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Um It's very nice to have been asked to give you all um this talk today. I understand you've been doing a series um of OBS and Gyn talks. So, um hopefully not all of this is completely new to you. Hopefully, some of this is sort of just a refresher. Um There are some bits where I like, I will ask questions and things. I can't see any comments in, in a chat or anything like that. So please do feel free to like answer out loud and if you've got any questions, um then there, I'll pause at certain points to um give opportunity for questions and otherwise, if you could just keep them till the end, that would be great. Um Just to introduce myself. So I am currently working as an ST two doctor um in community section and reproductive health. Um That is a run through program um where essentially we are, we're a subsidiary of um the Royal College of and Gynae at the Faculty of Sexual and Reproductive Health. So I work predominantly in gynecology and in um sexual health. Um I did do a bit of obstetrics, but it's not my, not my area of expertise. Um And the main thing that I do mostly on a daily basis um is complex management of contraception. So, um that's the main focus of my talk today. Um I was hoping to try and squeeze some S ti bits and bobs on the end, but I've got to be honest with you, um This talk kind of takes up quite a lot of time already anyway. Um So I'm not sure we're going to be able to get that on the end. But hopefully by the end of this talk, you should be able to sort of understand the benefits of pregnancy planning, the principles of contraception. Um knowledge about all the sort of commonly available contraceptive methods that we've got here in the UK um and be able to communicate obviously mechanism of action, failure rate, side effects, all of those kinds of things um to people. Um And then also, um I've got a section on emergency contraception as well because I know that that's something that um occasionally people get tripped up on um in real life and contraception, to be honest, is not something that's taught overly well at med school and it is actually quite complicated. So, um without further ado I'm gonna kick things off, you've got a 19 year old young girl who comes to see you um in say you're in your GP clinic, something like that called Chloe. Um She's heard of the, the pill um but isn't really aware of much else um in terms of contraceptive methods, what's going on. Um So, has anyone heard of any other methods of contraception? Has anyone got any ideas they can throw out at me? Stunned silence. That's OK. Um So we've got a lot of different methods of contraception in the UK. I'm gonna run through a list of y of them with you now. Um And this is by no means um all of them either. Um So number one, you've got your barrier methods. So we've got internal or external condoms, diaphragm cap, um usually used in conjunction with spermicide. Um And those are our main barrier methods really. So, none of these involve hormones. Um And they are all sort of like fitted and then removed at the time of intercourse. So we've then got um the spermicide gels which go along with those. Um We've got a selection of pills. So we've got the, the mini pill, commonly known as the mini pill, which is the progesterone only pill. We've got combined methods of hormonal contraceptions. We've got estrogen and progesterone in those and that includes a pill patch ring. Um So we got a couple of different pills, the most commonly used ones up there. Um The most common sort of first line one we tend to start with um in a lot of places at the moment is Microgynon. Um We've also got the implant, subdermal implant placed just underneath the skin. Um and in the, in the skin of the arm and that is a progesterone method also. And then we've got your coils, we've got the I US, the IUD and the injectables. So we've got the depo Provera Contraceptive injection, which is IM and cyano. We also have now which is actually subcut and the patient delivers themselves. Um so briefly going through barrier methods. So the diaphragm um is one that you may not have heard of. Um essentially barrier methods we use to prevent sperm from traveling through the spinal canal. If the sperm can't get into the uterus and can't get into the tube, then it obviously can't fertilize the egg. Um And the other bonus is that some um some forms of barrier methods help to prevent the spread of certain S TRS, predominantly condoms um are used to help prevent the spread of S TRS as well. Um So we've got caps diaphragms. The diaphragm um is and the caps essentially cover the cervix. So they cover the neck of the womb. So the sperm can't get through the neck of the womb to reach the edge the egg. Um but it does have a lot of drawbacks and it does require quite a bit of um forward planning. So with diaphragms, they have to be inserted ahead of sexual intercourse. Obviously, you have to plan to some extent if it's been in place for three hours or more or if you've already had um sex once, then you need more spermicide to apply and then you also have to leave it in place for at least six hours afterwards. Um And even if we do all of this correctly, it's still only about 92 to 96% effective with perfect use. And as I'm sure some of you can imagine even like fitting this yourself and making sure it's in the right place. All of these, there's quite a lot of margin for error. Um So I won't talk too much more about barrier methods because those are um fairly straightforward. Um So we'll move on to the hormonal contraception now. So Chloe has heard that hormonal contraceptives prevent pregnancy by causing abortion. Is this true or is this false? Ok. So this is completely, completely untrue. Um The main methods through which hormonal contraception work is usually three fold, number one and the main one is inhibition of ovulation. So, if there's no egg can't get pregnant, um most hormonal contraceptives also have effects on the endometrium to help prevent implantation and on the cervical mucus to help prevent sperm from actually being able to get through and get to the egg in the first place. So, um it's not at all the case um that hormonal contraception prevent pregnancy through causing abortion. Um Hopefully, these diagrams will be uh fairly um familiar to you. Um as me as sort of close to the end of medical school as medical students. Um And I'm sure these are probably diagrams that have driven