Computer generated transcript

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

No, they just don't wanna have a look at my. That's fine. I'm sure. Yes. Yeah. Oh, hi. Hi. All. I hope that you can hear us a message in the chat. Let us know that you can, that you can hear us. It is probably still letting some people in, I me in the shop now if you, oh, I can find that. No. Brilliant. Ok. So this next session is going to be run by Catherine and Ruth. So, um, thank you all for coming. It's going to be a pretty useful session. I think Cath and Rufus spent a lot of time kind of trying to break down the topic. Contraception, which I've always considered myself and I think the others would agree quite a complex topic in itself. So it's more a session to go through the complexities of it. Try to make you guys understand it and then go into the breakdown of if it was to come up as a station, which is a very fair station for them to give how you would break it down in a simplistic sense to advise patients on using these medications or counseling these patients. If you had it as a station. So I'll let Catherine and Ruth take the lead. But I hope you all enjoy. Thank you very much. Um Can I just ask, I can see that the slides up here. Can I share my own screen? Because I've changed the slides a little bit, Ronan. So, is it ok if I share my own? The one on the drive car? 00, Fab, this is the one on the drive. Did I change it like in the last hour? Oh, no, probably not then. Ok. Do you mind if I just change mine then mine on? Yeah, that's fine. All right guys. Uh and any questions in the meantime, you can pop it on the chat. Um Jack Me and Red would be here to answer it. Fab Lovely. So the beginning so I can't actually see anyone. So um because I've got my uh full screen on. So guys, please, if you have any questions, please put them in the chat, um I will kind of keep an eye um at the end and obviously the guys are here to, to help out if you need any questions answering. Um If there's any point, there's any questions that we want to verbally speak out. Um Guys on the team, could you just stop me flow and um mid flow and just say, can you write this question or if, if I'm sure you guys were able to answer anyway? But um thank you. Thank you because I can't see anyone. So that's just presenting to um, the screen really weird. But anyway, hi, everyone. Um, I'm Cath. Um, I'm part of the, er, is 101 team, very proud member of the team. Um I hope this is a helpful session for you. Um, it's about contraceptions, H RT. As you can see, I'll be talking about some of the contraception methods. Please don't worry about um, the nuances in the manu shy of this topic. So it is a very complicated topic. Um, and so don't worry about the nitty gritty, even like doctors that, you know, have been working for years and years and years still have to look at um, some of like the contraindications and some of the um to kind of find each other but just learn the headlines. So the, everything's available on the slides, I'll point out during the pre presentation which slidess, er, sorry, which points are kind of most important to remember, er, for your, in the context of iss then. Um, so yeah, this contraception H RT could come up um, in two kind of stations, I suppose communication station, um, and also the Pharmacology Station as well. Er, I believe, correct me if I'm wrong. But I think the year I did it, there was a station on um, contraception. It wasn't the, er, rotation that I sat but I think the other cohort had, had contraception as their pharmacology station. Um Was I had the easy bisphosphonate. So I was quite lucky with that. Anyway, so let's get started and please again, stop me and guys speak over if you want me to answer anything. Cool. So this is just a really quick um overview of the menstrual cycle. I'm not gonna go into it in great detail. I know I shared a couple of links um over email. Don't worry if you haven't had a chance to watch it. It's just basically giving you a grounding for understanding the ins and outs of conception and why contraception works. Um And just kind of helps really the instant thing. The important thing then is to learn about this ovulation. Can you see my cursor guys if you can't, don't worry, can you Roland R guys, would you mind just telling me cos I can't actually see. Can you see my case, sir? Yeah. Yeah. Yeah. Fab amazing. Thank you. So, um as you can see here, just, just as ovulation is coming up, the LH and FS H peaks and it's this LH surge, which is actually what's called is what s like causes ovulation. Um And then obviously it shoots down and then you get your increased in estrogen and progesterone and that is um will be important later on. So it's just a really quick overview. I won't lab the point. So this is just a, a brief overview of all the kind of um er possible methods of contraception. The main ones that could come up in the context of is a combined pill progesterone only pill. Um, these are unlikely to come up. Um, you could mention them possibly but it's more likely to be the pill implant injection and both the coils. Um, and as a side, no, I'm not just talking about the coil that's gonna be Ruth's, er, department, her expertise. But, um, the, the way I try and remember it because I know the progress test that came up once and you had to differentiate between IUD and I us and I didn't, I didn't know them as that. I just knew them as copper and hormonal or progesterone. So I think it was IUD. Um, so D and C come together in the alphabet. So, er, the IUD is the copper, um, and then R USS and P come