Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OSCEAZY X GEEKY MEDICS Contraception Counselling Megan HodgsonTypes of Contraception Emergency Contraception Pharmacology CounsellingTYPES OF CONTRACEPTIONA 17-year-old female requires contraception. She is unsure when she would COCP like to start her family. She suffers with heavy menstrual bleeding and acne. She would like to control when her period bleed occurs around events. She is not keen on any “internal” contraceptive methods. A 34-year-old female requires contraception. She has finished her family for IUS now but may change her mind. She experiences heavy, painful periods. She does not want have to think about contraception in the next 4 years. An 18-year-old female requires contraception. She says she is very forgetful. Implant She is considering having a child in 4 years. She has a BMI of 36. She experienced a pelvic infection 2 months ago. A 26-year-old female requires contraception. She was diagnosed with fibroids Depot Injection recently, which have not resolved. She is considering having a child in 2 years time. She is an air hostess and would be unable to regularly take any medication at the same time each day COCP What is it? • A hormonal contraceptive pill containing both oestrogen & progestogen Mechanism of Action • Inhibits Ovulation Treatment Course • 3 weeks on with 1 week pill-free or placebo) • OD at same time (no breaks) • 'Tricycling' - taking three 21-day packs back-to-back before having a 4 or 7-day break Effectiveness • 99% (with full compliance) Starting the COCP • 91% (with traditional use) • Start in first 5 days of cycle → no additional contraception required • Fertility returns after ~1 month • Start at any other point → alternative contraception (e.g. condoms) for first 7 days COCP Advantages Disadvantages • Highly effective • Easy to forget to take it • Does not interfere with sex • No protection against sexually transmitted • Contraceptive effects quickly reversible upon infections (STIs) stopping • Not effective in patients who have had a gastric • Makes periods regular, lighter and less painful sleeve/bypass/duodenal switch (cannot have oral contraception ever) Cancers it is protective for: • Temporary side-effects: headache, nausea, breast • Ovarian cancer (effect lasts several decades after tenderness cessation) • Endometrial cancer (COCP suppresses Cancers it increases the risk for: endometrial cell proliferation - effect lasts several • Breast cancer decades after cessation) • Cervical cancer • Colorectal cancer Other conditions it increases the risk for: Other conditions it is protective for: • Venous thromboembolic disease • Pelvic inflammatory disease • Stroke • Ovarian cysts • Ischemic heart disease • PMS • Cholestasis • Endometriosis • Benign Breast disease • Acne vulgaris COCP CONTRAINDICA TIONS • >35 years old & smokes <15 cigarettes/day • >35 years old & smokes >15 cigarettes/day • BMI > 35 • Migraine with aura (e.g. visual changes, • Migraine with no aura paranesthesia, focal weakness, • DVT or PE family history in 1st degree dysphagia) → increased risk of stroke relative <45 years old • Personal history of DVT or PE • Controlled Hypertension • Personal history of stroke or ischemic • Immobility (e.g. wheelchair use) heart disease • Carrier of known gene mutations • Uncontrolled Hypertension associated with breast cancer (e.g. • Current Breast cancer BRCA1/BRCA2) • Recent major surgery with prolonged • Current gallbladder disease immobilisation • Diabetes mellitus diagnosed >20 years • Breast feeding and <6 weeks post partum ago • Positive antiphospholipid antibodies COCP is affected by P450 inducers & inhibitors Intercourse during the pill-free period is only safe if next pack is started on time Vomiting <3 hours after taking COCP  take another pill straight away & take COCP: OTHER KEY next pill as normal. INFORMA TION Use another contraception type until COCP has been taken normally for 7 days (without vomiting) Diarrhoea >24 hours  take pill as normal. Use another contraception type for 7 days until diarrhoea stops POP What is it? • A hormonal contraceptive pill containing Mechanism of Action only progestogen Traditional POPs (3 hours): Micronor, • Thickens cervical mucus Noriday, Nogeston, Femulen • Stops ovulation (levogesterol) 12-hour POPs: Cerazette (desogestrel) 24-hour POPs: Drospirenone Treatment Course • OD (at same time each day, no breaks) Effectiveness Starting the POP • 99% (with full compliance) • Start in first 5 days of cycle → no additional • 91% (with traditional use) contraception