you all crazy at some point or another. And that's fine. Um But in all honesty, to understand any of any hormonal contraception, the whole key to all of it is if you understand these two diagrams, you can essentially work out and understand how any hormonal contraceptive works. So brief recap, you've got your gonadotrophic releasing hormone released by the hypothalamus goes on to stimulate the anterior pituitary gland to release um luteinizing hormone and follicle stimulating hormone. These hormones then act on the ovaries and result in the production of estrogen and inhibin. Once the egg has been released from the graphene follicle, you get the corpus luteum which produces progesterone and that high progesterone level has a negative feedback impact on the hypothalamus. Therefore, reducing the amount of LH and FS H produced all these levels fall. The corpus luteum degenerates. And then we end up with that progesteronic second phase of the cycle eventually causing menstruation. So the cycle can begin again, that positive feedback is purely stimulated by the heightened levels of estrogen around days, 12 to 14 of a typical 28 day cycle, which then has when it reaches a threshold level, results in a positive feedback to cause the LH surge, which is what you see over here. Um which triggers the start of population essentially. So very whistle stop, um reminder of that there, but really if you can understand this, you will understand pretty much any hormonal contraceptive method. And the the thing that patients are most concerned about when it comes to hormonal contraception. In all honesty is the side effects. Um Both estrogen and progesterone carry side effects. Um Quite often the side effects can also overlap. Um And these, these ones listed here are some of the most common side effects reported by users. Um It's really important to know to realize that weight gain um is reported by a lot of people when taking hormonal contraception. Um but the only form of contraception where we've actually proven a causal link with weight gain is with the depo Provera injection. Um And actually, even then the risk of weight gain is about one in four um side effect of weight gain with other methods is often kind of sort of not direct put putting on a fatty tissue, but it's due to a roundabout way of other things. So it's either due to increasing their fluid retention or increasing their appetite. And then um obviously the knock on effects of that um and changes in lifestyle habits. If someone is using hormonal contraceptives, they're having particular problems with side effects on one side or the other. Um Then sometimes if it's particularly if they're on a combined method, we can switch them to something that has sort of a lower content of the, the the the one that's causing their problems. So if they're having lots of problems with like acne greasy hair, those kinds of things, we can sort of get them onto one with a lower progesterone dose and a higher estrogen dose and try and balance them out that way. Um So for example, we can use like higher or lower dose estrogen combined pills. Um But to be honest, the bigger risks when we, we'll, we'll go on to talk about risks with hormonal contraception. But sort of these are just side effects. There are other risks we need to consider. Um So let's take combined hormonal contraception, for example. Um So we're containing estrogen and progesterone with these that includes the patches, the pill, uh the pills and the ring, as I said, um vaginal ring is one that not everybody has heard of, but it's a com essentially you insert it into the vagina, it releases the estrogen and the progesterone locally, but it does still enter the bloodstream. Um You wear it for three weeks at a time and then you have one week off where you take the ring out and you have, you have your bleed, it carries the same risk as other methods of h combined hormonal contraception and it has very similar effectiveness rates as well. Um The main way that combined hormonal contraception is working is we're giving a constant level of estrogen and progesterone throughout the cycle, which then we don't get that level of estrogen that triggers the LH surge. So we don't get ovulation and instead we actually get that negative feedback effect. Um So we end up having a pretty static um level of hormone, we lose the cyclical nature and we then end up not having an not ovulating essentially, that's how it works. Um with the pill, which is most people's main focus because it's the most popular method of combined hormonal contraception. We have different ways of taking it and we also have different types of pills. We have monophasic pill pills, biphasic pills and triphasic pills. The monophasic pills are the most common ones. They deliver the same amount of estrogen and progesterone every day. Like I said, biphasic pills are slightly different. So they um actually change the progesterone at estrogen ratio in the second half of the cycle um to help with allowing the shedding of the uterine lining. Um and triphasic birth control pills have essentially changing estrogen concentrations throughout the cycle. Um But we've not, there's there's no evidence to say that one of any one of those is more effective or better than any of the other types. It's just, you know what suits individual patients. And um unfortunately, for us as prescribers, um there are like so many different pills and so many different possible um different different combinations. Um and in a way this is good for patients because we can look at increasing estrogen content, decreasing estrogen content and the same with progesterone vice versa and we can use different progesterones as well, which can have different side effect profiles. However, as a clinician, it means when it comes to prescribing these things, it's often pretty tricky um to know where to start, generally speaking. Um we tend to start most people in with Microgynon 30 which is a constant monophasic pill dose of estrogen and progesterone at a particular level. Um And then if people are having problems, then we can perhaps look at altering which pill they're on um from there. Um And then we have different ways of taking it. So, not only are there different kinds of pills, but then we also have different ways of taking all of those pills. So, um the, these are all for the monophasic pills. So the pills that are the same amount of estrogen and the same amount of progesterone