together in the alphabet. So the R US is the um progesterone one, or Mirena. So Mirena's a brand name. So M and S sort of come to together in the alphabet. Just a little side thing to help you remember the different ones, cos they may not say copper coil or um progesterone coil, right? These are different methods. Um, again, I've highlighted the ones that could come up um, in eys um I excuse is this pill patch ring. So, yeah, that, that, those are the different types of um hormonal ones you can get that are combined that patch and should kind of be, er, sorry patch and ring should be lower down and I'll change these before I send you out. The, the official, um, slides. Don't worry too much about these. I have put them in the slides, um, these natural methods and barrier methods, but to be perfectly honest with you, very unlikely cavers. And even if you did want to mention them, for example, condoms, everything that I would tell you, you'd already know. Anyway. So we're just gonna go over the, the kind of high yield ones then that, that could come up. So I'm gonna skip now to slide 12. Um because the ones that are here that you can read in your own time, these are all the ones that could well unlikely to come up. These are like the natural methods, um, lactational amenorrhea. I'm not gonna bore you those details because to be honest, they're not really that important, the more important ones, the ones I'm gonna go over now. So this is a little spider diagram. Um Just to kind of give you an overview, just different way of laying it out really. Um Again, you'll have these slides. So don't worry about the fact that I'm whizzing through them now, right? So let's start with the combined oral contraceptive pill. Um I think this is probably the one that's don't quote me, but this is probably the one that's most likely to come up if it does come up. Um, so can anyone, obviously, I can't see the group chat but, um, can somebody tell me what the mechanism of action is for, um, for the combined oral contraceptive pill? And then guys, if you wouldn't mind just reading it out to me, that would be fantastic. What is the mechanism of action of the combined oral contraceptive pill? If you guys know, you may not know, you may just know that it stops you getting pregnant and if that's all, you know, that's fine, it's just a way just to try and help you remember. And actually, I've got an idea of how I can possibly just trying to, as I'm talking to you, I'm just trying to log on um there we go fab a OK. What I'm actually doing? Um I'm actually on a different website now. Er Sorry, what um thing. So I can see that in the population. Yeah. Brilliant. That's exactly what it does. So it inhibits ovulation due to negative feedback on HBO. This is why I mean, gave that um that table, that kind of graph at the start. It also thickens the cervical mucus and that's the action of progesterone. So it's harder for sperm to penetrate and also thins the endometrial lining which reduces the chance of implantation. And this is why kind of the period is why you get a period. So when your um eastern levels go up, you, it's you kind of shed the lining. So you get a thin lining. So, yeah, excellent. And when used correctly, it's 99% effective. So, um this is something you could say in this case station. So it's very, very effective if used, if used correctly. Obviously, that caveat. So the traditional regime, um which is kind of probably the one that you've heard of the most is to take it continuously for 21 days and then seven days off. That's like the traditional way that, that we, um like I say, we, that women will use it. Um There are other ways that you can use it so you can have sugar pill for those seven days off. That's just simply to make it easier for women to remember to take a pill every day. So they don't have to necessarily worry about stopping and starting. And the important thing here is you get a withdrawal bleed. So it's not a period. It's classically, I remember um the GP um that I was on placement with and she was kind of an expert in Gyne and women's health. She told me that that bleed was there to kind of reassure patients that they're not pregnant, but you don't actually need it. It doesn't really contribute to the, to the contraceptive effect. So, um you don't need it, which is why there's more tailored regimes now where you can take it continuously without having a break at all. Um That's not the traditional way. But just for you to be aware, there are different ways of doing it. So you can take it for 21 days and four days off. You can have it for nine weeks on and seven days off. You can even take it, um, for, well, for as long as you can until the breakthrough bleed starts and then you stop it for four days. But basically the headline here is just remember three weeks on one week off and there are some specific ones that people can take if they want to fine starting the pill, not really that important. Uh but just for you to be aware. Um So you can start it on any day of the cycle, but it's important to know that depending on when you start it, you may need to have extra protection. So if you're starting on day 1 to 5, your cycle, um and that's just for clarification. Um in case you didn't know day one is the first day of your period. So that's if you start day one to day five, you do not need any extra contraception, you're immediately protected. Um If you start after day five, you do not have immediate protection. You need to have um additional contraception, whether that's um condoms or abstinence, whatever. Um for seven days. And the reason for this is you need to have the contraceptive pill. Sorry, the combined oral contraceptive pill, you need to have it for seven days continuously for it to be effective. Um I can see that someone has given a question. Should we explain the other types of pills available at the start to? Um I Sandra, I would um say right. So there are, these are different ones available. I'm gonna go through each of them in turn. So you could say that um, when you say other types of pills, I don't know if you mean just the combined oral contraceptive and the progesterone only or you mean the different subtypes within cos the combined oral contraceptive pill has different um brands and the progesterone only pill has different brands. Um for ease. I would, let's just say there's a combined oral contraceptive pill which has Eastern and progesterone or you have a progesterone only. I would keep it simple. Don't worry too much about the subtypes of each drug. Um It's basically a little bit like um you've got a main ingredient drug and then you've got the brands type. Um like I can't think of one of Co Cocodamol. Yeah, Cocodamol. That's the name of the drug, but you've got different brands. Um It's a little bit like that. So just keep it simple, Easter and progesterone or progesterone only hope that answers your question. Um Thank you Jack for, for answering that. This is the thing that I wrote during my um when I was in my actually cos it used to confuse me f you're welcome, Sandra So, um, it used to confuse me. So remember that week, er, day one of your cycle? Oh, we're going back. Let me do that. Sorry, week one of your sorry day one of your cycle is when you first had your period. And remember that week one on the pill is actually week two of your cycle. Um, I don't know if that makes sense, but remember when you bleed, that's not actually week one of your pill, when you bleed, that's one week a week one of your cycle. If that didn't make any sense, don't worry. It was just something that confused me that I thought if someone out there was confused by it, this kind of helps um brilliant. So missed pills, it would be very mean to give you this. Um But a patient might ask, um in the, er, might ask what to do with a missed pill. In that sense, I would say, er, given the generic answer, say something like there's a really good resource on NHS website about what to do because there is actually on the NHS website, it gives you a good um outline and actually for Iski in general, I would advise to say, um like um guide them to direct them to websites. So a NHS website or um patient information, patient information, another good one, if you're not really sure yourself, it's a good cop out. Um But this is quite confusing when actually GPS do um, do do have to look this up as well. This thing I did again for my, um, for my is, is exam. Um, you do not need to know the ins and outs. This is just to be aware of. Um, so can anyone tell me what, er, is considered a missed pill? This is actually kind of important and some, it's actually not that understood by, not understood. It's, um, sometimes people aren't aware of the actual definition of a missed pill. So in the, in the context of a combined order, contraceptive pill, what is considered a missed pill? If anyone knows, pop in the chart. If you don't, that's fine. I'll crack on in the um, interest of time, right? Ok. What I'm gonna do is I'm going to crack on unless someone wants to do it in the next few seconds. No answers yet. That's fine. Yeah, I can see, I can see. Oh, there we go. Well done, Marcel. Excellent. More than 24 hours. So that's, that, that's a bit. Um, misleading. People can be misled by the term missed pill. Say if it's Monday morning and patients taking it 8 a.m. on Monday morning. If it's Tuesday at 9 a.m. that's not missed pill. They can still take it if it's Wednesday at 801, that's considered a missed pill. So let me go through that again. So Monday at 8 a.m. they take their combined oral concept. A pill. Wednesday at 801. That's when it's considered a missed pill. Any time before that, it's not considered a missed pill. It's a late pill, which is different to being um missed pill. Great, well done Marcel. That's, that, that's great. Um So over 24 hours late. So I 48 hours or more since the last pill, this is in the combined oral contraceptive pill. So what do you do if you miss a pill? So the action depends on how late the drug is and when in the cycle, the pill was missed. So again, this is the niche things that you don't really need to worry about. But this is just for you to be aware of. This is a good, if I say to myself, this is a good um flow diagram. So if it's less than 24 hours, just take it. It doesn't matter. You don't need to um skip or you don't need to. Um It's, it's fine. If you take two, you may end up taking two in one day in a 24 hour period. That's fine. So if it's over 40 hours, you take the missed pill ASAP um and take the remaining pill. Um at the usual time, you don't need all or emergency contraception. You don't need um additional contraception. If you've missed two or more ie 72 hours. Since your last one, you take the late or the missed pill as soon as you possibly can um, and continue taking the remaining pills at the usual time. You may take one pill, um, sorry, two pills in one day. But you do need to take um, extra precautions, um ie condoms or absence. So, and then there's a little bit more of nuances then about when you take an emergency c reception pill that again will not, you won't be expected to the mind you share of this in, in the ski. It's just for you to be aware of if you want to have a little, look at that in your own time. Er, and again, remember you need to have the contraceptive pill for seven days consecutively for it to be effective. Again, this is a good thing just to, if you're not sure, you just say it's a really good website and in general, in is skis in general, actually just direct patients to online resources. Um because that will probably just give you a mark, right? Advantages and disadvantages of the pill when I say the pill, um I mean, the combined oral contraceptive pill. So, uh but the bold ones are the ones that kind of the headlines really. So it can help with menorrhagia, which I'm sure you all know is heavy bleeding, dysmenorrhea, which I'm sure you all know is painful bleeding and endometriosis compared to a pop is the um progesterone only pill. There's a lower risk of ovarian cancer, endometrial cancer and colorectal cancer. Um But the disadvantages are there's the estrogen effects um which nausea, breast tenderness, irregular bleeding and progesterone effects and mood swings. Um The main ones to be aware of um out of all this slide, the ones ii would say to be aware of the most VT E so clots um and cycle and breast cancer. So there is a small risk of these and CVA mis actually should be a um uh bold as well and what's not written here, it's not a disadvantage as such it to be aware of. Um, if you've got migraine with aura, um you'd think really hard whether we should be given this. Um because um there's a, there's a very small risk of having um a clot in the, in the brains of venous sinus thrombosis, which can sometimes present similar to migraine with aura. So they kind of say that you shouldn't be having combined if you've, if you've got um migraine with aura, it's a little bit more gray if it's migraine without aura, but we'll come on to that. Er, yeah, and a as Jess Jess, sorry, I don't know where that came from. Jack said um, mobility issues as well because that's probably linked to the um VT E because obviously anyone who's sedentary has an increased risk of VT E and has an increased risk because it's actually the estrogen component which gives you, makes you more clotty, right? I realize I'm babbling on a little bit. So I'm gonna go a bit quicker now just to um poor ruth is gonna have to squeeze everything in otherwise. So I'll, I'll, I'll speed up now. So, um yeah, here again, I would seriously, highly, highly, highly, highly, highly recommend um a website called UK Meq. Um That's UK M EC. Please look it up. It's really good. It's got a table of all the contraindications and um what to think about when you're thinking about me. Um contraception. So please, please, please, please please look at it the end of this placement. Um End of this presentation, there's a link to it. It's great. So, um I don't want to er delay er this presentation too much. But can anyone tell me why breastfeeding and postpartum is um kind of contraindicated? So it's contraindicated to give the combined oral contraceptive pill in patients who are postpartum or breastfeeding. Anyone put it quickly. Um And again, there are other things here that are in bold, those things you're aware of. So, current breast cancer, migraine with aura as Jack said, major surgeon, prolong ability, stroke, tia a um smoking reduced breast milk. Exactly. Yes, breast milk production, it does. So um estrogen er uh increase. Exactly. Katie and Sha Brilliant. So yes. So when you are pregnant and up to six weeks, postpartum, you are increased risk of A VT E. Um So that's why they say you shouldn't really be having it. Um if you are postpartum and it is a double whammy if you're breastfeeding as well. Um, estrogen can actually um inhibit um milk production. Er I did try and find a, a kind of um feedback picture for you but I couldn't find one just so, yeah, take it from me, it reduces milk production. Uh as a side note, progesterone doesn't affect milk production. So it is OK to use progesterone um if you're breastfeeding. So again, the um kind of headlines here are in the bold, remember those ones. Ok. Um This is, this will be quicker, don't worry. Um And this one is the progesterone only pill which is sometimes known as the mini pill. Again, anyone know in actually, in actual fact, I'm just gonna tell you cos you probably know already what is the mechanism of action? It thickens the cervical mucus um to prevent sperry and depending on the preparation. Um And by that, I mean, the different uh types of progesterone pill, it can suppress ovulation, but it's not as effective as the combined oral contraceptive pill. So have a glass of water, some talking and rambling. OK. And again, if taken correctly, it's more than 90% effective. Um I remember the GP um that I was on placement with, told me that actually the combined or concept a pill is more effective, but don't take my word on that because I don't think I've found any evidence for that, but I'm willing to be corrected. Excellent So again, different preparations, there's four old types and there's the cerazette. Um and seros version is actually preferred because it's um it's got a longer window um where you can forget it. Um But by that, I mean, missed pill, excuse me. And it's associated with fewer side effects. So the Desert GRE which is one of the older types has a 12 hour window to take the pill. And by that, I mean, there's a stricter time. You have to take it within 12 hours of um of repeating it. So say for example, if it's 8 a.m. on a Monday that you take it, um you should be taking it 8 a.m. on a Tuesday, but you've kind of got a 12 hour grace period, whereas it doesn't actually matter if you're a little bit late. Whereas the er, Norethisterone on the um Le GRE, there's a three hour window. So it's obviously a stricter um window and anything after that is considered a missed pill. So yeah, take every day at the same time. So this is one thing you could tell patients in Whisky Station, this one is a lot stricter um when you take it. Um So you don't have as much lenience with being late for that one. And again, if you start it, day 1 to 5, don't need extra contraception. If you start it, er, after day five, you need extra contraception for two days. Um And the one thing here um which is important to know about is um you can take it during um breastfeeding because it doesn't affect breast milk production. Um unlike estrogen because it's the estrogen hormone that has that effect on the hormones. Brilliant. Um And again, here, these you can look at these in your own time, but again, the bold are the kind of headline stuff. So there's no oestrogenic effects. Um That's technically not true. Actually, I would argue that's not accurate because it, there is a small um I don't wanna say risk, but there's an association with VT E clots, but not as much as estrogen. So, um that's not something to be aware of. It's, it's more associated with the estrogen effect. Um And again, no significant increase in breast cancer or venous disease. However, it, they do say that if you've got current breast cancer, you should be wary. Um And just cautious of using progesterone only pill. Um And that's because as I'm sure you all know with, with breast cancer, you've got estrogen positive and progesterone positive. So, um both um hormones can be associated with that progesterone um is the, it's known to cause irregular bleeding. So, even though it may help with dysmenorrhea, um and endometriosis, it can actually cause irregular bleeding as well. Um And again, it can cause the progesterone side effects as listed there. Um So when you can't have the combined oral contraceptive pill and you can have the um progesterone pill. So this UK Mek one A again, if you take anything out of this, please, please please look at that. Um pro that document is brilliant. If you've got hypertension, you shouldn't really be having the combined contraceptive pill, but you can have um the progesterone only pill. UK Mek one means perfectly safe to have UK Mek two means it's ok. It's good to have um UK Mek three means maybe wanna be wary of it. UK Me four means do not take it under any circumstances. So, UK Mec one is good to take, you're all good postpartum. You're good to take progesterone only pill, smoker regardless of quantity, you're fine for taking the progesterone. Um I don't know why it says valvula. That's I should say valvular apologies for that. Um All of these, you're OK to take the progesterone only pill. The reason is two is because as I said, there is an association with uh VT E not as much as combined oral contraceptive pill and the same with migraine um with or without aura um with, with combined oral contraceptive pill probably shouldn't be giving it at all. Whereas progesterone only, you can maybe think about it. But again, these are the gray areas you don't really need to to worry about. And then here are the contra uh contraindications for progesterone only pill. So as I mentioned before, current breast cancer, you shouldn't be using progesterone only pill. Um But if it's previous um, breast cancer. You can maybe think about using it. Um, and also this undiagnosed vaginal bleeding, uh, you also shouldn't really be giving it because um, the progesterone only pill can one, it can cause um PV bleeding and also it can inhibit it as well. Er, it depends on the person, depends on the preparation. So it could theoretically be masking any PV bleeding or it could also make you bleed and make you think. Oh, it's fine. It's just a pill when actually you've got something underlying. So that's the reason for that. I believe that's oh, there yeah, just depend again depending on the type of um preparation, preparation. Um what you consider a missed pill. Um And you can look at that in your own time. Um But again, that's very kind of fine print type stuff and I believe that's the end of my section. So I'll hand you over to the capable hands of Ruth. Um What I'll do, Ruth, I will stop sharing mine so that you can control your own. Ok? I'll do that. Now, any questions, please pop it in the chat. Um and I will share my email address as well in the chat so that you can email me whenever you want. Cool. Thank you very much, Ruth. I will let you crack on. Thanks car, right. I'm just gonna find the right slide. Ok? So this is me. So just carry on with the contraception at the moment. So, um I'm gonna be talking about the long acting reversible contraception. So that's the depo injection, the implant and the two different types of coils which um Cath mentioned earlier. Um So firstly, the depo injection. So this is progesterone. Um It's an IM injection which is given every 12 weeks. Um and it works by inhibiting ovulation. Um Its main side effects is that it can cause irregular bleeding. Um And it's also the only um proven contraception to that's been shown to cause weight gain. Um The main contraindications of the depo injection is um breast cancer. If they've currently got breast cancer, they can't have the um depo injection. Um And the main disadvantages of this is that it can't be reversed once the injection has been given. Um And it can also lead to a delayed um fertility for up to 12 months as well. Um So then moving on to the implant. Um So this is actually the most effective form of contraception. Um And again, this is progesterone only. Um it's implanted under the skin in the upper arm. Um It needs to be done by um somebody who's trained in this. So it's usually like a doctor that does this um and its mechanism of action is to prevent ovulation. Um That's its main way it works. Again, common side effects is irregular bleeding. Although, although you can use a combined prescription with the um combined oral contraceptive pill to help manage this um unusual once um the irregular bleeding has stopped. Um patients don't um continue having um bleeding. Um I've just put here that if a patient's not have bleeding for a while and then starts to have heavy bleeding, it's important to rule out any like S ti s um that the patient may have. Um and it's also long lasting so it lasts for three years. Um And again, like Cath mentioned, it's similar to progesterone only pills. So there's less um contraindications to the the implant. Um And yeah, like I said, you need a trained professional to insert and remove um remove this. Um So next, moving on to um the coil. So there's two different types of coils um which c briefly mentioned. Um So the first one is the I US, which is the Mirena. Um So this is progesterone only coil. Um and it, it only affects the uterus. So this can be um useful for women who find that the hormones affect um their mood and that sort of thing. Um So, um it just is targeted at the uterus. Um So its mechanism of action is prevents endometrial proliferation um and causes cervical mucus thickening. Um Again, a common side effect of progesterone is the irregular bleeding and spotting. Um Also some smaller risks associated with the I US is that there is a small risk of perforation um and an increased risk risk of um pelvic inflammatory disease during the 1st, 20 days. Um Oh, sorry. I just seen a question. Why do we not give, um, so the question is why do we give combined oral contraceptive pill in bleeding of the implant but not of the depo injections? They both cause regular bleeding. I, I'm not 100% sure on that. I'd have to look that up and get back to you. I think, I just know that, I don't think they do it with any of the other irregular bleedings only with um the implant. Um I don't know 100% why if anyone else knows, feel free to pop that in the chat, but if not, I'll have to look that up and get back to you. Um And then going back to the coil. So um yeah, like I said, a regular bleeding, you can't, I don't think you can use the combined oral contraceptive pill of this one. Um And um yeah, this is also very effective. Um and tends to be with this one. Once you've had the irregular bleeding again, it tends to become lighter. Um And patients sometimes stop having a bleed at all. Um And then compared to the copper coil, um the copper coil doesn't have any hormones in it. So this is just um causes contraception by preventing fertilization by reducing sperm motility and survival. Um So, um this again, so this can be good for patients that again, don't really um find that hormones work well with them, um, have a big, um, side effect of this is that patients tend to have much heavier, longer, painful, be painful periods. Um, and again, the same side effects as the, the I USS perforation and P ID. Um, and with, with the, um, IUD S they can be effective straight away, um, following in such, in such. Sure. Um, so, yeah, and let me just have a look at the chart. The risk of p of quote is that independent whether they have an S TI at the time of insertion? Yes. Um I think so. I think it just increases the risk of pid generally due to the risk of infection from the insertion of the coil. Ok. So, um moving on to the emergency contraception, um there's three different types. So um the first one is the copper coil, which is the most effective method of emergency contraception. Um and should be offered to all women if they meet the criteria. Um So in this case, it has to be inserted within five days of unprotected sexual intercourse. Um If a woman presents after um five days, then it can be fitted up to five days after the likely ovulation date. So this can be really um helpful in patients that present it after five days. Um Again, it has the same mechanism of action as it does in contraception and it is 99% effective regardless of where it's used in the cycle. Um And like we've mentioned earlier with um pelvic inflammatory disease and ST is um prophylactic antibiotics may be given if the patient is considered to be high risk of ST is. Um and yeah, following this, it can then be left in to provide contraception if the patient wants it to. Um but if they want it removed, it needs to be kept in until at least the next period. Um And then there's two different types of pills that can be taken for emergency contraception as well. Um So this is um Levonest, which is known as Leonel and Sso Aetate, which is LA one. Um So you've probably heard of both of these and they're quite similar, but there's just some key points that you need to know with both of them. Um So again, they both act to stop um population. However, the leel can be taken um within 72 hours, up to three days after unprotected sexual intercourse. Whereas um the one can be taken up to five days post um unprotected sexual intercourse. Um So this is really important to learn, um especially it often comes up in PT S as well. Um So make sure, you know, your hours of them both. Um And they can both be used in more than one menstrual cycle. Um I think one of them previously wasn't allowed to be used for more than once, but they both can be used more than once. Um Again, another important fact which differs between the two is that with leal, you can use hormonal contraception um straight away after taking leel. However, with um the L1, um you need to wait five days until you can restart um contraception. Um an important contraindication of the L1 is um asthma. Um So look out for this um in histories or in questions um and they shouldn't be used together. Um And I think with the levanil, if they want it within three hours, then the first dose can be re um repeated. Um And then just lastly, um with the leve, now you can continue breastfeeding as normal. Um But with the other one, you need to delay breastfeeding for one week. Um So that's the emergency contraception. Um So if anyone has any questions about that, feel free to put them in the chat or the or the like long lasting um contraception, um cause I'm just lastly gonna talk about hormone replacement therapy just as a little side note because I think this is um becoming more and more like popular in exams um as it's becoming a lot more popular within, within like GP and that sort of thing. So, and it can be quite confusing. Um So you fancy these are just my tips for um for HRT. So firstly, the first thing you need to ask if a patient comes in for HRT is, does the woman have a uterus or not, this will um affect what type of HRT you give her. So if the woman does have a uterus, um then they will need a combined HRT with estrogen and progesterone. Um So, the estrogen is what is actually treating the symptoms of um HRT. So like um the hot flashes, the mood changes, um all of the symptoms that come with um menopause um have the progesterone is what is, what is used to protect the uterus from endometrial cancer due to you give an estrogen. Um And so you then need to give them both estrogen and progesterone. Um Just on a side note, when you then give the patient progesterone, this slightly increases their risk of breast cancer, but its main role is to reduce the risk to um you need to, this reduces the risk of um endometrial cancer. So it's kind of weighing up the risks. Um And then if the patient doesn't have a uterus and then they will only need estrogen HRT. So um because they don't need the progesterone to protect the uterus from endometrial cancer. Um So that's a really important thing to find out first um as well. And yeah, like cat said, you need to ask about previous breast or endometrial cancer as this contraindication. Um And then the next question that um you need to ask about which this is where it can get a bit confusing is when was the patient's last menstrual period. Um So if the patient's last menstrual period was less than a year ago. So they're perimenopausal, then they will need sick like or sequential HRT, which produces a withdrawal bleed. So this means estrogen is taken every day, but then there are breaks um from the progesterone. And um I was having a look into this cos it's quite confusing, but basically, the, the reason for this is because if they're still having periods, they still need to have their withdrawal bleeds. Um So that's why you give them the break. Whereas if um their period was ov their last menstrual period was over a year ago. So they're like fully postmenopausal, then they can have continuous H RT. Um So this doesn't produce a bleed and then they're taking estrogen and progesterone every day. Um And this obviously only, this is only for patients that do have a uterus. Um So yeah, they're the key things to remember. It can be quite confusing. Um I'm really sorry, but in I'm writing something out and I thought it would actually be so much easier if I just explained it. I'm really sorry to cut across you. Um Otherwise I'll be writing all, all evening. So the reason they give um progesterone, are you gonna explain actually why they give progesterone um alongside estrogen and not to have unopposed estrogen to protect the uterus from? Yeah, exactly. So the reason for that is because estrogen is the thing that makes you proliferate. Uh the endometrial lining proliferate. So, if you were to give estrogen unopposed, ie without progesterone, the endometrium theoretically will just keep proliferating, which obviously makes you increase chance of cancer in the endometrial lining. Um So you give progesterone to kind of stop it building up. So it kind of like sheds it, then thins it whatever. Um And then that's why if someone that doesn't have a uterus, you don't really need to worry about their endometrial lining getting too thick because they don't have an endometrium. Um So I'm just writing something quickly in the chat now, but um just wanted to explain that because it can be quite a confusing when you say unopposed Eastern isolate. What does that mean? It means just give you estrogen without the um without the progesterone, cos the progesterone think of it as protecting the um endometrial lining from getting too thick. All right, thank you. Sorry, I'll, I'll let you. Thanks. Um So yeah, just to clarify. So there's combined um H RT or only HRT and there's also um sequential HRT or continuous HRT. So you just need to think about all these different ones when you're prescribing HRT and the reasons behind that. Um So yeah, hopefully that makes sense and once you go over it, um hopefully it'll make a little bit more sense. Um And like we said, some contraindications, um I've already mentioned is current or past breast cancer any estrogen sensitive cancer. Um if they've got undiagnosed vaginal bleeding, um as this could, like if they're postmenopausal and got um vaginal bleeding, you want to be thinking about endometrial cancer. Um and again, untreated endometrial hyperplasia. Um So again, just moving on to the different types of H RT preparations because there's lots of different ones that you can give. Um so the estrogen can either come in tablets, patches, spray or gel. Um However, estrogen tablets aren't very often given now because they've been associated with a higher increased risk of um VT E. And so the patches spray and gel or the topical ones um are, are therefore used more because there's no increased risk of um VT E. Um And then with terms of um the progesterone, these can come in tablets, um patches um or the coil. Um and just to note here that the coil has a different license for contraception and H RT. Um So for contraception, um it's five years whereas for HRT, it's four years. Um So it's just slightly different and it's also really important to note that the coil is the only um form of HRT, which can be used as contraception as well. HRT. The other versions aren't actually licensed for contraception. So any woman that's um under the age of 55 and on HRT should be offered additional contraception. Um So the best thing for this would just to be have the coil as the progesterone and they can take the estrogen um on the side um as well. And then just like we've mentioned, there is an increased risk of ovarian cancer with or H RT. Um and the progesterone increases the risk of breast cancer and the estrogen itself increases the risk of endometrial cancer, which is why you need the progesterone. Um So yeah, I think H RT is quite confusing topic. So hopefully that just gives you a bit of an overview of HRT and somewhere to start um with your revision. Um Yeah, so that was all of my main parts there. If anyone has any specific questions, feel free to email the email, email me and I can get back to you with um any questions that you have because I know it is quite a confusing topic and honestly, I still get confused sometimes. Um So these are just some of our final tips. Um Should I add on the I think it was, I wrote a couple of things here. So the underage relationship safeguarding that could come up definitely in this sort of history. Um Asking, do they feel safe at home? Are they being um coerced? Um So if they're maybe they're 14 and maybe their boyfriend, I'm making a very big generalization here, but maybe their boyfriend is 35. Um And you know, it could be some sort of grooming going on. So there's something that's something to think about. Um And even if they're of normal age, you still wanna make sure they feel safe at home. Um Make sure to take a sexual history. Any S ti S um Gyne obstetrics history can be important as well. And again, really important to um direct patient to the NHS website about contraception and in any excusation, to be honest. Um I remember the ice, the kind of love it. So, yeah, that's my little, little take on that. Thanks path. Um These are just some review resources that we've put on here if you wanna do any more um extra reading and I think that's everything. So thanks guys. Hope we hope you find that useful. Um Yeah, we know it can be quite a confusing topic. So any questions let us know um and if you could fill in the feedback form when you go, that would be great. Thank you. Uh Any questions in the chat. Um I've just bobbed down the chart now but with any pediatric or gyne obs or geriatric. So any of those patients you need to need to screen for safeguarding. Um It's a possible fai failing of gestation if you missed that out. Um I remember having a pediatric station for mine with migraine. It was like a 15 year old. It, it was a 15 year old with migraine. But again, it's so important to ask whether they feel safe at home. All you need to do is ask, are you safe at home. But yeah, but thanks for coming. Otherwise, I hope you find it useful. I've popped the feedback on the chat and the video and the session is recorded so you can go back and watch whenever you want. Sorry, you go no clock on Ruth, you're gone. Oh, I was just gonna say that we're gonna be sending out the feedback from the E BOX um by the end of this week. Um So yeah, just keep an eye on your emails. I've done a little test of one. So I just wanna say to people that here when I send the feedback out, it'll be, it's easier to view if it's on the laptop, um, rather than on your phone because the form goes a little bit deformed on the phone. So just make sure I have you on your laptops, um, when I do eventually send it out, but it will be by the end of this week. Cool. I, and I was just gonna say, please don't worry about this topic. It, it is a confusing topic and you know, we all have to keep looking it up. Even doctors who have been working for years and years and years, so have to look it up, just go for the headline stuff. Um And yeah, like the guys are saying, please, please, please do the feedback forms cos it really helps us, um, kind of get better and, uh, that's all we want to do is help you. So yeah, and again, email any questions, please email. Um and my email address is in the chat as well. So feel free to email Roland. Do you realize you're on mute? I could see you talking or maybe you're not on mute but I mean, I could see your mouth moving but I couldn't hear anything. You look very animated. You've got like a little um I don't know, it's like a triangle with an exclamation mark in it. If you don't have any questions, that's it. Ok. I think we'll end the session now. Thanks for coming again today. Ok, Rodan, could you um stop the live session?