required • Start at any other point → alternative • Fertility returns after ~1 month contraception (e.g. condoms) for first 2 days POP Advantages Disadvantages • Highly effective • Easy to forget to take it • No protection against sexually • Does not interfere with sex transmitted infections (STIs) • Contraceptive effects reversible upon stopping • ADRs: irregular vaginal bleeding / • Useful for people who cannot take spotting, breast tenderness, acne, weight gain, mood changes, change oestrogen in libido, ovarian cysts Contraindications Other Information • Pregnancy • After birth, you can start taking the POP straight away • If start POP in first 20 days after birth  protected • Breast Cancer immediately from pregnancy • Undiagnosed PV bleeding • contraceptive methods (e.g. condoms) until you’ver • Severe decompensated liver cirrhosis taken POP for 2 days • Severe arterial disease • POP is safe to use during breastfeeding • Vomiting <2 hours after traditional POP or <3-4 hours after desogestrel makes POP ineffective (continue taking normally, but assume that pill was missed) MISSED PILL RULES COCP POP 1 MISSED PILL TRADITIONAL (‘3 HOUR’) MINI PILLS TAKE LAST PILL & CONTINUE TAKING PILLS DAILY MUST BE TAKEN WITHIN THE SAME 3 HOUR PERIOD EVERY DAY NO EXTRA PRECAUTIONS REQUIRED OF THE MONTH 2 OR MORE MISSED PILLS ‘12 HOUR’ MINI PILLS TAKE LAST PILL & CONTINUE TAKING PILLS DAILY MUST BE TAKEN WITHIOF THE MONTH2 HOUR PERIOD EVERY DAY EXTRA PRECAUTIONS REQUIRED: ABSTINENCE OR CONDOMS UNTIL 7 DAYS OF PILLS TAKEN IN A ROW WEEK 1 / PILL-FREE INTERVAL: CONSIDER EMERGENCY IF OVER 3 OR 12 HOURS LATE RESPECTIVELY: CONTRACEPTION TAKE 1 MISSED PILL ASAP TAKE THE NEXT PILL AT NORMAL TIME WEEK 2: TAKE REST OF PACK NORMALLY, NO EXTRA PRECAUTIONS REQUIRED UNTIL PILL HAS BEEN EMERGENCY CONTRACEPTION REQUIRED AFTER 7 TAKEN IN NORMAL PATTERN FOR 48 HOURS (E.G. CONSECUTIVE DAYS CONDOMS) WEEK 3: OMIT THE PILL-FREE INTERVAL DEPOT INJECTION What is it? Mechanism of Action • Hormonal contraception of slow- • Inhibits ovulation release progestogen (no oestrogen) • Thickens cervical mucus • “Depo Provera” • Thins endometrium • Medroxyprogesterone acetate 150mg Treatment Course • IM injection every 3 months (can be given up to 14 weeks Effectiveness without need for extra precautions, • >99% (with full compliance) can be taught how to do it at home) • 94% (with typical use) Starting the • Start in first 5 days of cycle → no additional contraception required • Start at any other point → alternative contraception (e.g. condoms) for first 7 days Depot • If chance of pregnancy when receiving injection → take pregnancy test 3 weeks after unprotected sex Injection DEPOT INJECTION Advantages Disadvantages • Highly effective • Cannot be reversed once given • Does not interfere with sex • Delayed return to fertility (up to 12 months) • Don’t have to think about contraception during this time • No protection against sexually transmitted infections (STIs) • Temporary side-effects: irregular Contraindications bleeding, weight gain, increased risk of osteoporosis (only used in adolescents • Liver/Genital/Breast Cancer if no other method suitable) • Undiagnosed PV bleeding • Severe decompensated liver cirrhosis • Ischaemic Heart disease Other Information • Caution: Smoking, Diabetes, • If you miss an injection, use alternative contraception (e.g. Hypertension, Hypercholesterolemia, condoms) until you get the injection + 7 days after Obesity • After birth, you can start taking the injection straight away • If start injection in first 20 days after birth  protected immediately from pregnancy • Injection is safe to use during breastfeeding IMPLANT What is it? • Hormonal contraception of slow- Mechanism of Action release etonogestrel progestogen (no oestrogen) • Inhibits ovulation • Thickens cervical mucus • Thins endometrium Treatment Course • 3 years Starting the Implant Effectiveness • Start in first 5 days of cycle → no • >99% (all use) additional contraception required • Most effective form of contraception • Start at any other point → alternative contraception (e.g. condoms) for first 7 days IMPLANT Advantages Disadvantages • Highly effective • No protection against sexually transmitted infections (STIs) • Does not interfere with sex • Trained professional required to insert & remove • No oestrogen → can be used in PMHx device of migraine with aura, • ADRs: irregular/heavy bleeding (mx: co-prescription thromboembolism, etc. of COCP, speculum & STI check if bleeding continues), breast tenderness, acne, appetite • Lasts 3 years (long-acting) increase, mood