for the whole cycle. Um and the standard way to take these pills was to have three weeks on and then one week off and then in that week off, you would then have a bleed um in the hormone free interval, which is what we call it the HF I um and that is induced by us stopping the pill, the withdrawal of the hormones then triggers a bleed. Um just kind of stimulating a natural menstrual period. Um Now, the only main reason it was ever designed that way was to be honest, to make it more acceptable to the general public and to the general population. Um People, when the pill first came about, people really did not like the idea of interfering with nature's way. Um You know, the pill revolutionized healthcare for women. Um And, you know, societally revolutionized a lot of things for women as well. Um As it opened up a whole new world of possibility really. Um But as I'm sure you, you can imagine there was quite a lot of resistance to this at the time also. Um So it was designed to be taken this way. Now, there is absolutely no medical reason why somebody who's taking hormonal contraception needs to have a bleed or needs to have a period, there's no medical indication for that. So actually, you can run pills back to back. Um Now there are different ways of doing it. Some people just shorten the hormone free interval and just shorten it to four days instead of seven. Um some people will do what we call tri cycling. So they'll take three packs or three months worth back to back and then they'll have a 4 to 7 day break after that and then start again. So they end up having sort of four periods in a year. Um or you can just take it back to back to back to back to back and never have a break. Sometimes people will get a bit of breakthrough bleeding and sometimes people choose to pause their pill for a few days when that happens just to get all the bleeding out. Um But you don't even need to do that if you don't want to, you can just continue to take your pill throughout. Um Some people do then find they have problems with more continuous or more problematic bleeding in, in that case, um If that happens, we usually just say to them just take a 4 to 7 day break and then start again and essentially you're just resetting. Um But as great as these options are um for patients because it gives us a lot more flexibility again, as a clinician. If you're not aware of these things, it can get confusing. Um So it's really important to think of those. Now, the C eu supports these tailored what we call tailored regimens um for all of the monophasic pills. Um But essentially they're all just as effective. It doesn't really matter which, which me which way you go for them. Um The only added bonus is the, the fewer hormone free intervals you have the lower risk of you, then missing a pill and ovulating and then getting pregnant. Um J just purely down to user error. The riskiest time for anyone who's taking any form of combined hormonal contraception is after a hormone free interval is making sure you start back on time and you don't miss any in that first week because that's gonna be the riskiest time because you're reestablishing that hormone level um to prevent ovulating. Now, we've been through obviously the combined hormonal contraception and there are a lot of benefits. Um but there are also a lot of drawbacks. Every medicine we prescribe ever as, as a clinician has both benefits and has risks or side effects. Um And combined hormonal contraception is no different to that at all. And the biggest thing people get very stressed about is cancer risk. Um Now, the pill um does give you an increased risk of breast cancer and an increased risk of cervical cancer according to studies. Um however, it also decreases your risk of endometrial cancer, ovarian cancer and colorectal cancer. So, it is a balancing act. Um The protection against endometrial cancer and ovarian cancer increases the longer you're on it and actually stays for many years even after you stop taking um the combined pill. Um and the small increased risk of breast cancer whilst using the pill decreases over time after stopping and then eventually, after 10 years use, uh 10 years later, there is absolutely no increased risk of breast cancer at all. So we know that it's a transient, increased risk. Um Generally speaking, we advise that people with a significant family history of breast cancer or if they've got any known genetic mutations linked to breast cancer, like the BRCA genes, they should definitely avoid combined hormonal contraception. But for the average woman, this risk is an increased risk slightly, but it's coming from a place where these w these young health otherwise healthy women have an extremely, extremely low risk of breast cancer in the first place. So even if we increase that risk a little bit in absolute numbers, the number of extra women who are developing breast cancer as a result of this is still extremely, extremely small. Um So it's all about putting things into context. Um Currently, the guidelines still state that women who've been using combined hormonal contraception for more than five years, it is increased with a slightly increased risk of cervical cancer and that risk reduces over time after stopping the pill and is no longer increased about by about 10 years after stopping. However, this is based on quite old research now. Um and we actually now know that the main thing that causes cervical cancer is the human papilloma virus or HPV. Um And if anyone's got high risk HPV, that will increase the risk of um developing cervical cancer. And at the time when a lot of these major sort of groundbreaking studies about the pill were done, this was a time when prior to that, you know, women really haven't had much sexual freedom at all without risk of pregnancy. And so as a result, people's behavior and people's sexual practices were changing quite a lot. Obviously, the more sexual partners you have, the higher the risk you are then gonna contract HPV. And so it's likely that there was like quite a lot of confounding factors involved in this. So, officially, it's still on the guideline that it's increasing cervical cancer. But in reality, we actually know that HPV is much more important when it comes to cervical cancer risk than the pill. The pill's kind of negligible. Really. The other big one with combined hormonal contraception is cardiovascular risk. Um So we know that for people taking combined hormonal contraception, there