?” “Can I come get it fitted the next day?” UCL Year 5 Mock 23/24Domestic and Sexual ViolenceDomestic and sexual violence ■ Women experiencing domestic violence seek EC more frequently than other women ■ 1 in 4 women have experienced rape or sexual assault ■ You must about safety and whether the intercourse was consensualDomestic and sexual violence ■ Remember that the effectiveness of the COCP/POP relies on being able to take the pill every day ■ Contraception in abusive relationships can be controlled or restricted ■ If a patient suggests this is happening, consider offering a LARC as well as providing further supportSBA 1 A 27-year-old woman presents to the sexual health clinic wanting to swap from the COCP to a long-acting form of contraception. However, she is unsure which type would be most suitable. She has no diagnosed medical conditions, but experiences severe dysmenorrhea, so would prefer a method that will stop menstruation. What is the most appropriate form of contraception for this patient? A. Contraceptive implant B. Continuous use of the COCP C. Mirena IUS D. Copper IUDSBA 1 A 27-year-old woman presents to the sexual health clinic wanting to swap from the COCP to a long-acting form of contraception. However, she is unsure which type would be most suitable. She has no diagnosed medical conditions, but experiences severe dysmenorrhea, so would prefer a method that will stop menstruation. What is the most appropriate form of contraception for this patient? A. Contraceptive implant B. Continuous use of the COCP C. Mirena IUS D. Copper IUDSBA 2 A 21-year-old woman is referred to the sexual health clinic for a discussion around contraception. She is generally well, but experiences frequent migraines with aura, for which she takes sumatriptan and topiramate prophylaxis. What is the most appropriate form of contraception for this patient? A. Contraceptive patch B. Copper IUD C. COCP D. POPSBA 2 A 21-year-old woman is referred to the sexual health clinic for a discussion around contraception. She is generally well, but experiences frequent migraines with aura, for which she takes sumatriptan and topiramate prophylaxis. What is the most appropriate form of contraception for this patient? A. Contraceptive implant B. Copper IUD C. COCP D. POPSBA 3 A 31-year-old patient presents to the GP missing her day 17 and 18 doses ofher COCP whilst on holiday. She took the second missed pill on day 19 as soon as she realised, but she is very concerned, as she had unprotected sexual intercourse on day 14. Alongside advising her to use condoms for 7 days, what further advice should be given to this patient? A. No further advice is needed B. Attend sexual health clinic for emergency contraception C. Take a pregnancy test in 3 weeks time D. Omit the next pill-free intervalSBA 3 A 31-year-old patient presents to the GP missing her day 17 and 18 doses ofher COCP whilst on holiday. She took the second missed pill on day 19 as soon as she realised, but she is very concerned, as she had unprotected sexual intercourse on day 14. Alongside advising her to use condoms for 7 days, what further advice should be given to this patient? A. No further advice is needed B. Attend sexual health clinic for emergency contraception C. Take a pregnancy test in 3 weeks time D. Omit the next pill-free intervalSBA 3 A 31-year-old patient presents to the GP missing her day 17 and 18 doses ofher COCP whilst on holiday. She took the second missed pill on day 19 as soon as she realised, but she is very concerned, as she had unprotected sexual intercourse on day 14. Alongside advising her to use condoms for 7 days, what further advice should be given to this patient? If you saw this patient in your clinic, what else would you need to consider? THANKS FOR W TCHING! Please fill out the feedback form on Medall and see you next week!