changes, change in libido Contraindications Other Information • Liver/Genital/Breast Cancer • Site: Proximal Non-dominant arm, overlying • Undiagnosed PV bleeding tricep muscle, subdermal • Severe decompensated liver cirrhosis • Applicator designed to prevent ‘deep’ • Ischaemic Heart disease / Stroke insertions (e.g. subcutaneous, intramuscular) • On P450 enzyme inducers • Radiopaque → easy to locate if impalpable • Can be inserted immediately following termination of pregnancy IUS What is it? Mechanism of Action • Hormonal contraception of slow release • Thickens cervical mucus of etonogestrel (progestogen) • Thins endometrium Treatment Course • 5 years Starting the IUS Effectiveness • Start in first 5 days of cycle → no • >99% additional contraception required, immediately effective • Start at any other point → alternative contraception (e.g. condoms) for first 7 days IUS Advantages Disadvantages • Highly effective • Initial frequent uterine bleeding → intermittent light menses with less painful • Lasts 5-10 years (long-acting) and some women become amenorrhoeic • Expulsion: 5% risk, occurs in first 3 months • Ectopic pregnancy: proportion of Contraindications pregnancies that are ectopic are increased (but absolute number of ectopic • Pelvic infection / PID <3 months ago pregnancies is reduced, compared to a • Gynaecological cancer / Breast cancer woman not using contraception) • Fibroids distorting uterine cavity • Infection: increased risk of PID in first 20 • Small uterine cavity days after insertion • Undiagnosed PV bleeding • Uterine perforation: 0.2% risk • Long QT syndrome • Ischaemic Heart disease • Pregnancy • 48 hours - 4 weeks postpartum • Severe liver cirrhosis / hepatocellular cancer IUD What is it? • Non-hormonal contraceptive method using a piece of T-shaped plastic Mechanism of Action wrapped in copper • Copper is a spermicide (kills sperm & decreases motility) Treatment Course • Intrauterine inflammation • 5-10 years • Copper on Stem only: 5 years • Copper on Stem & Arms: 10 years Effectiveness Starting the IUD • >99% • Effective immediately after insertion IUD Advantages Disadvantages • Highly effective • Heaver, longer, more painful periods & • Lasts 5-10 years (long-acting) Irregular bleeding • Expulsion: 5% risk, occurs in first 3 months • Ectopic pregnancy: proportion of pregnancies that are ectopic are increased Contraindications (but absolute number of ectopic pregnancies is reduced, compared to a • Pelvic infection / PID <3 months ago woman not using contraception) • Gynaecological cancer / Breast cancer • Infection: increased risk of PID in first 20 • Fibroids distorting uterine cavity days after insertion • Small uterine cavity • Uterine perforation: 0.2% risk • Undiagnosed PV bleeding • Long QT syndrome • Copper Allergy • Pregnancy • 48 hours - 4 weeks postpartum Condoms Patch • Physical barrier to sperm entering cervix • Slow release of oestrogen & progesterone OTHER • Protects against STIs (only method to do • MOA: Inhibits ovulation this) • Patch cycle lasts 4 weeks (worn everyday • New condom with every act of sexual for 3 weeks, change weekly, 4th week: CONTRACEPTIVE intercourse patch not worn → withdrawal bleed) • Disadvantages: Low success rate, can slip • Contraindications: >35 years old & smokes off / break → conception, interrupts sex >15 cigarettes/day, Pregnancy, METHODS • Latex Allergy  Latex-free condoms Breastfeeding, BMI > 35 • Oil-based products damage condoms • Less effective in patients >90kg Male Sterilisation Natural Family Planning Female Sterilisation • Long-term contraceptive – must have • Long-term contraceptive – must have completed • Fertility awareness method: tracking periods to completed their family their family see when most fertile and avoiding sex / using • Single Operation: Falopian tubes • Single Operation: Vas Deferens cut and tied via condoms on these days clipped laparoscopically. Under general anaesthetic. Takes ~20 minsum. Under local • Track: body temperature, vaginal discharge & • Failure rate: 1 in 2,000 menstrual cycle anaesthetic • Risk: Anaesthetic risk, Bleeding/ Bruising, Infection, • Only 76% effective (typical use) • Failure rate: 1 in 200 Irreversible, Swollen scrotum for few day, Sperm • Cannot use with irregular periods, taking • Risk: Anaesthetic risk, Bleeding/ granulomas form if leak occurs, Chronic testicular medications contraindicated in pregnancy or Bruising, Infection, Irreversible pain (1-3%) need to avoid pregnancy • Can take up to 3 months for remaining sperm to be • Withdrawal method not effective or