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Particular women's health. Um And these are my declarations of interest. So, um I did a sort of part one of contraception a couple of weeks ago and then I just sort of continued the slides. So I'm going to just very quickly with through a few of the principles that we discussed last time in case some of the people here are different. And then we'll spend most of the time on the methods of contraception that we didn't discuss last time. So broadly speaking, um the key thing about contraception is whether it is something that you have to remember every day pill or every week, like the patch or every three months, like the injection or whether it's something you can just put in and forget about like the coil or the implant and understandably method you can just put in and forget about obviously have a lower failure rate than things you have to remember every day. If someone comes to see you and says that they want to go on the pill, they may mean that they want to go on the pill, they've done their reading, that's the best thing for them. But people women often use the pill as shorthand for contraception. So just check that they, that woman has done her research and that she whether she actually knows that she wants to go on the pill or whether what she means by the pill is some form of contraception. Don't forget sexual health. Um I'll with through this quickly, this this is just a reminder that the failure rate in studies and the failure rate in typical use are not identical because obviously in typical use, people forget to take things. Um So for example, if you look, look at combined pills, the failure rate and study is 0.3%. The failure rate in typical use is 9%. That's not going to be 9% for everyone. A teenager who is living at home and has to hide her contraception from her mum is much more likely to have a failure, failure rate from the pill because she's forgotten it than someone who maybe has a more regular lifestyle and who can remember to take the pill and doesn't have to hide it. So it's all about the right contraception for the right person. Um This um is important the UK met categories in terms of safety of contraception, not efficacy. They're broadly speaking, there are four categories. Um One being fine, no problems for being absolute contra indication and two and three being relative contra indicate with the two benefits, generally outweigh the risks and the three the risks generally outweigh the benefits. And it's quite a useful document to look at if you're thinking about prescribing contraception and a woman has a few health issues and you're not sure how important they are. That's just a few pages from that. And just remember safeguarding, particularly if you're dealing with teenagers, obviously, you'll be dealing with the legal framework of the country in which you're working, which may be different from in the UK. Um In the UK, the age of consent is 16, but we're not going to prosecute every 15 year old girl who's having sex with her 15 year old boyfriend. But we would be much more concerned about uh people having sex where there are concerning factors such as their partners, much older than them, or there is a difference in power between them because someone's having sex with their teacher or something like that or there as drugs or alcohol grooming and things like that to involve. So just be aware of that and I won't dwell on Fraser and Gillick competence because this is UK specific, but it's quite a useful set of criteria even if this is not the law where you are working. Just to think about whether you should be concerned about a teenager who is having a relationship. And these are a few more things to think about. Maybe to ask about if you're seeing a teenager, remember always see the girl on her own because she may not feel comfortable to talk in front of her partner. Um, and a question I like is if you didn't feel like having sex one day, would that be okay or would that be a problem to try and get an idea of whether she's likely to be being coerced into having sex? Okay. And I'm gonna, with, through all this stuff because we discussed it last time. But if we have questions at the end, particularly from people who weren't here last time about the pill and things like that, then I'm absolutely happy to go back. So we can start with talking about the implant. Um uh I can't turn my phone off because it keeps beeping at me. So the implant is a great method of contraception. It has the lowest real life failure rate of any method at all. Naught point, naught 5%. So that is one pregnancy for 2000 women who use it for a year. There were early on, um, in the implant's history, there were some manufacturing problems, there were some pregnancies to do with um, implants that didn't actually have the active ingredient in it. And as well as those very unusual true failure rates, there will be some a pattern, apparent failure rates when a woman has an implant put in and she is already pregnant and no one realizes. But true failure of the implant is extremely rare. It's fitted in the arm. And if the woman is happy with it. Then in three years' time when it runs out she can have it taken out. Mhm. Sorry, you're gonna have to. Excuse me. I've got cold. She can have it taken out in three years time and another one put in, usually in the same arm. I've now got women who have fitted their fourth or fifth implant in the same place. There is a theoretical risk of damage to the skin skin thinning or stree I, but it's unusual, I've never actually seen it in real life. So as long as there's no damage to the skin, you can just fit the implant in the same place as the next time as the last one. Um the licenses for three years um during COVID when obviously women had a problem with getting their implants changed as they were coming up to that three year period, the Faculty for Sexual and Reproductive Health Health, which is the main guidelines body for contraception in the UK. Looked at the research about the use of implants for longer than three years because obviously these methods don't just switch off at three years. Um It's just that when the manufacturer applied for the data, three years was all they had a license for. And the F srh looked at studies where people had used implants for four and even five