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PSA Prep Course COCP and HRT DR CHANG KIM FY1 1Disclaimer We are a group of F1 doctors preparing this course to help prepare/as a supplement for your PSA. Please do not use this as your sole source of revision. None of the patients/cases are based on real-life scenarios, and any similarities are coincidental. Some drug concentrations/preparations may have been changed for ease of calculations, and may not resemble real-life clinical practice. Always consult your university for exam-related queries and support, and the BNF/Medicines Complete for up-to-date information on drugs and prescriptions. 2Learning Objectives Different types of contraceptives ◦Pill regimes ◦Missed pills ◦Patient advice HRT options ◦Patient advice 3COCP 4 COCP vs POP Combined oral contraceptive pill Progesterone only pill Contains oestrogen and progesterone Contains progesterone only ◦ Norethisterone Typically taken as 21/7 regimes ◦ Levonorgestrel ◦ Can have 21/4, 63/7, continuous regimes ◦ Desogestrel Taken continuously Various contraindications Stricter missed pills rules “ED” preparations e.g. Microgynon 30 ED are when they constantly take tablets aka the placebo pills for the 7 days at the end of their cycle. 5Question 1 to start her university degree and would like you to prescribe her usual Microgynon 30 tablets, which she takes for contraception. She states that she usually takes the pill for 21 days, and has a 7-day break. Please write a prescription for her medication request. 6 Question 1 An 18-year-old female attends your GP practice for the first time. She recently moved into town to start her university degree and would like you to prescribe her usual ethinylestradiol 30 mcg with levonorgestrel 150 mcg (Microgynon 30) tablets, which she takes for contraception. She states that she usually takes the pill for 21 days, and has a 7-day break. Please write a prescription for her medication request. This is how the question would actually be worded on the PSA exam, have intentionally left it out to make the question harder so you learn to navigate around the BNF. 7Question 1 What ethinylestradiol with levonorgestrel (Microgynon) looks like on the BNF: How would you write a prescription for the COCP? 8 Question 1 BNF/MedicinesComplete Search “microgynon” Contraceptives, hormonal / Treatment summary Preparation choice Method 1 9 Question 1 BNF/MedicinesComplete Search “microgynon” Estradiol with levonorgestrel / Medicinal forms Medication: Ethinylestradiol 30 micrograms/levonorgestrel 150 micrograms monophasic 21-day tablets Dose: 1 tablet Route: PO Frequency: OD 10Monophasic vs Multiphasic Monophasic Multiphasic All pills have the same dose of Different phases aka “strengths” of medication medications No confusion with taking the Need to take the pills in order medication Mimics the body’s normal menstrual Less side effects from fluctuating cycle hormones Designed to reduce the total hormone dosage 11 Multiphasic example Logynon coated tablets (Bayer) 30mcg, Levonorgestrel 50mcg)ylestradiol 5 white tablets (E 40mcg, L 75mcg) 10 ochre tablets (E 30mcg, L 125mcg) Key take away message, don’t worry too much about the multiphasic contraceptives Be aware that they exist, but don’t worry too much about the specific prescriptions. 12 Multiphasic example Key take away message, don’t worry too much about the multiphasic contraceptives Be aware that they exist, but don’t worry too much about the specific prescriptions. 13Missed Pills: COCP 14 COCP Missed Pills: summarised If 1 pill missed: ◦ Take missed pill straight away ◦ Continue rest of pack as normal If 2+ pills missed: ◦ Take the most recent missed pill straight away (only 1 pill) ◦ Abstain/use condoms for 7/7 ◦ If recent intercourse in previous 7/7 seek advice for emergency contraception NB:- If <7 pills left in pack after a missed pill: ◦ Start the next pack back-to-back ◦ No rest/withdrawal bleed period E.g. if you take the pill normally at 12pm, and you remember at 8am that you forgot to take yesterday’s pill, take that forgotten pill at 8am, and carry on taking pills regularly at 12pm. If