is an increased risk of venous thromboembolism and pulmonary embolism. Um This risk can be slightly higher or lower depending on the type. Um the concentration of the progesterone and the estrogen that are used. Um and there was also a slightly increased risk of myocardial infarction and stroke. Um and that seems to be dose dependent to the estrogen content. Now, um this table here is taken from the faculty of sexual and reproductive health um from the guideline. Um and it shows you just how much um of an increase there is in risk of vte e um with different kinds of combined hormonal contraception and which ones are the more risky ones. So, anything containing desogestrel, danone or gestid um is slightly worse than things like etonogestrel or norgesterone and, or norethisterone. Um So some of the newer pills have a slightly worse side effect, er, worse side effect profile than that. Um It's also worth noting that the Drospirenone um containing pills are often some of the ones that are used most to help people with acne. Um, er, but they do have a slightly higher VT risk profile. So that's just to bear in mind. Um, we have very limited evidence about whether the other forms of combined hormonal contraceptions are things like the pill or um, er, about the, the patch or the ring or basically which one is worse for this? We don't know. Um, but we know that all three of them do convey an increased clot risk. So it's not like with H RT where they might say using a patch is better to reduce risk of certain problems. Um With contraception, it doesn't seem to make any difference which method of delivery that you're using for the hormones. Um Essentially, the reason why this happens is we know that estrogen acts on estrogen receptors. There are estrogen receptors in the liver as well as like the breast and the reproductive organs. Um and that actually stimulates production of both anticoagulation and pro coagulation factors. However, on balance the pro coagulation factors outweigh the anticoagulation factors. And that's obviously not in a lot of detail, but just the very bare bones of the reason why. Now this is why we need a really good history from anyone who was starting on any kind of contraception. And we need to think about the patient in front of us, we need to think about other things. So lifestyle factors, we need to think about age. Do they smoke? What's their BM? I is there any obesity? Um and we also know that patients who have a history of migraine with aura are at an increased risk of ischemic stroke with combined hormonal contraception. So we need to talk about that as well. And specifically always ask about migraines. Um So essentially a comprehensive history is the only way you should ever be starting anybody on any form of contraception. Um and it is really crucial. It's not, it's not as simple as, oh, I'll just give them a pill, cos they want a pill, you really do need to have the full history and know exactly what um your patient's history is and what they're looking for. Um So that's combined hormonal contraception in a nutshell. Does anyone have any questions about combined hormonal contraception before I move on to the um single hormone methods? I can't hear anything. So I'm just gonna move on. Um So progesterone only pill um is next up on the list. There are a number of different ones. Um We've got our traditional po ps. So that's things like norethisterone 11 Gesterol, um commonly known as Noriday is the most, the most common one to be honest would have been Noriday. Um And the mini pill is taken at the same time every day with no hormone free interval apart from the sl which is very new, but I'm not gonna go into that because it has literally only come out on the market a couple of months ago and it's probably d don't worry about it yet. You y you, you'd be very unlikely to be able to actually get it anywhere at the moment. So we're, we're gonna park that to one side just for a second. Um, the traditional po PS, the Norethisterone Levens TRL have a three hour taking window. So if you're taking it at the same time every day, 8 a.m. every day, um, it means you would have until essentially 11 a.m. before it counts as a missed pill because of that, that's quite constrictive. Um So these days, they're not commonly used really anymore. People tend to have desogestrel, which is most commonly seen brand version as seros over here. Um And the reason for that is desogestrel has a 12 hour taking window, um which obviously gives you a lot more leeway um and ability to um try and prevent m more missed pills that way. Um Now the mini pill shows no increased risk of VT E no increased risk of thrombotic events. So the cardiovascular risk profile is much, much better and we do know from a very, very new data that's come out within the last year to 18 months that there is still probably a small increased risk of breast cancer, even with progesterone only methods. But um as I said earlier, the absolute numbers um and effects on patients is still very, very small. So Chloe's tried oral contraceptives before, but she's struggling to take them. And so she wants to know, is there anything she can use where she doesn't have to remember to take it every day because she just thinks she's gonna forget and that's not gonna work out for her. Um The way we go on with this is we look at what we call our lark methods or our long acting reversible contraceptives. Um And that includes the injection, the implant, the copper IUD and the hormonal intrauterine system or I US. Um and they all last for varying lengths of time. So, contraceptive injection lasts for about three months at a time. Um 13 weeks to be exact, the implant for three years, the IUD you can have copper coils for either five or 10 years and the I US, you can have for 356 or eight years depending on um the hormone content and which brand you have gone for. So progesterone injectables. Um As I said earlier on, we've got the depo Provera and we've got the cyano. Um The depo Provera is an intramuscular injection. Cyano is subcutaneous. Um They're both given once every 12 to 14 weeks. Um As I sort of alluded to earlier in terms of side effects, um the depo is slightly unique in some respects. Um The most common side effects with any progesterone method is altered bleeding pattern for progesterone injectables. Most people can have some infrequent bleeding, spotting or prolonged bleeding to start with but tend to end up amenorrheic. Um By the time they get to about a year with uh the depo injection, it does also cause the weight gain that I mentioned before. So about one in four people who take the contraceptive injection will gain weight. Um which means the majority still don't, it usually becomes obvious pretty soon after starting the method. And it's much more likely in um, young people who already have a problem with weight and already have ABM I of over 30. Um However, just because somebody has ABM I of over 30 they're obese, it doesn't mean they can't use the progesterone injectable. Um The progesterone injectable is also the only method of hormonal contraception we have where there is a delay in return to fertility. So none of our hormonal contraceptive methods, literally none of them have any long lasting or permanent impact on fertility. There are literally ii don't even know how many myths about this that go round on the internet. Um In person on social media, Tik Tok is the bane of my life at the moment for this. Um There is no long lasting impact on fertility with any contraceptive method um with every other contraceptive method. Um Fertility returns back to normal pretty much immediately after stopping the method. The only one with a delay is the injectable and that delay can be up to a year. Um So that's really important to bear in mind if you've got women who are perhaps looking at starting a family in the future, they need to bear that in mind that they're gonna need to come off their injectable. Um, a fair, a fair bit before they plan a future pregnancy. Um However, I think the main thing, the main place, a lot of these myths come from, I think, to be honest is the fact that fertility from your, your sort of early to mid thirties does start to significantly decline. Um And so we are getting generations of people coming through who've grown up on taking hormonal contraceptives and spent most of their twenties taking hormonal contraceptives, they're then trying to get pregnant in their thirties. Um And then they come off their contraceptives and struggle to get pregnant. Um And they attribute that to their contraceptive when actually, it's nothing to do with their contraceptive method. It's just the fact that they're, they're 36 for example. Um And so the, the quality of their eggs and the number of their eggs is significantly reduced. Um And the last thing with the injectable um is that it can affect your bone mineral density. Um So we have no evidence, it causes fractures and no evidence it causes osteoporosis. Um But it does cause thinning of the bones with prolonged use. Um So, for anyone who has been on it a very long time or for people from the age of about um 45 we do suggest considering switching to another contraceptive method. Um as people start to approach menopause, and obviously, they have the increased risk of osteoporosis already. Um But in terms of um when they absolutely cannot have it anymore, it is contraindicated after the age of 50. Ok. Um Next up, we've got the subdermal contraceptive implant. So this is progesterone, again, released over three years. It's r it is the most effective form of hormonal contraception. It is brilliant. Um There's virtually no pregnancies at all on when somebody has an implant in situ, the vast majority of pregnancies reported with an implant are actually because they've been in their extremely early stages of pregnancy at the time of fitting. Um There's no adverse effect on BP, no increased risk of et or cardiovascular disease. As we said before, this one has no effect on bone mineral density and it has a really rapid return of ovulation and fertility following removal. Um I've actually seen patients in my abortion clinic where we have scanned them um worked out. Um Obviously, the measurements on the, the fetus for dates um walked it back and realized that they will have ovulated and gotten pregnant within sort of 24 to 48 hours of their implant being removed. Um So it's an extremely rapid return of fertility and that's really important to mention to patients if they're gonna get their implant removed as just beware, um you can get pregnant very quickly um, we then have our progesterone I USS. Um, as I said before, of which there are many. Um, so we've got, they're all, they're all lenore. Um, and you've got the Jad Kyle, Myrina Levis and the Benex. Um, the most commonly used one is definitely the Mirena, the Mirena can be used for contraception for eight years now. Um, and can also be used for endometrial protection with hormone replacement therapy for five years at a time. Um The main way it works is it prevents ovulation, it thins the endometrial lining, um and also thickens the cervical mucus and it releases the progesterone locally directly in the area it's needed. Some of it does make it into the bloodstream but a smaller amount. And so some people also find that they don't suffer with the progestogen side effects as much with the I US as they would with perhaps the mini pill. Um Most common side effect of this um is reduced menstrual bleeding and irregular menstrual bleeding. Um And then about 20% of people who are using the, um the Mirena coil will end up completely amenorrheic at one year. Um It's also um fantastic because it's actually licensed for um treatment of heavy menstrual bleeding. Um And so it can be great for patients with endometriosis, for patients with um like o other causes of heavy menstrual bleeding, fibroids, things like that. Um And it's actually been shown that after insertion, it can reduce heavy menstrual bleeding by up to 90%. Um So there's a reason that the Mirena is actually first line for the management and treatment of a lot of these conditions. And then, as I said, it can also be used as the progesterone component of H RT for um people who still have a uterus. Um and then sort of keeping on the theme of intrauterine devices. Um The last method of conscious of er sort of contraception. I'm gonna mention um in this category is the copper intrauterine device. So, the copper intrauterine device um can be five years or 10 years depending on the copper content. Um The copper is toxic to both sperm and to ova. Um and it has a local inflammatory reaction on the endometrium which helps to prevent implantation. Um It works both pre and post fertilization. So it can also be used as a method of emergency contraception, which we will come back to later. Um But because of that inflammation, the main side effect is more heavy and more painful periods. Um because it, this causes more prostaglandin release um and other like vasoactive agents and things like that. Um And occasionally people can also have intermenstrual bleeding um with the copper coil in it, you all of the coils sit inside the womb just like this. Um and then the strings come down and hang just outside of the external OS. We usually trim them to about 2 to 3 centimeters. Um, and the patient should be able to feel the strings in theory, er, with their finger if they inserted a finger into their vagina. Um I'm very briefly gonna include this because this is something with that with a lot of my students. Um, I find people tend to get quite confused about, um, and that is the use of intrauterine contraception and ectopic pregnancy. So both the I US and the IUD are extremely effective at preventing pregnancy, but nothing in life is 100%. And if a pregnancy does occur, it's much more likely to be ectopic and be a pregnancy that is then stuck in the tube. Like you can see in this picture um from a laparos, laparoscopic salpingectomy here, you can see you've got your womb over here, here's the fallopian tube, here's the ovary and the fimb over here. And this right here is a very juicy ectopic pregnancy pretty good going on that. If that bursts, that would be a bad time. Um However, some people then get confused and think if somebody has had an ectopic pregnancy, they can never have a coil again. And that is not at all. Um the case. So, intrauterine contraception is not contraindicated in patients with a history of ectopic pregnancy because ultimately, by having the coil in place, you're still massively reducing the chance of getting pregnant. So, um it's still um absolutely fine for somebody who's had previously had an ectopic pregnancy to have a coil. Really, we have to think about. Um, you know, there are so many other risk factors for ectopic pregnancy that we can also look at. Um, so obviously anyone who's had one ectopic pregnancy immediately increases their risk for another one. Anyone who's had fallopian tube surgery, previous pelvic or abdominal surgery, anyone who's undergoing IVF, anybody who's previous previously had, um, any sexually transmitted infections or pelvic inflammatory disease, anyone with endometriosis, smoke, anyone who smokes, anyone who's over the age of 35. So actually, there's a lot of different things that can affect ectopic pregnancy and are risk factors for ectopic pregnancy. And overall, the effect of having a coil in situ is actually you're less likely to get pregnant, so you're less likely to have an ectopic pregnancy. So, um I always like to just mention that because I think it's one that um confuses people a little bit. Um And then we come on to um something which I seem to spend my life talking about um with patients at the moment and that is natural family planning. Um It's otherwise known as sort of fertility awareness methods and a lot of you may have seen adverts for apps to do this. The biggest one being one from the US, which is called Natural Cycles, um which is just being advertised absolutely everywhere. Um And basically what it does is it includes a range of different ways of tracking symptoms throughout and tracking changes that occur throughout the menstrual cycle to work out when you're ovulating, you avoid sex when you're ovulating and then you don't get pregnant is, is the general premise. In order to do that, we need to know the lifespan of the gametes in the human body. So for sperm, that's 5 to 7 days, officially, according to guidelines, it's five days, there have been some studies that suggested perhaps a bit longer. Um And for the egg, um that is viable for 24 hours. So we have to combine all of these um lengths of time together to work out when in the cycle, these two things may potentially overlap um to create what is essentially the physiological fertile time. Um And then we avoid that is the idea for most people when you allow for variation in cycles, um the fertile window ends up being a lot longer than sort of 24 hours or five days. Um And is considered to usually be between eight and nine days of the cycle if you calculate it correctly. Um However, the ways in which we do this all require a significant amount of effort, commitment and very minimal variance in both people's natural hormone cycle and their lifestyle. Um So we've got the rhythm or the calendar method which basically calculates it purely based on numbers. So how long is your cycle? Um If we take how long your cycle is, we can, then track back 14 days, work out what date of your cycle you would ovulate, give you a set number of days before and after ovulation to avoid. That's it. Um It needs at least 12 cycles with no obviously external hormonal influence before it can be considered effective. Um And even then with perfect use, the failure rate is still about 5%. With typical use, the failure rate is closer to 20%. So we never just use that on its own. And that's why we have to look at other things like the cervical secretions and the basal body temperature as well. Um So we usually advise people to take all of all three of these things into consideration all at once. Um And so we monitor the basal body temperature. We give them a thermometer. They use the, they take the thermometer immediately on waking every day um before they do any kind of activity at all. So even if they got out of bed and walked across the room to get their thermometer, that would invalidate the result. Um And they need to do that after at least three hours consecutive sleep. Um So I immediately um unless you're in a stable job where you have the same hours all the time, you wake up at exactly the same time every day, you get good sleep every night, um That's immediately gonna make that difficult. Um And then even then when we meet all of the criteria for the calendar method and for the body temperature. And we check our spiral crucis and we check all of these things altogether. Um Then there's a 1 to 2% failure rate with perfect use but still a typical failure rate of about 7.5%. Um However, all of this actually relies on your patient having a regular menstrual cycle that's extremely reliable, never changes. Um There are a lot of different things that can affect basal body temperature as well. Alcohol stress, illness, um All of these things too. So we're relying on people having an extremely stable lifestyle and home life also in order for this to be effective. Um So, as I'm sure you can imagine for the vast vast majority of people, this is not gonna be very effective at all. Um In terms of permanent contraception, there are two methods, obviously, either what's typically called male sterilization or vasectomy or female sterilization, which is a tubal ligation. Um Both of them are considered to be permanent procedures. Officially. Technically, both of them are potentially reversible, but there's never any guarantee that the reversal will work. So we consider them to be permanent procedures. Um And especially with vasectomy reversals are not attempted by the NHS. Um The main complications of a vasectomy is things like hematomas, sperm, sperm granulomas, um getting infection at the wound site or um in very rare circumstances, occasionally sort of chronic pain syndromes, tubal occlusion is done under a general anesthetic. Whereas vasectomy is minimally invasive under a local anesthetic. Um and it's an invasive procedure. It carries all the associated risks of having a laparoscopy and A G A. Complications of that can include infection, bleeding, um, procedure failure and increased risk of ectopic pregnancy. If there is procedure failure, damage to local other organs, things like bladder bowel, um the ureters, um damage to ovaries to tubes. Um And so it's a much riskier, much higher risk procedure. Vasectomy is also a lot more successful than tubal occlusion. So, with tubal occlusion, um about one in 200 is the failure rate with a vasectomy. The failure rate is one in 2000. So it's an infinitely safer and more successful procedure to have a vasectomy rather than to have a tubal ligation. So the key thing when we're consulting patients is we need to think about how effective all of these things are. So we tend to put them in three categories. The highly effective category, the effective category and the relatively effective category. And by that, we mean how many women will get pregnant in a year if they're using this method of contraception. So for highly effective methods of contraception, that's less than one pregnancy per 100 women per year. Whereas with relatively effective, you can expect there to be 10 or more pregnancies per 100 women in a year. And this is where the different methods of contraception sit So condoms diaphragms are in the relatively effective category, we then move up to things like the um C HC, the injection. And then our lark methods predominantly um are in the highly effective category. And then this is essentially what that looks like in the long term. So obviously, all methods can fail. Nothing is 100% in life. However, the biggest impact on failure rates is user error. And so as a result, our sterilization procedures, our coils and our implants are all on this end of the scale with less than one pregnancy per 100 women in a year. Um everything that involves the user um is then far, far less effective. So male condoms, the f the number of women who typically get pregnant using male condoms in a year is 18 with the diaphragm is 12, oral contraception is nine, the injection is six. and then we come down to less than one for everything else. Now, you may have noticed that throughout all of this, when we're talking about the effectiveness of contraception, I've been quoting two different figures to you. One of those is the perfect figure and then one is the typical figure. Now, whenever you look at any contraceptive um ever and you look at their leaflet, you look at the manufacturer's information, they will always quote to you the perfect use failure rate. Um and that's all very well and good, but we don't live in a perfect world and humans are not perfect and they're not gonna perfectly take their pill all the time or perfectly use their condoms all the time. You know, condoms come off, condoms, tear people forget pills. People become unwell and have vomiting episodes and stick their pills back up. Life isn't perfect. And so this is why when it comes to talking about effectiveness of contraception, we prefer to talk about the typical use. So this is like allowing for human error. If 100 people uses contraception, what is the actual outcomes we see in the real world? And that's why we talk about typical use. And it's really important that we counsel patients about typical use um when it comes down to it. Um but if you look at the leaflets, they will only talk about per perfect use. Um And then this is just another diagram showing that again, essentially. So before I move on to emergency contraception, does anybody else have any questions about anything we've done already? Anyone at all? No. OK. That's fine. Um So I'm gonna move on briefly and I'm gonna go through the bare bones of emergency contraception um because this is important and this again is something that is not done brilliantly all the time. Um Sorry, we've got three different methods. We've got um two different tablets and we've also got the copper IUD these, these are our different options. OK. So we've got Levonogestrel, otherwise known as LNG brand name Leel, we've got rystal acetate um or UPA which brand name is LA one and then the copper coil. So when is emergency contraception needed? That's the main thing. So if a condom is not used or somebody has a condom accident, if they have missed more than two of their combined pill, if they are late for the mini pill, if they are more than 14 weeks after their last depo injection, if we can't feel that implant or the implant has been in for um I need to edit this, that should say more than four years now. Um And if the coil has either been expelled, pushed out or we can't find their coil threads, then we may need emergency contraception. Also, it's also really important to know that any patient who is taking liver enzyme inducers. Um it will affect any form of hormonal contraception. Um and it will affect that for up to 28 days afterwards as well. So there's a lot of a lot of different reasons why somebody might need emergency contraception. And if we look at our different methods of emergency contraception, this is how effective they are. So, um this is a pictogram. It's showing 1000 women who've all had a single episode of unprotected sex in their cycle. Um whilst not on any form of contraception. And essentially, if we give them nothing, 55 of those, 1000 women would become pregnant if we gave them ll then 22 of them would still become pregnant if we gave them L or 1, 14 of them would still become pregnant. And if we gave them a copper IUD, only one of them would still go on to become pregnant. So the copper IUD is about 10 times more effective than any other form um of emergency contraception. Um The other key thing to note is that lel is more effective the earlier it's taken after the unprotected sex. Um And that isn't the same for a one. So you take them slightly differently as well. Um This diagram essentially represents a risk to all people at any stage of the cycle on a population level. So you can't use this diagram to specifically work out for the person in front of you because it depends on where they are in their cycle when they've ovulated, et cetera, et cetera. So how does it work well with oral emergency contraception? The key way it works is it's delaying ovulation by at least five days. So we wait for the sperm to die, then you can ovulate safe. No sp the sperm doesn't come into contact with the egg, it's fine. So we're trying to avoid that overlap of the sperm being present whilst the egg is alive. Um And that is the case for both levonogestrel and um IDA Prestol, both of them work in that way. Um This diagram here is from the Royal College of emergency medicine. Um And I just think it's quite a good um summary. Um So, leven estrol will only delay ovulation if it's taken before the start of the LH surge. Whereas UDA Prestol can still work after the LH surge if ovulation hasn't yet occurred, um which is why it's more effective essentially, whereas the copper coil actually prevents implantation. Um And that's how that works instead. So it's a little bit different. Um Now, the main way that the copper coil does that is through its effect on sperm and ova. Um And then if fertilization does occur, as we've mentioned earlier, that inflammatory reaction will prevent it from staying um a judicial review in the UK in 2002. Um So concluded that in UK law, pregnancy begins at implantation. Um The earliest implantation is believed to occur about six days after ovulation. Um And actually over 80% of implantations occur about 8 to 10 days after ovulation. Um And so, as a result, you can use the copper coil up to five days after unprotected sex. Um But also if it's later, you can use it up to five days after the earliest predicted ovulation. So it's whichever one of those two comes later, either five days after sex or five days after ovulation, whichever is later. Um So that's really important. And again, neither of these methods of emergency contraception are inducing an abortion. So that's a very whistle stop tour I'm aware it's by no means a comprehensive look, but it should hopefully be enough um, to get you through, um, through your exams and enough to get you by that, you'll be able to counsel people, um, c counsel people well enough. Um, even if it's not your area of expertise. Um So we've got a lot of different methods of contraception available in the UK. As I said, this list was by no means exhaustive. Um condoms do protect people from S TI s but they do have a higher contraceptive failure rate. So using them in conjunction with hormonal contraception is much safer. The long acting reversible contraceptives such as the subdermal contraceptive implant and the intrauterine devices are the most eve effective reversible methods of contraception. And the IUD is the most effective form of um emergency contraception. Um Choice of method all comes down to a lot of different things. So, patient factors, family history, and also the patients choice and what the patient wants. Um If you wanted any more reading, the best places to go are the faculty of sexual and reproductive healthcare website, the FS Rh website, they've got guidelines for literally absolutely everything. Um There is, oh, I need to edit this now as well. They have literally as of last week taken the sex wise website down, which makes me very sad because it was a very helpful website. Um But you should still be able to find the family planning association um leaflets, which are these, they look like this. Um And they have them for every different form of um contraception which you can download from the internet and print out and they are really helpful for patients. Um And then you've also got um if you want to do more learning on this, the e-learning for healthcare S Rh package, um I think most UK medical schools are signed up to the e-learning for healthcare website and should be able to give you a login if you wanted access to those online modules as well. Um So thank you for listening. Um If anyone's got any questions, I am more than happy to answer those. Now, I believe this is the er link for feedback, I think. Yeah. So if you er fill out that um QR code, so if you scan it, it'll take you to the form and that is a link to the feedback form. Um So please, if you could do that, that's really useful for us. Um And it will also allow you to get access to the slides and the event recording. I've also a link to that in the chat. Yeah, so I'll leave that up there for a minute. Um And then I'll swap over to the chat and check if there's any questions and things and one week uh the, the is like, ok. Ok. Um So I'm still here. Um So I'm happy to answer any questions about anything I've talked about today. If anyone does have any s ti questions or whatever, I'm happy to try and answer those while I'm here also. Um, and if anyone has any questions about my training program and what I do, I'm happy to answer that as well because we're a small specialty. There aren't many of us and most people, if I'm honest, haven't even heard of us before. So, um, I'm happy to answer any questions about anything. If anyone has anything, um, feel free to just shout out or stick it in the chat. I don't mind. Um, and then if not, I will leave you all to get on with your Thursday evening. Uh, I'm gonna take a deep breath. Yeah, there's no, um, questions just yet. No, that's fine. I'll give him a couple of minutes in case anyone thinks of anything. And then after that I'll, um, I'll let people go. I'm very aware it's a bit of information overload. So I don't think I even know how many people we've got on. Um, so people have dropped off. We've still got nine people or so. So there might be on that feedback for Yeah, fair enough. Do you, do you have, that's what you want. What is one that and also a combination of blood house I II. How are you doing now? Hi, Betty. You gonna come say hi. You gonna come say hi. I know. So is my cat. Yeah.