years and they, there have been no pregnancies and they said that the risk of pregnancy in the fourth year of an implant is exceptionally low, it's not zero. Um, they can't say that it is as low as in the risk of the three years. So during COVID, the guidance was that it was fine to keep an implant for four years that has now been withdrawn because we don't have that, that sort of balance. You know, during COVID, we were balancing the risks of people coming into the surgery and possibly catching COVID with the benefits of them coming into the surgery to have their implant change. So the guidance in the UK is now three years, but the risk is so low in the fourth year that if someone comes for a change in the fourth year, you can assume it is still working and just change it without asking them to use condoms for a week or do a pregnancy test or anything like that. It prevents ovulation, that's how it works and it's rapidly reversible. So when you take it out, most people will ovulate um in about three weeks, we'll see in a minute how that is different for the depo injection. So if someone comes to see you and they, you know, they may be in there late thirties and they want to get pregnant in a year or two, then the implants are better method than the depo because of that rapid reversibility. There's no problem with using it in women who have obesity. There's a little bit less data in those with a body mass index of over 40. But all the guidelines say that it's safe to use and you don't have to replace it earlier or put two implants in or anything like that. You do need special training to insert and remove it. It's fairly straightforward. The top picture is the applicator that it comes in and to remove it. You just make a little, put some local anesthetic and make a little incision with a scalpel. Um and, and take it out with some sort of forcep things. But occasionally, when someone comes to have that implant removed, I will find that I can't feel it under the skin. An implant should be very easily palpable because it's put in very soon superficially. And if it's deep, either because it's shifted or more commonly because the woman has gained weight and has gained weight on top of the implant, then it has to go to a deep implant center where they would usually remove it under ultrasound guidance. You wouldn't want to go digging around trying to find an implant that you can't feel because obviously you're gonna risk damaging nerves and blood vessels and things like that. So the most common side effect of the implant and one that really needs to be explained carefully when you're counseling, the woman is a change in bleeding pattern. So these are the figures from the F srh Guidance on the implant in terms of what sort of what sort of bleeding women are likely to encounter. Um We don't know why they get funny bleeding. It's probably related to vessel changes with fluctuating estrogen levels. Um There's around a 50% chance that difficult bleeding will settle in the first three months. So I always say to women if you have unusual bleeding, unless it's really terrible, keep the implant for three months because it would be a shame to take it out at four or six weeks and lose that chance of an effective long term contraception. But some don't settle. And most studies show that even with the best, the best counseling and everything in the world, about 10 to 20% of women will have their implant taken out during bleeding. So these are the figures. Um I think that if I start talking to women, about 22% this and 7% that and 38% that they're going to glaze over and I'm going to lose them. So, what I tend to do is I ask is I, I use the fingers on my hand and I say, think about five typical women using the implant. So 22% have no periods. That's close enough to one in five. So I say one in five women, her periods will stop and then I stop. And I say, is that okay with you? There are most women are like, yeah, fantastic periods are a real nuisance. Why wouldn't I want them to stop. But there is the occasional women often for cultural reasons who has concerns about her periods stopping. You need to explore that. That's the one woman in five who's periods stop. And then at the other end of things, 18% of women have prolonged bleeding. Well, that's also close enough to one in five. So one more woman in five will have really heavy and difficult bleeding and might have the implant taken out early because of it. So that's two women out five and then the other three women out of fiber in the middle and they will either have normal bleeding or irregular bleeding, which is usually light and annoying rather than heavy and sort of making you anemic. And again, give it some time to settle down in terms of what you can do about bleeding. This rather depends on why the woman's using the implant. If the implant is her first choice of contraception and she can, she could also use an estrogen related contraception if she wants to. So she's got no health related contra indications to estrogen. Then what I usually do is give her the combined pill over the top of the implant, three packets taken back to back. So that's nine weeks that will settle the bleeding down and just anecdotally when she stops that often, the bleeding improves and it's not so bad. If it becomes a problem again, then she can either take the implant out or if she likes the implant for contraception, but she doesn't like the bleeding. She can use both long term. So she's using the implant for contraception and the combined pill for bleeding. And it doesn't matter if she forgets a few pills because obviously she's got the implant as backup. This isn't licensed, but it's very commonly used for women who can't take estrogen because of a medical problem. They don't have as many options. And in fact, they've got no real options in most of the guidelines. But anecdotally using the progesterone only pill that these are gestural pill, which is effectively the same hormone as the implant because one um one version of progest a gin is metabolized to the other. I can never remember if it's the one in the pill that's metabolized to the one in the implant or the other way around. Um So anecdotally giving the progesterone only pill, the desogestrel pill on top of the implant, either in the normal dose or a double dose often does settle down again, that can be used long term. But none of these options are licensed and um side effects otherwise, in my experience are not common. So in theory, you can get hormonal side effects such as breast tenderness, you can certainly get acne, um depression and headaches have been reported. But of course, it's always difficult to know the causation because if you take a group of women without the implants, some of them will be depressed and some of them will have headaches. But I usually find that if the bleeding isn't a problem, it's a fairly well tolerated method of contraception. When you're putting it in, there's always a risk that woman could be allergic to the local anesthetic or who get some infection in the skin. But I've been fitting them for, well, 15 years I've must have fitted hundreds and I've never actually seen that as a side effect. So that's the implant. Now, the depo. So 15 or so years ago, I was giving loads of depots. I always had a few in the cupboard in my room because people would come in for them. And now I hardly ever give it such that I have to go hunting around and asked one of the nurses where they kept these days if someone comes in and wants it. And I think that is because the implant has been more popular. So we talked about the implant having a failure rate. A real life failure rate of 0.5% and the pill 9% the depo is closer to the pill. Actually, it's a 6% real life failure rate. And that is largely due to people forgetting to come back for their repeat injection. You have to come every 13 weeks. Um, if you're up to 14 weeks, that's fine. It can be given if you're longer than 14 weeks and you have to think about things like whether the woman has had unprotected sex, whether there's a risk that they could be pregnant. Now, there is a significant average delay in return to fertility with an average of 5.5 months, but it can be up to a year. But this needs really careful explanation. I have arranged more than one termination of pregnancy for a woman who was told the average delay in return to fertility is 5.5 months. And what she heard was great. I can go 5.5 months after my last injection. And I don't, you need to use any other contraception and that's not correct because every woman is different. So the importance of the delay in return to fertility is to do with wanting to conceive, not wanting or not wanting not to conceive. So, if I had a woman who was 37 getting married next year and wanting to have a baby, I definitely wouldn't give her the deeper injection because um you know, she, her fertility's on the reduction anyway because of her age and um she wants to get pregnant next year. Um So it's just really important that you explain it that this delay is an average and individual women don't know what's going to happen to them. It is the only pill. It is the only method of contraception for which there is some evidence for weight gain, particularly if the woman has obesity before she starts using it. And if you gain more than 5% of weight in the first few months of using it, that does predict further weight gain. People are always coming in and going. I want to stop my pill because it's making me fat. I want to stop my implants. It's making me put on weight. But actually, there's no evidence for weight gain for any of the other methods. And the study where, where there are studies looking at it broadly speaking, you know, third gain weight, third lose weight Thursday the same. But of course, it's much easier to a lot of people gain weight, particularly during the pandemic. It's much easier to blame your contraceptive method than to, to think about the things going on in your life. And of course, we know now that obesity is much more complicated than just eat less, uh eat less, move more. It's, there's lots to do with hormones to do with how full you feel and all that sort of thing. But this is the only method that is actually associated with weight gain. Uh, excuse me. So, um, difficult bleeding is common in the first three months particularly. And then it often settles down to no period. But of course, this is an injection once it's in, it's in, can't take it out, you can take the implant out any time. So just be careful, I would not give someone their first implant. A month before they were due to get married or if they're about to go off trekking somewhere remotely where heavy bleeding would be a real nuisance. So, just have a think about that and have a chat to the woman about those first three months and the fact that you can't take it out. So the depo injection works by preventing ovulation in the same way that the implant does, but it, it sort of does it more. So if you think about normal ovulation every month, a woman will make an egg and she also make a lot of tiny other little follicles that don't go anywhere and don't become an egg. The depo injection kind of sits very heavily on the ovaries and it stops all of that. No egg, no little follicles, no ovarian activity at all. Whereas the implant kind of sits a bit lighter on the ovaries. And whilst you're not making the egg, you will make the little follicles that don't go anywhere. And because of this difference, the depo but not the implant is associated with a reduction in bone desk density. It's not very big and we know that it returns to baseline when the method is stopped. You can imagine that to investigate this fully and to control for other causes of low bone density, like smoking and diet and anorexia and weight bearing exercise, you need massive studies which which we don't have on which will probably never been done never be done. So we have to sort of work on a pragmatic basis and think, you know, what can we logically do? And the two groups of women about whom concerns have been raised our teenagers because you reach your peak bone density sometime in your twenties. If we give the depo to teenagers, will they never reach their peak bone density. And therefore they're more prone to osteoporosis later in life. And those who use the depo going into the menopause, same thing if your bone density, it goes down during the depo and then you're expecting it to go back up when you stop. But by the time you stop, you've gone into your menopause. Is your bone density ever going to come up or are you going to be at increased risk of osteoporosis? So these are the women we have concerns for. Um there's no evidence to suggest that regular dexa scanning is useful. And the F srh in their guidance has given four points of just sort of pragmatic advice which are firstly, the depo probably shouldn't be first line for teenagers. You should probably use it only if all the other options have been discussed and are unsuitable or unacceptable. Um Someone who's on the depo should have a proper review every two years, not just I have come from my injection, but an actual proper review about whether it's still the right contraceptive method for them. If there are significant lifestyle or medical risk factors for osteoporosis. Then think about another method. And generally speaking, women are advised to switch off the depo at 50. But as with anything, there are always some woman who for, for whatever reason would really struggle with using another method of contraception. And you know, using the principles of shared decision making a good um documentation. Sometimes you will consider longer, but certainly you should not be a woman, shouldn't just be carrying on the depo passed her 50th birthday without a really good conversation with a healthcare professional. So that's the depo and I would add that the subcutaneous depot can be given at home, which was useful during the pandemic and and ongoing. Either the woman can come in and the practice nurse can teach her how to do the first one. But also there are some very good videos on the manufacturer website and women can often just do the first one at home. So intra uterine devices. Um broadly speaking, there are two types, there's the copper intrauterine device and then there's the hormone intrauterine device, which is usually called the intrauterine system or I US. Um they work in various different ways. Um Reducing implantation is one way in which they work, but it's not the only one. Some women, particularly if they have a very religious background will not want to use a method that might stop a fertilized egg from implanting because they might feel that if you feel that life begins at fertilization then although um stopping a fertilized egg from implanting, certainly in the UK is legally contraception. Not some women may feel different about that. So you, you may have women who won't consider a call for that reason, but coils, coils, which is a slang word for intrauterine devices, they work in lots of other ways. So there is um opera has a direct toxic effect on the sperm and the egg as well as thickening the cervical mucus of sperms less likely to meet the egg. The intrauterine system has an effect on the endometrium. It thins it down. Um so that uh and and also reduces sperm penetration through the cervical mucus. So it works in a variety of ways. Most copper IUD s last for 10 years. Although there are some devices that last for five years, obviously a 10 year one is better, but some of the five year ones are smaller. So if you're having difficulty fitting a copper IUD, for any reason, you might try a smaller one which might not last as long. There's various intrauterine systems on the market which I've put there in the table which have different lengths of time. Um In the UK I, the new IUD guidance is about to come out and it's probably going to advise six years for the Mirena because it's actually exactly the same dose as the other brand leader, Cert, which has a six year license. So it's a bit of a nonsense that they don't have the same license, but it's not quite out yet. Um, but if you fit one close to the menopause and it can last for longer. So if you fit a 10 year copper IUD at any time over the age of 40 then that can stay to the menopause. And that might be up to the age of 55. So it might work 15 years. And if you have a 52 mg I US, that's the marina or the leader cert um inserted over the age of 45. Then that can state all the menopause. You've got to be careful and make sure you know what your woman is using her I US for it can be used a 52 mg. One can be used as the progesterone component of H R T. But if used for that, it has to be five years whenever it was fitted. So if a woman has one fitted at 45 for contraception and say at 48 she starts taking HRT and she's using it for HRT, then she has to have it changed at 50 even though it would be good for contraception right up until her menopause. That that's really important because we don't want to risk the safety by using them for too long as part of the progest, a genetic component of HRT. Um the I U S can also be used for heavy bleeding. And occasionally you'll have a woman who doesn't need contraception. Maybe she's not sexually active or she's been sterilized and isn't using HRT and is only using an eye us for heavy bleeding. And although the license remains the same pragmatically, if she's using it for heavy bleeding and it works and she's not getting bleeding, then she can, you know, she can use it for as long as she likes, as long as it's still working. Um, most people who work in family planning will have a record how long the longest IUD has been in that they have removed. Mine's 26 years. I had an elderly woman come into our clinic. And so I have to remember, I've still got this thing and I wonder if it should be taken out. Generally speaking, when you, when you find uh uh coils that have been in for a long time and have not been removed, they should be taken out if possible because um, there's, there, there is a risk that they could be a focus of infection. So these are some pictures you can see the eye us. Um That sort of white thing is a little reservoir of hormone which is released very locally and very slowly. And with the copper, you can see the copper banding around the arms of the, of the t of the coils. So this is what I talked to when someone comes in to have a coil fitted. I tell them about the failure rate, which is slightly higher than the implant, but lower than most other things. Um I tell them there's a risk of perforation. So what I usually say is everyone's uterus is a slightly different size in the way that we all have a different size, nose or different size hands. And in the part of the process of fitting, you use a little plastic stick to measure it, there's always a possibility of getting that wrong. And so, perforation is damage to the top of the uterus there. Um It usually heals obviously. So even when we identify it, we usually don't need to do much other than keeping an eye on the woman and maybe giving us some antibiotics. And it probably happens more often than we realize, much less common, maybe 10 fold, less common is damage to. What is the other side of that uterine wall, which is the bladder or the bowel? And obviously, that would need an operation to fix it, but it's uncommon perforation easing three sixfold if the woman is breastfeeding. So, um I would suggest that probably only experienced coil fitters should fit for a woman who is breastfeeding. Um mhm. There's a small risk of pelvic infection about half a percent in the 90 days after fittings. When I trained to fit coils, we used to do a chlamydia swab as routine and we wouldn't fit the coil if there, if the result wasn't back the guidance now is actually that's not necessary um to do a swab, you should only do it if the woman has a risk practice for sexually transmitted infections, for example, multiple partners or previous S T I S or being young. Um And, and if you do take one, you can take it at the time of fitting and wait for the result to come back. Um There is a risk of the coil falling out expulsion and this is quite high. It's about 5%. And it's most common in the first three months of insertions. So you can just see in these pictures, they don't show it very well that the string that there is a string attached to the coil and that is coming down outside the cervix. So when I fit a coil, I always teach the woman how to feel for the threads. I teach her to feel inside a bit like if she was putting a tampon in and I let her touch the bit of the threads that I've cut off. So she knows what they feel like and tell her that she must feel for them a few days after the coils being fitted. And then she should usually feel for them after her period each month. If she has a copper coil, if she has a hormone coil, then her periods may stop. Quite a lot of people get irregular bleeding for three or six months and then no bleeding at all with the hormone coil and that's fine. Um, but in which case, you should just feel for them once a month and if she can feel them and she can feel them and she can feel it. And suddenly one month she can't, then she needs to not rely on the device for contraception and she needs to come in so we can examine her. Sometimes the coil has just moved up a little bit and the the thread site in the cervical canal and sometimes we can just bring them down a bit to reassure ourselves that they're there or we can just do a scan to show that the coil is still there, but it can fall out. And so it's important that we know if a woman suddenly can't feel her thread, so we can check that it hasn't fallen out or indeed hasn't migrated through the uterine wall and is floating around somewhere in the abdomen. Um There is no need now for a regular check, six weeks after someone has a coil fitted, we used to do that, but it was mainly to check the thread. So if the woman is comfortable that she can check the threads at home, then that's fine. There is a bit of an urban myth that intrauterine devices increase the risk of an ectopic pregnancy. And if you look at that picture, you can see where that risk where that thought comes from because it seems logical that the device is stopping a pregnancy from implanting in the uterus. And therefore, where is it going to implant in the tube? But what we have to remember is because of all the other methods of action that I mentioned, the intrauterine device drastically reduces the total number of pregnancies, both intrau trimmed and ectopics. So the absolute number of ectopic pregnancies is much, much lower in a woman who has an intrauterine device compared to a woman who's not using one, what is increased is the proportion of pregnancies that are intrauterine. So, if a woman's implant fails, then there is a significant risk up to 50% in some studies that the pregnancy will be intrauterine. So if a woman comes in with a positive pregnancy test and she has an interview trying device insight you, then she very much needs an early urgent scan to check where that pregnancy is. If the pregnancy is interview trying and she wants to continue with it, then generally speaking, it's considered better practice to remove the device because although removing it does cause a risk of miscarriage, it's thought that it could cause more risks later on in the pregnancy, but that's not always done. And there are anecdotal stories of babies being born clutching the intrauterine device in their hand as they as they are delivered. So I'm going to move onto emergency contraception now, which is contraception that you take after you have had unprotected sex. Uh maybe because you were using condoms and one broke or you realized after you had sex that you'd forgotten your pill for a few days until you weren't protected or you just got carried away, didn't use anything at all. There's two methods broadly, speaking of emergency contraception tablet, and they're just generally one tablet that you take in one go and they work by delaying ovulation. And then there is the copper intrauterine device, which can be used as a emergency contraceptive method. Of course, it has the advantage that can then stay in and be used long term if they want if the woman wants it. Uh huh. The copper IUD is by far the most effective form of emergency contraception and we should be offering it to every single woman who comes for emergency contraception. I have to say I don't, I cannot remember a single woman who's ever accepted it. People tend to just want the pill because it's easier and obviously offering the copper IUD causes problems for us as healthcare professionals because we've got to have someone available to fit it at short notice, but you always should offer it if a woman says yeah, I'll have a copper IUD for my emergency contraception. That's great. But for whatever reason, you're not going to fit it there and then maybe you haven't got an appointment, she's going to come back that afternoon or she's going to come back tomorrow, then make sure that you also give her oral contraception at the point where she first comes because then if she changes her mind or you can't get the copper IUD in, at least you haven't missed the window opportunity to give the oral emergency contraception, oral emergency contraception only works up to the time of ovulation. So if the woman knows her cycle length, then you can work that out. And broadly speaking, ulipristal is more effective than leaving a gestural. So there are a few reasons to give leave in a gestural which I'll go into in a minute. But if I was giving orally, see, I would usually use Ulipristal as my first line. The other nice thing about the copper I U C D is it can be given up to 100 and 20 hours after unprotected sex or up to 100 and 20 hours after the earliest predicted date of ovulation. So if you think of a woman with a predictable 28 day cycle who's had unprotected sex on days 358, 10, 11 and 17 and is coming in to see you one day 18, she's probably ovulating on day 14. So you do just about have time to fit a copper coil which covers her for all those elements of unprotected sex. Whereas the oral E C only works up to 72 hours after unprotected, unprotected, unprotected sex for levonorgestrel or 100 and 20 hours for Yellow Crystal. So that is another advantage of the copper I U C D but people still don't want it. Um Both the oral contraceptives or emergency contraceptives can be used more than once in a cycle. So, reasons why you might use levonorgestrel instead of ulipristal might be because of interactions and I'll say a bit more in the, in the next slide or because a woman has severe asthma, which is managed with oral steroids, which is a relative contra indication to Blue Crystal. The levonorgestrel is less effective. If a woman weighs more than 70 kg or have a BM I more than 26. So that's not particularly overweight and not particularly heavy. So if you are using leaving a gestural in such a woman, then they need to take a double dose a few years ago. There was an alert sent out to all people who prescribe contraception about Ulipristal because it was discovered that if you give a progestin within five days of using Ulipristal, then the crystal, its use as an emergency contraceptive is less effective, it is more likely to fail. And this is something that we will regularly doing because we were regularly having someone come along for emergency contraception. Say, yeah, absolutely. Here's your emergency contraception. But what are you going to do from now on? Do you want the pill? Here's a packet of the pill started straightaway. Do you want an implant? Why don't you have your implant fitted now and take the emergency contraception the same day. So now if you're giving someone ulipristal and they want to start an ongoing method of contraception. If it's a hormonal method, they can't start it for five days. So by all means, give them the packet, it feels to take away, but they have to hang on for five days before they start it. If they want an implant, they have to come back in five days. There is a theoretical risk of reduction in effectiveness of the Ilo crystal. If a progesterone has been taken in the five days before taking Ulipristal. So the women, this effects are those who are taking it because they take the pill, but they've taken it irregular, you know, they keep forgetting pills, but maybe they've taken a couple in the last five days, they might want to think about using leaving a gestural or having a cockpit IUCD instead. And then if you have a woman for whom you think quick starting her long term contraception is really important because she's not going to come back or she's, you know, she's about to go traveling or something. Then again, you might want to think about using leaving a gestural so that you can then quick start something like the implant with all the caveats. We we talked about from quick starting last time about doing pregnancy tests and so on. So those would be reasons to use levonorgestrel. They both have reduced effectiveness with enzyme inducers. Um and the advice is strongly to push the copper coil that if a woman will not have a copper coil, then to use levonorgestrel as double dose. But we don't really know how effective that is. Um, if the woman vomits within three hours, she should retake it. To be honest, that is unusual. The fact that we still tell people that is a hangover back to the days when we used a very high dose combined pill for emergency contraception, it often did make women throw up. But if she does her up with three hours, she needs to take it again. Um Similar thing with ectopic pregnancies as to as to with the coil, the overall number of pregnancies is greatly reduced and therefore the overall number of ectopic pregnancies is greatly reduced. But if it does fail than the proportion of ectopics is probably higher than for other pregnancies. So I usually advise women that if they, if it does fail, um they need to come in for an early scan and particularly if they have any pelvic pain, they need to come in urgently, the next period might be delayed, it might be light. And obviously what you think is a light period might actually be something like an implantation bleed. So if the next period is in any way unusual, then the woman should have a very low threshold for doing your pregnancy test. And there is no evidence of an excess number of fetal abnormalities if a woman uses emergency contraception and it fails and then she decides to continue with the pregnancy. Um It's important how you frame these words because the overall risk of fetal abnormalities is about 2 to 3% changes with the women's age. So there will be some women who took emergency contraception, it failed. And then they have a baby with a cleft lip or some other abnormality and they think it's their fault because of taking the emergency contraception, but it almost certainly would have happened anyway. So societal considerations, I was talking earlier about women who have sort of religious concerns and so on. And in the UK, as I said, the prevention of implantation of a fertilized egg is very much considered to be contraception, not terminations. So you can reassure a woman about that. But obviously she may have her, her own ideas based on her religion and we all know what's happening in the States with the sort of dismantling of women's rights over their own fertility. Um In the UK, the emergency contraceptive pill is available over the countess. You can buy it from a chemist without a prescription. Um is quite expensive. It's about 30 lbs because that includes a fee to the chemist because they have to make a bit of an assessment about whether it's appropriate, sorry to the pharmacist. Um And the, the concern is that it's an opportunity lost because whenever I give out the emergency pill. I'm talking about long term contraception. I'm offering them an implant or do they want the pill? Do they want the copper foil? That, that might be lost opportunity? So it's probably useful for some people. And in some areas there are schemes where those aged under 25 can get it free over the counter, but I don't think it's ever going to be replacing um giving it by doctors prescribing by doctors. And the other question is, should women, if they don't use a reliable method of contraception, maybe if they use condoms, should they have some at home just in case? Because with the pills, as I said, they're leaving a gesture works up to 72 hours after unprotected sex and all oppressed up to 120 hours. But certainly the earlier they're, they're taken the better and people sometimes do call them the morning after pill because if you take them the morning after, that's much better, we don't routinely give them out in advance of need, but it might be considered particularly in certain situations, like if you're traveling to a remote area where you're unlikely to be able to get to a doctor any time quickly. So, contraception after childbirth um is largely the same as contraception at any other time in that you need to take a careful history of the woman's medical condition and smoke and all that sort of thing. Um And, and um, and make your decisions based on that. But there are a few things to think about. It is ideal if contraception could be discussed in the antenatal period while the woman is pregnant, because there's a risk of pregnancy from 21 days postnatally. And I don't know if anyone in the audience has kids, but, you know, at 21 days, you can't think straight, you're exhausted, you haven't slept, you saw your baby's crying all the time. You know, you're not really in the greatest position to make decisions. So, if you've already thought about before, that's helpful. The entry drawing device can be inserted within two days of delivery and that includes at delivery. So it can be inserted immediately after a vaginal delivery and it can be inserted direct under direct visualization at a Cesarean section. And it, for those women, for whom that is offered, it, the studies done so far has shown that it's quite, um it's quite well accepted and, and, and they are kept for quite a long time and that goes for the copper coil and the entry you trying coil, that's where the entry trying system. Um So that's something worth thinking about. And, you know, when you're you qualified and running services and so on, if you work in obstetrics to think, you know, do we routinely offer this to women? But we know that the immediate post partum uterus is much more friable, much more fragile than the uterus. The rest of the time as it's sort of contracting back to normal, particularly if the woman's breast feeding. So if someone wants an injury, you try and device and they have not had it by 48 hours after having the baby, then they should wait for four weeks, 28 days because the risk of perforation is considered to be too high to fit it in that intervening period. All other progesterone only methods can be started pretty much straight away although you don't need contraception for the 1st 21 days. Um And the combined pill or patch can be used from six weeks um after delivery. Um It is the other reason why it's important to have these discussion's is an inter pregnancy into full of less than 12 months, is associated with prematurity and low birth weight. And in my experience, working in a deprived area, women who are having a baby after baby with less than 12 months between them often coming back to their post natal check pregnant again. Um They always have the most control the most agency over their bodies over their fertility and so on. Sometimes there are quite significant cultural pressures to have more babies in a short period of time than the woman herself may really want. So it's worth discussing anti Nikolay and and having the ability if you can to fit things like implants at the post natal check. Postnatal checks are traditionally done at six weeks, but there is definitely an argument that we should be doing them at three weeks. So we're not leaving women unprotected for a period of time. So another method which is relevant to women who have just had a baby is the lactation amenorrhea method. So, there's a lot of urban myths around about breastfeeding and pregnancy. Lots of women think I can't get pregnant women breastfeeding and that is not true as a statement itself. That is not true, lactation, amenorrhea, amenorrhea method has three criteria. So if you want to rely on the fact that your breast feeding to provide you with contraception, then your baby has to be less than six months old. You have to not have had any sort of bleeding come back. So you have to be a Minarik and you have to be fully or nearly fully breastfeeding. So that means day and night. No, not having a gap of more than four hours during the day or six hours at night. And, and the baby has to be having almost nothing else other than your breast milk. A little bit of different liquids or vitamins or something is fine. But, but basically breast milk has to be the main thing. And even if you do all of that, the failure rate is still around 2%. And if you compare that, you know, sort of 0.2 or 0.8% for the various intrauterine devices and point not 5% for the implant's a woman even who does meet all these criteria, she might well want to have a better method of contraception. That's absolutely reasonable. Um And as I said before, contraception, most of it can be used while breastfeeding progesterone, any contraception generally at any time and combined hormonal contraception. Um it's usually started six weeks, postnatal e sterilization. Um Women and men often think that sterilization is the best method and this sort of almost this view that um you know that you cannot get pregnant after you've been sterilized. But of course, it has a failure rate like anything else. And female sterilization has a failure rate of 0.5%. So that's 10 times higher than the implant. Um Mail, vasectomy has a failure rate, a lower failure rate of 0.15%. It's also a much smaller operation. So I do always talk to a woman who's coming to be wanting to be sterilized about whether her partner might want to be sterilized as well. It must be considered to be permanent. This is really important in many healthcare systems. Reversal of sterilization is not funded. Um And so usually the consent should involve a proper probing about whether the person has completed their family. And you know, if the worst happened and you know, the whole family went under a bus or something, would they still want to be sterilized? Um Women sometimes find that they get heavier periods after they've been sterilized. And sometimes that may be, um, not actually correct that the operation has caused that it may be that they were on something like the pill which made their periods artificially light. Um And, and then they're normal periods have come back. But even for women who that isn't the case, there is some suggestion that possibly in the normal run of things, you get some retrograde flow of menstrual blood out of the fallopian tubes. And if you put a clip on them, that can't happen, so the periods can get heavier. There is obviously the risk of surgery. Um there was a hysteroscopic sterilization device um but that had lots of problems as massive lawsuits. So that's not really used anymore. So it's a laparoscopy and obviously, with any laproscopy, there is a risk of general anesthetic, a risk, all the risks of surgery, bleeding, infection, so on. And the risk that for whatever reason, the surgeon might have to convert to a laparotomy, as I say, there's a failure rate. There is a small, small risk of chronic post vasectomy pain about maybe about 2 to 3% that men would be counseled about if they want to go for a vasectomy. And if you do have a vasectomy, then you would be asked to send samples for a semen analysis for several months afterwards. And it's only usually when there's been two in a row that show absolutely no semen no sperm in no sperm that that the, it will be deemed to be safe to rely on it. So I'm going to just run through a couple of case studies. So I'm unhappy if people want to shout out ideal just to think about it. So Emma is 15 and she's made an appointment to see you and she sits down and says I want to go on the pill. So if anyone wants to shout out, I don't think I can see hands up because because I'm sharing my screen. But if anyone wants to run Mutant, say what they're thinking. Um Yeah, I can't, can't see that assad. Yes, ma'am. I was thinking of course, we asked a question of pretty much the first one was like that. She's having a perfection line is pregnant all of a sudden unexpectedly first we need to know why. Yeah. Absolutely. I couldn't hear most of that, but I could hear you. You need to know why she wants to go on the pill. Absolutely. So is she so yeah, anything else I could repeat? I was saying is she unexpectedly pregnant or she's like having the language sexual life in that manner? Yeah. Absolutely. So, is she having sex already or is she wanting to start having sex? Some teenagers are very responsible there in a relationship, they're starting to think about having sex. They come in advance that others might have got carried away and have sex anyway. And you know, might be at risk of pregnancy already. Absolutely. Um, so yeah, I would definitely want to know. So I would be aware that she's 15. So I would be wanting to think about all the safeguarding issues that I talked about before. Um, has she had sex already? Is there any possibility of pregnancy? Does she need emergency contraception? And what are her priority? So, does she really want the pill or would she be better with something like an implant that you can just fit? And then she can forget about, I'd want to know about her medical and social and family history. If I was giving the pill, I'd be interested to know. Where does she live? Does she live with? Mum? Does mom know that she's wanting to be sexually active? Can she tell mom that she's using contraception? Because if she can do that, then she won't need to hide it. It's much less likely that she fails. And I would be thinking about whether I can quick start something today and then final case study. So Mina has come to see you. She's 24. She normally uses condoms, which isn't great because they've got quite high failure rate anyway. But she had unprotected sex 48 hours ago on day 15 of her cycle and she uses an app to track her cycle and knows that it's a pretty regular 28 day cycle. So, is there anything else you'd want to know what might be her options. Okay. I won't put anyone on the spot so she is likely already post off. Oh, sorry. Go on assad. Uh Yes. Again you would just ask like, uh, uh, no, no, I, I don't have anything. We just ask any other protection. She should, uh, before coming to the clinic that she took a pill or something, she would tell everything if she, she wouldn't have. No. Yeah. No. Has she used anything? Definitely. But she hasn't. So, um, so she is day 15, she said of unprotected sex a day 15 of a 28 day cycle. And so she's probably already ovulated, which hugely narrows her options. I'd want to know about other unprotected sex she'd had, I might want to think about risk of S T I S and so on. Um, but post ovulation, as I said, the effectiveness of the pills is much reduced. So, really a copper coil is probably her only viable option. And I would very strongly recommend a woman in this situation did have a copper coil as, um, as her emergency contraception, which she could then keep afterwards if she wanted often in reality. What happens is the woman goes, oh God, no, I don't want to coil. That's really horrible. Um, and you end up giving them the pill, the emergency contraceptive pill anyway, because you never know they might be having a slightly longer cycle than usual. They might not have ovulated and you kind of give it as it's better than nothing, but you have to sort of counsel that there's a higher risk failure. So that's what I've got to say. We've got a few more minutes left. So I'm happy to answer questions if anyone has any done dual into silence. Thank you. Okay. All right. Well, I will leave you to it, please, as being said, do give feedback because it's really useful for future talks and thank you very much for coming.