you take the pill normally at 12pm, and you remember at 12pm that you forgot to take yesterday’s pill, take 2 pills together (forgotten pill straight away + next dose at regular time) If you take the pill normally at 12pm, and you remember at 12pm that you forgot to take the pill for 3 days, repeat as above 15 POPMissed Pills: summarised If 1 pill missed <3 hours*: ◦ Take missed pill straight away ◦ Continue taking rest of the pills at your usual time If 1 pill missed >3 hours*: ◦ Take the most recent missed pill straight away (only 1 pill) ◦ Abstain/use condoms for 2/7 ◦ If recent intercourse during missed pill period seek advice for emergency contraception *12 hour time limit if taking desogestrel POP pills take 2 days before providing adequate protection from pregnancy. 16Patient Information Vomiting: ◦ If sick within 2 hours of taking pill, take another pill Diarrhoea: ◦ If severe diarrhoea lasting >24h, act as if they missed pill ◦ Continue until diarrhoea is no longer severe COCP risks: ◦ Increased risk of VTE, MI, Stroke ◦ Increased risk of breast & cervical cancer POP risks: ◦ Increased risk of ovarian cysts and breast cancer 17 COCP Contraindications Pregnancy Smoker & > 35yrs (or ex-smoker <1 year) BMI >35 Migraines with aura Breast-feeding up to 6 weeks CV/VTE risk factors FHx breast cancer HTN >160/100 From this list the common ones are the patients with migraines with aura, or with cardiovascular/VTE risk factors. The list is extensive, and always consult BNF for the full list, as follows: Acute porphyrias; atrial fibrillation; benignhepatocellular adenoma; Budd-Chiari syndrome; cardiomyopathy with impaired cardiac function; complicated congenital heart diease; complicated valvular heart disease; current breastcancer; hepatocellular carcinoma; hypertension (blood pressure systolic 160 mmHg or diastolic 100 mmHg or higher); hypertensive retinopathy; ischaemic heart disease; known thrombogenic mutations (e.g. factor V Leiden, prothrombin mutation, protein S, protein C and antithrombin deficiencies); less than 3 weeks postpartum in non- breastfeedingwomen with other risk factors for venous thromboembolism; less than 6 weeks postpartum in breastfeedingwomen; major surgerywith prolonged immobilisation; migraine with aura; peripheral vascular disease with intermittent claudication; positive antiphospholipid antibodies; previous or current venous thrombosis; smoking in patients aged35 years and over (15 or more cigarettes daily); stroke; systemic lupus erythematosus with antiphospholipid antibodies; transient ischaemic attack 18POPContraindications Pregnancy Breast cancer Severe liver cirrhosis Liver Tumours 19 Question 2 A 34-year-old female with a past medical history of endometriosis presents to your clinic for a routine review. She says that she experiences severe abdominal cramps for which she takes analgesia regularly during her episodes, and would like some additional medication to help further alleviate her symptoms. PMHx: endometriosis, migraines with aura DHx: Paracetamol PRN, Ibuprofen PRN Please write a prescription for one drug that would be appropriate to manage her symptoms. Answer: a progestrogen eg. Desogestrel PO OD 75 mcg 20 Question 3 A 25-year-old female attends your GP practice for contraceptive advice at 11 am. She normally takes a norethisterone POP for contraception at 3 pm every day, however, she has had a bout of diarrhoea for the last 24 hours, and asks if she needs to take any further precautions for her contraception. Which of the following advice should be provided to her? A. She does not need to take any precautions and can carry on taking the pill at 3 pm B. She needs to take a pill now and carry on taking the pill every day at 11 am C. She needs to take a pill now and carry on taking the pill every day at 3 pm D. She needs to take a pill now, take one at 3 pm, and use contraception for at least 2 days E. She needs to take a pill now, take one at 3 pm, and use contraception for at least 7 days Answer: D 21 Question 4: From PSA Mock Paper 2 Answer: B She has had at least 27 hours of a pill free period, therefore should seek advice for emergency contraception as a first instance. D is what you would do after B but B has greater importance. 22HRT 23 Hormone Replacement Therapy Hormonal treatment used to alleviate menopausal symptoms Reduces risk of osteoporosis, CV disease, stroke Different modalities: ◦ Tablets ◦ Patches ◦ Gels Different preparations ◦ Implants eg. Mirena coil ◦ Combined oestrogen and progestogen ◦ Oestrogen only Menopause symptoms eg. Hot flushes, weakened bones, vaginal dryness, mood swings 24 Hormone Replacement Therapy Combined HRT ◦Monthly ◦Three-monthly ◦ Daily oestrogen ◦ Daily oestrogen ◦ Progestogen at the end of cycle for 10-14ogestogen for 14 days, every 13 weeks days ◦ Peri/post-menopausal ◦ Peri/post-menopausal ◦Continuous ◦ Daily oestrogen and progestogen ◦ Post-menopausal only This slide has been added to provide a familiarity with the differentpreparations of HRT available. Progesterone is added, as those with wombs are at an increased risk of endometrial hyperplasia and cancer with unopposed oestrogen The addition of progestogens mimics the natural menstrual cycle, resulting in withdrawal bleeds 25 Hormone Replacement Therapy Oestrogen only HRT ◦Unopposed oestrogen therapy with no additional progestogen ◦Used in those without a uterus ◦ No need for endometrial protection provided by progestogens This slide has been added to provide a familiarity with the differentpreparations of HRT available. 26Risks of HRT VTE ◦ Increased risk by 2-3x ◦ Transdermal HRT is preferred in those with an increased VTE risk Ischaemic stroke Breast cancer Endometrial cancer 27 Question 5 A 55-year-old woman presents to her GP for a review of her current hormone replacement therapy. She requests an alternative preparation that will not give her monthly withdrawal bleeds. She would prefer to continue to use a transdermal preparation. PMH: Menopausal flushes. DH Estradiol 50 micrograms/24hr transdermal patch and estradiol 50 micrograms/norethisterone acetate 10 micrograms/24h transdermal patch combi (Evorel Sequi) One patch transdermally twice weekly for 2 years. OE: Weight 68 kg (no recent change), BP 130/80 mmHg Write a prescription for ONE drug that is most appropriate to stop the withdrawal bleeding. Please write as medicine, dose, route, frequency Estradiol 50 micrograms/norethisterone acetate 170 micrograms/24 hours transdermal twice weekly patch, 1 patch, transdermal, twice weekly 28 From PSA Mock Paper 2 Estradiol 50 micrograms/norethisterone acetate 170 micrograms/24 hours transdermal twice weekly patch, 1 patch, transdermal, twice weekly. CORRECTION FROM RECORDING: Oestrogen + progestogen should be given continuously in HRT to protect against the risk of endometrial cancer, whilst preventing withdrawal bleeds. 29 Question 6: From PSA Mock Paper 2 Answer: E Increased risk of breast cancer. Additional contraception should be pursued until menopause completed Oestrogen protects against osteoporosis 30 Question 7: From PSA Mock Paper 2 Answer: E Weight changes is noted as a common specific side effect with oral use. 31Tips and Tricks Usually, typing the brand name on BNF will come up as the prescription drug name equivalent. Scroll to the bottom of the drug monograph to see other drugs in the same class 32Non-Pill Prescription Cheat Sheet COC Patch example prescription ◦ Estradiol 50 microgram per 24 hour, Levonorgestrel 7 microgram per 24 hour transdermal patch, 1 application, once a week 33Non-PillPrescription Cheat Sheet COC Vaginal Ring example prescription ◦ Ethinylestradiol with etonogestrel, 1 unit, once a month for 7 days Quickest way to find: ◦ Search “vaginal ring” 34Non-PillPrescription Cheat Sheet POC Depot Injection example prescription ◦ Medroxyprogesterone acetate, 150mg IM, every 12 weeks ◦ Medroxyprogesterone acetate, 104mg SC, every 13 weeks Quickest way to find: ◦ Search “Contraceptives, hormonal” 35Non-PillPrescription Cheat Sheet POC Implant example prescription ◦ Etonogestrel, 1 implant subdermal, once only Quickest way to find: ◦ Search “Contraceptives, hormonal” 36Converting to different preparations 37Feedback & Next Session Diabetic Drugs 29 Oct 2022 Dr Chang 38