used up → sperm samples required 16 & 20 weeks recommended encounters whilst awaiting resultsn sexualA 21-year-old female requires contraception. She is considering having POP a child in the next couple of months. Her BMI is 34. She takes Sumatriptan for a headache she has, with associated numbness in her hand, arm & face A 45-year-old male requires contraception. He has completed his Sterilisation family. He does not want either him or his wife to have to think about contraception again. A 33-year-old female requires contraception. She has finished her IUD family for now but may change her mind. She does not want have to think about contraception in the next 5 years. She wants a contraceptive method that is effective immediately.EMERGENCY CONTRACEPTIONA 25-year-old female requires emergency contraception. She had Ulipristal unprotected sex 3 night ago from your appointment with her. She has already taken Ulipristal during this menstrual cycle A 32-year-old female requires emergency contraception. She desires IUD the most effective form of emergency contraception and is interested in starting contraception long-term. A 23-year-old female requires emergency contraception. She had Levonorgestrel unprotected sex last night. PMHx: Severe Asthma & Long QT syndrome. Levonorgestrel Ulipristal IUD • Levonorgestrel 1.5mg pill (3mg if • Ulipristal 30mg pill • Copper inhibits fertilisation or BMI >26 OR >70kg) • Inhibits ovulation (progesterone implantation (toxic to sperm) • Inhibits ovulation & implantation receptor modulator) • Inserted within 5 days of • 1 pill taken ASAP within 72 hours • 1 pill taken ASAP within 5 days of unprotected sex OR up to 5 days of unprotected sex unprotected sex after ovulation date • 95%  58% effective if used • 98% effective (efficacy decreases • 99% effective within 72 hours (may have with time) • Most effective method of already ovulated, efficacy • Contraindications: Severe emergency contraception → offer decreases with time) Asthma to all unless contraindicated • Contraindications: None • Only method that can be used if • Hormonal contraception the woman has ovulated • If vomiting occurs <3 hours → effectiveness is reduced - barrier • Give prophylactic antibiotics if Repeat dose method precautions / abstain patient at high risk of STI • Hormonal contraception can from intercourse for 5 days after • Can leave in-situ for long-term start immediately after using taking Ulipristal before contraception. Must be kept in Levonorgestrel restarting hormonal until next period • Can be used more than once per contraception menstrual cycle if required • Can be used more than once per menstrual cycle if requiredPHARMACOLOGY COUNSELLING Structure of Communication Stations Introduction WIPE Story so far Brief Patient History Prior Knowledge & ICE What does the patient understand about the topic? Tell patient what you plan to discuss. Explain consultation Ask what they want to cover. Talk through Topic Summarise findings & make plan Check patient’s understanding Ask patient to summarise key points Offer other information sources e.g. Leaflets, Websites, Specialist nurse contact, Follow-up appointment Treatment / Drug • Check for contraindications to treatment • Check patient understanding of contraception • What is it? • How treatment works • Treatment course & how it Is taken • Effectiveness • Advantages • Disadvantages / Risks • Other important information • Cover small amounts of information in little CHUNKS • CHECK the patient understands the information in each chunk before moving on to the next chunk Role Final Year Medical Student Setting General Practice STUDENT Patient Matilda Johnson, a 29-year-old female presents wishing to discuss contraceptive options. INSTRUCTIONS Student Please take a focused history from this patient. EXAMPLE Task At 7 minutes, the examiner will stop you and ask differentials.se your findings & present your BE RESPECTFUL AND ADDRESS PATIENT’S CONCERNS THROUGHOUT COCP COUNSELLING EXAMPLE ’’CHUNK AND CHECK’’ THROUGHOUT - ’’Can you just repeat back what I said about the ...... so I know that you have understood it’’ OFFER LEAFLETS, RELIABLE WEBSITES & CHECK-UPS THROUGHOUT CONTRAINDICATIONS TO INTRODUCTION COCP RISKS COCP ESTABLISH PATIENT’S UNDERSTANDING OF TYPES DISADVANTAGES OF OF CONTRACEPTION COCP STARTING THE COCP EXPLORE REASONS FOR ADVANTAGES OF MISSED PILLS RULES WANTING THE COCP COCP EXPLANATION: ICE SUMMARISE EFFECTIVENESS OF COCP EXPLANATION: WHAT EXPLANATION: HOW IS THE COCP? THE COCP WORKS FOLLOW-UPPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK