Computer generated transcript

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

So, uh, my name's upon A, I'm a G P in North London. Um, I can see from the chat the most of you are sort of in your later years of medical school, I assume, unfortunately, don't know much about how medical school in Ukraine is run. So I'm not sure if I'm assuming it's a five or six year degree, same as it is over here. Um, we're going to cover emergency contraception today. It's very happy to take questions as and when. So I, if you want to put on the chat, I might not see them, but I think if we can keep an eye or, or I'll look at them at the end and we can, we can go through any questions, then I have got some questions for you in here. So up to you, how you want to do that? I'm absolutely happy for you to amuse yourselves and just answer the question or if you want to put it in the, in the chat, that's absolutely fine as well. Um, just, uh, let me just put the slight show on. So, uh, so we're covering emergency contraception. Uh I think we'll just briefly go through what we're going to cover on the topic today. So we're going to go over what it is and when you need it, what the types of available emergency contraception are with the caveat to that, how we think they work. We don't know for all of them, how effective they are. But A P period math, which is necessary for any kind of contraception and then look at some of the reasons why when you can't use it or when you shouldn't use it and alternatives available, I will do some cases at the end. So yet, like I said, any questions, just message in the chattel, amuse yourself. Sometimes I talk too fast. I have been told that said if I'm going to quickly, then just tell me I'll slow down. Um So just to start with what is emergency contraception and when, when do you need it. So the most kind of straightforward answer to that question is emergency. Contraception is a treatment of some kind to stop you, stop a woman getting pregnant when she doesn't want to. And in most cases that would be because she's had either consent or non consensual penetrative vaginal sex within the current menstrual cycle without a condom or any other form of contraception. There are a few other instances when we think about emergency contraception and if anyone has any thoughts, if you want to shout them out, sticking the chat, when else might you need emergency contraception. Is it like a mist pill? Yeah, MS Pill? That's a good one. So, Miss Pill, depending on the pill can be quite complicated. It depends on which pill you've missed and how many you've missed and which week you've missed them in. But yes, absolutely. That's one of them. Anything else we'll go through them. So, don't, don't worry. Um, so the other things, a few extra ones here. So Miss Pills comes under contraception failure. So you were using some kind of contraception, but it's not worked for any reason. So that could be MS pills like we've talked about. It could be because the condom broke, it could because your IUD fell out. There's lots of different possibilities with that. The other one to think about, especially with the kind of the oral contraceptives, the things you're taking the tablet is that you can get medication interactions with them. So the most common one, that kind of textbook one is Saint John's Wort. And that's the one that comes up in exam questions. But there are a few other ones. So specifically thinking about HIV positive patient's some of the retrovirals they can be on, can interfere with their, with their contraceptives. A couple of anti epilepsy meds can do it and we don't really use it, but I am sorry, revamp assim, which is quite unusual antibiotics for us in the UK. Um It affects liver enzymes. So it's kind of all people 50 system, medications can also affect the effectiveness of your contraception. The other one to think about, which is kind of the more common one that often comes in and the patient's don't think about is sort of young women presenting with food poisoning or a gastrointestinal bug that come in and say actually, I've been having diarrhea for a week or, or five days or whatever, if you are taking an oil contraceptive and have diarrhea, vomiting within sort of three hours of taking that tablet, you think of that tablet is not being effective. So if you've had a week of diarrhea and vomiting, you can have lost a week of pill there. So, and if you've had sex kind of recently in that time, then you might need to think about emergency contraception. Just a note note about pregnancy. So in the post, a kind of delivery period, if you have had a live birth, if you had, if you've given birth to a child, then you need emergency contraception from day 21 after delivery onwards, that a supplies for cesarean sections or natural general delivery. Now for emergency contraception in other circumstances. So if you had a, a terminations in a miscarriage or there's been sort of an ectopic pregnancy which has been surgically corrected, that they need emergency contraception for five days. So if anyone's having sex in that period, after 21 days, post delivery or five days, post, the other things I need to think about it if there's no other, other forms of contraception involved. Um So questions that we ask in um when we're trying to establish what emergency contraception to use and whether it's appropriate or not, these are quite personal questions. Quite a lot of patient's when you first um kind of come across it and talking to them sometimes get a little bit offended because you're asking things that to them don't necessarily seem sorry relevant to the to the situation because a lot of people, especially because in some countries, you can end in the UK as well, you can go to, you can buy it over the counter so you can go to a pharmacy into any emergency contraception. Um and, and the different kind of the laws about how much information you need an ounce and things like that change depending on country. So people, especially from Americans have it a lot because they just buy it from the pharmacy. Get confused as to why we need all this information. But hopefully, as we go through the lecture today, it'll make it'll make sense as to why we need that. And it's mainly because a lot of people take emergency contraception, you know, window realizing it won't be effective or take the wrong kind when the a different one would have been effective just to go through the questions briefly. We need to know when did they have sex? When was the unprotected episode? Sex and, and to be clear, we need to know a little bit in detail about what kind of sex it was. So people, there's differing levels of education around kind of how people get pregnant and what sex constitutes. It's worth just making sure that what they think is a risk is actually a risk. Um And the timing of matters a lot because the licenses for different emergency contraceptions change depending on a number of hours since, since the episode. Um I need to know if there's been other episodes of um printed six since their last period. So that one is specifically looking at, is there a chance they could already be pregnant? Um And it again affects which type of emergency contraception you would recommend if they've had previous emergency contraception use in this cycle. It's not a problem, but it will change what you offer them. And it might mean that you suggest something else as opposed to what they previously used. Um And it might make you think actually when, when you think a little bit harder about, do you need to ongoing contraception in this case? Because we've now had multiple uses emergency contraception in one month, um they have, they use any contraception, this cycle, especially hormonal will come back to why that's important. We need to know when their last period was. This one's coming back to this kind of risk of pregnancy again, if there last period was two months ago that we should be thinking about pregnancy before we think about emergency contraception. Um, we also need to know what the normal length of their menstrual cycle is that will come into the period math that will go into an obit. How much the patient weighs, can affect the dose that you're using. Um, and any other medical problems or medications coming back to the kind of, if there were an anti epileptic medications that might affect what you're suggesting and what they are able to use as emergency contraception. Um, just back to the pregnancy test aspect of it, the oral types of emergency contraception to the tablet forms, the ones that are licensed in the U K, I'm just gonna specify that are not known to have any dangers. If the patient's already pregnant, there's no necessary risk to the foetus if you give emergency contraception and it's, it's kind of too late and they already got pregnant. It won't work, obviously because they're already pregnant and the ones that are licensed, the UK are not an abortive agent. So the, the two tablets that we can give here if, if, if they want some people get confused and think they can use it as a determination, but it's not, that's not how it works. Um The earliest a pregnancy test can be positive as three weeks post the operative sexual intercourse that led to the pregnancy because we need to wait for the beta HCG hormone levels to reach a point where it can be detectable on the pregnancy test. Now, that's relevant because there is a failure rate for emergency contraception. And some of that is because people don't realize that just because they tested negative doesn't mean they're not pregnant. Um The, if there's a question mark in that area, the the problem is the IUD. So the will come and talk about it a bit more detail. But one of the forms of contraception as the emergency contraception can't be used if there's a chance of pregnancy because you're interrupting a kind of a pregnancy and then that would come have a bit of an issue under the UK law because for UK law, you can use it as emergency contraception where you're preventing it leading up to the fertilization. So you're trying to interfere the process is leading to fertilization. Anything after that, especially after implementation, then counts as a termination and that comes under different laws. Um The times to think about 20 tests, multiple episodes of perhaps sex in the current cycle or if they've missed a period. So those are 22 big ones to think about any questions at that point or I'll just keep keep going. I think we're okay. Thank you, Peppard. Um So just a side note, my next lecture is going to be on S T I S and SDI histories. Um But the population of people coming in asking for emergency contraception has an overlap with the population of people that need ST I screening. So not everyone that comes in and says they need a motive conception will necessarily need ST I screening. They might already be up to date. They might have, be with a regular partner that they've both been screened, but they just missed some pills or had, had some other issues. But the, but there will be population there where it's, it's a good time to think about it and just ask, do you need some ST I screening at the same time? It's important to note that it won't probably done the same appointment because often with emergency contraception, you're dealing with sort of within the next sort of three or four days after the episode. Whereas the committee and gonorrhea tests, the earliest the swabs can come back positive is about two weeks. If they're symptomatic, it's earlier. But, but generally for asymptomatic patient's. Um, and there's different windows for testing for HIV hepatitis syphilis and kind of other things which will go up through in my following election a couple of weeks time about S T I S. Um, but that's just a thing to think about whenever someone comes in for emergency contraception. Um This is just a note about the fact that I'm aware that most of you kind of are Ukrainian medical schools and the UK in the UK emergency contraception is one of the few things where we tend to use brand names to discuss them as opposed to, they're, they're kind of biochemical names. The names are different in different countries. So it's just a different branding that's available. So I had a quick look and sort of when I say L1, the equivalent in the Ukraine is something called Alyssa. When I say Lebon, L, the equivalent will be S Kapil. There's a very helpful website called the European Consortium of Emergency Contraception where I got this off, which has a breakdown of the available emergency contraception by countries in Europe. So it kind of goes through a bit more about the actually has the prices of the different tablets and the different brand names per per country. So I think that's quite useful just to be aware of um the website mentions um Mifepristone and the use per method which are available in lots of countries. So for example, the use the method is used in um the U S as well. We don't use it. I'll just explain what is the US pay method is a method where you kind of double dose on your combined oral contraceptive pill twice, two hours apart. So you're just, it's still the progression dose you're trying to increase. But what you're doing is using it using your normal pills as a form of contraception. We don't use it in the UK for the last couple of years because they found that Levan LRS couple. So they live in a gestural tablet has been shown to be just much more effective in all studies across the board. And because we have it easily available, we've sort of stopped using the take two of your own tablets. There is tables if you look up the use pay methods. So if there's ever shortage issues, you can't get a hold of um the kind of tablets that were used to prescribing. There are tables which tell you by brand name, how many of your normal combined contraceptive pills to take as two separate doses to be used as emergency contraception. So I won't go through them but you can find them online. And Mister Kristen uh as emergency contraception is apparently available still in Ukraine, but we don't use it in the UK. It just, it wasn't thought of something. It's not licensed for emergency contraception. It is licensed as a early term abortive. So we do use it for sort of early medical terminations but not as emergency contraception and period math. So this is the better it is across the way. Um You can't use emergency contraception in the entirety of your cycle. Technically, you could give it, but it's not going to be effective at a certain point. So the way the emergency contraception works will affect when in the cycle it can be used. So just if you look at the diagram across on this side, I've put at the top where you kind of how long you can use them for. So we think of the big gray line down the middle is when you ovulate and that fought an average would be calculated as the average cycle length for the woman. So normally would say 28 but it can be 30 can be 35 whatever it is minus 14, taking off two weeks. And that is the point where we're thinking is the estimated ovulation date. So that will vary by woman. And that's why it's so important to understand. When was the last period and when, how long are there periods in general? How long is the normal cycle length? Now, the other thing to think about is people who have things like Polycystic Ovarian syndrome might not know. So they might not have any ideas when they're um previous period was and they might not. Sorry. Hello. Did someone say something? No? Okay. No worries. Um So they might not know how long they're recycling cause it can be very variable. And there are different rules for how you treat people who we think of as a moderate. So people who either aren't having regular periods or not having periods at all, we'll talk about that a bit later. Um So coming back to the ovulation date, if we're saying our relation is when the egg is released. Once the egg is released, oral contraceptives, oral emergency, contraceptions will not have any effect. They both work by preventing or delaying the release of an egg. So, even if you buy a tablet and you're sort of day 1920 of your cycle, if the egg is already out, it's not doing anything in those circumstances. The copper IUD may still have a role and we'll talk about why that is in a bit. Um, but just to, just to keep, keep this graph in your head, um, as to kind of when they are useful and graduation. Huh? Oh, so he's after that. So breaking it down to the individual ones available. So if we talk about Leather Nell first, so Lebon L is a tablet which contains 1500 mg of levonorgestrel. So it's a progesterone tablet. We don't actually understand how it works. We have, they have some ideas but there's kind of not a clear answer as to why it works, how it works. We just know it does work. We think it works by kind of a mimic a progesterone and delaying ovulation in the UK. It's currently licensed for up to 72 hours. So three days post the episode of operated sex. It's best thinking of it as 72 hours because obviously you need to do the math. So three days is a bit more iffy as to how you're calculating that. Now, the evidence kind of the research suggests is actually effective up to 96 hours, but the license currently for us doesn't, doesn't hold with that. But I think if you were kind of desperate, you don't have anything else available and you just need to do something that you could give it realistically if you give it afterwards, you're just kind of wasting a tablet, but it's not going to cause any harm to the woman. Um There are a few circumstances in which you might need to increase the dose of Lebanon that you're giving. So specifically, if someone is because A B M I of 26 always over 70 kg, Lebanon is thought to be less effective. And so you give a 3 mg dose rather than a 1500 microgram dose, just just doubling that. It's worth just, just taking a moment to think about that because 20 BM I 26 is not that uncommon kind of in my day to day population and a weight of 70 especially if you're tall is not, is not that high. So it's not, it's harder to kind of tell by just looking at someone if they're going to fit in that category. So it is worth checking with the woman how much they weigh or weighing them if they're if they're in the room with you just to make sure that you don't double dose it because it would be a shame if you kind of gave them a single dose and I need a double dose and then, and that resulted resulted in pregnancy and you can offer both, both of the tablets can be offered multiple times in one cycle. But like I mentioned before, if you are giving it multiple times, it's worth thinking, what else could we be doing? Because, because all forms of emergency contraception should be used as kind of the last resort or as an as and when you need it, ideally, you want them to be on some kind of long term regular contraception that will provide them with cover to reduce their having to come back with appointments repeatedly and risk of emergency contraception failing is it's kind of higher if you're not on regular contraception, um the we'll come back to why not five days after other one in a second. So with Levon L1 of the advantages of it is it's a tablet, you just take it once it's job done and you can start ongoing contraception immediately afterwards. You can have that conversation about what other form of contraception they would like going on words if they need that. Um and then, and then kind of start it next day. The other form of oral emergency contraception is Ella one is another brand name. So it's contains Ulipristal acetate and 30 mg dose. It's a mouthful this next book, but officially, it's a synthetic selective progesterone receptor modulator with a partial progesterone antagonist effect with high affinity for the progesterone receptor. Um in kind of more useful terms, what it does is they think it inhibits the LH surge. So we go back a couple of sides. Do we think here as uh this, this green line here is the LH surge which proceeds ovulation. It affects the progesterone levels to prevent this surge happening and thereby um stops uh the, the egg being released. Now, the thing that's important about this here is you look at this graph here, I've put Leaven L. Levon L is only effective up until the point where the LH surge begins. As soon as the elect splurge starts to begin, you kind of levels kind of lost its hopes, it stopped, it stopped being effective. L1, however, is useful up until the point in which the LH surgery reaches its peak. So you get a couple of extra days on L1, the never nell where it might be effective. So it's worth just remembering that uh generally the advantages of Ella one are the, it's licensed for up to five days or 100 and 20 hours. The sooner you take it, the more effective it is even compared to time for time. So if you were taking it at three days, this is taking 11 L at three days. Ello one has been shown to be more effective, not more than the copper IUD which will come to. But, but I it's thought of as first line oral contraception in the UK because it is more effective than 11 L. But there are more circumstances in which you can't use L1. So that's why 11 L comes into play. One of those is if you've had progesterone in, in the five days after or theoretically, but we're not sure in the seven days before you use L1, it could inactivate the effects of it. So because of the way low one works because it's interfering with the, the progesterone receptor. If they've already had protection in the system, it just, it's not going to help, it's not going to work. So the disadvantage there is that if they're already on a regular form of contraception, say they're on the combined pill. If they are then wanted to continue with that because they've had a few missed doses. They don't want to do that. They either have to have a five day gap after taking the emergency contraception in which time there again not covered. So they would need an additional form during, during that time or we need to switch something else or they just need to kind of take level. Now, similarly, we think if, if, for example, they've been on, they've been on progesterone or a combined pill, they missed a few days. But if they've had it within the last seven days, Ello, 1 may be less effective. So it might be worth thinking about Levon L in that situation. And the other one is that in um in vitro in animal studies, they've shown that Ulipristal acetate has a affinity for the glucocorticoid receptors. So that we don't use it in patients who have severe asthma who are requiring oral steroids. This is a theory that they could make their asthma worse by interfering with the receptors that would normally be treated would normally be binding by a peninsulem. So that's, that's just one other caveat to that. You can offer it multiple signs. But this is where the kind of the progesterone recently comes in. Because Levon Elysa progest A Gyn, if you've had Levon L in the cycle, you ideally don't give L1 in the seven days following that because otherwise the L1 might be ineffective. Similarly, if you've had L A one initially and then they come back and they've had another episode three days later. 100 sex don't give Levon L because you're then inactivating the yellow one again by giving Levon L. You gotta, ideally, if you're gonna give it repeatedly, try and stick to the same one twice. Um as I mentioned before because of, because of the way it works and then because of the projection kind of interference, you need to wait five days to start a contraception containing projection, which is quite a lot of them. So it's a combined pill is the, the protection only pill. It's the patch. It's the NuvaRing, it's the implant. It's the, it's basically all of them side effects. Not a lot. The most common side effects. People complain about headache, tummy, pain, feeling nauseous. Um and the most forms of contraception will affect what your period does next round. So, because of the way it's working, because it's delaying of relation, it's kind of causing a shift in your system. It can mean your periods earlier, come in your periods later. It sometimes means your period is more painful. The following one, the the importance of here is that it's not always possible to tell whether something is a period or if it's an implantation bleed, especially people who have lighter periods. So I always recommend everyone who has emergency contraception, do a pregnancy test at three weeks post just to make sure that kind of it's worked. Um If you vomit and this is relevant, that one of the main side effects is nausea. If you vomit within two hours of Lebon L or three hours of L1, you think of that as, as ineffective. So at that stage, you need to tell people if they vomit within those timeframes, they need to come back, either they'll have another dose depending on kind of how soon they vomited or they may need the copper IUD as an as an alternative. So just moving on to the to the copper IUD, um which is the most effective form of emergency contraception that's available kind of in the UK. It is the gold standard ideally, but it does have its own issues. So how does it work? We think the copper IUD works by causing kind of a local toxic reaction. So it affects the motility um of sperm and the viability of over from a direct countries. The copper having a having a toxic effect. If fertilization does occur, it does also have a inflammatory effect upon the endometrium layer. So we think it also prevents implantation just from a local information. So it's kind of a two pronged effect in the capacity as emergency contraception. We're really thinking of it as the inhibiting fertilization because that's what the legal definition definition is. But with the copper IUD, you can leave it in. So once you've um inserted it, you can state depending on the brand, it can stay in for five or 10 years as a form of ongoing long acting contraception. So that's that's handy if someone needs something ongoing. Now, the advantages of the copper IUD is it has a much larger time frame in which you can use it than the oral tablets. So we're just gonna go through this bit bit slower. So it's quite a bit to wrap your head around. So there's two different ways of defining when you can use the copper IUD. So if you've had one episode of unprotected sex in this cycle, all your episodes of unprotected sex in this cycle have been within the last five days, then you can use it up to five ways post the first episode. So I just say that again in a different way. One episode in a cycle or all the episodes within the last five days can use, um can have the copper IUD inserted until the kind of fifth day from the first episode. Or if you have had multiple episodes, kind of not in the last five days or it's been more than five days since the episode, one period, sex. You can still insert it up to five days, post the estimated date of ovulation and you would do whichever is later with the caveat that if there's a chance they could be pregnant, you can't then um then use the second one. So I just go back to the diagram before I think it's easier to look at this way. Do you think up here of the copper IUD say you're having uprooted sex on the on day four, you're fine to insert it up until day nine. But if they've missed that window, that's fine because if they only had one episode of on credit sex, you can go up to five days post um ovulation. So that were coming up sort of day 19 there. So this is a bigger, much bigger window of where it can work. And that's partly because of the mechanism. So because we think it stops both fertilization and implantation, you've got a much longer window. So we think of sperm as being viable for about five days in the vaginal tracks. So fertilization will occur within that five day window. But implantation won't occur for a while later. So if you're having kind of the most fertile window for anyone is the six days leading up population. So if you think of this bracket, just because of how long sperm is viable for. After this, it will still take some time for the fertilization to the medium plantation. So that's when the the secondary effect of the copper IUD comes in helpful. However, if someone's had sex on the fourth and the fifth and the sixth, that will limit your window to only being um uh being sort of five days. It depends a bit on timings. Uh It's just, it's a little bit more complicated with the copper. I do, you need to do some maths with that to make sure that you're not missing a pregnancy. That makes sense. I feel like that was cases will help. Um like I said, is the most effective option. The disadvantages of it are not, everyone can insert. It's, you need to be able to need to be somewhere with a clinician who can put the copper IUD in. So what they normally recommended the UK is if someone comes into you, for example, in a G P surgery and says I would like a copy of I D because you because you may not get inside it there and then you can refer them on to a service which will build it, insert it. But to also give them one of the two forms of oral uh emergency contraception the same time. So just in case something falls through, just in case they aren't able to get it done for any reason, there's no downside to giving them an oral form of emergency contraception and then having the copper IUD because this does not work in a hormone away. There was no hormones involved here. It's not gonna interfere with the action of either of the other two and respect respectively. The other two won't interfere with the copper IUD. Um It's in cases of sort of drug drug interactions as if someone says actually might have been on some weird antibiotics live cause my constructive pill to fail, you will want to use the copper IUD. The L1 gets inactivated by anything that's N diamond ends I'm inducing. So you can't use that. And, and Levon L theoretically, they suggest that you could try a double dose of it, but we don't Axion if that works or not. There's very limited kind of evidence in a very limited data set around that. We're just not done enough of it to, to know if that works. It's just kind of a, we think it might work downside of the copper A D and why it tends to be not as acceptable to patient's a lot of people come in and really don't want to go down that route is because you have to have it put in. It's not the most pleasant thing in the world, especially if you've not had Children. So, your cervix hasn't, hasn't been opened. Um, and it will tend to give people heavier, more painful periods. So anyone that's coming in and who already has dysmenorrhea, menorrhagia may not be the best option for them. In some circumstances. In the past, I have had to refer people to have the copper IUD even when they have had really heavy periods because the other two options just wouldn't have been effective. And the risk of kind of them getting pregnant and that to them personally was much worse than having the copper IUD put in having it left for a certain period of time and then having it taken out again. So it's not a, it's not a permanent thing. You can, you can take it out after a month if you want to. Um just what the rest of the copper IUD, like I mentioned, it's not the most comfortable thing to have put in. You can use local anesthetic or other painkillers nowadays, um, you can expel any form of IUD. So it tends to be a higher risk of expulsion if you, if you're in the window near delivery or in the first couple of months after having it put in women who have not had Children, have a higher risk of expelling it. Women who have very high heavy periods have a higher risk of expelling it. Displacement is uh an issue from two respects of, from when you're having it put in. Generally, you want to have threads visible. So you're putting the, the y shaped copper IUD in and they still have about an inch of threads visible. But beyond the Cervix, patient's are supposed to check their threads once a month and they say after your cycle every month, you should use your fingers to check your threads are still in situ the vast majority of patients I think I've met maybe three patient's ever who regularly check that their threads are so often. People come and say things like, oh my other half can't feel the threads anymore or I actually decided to go feeling it and I can't feel the threads and you don't know how long that's been the case for. And now that could be that the IUD has moved up further into the womb, which is fine. It's still effective in that sense. But you can't confirm that without an ultrasound. Now that could be that the IUD has been expelled. So you end up having to use the sort of emergency contraception in those circumstances. Sometimes when you don't know if the emergency contraception is where it's supposed to be. Um the other one is a risk of infections. So twofold. So when you're having this pro put in, uh it can risk introducing infections if you already have something like chlamydia and gonorrhea, that can increase your risk of things like pelvic inflammatory disease. If someone is positive for the committee of honoree and you know it and they need this as a medical conception, you don't delay using it, you just give them antibiotic cover with it. At the same time. The other side of this is that there are some studies that suggest the rates of recurrent thrush are higher for people who have IUD S in. So that may be something the longer term that becomes an issue. There's a risk of perforation when you're putting it in that there is also a very small risk of perforation from displacement later, the risk is highest in the first year. It's a very small risk, but it is still something to tell patients about and they need to be aware of. And then there is a risk of as a higher risk of ectopic pregnancy with the copper IUD in. But this is slightly complicated because you're not at increased risk of a ectopic pregnancy to baseline. So if you compare a population of women who are on no forms of contraception, their risk of ectopic pregnancy is higher simply because the chances of getting pregnant with the copper IUD in are not high. So you're, you're much less likely to get pregnant in the first place is just that if you were to get pregnant, then it's a higher risk of an ectopic pregnancy. So, still safer than no contraception, but less safe than some other forms of contraception. Just a few extra notes, things that I may not have mentioned elsewhere. No method is 100% effective. The copper IUD is the most effective one. It's something like no 10.1%. Um a pregnancy risk following insertion within the correct time window. But people can take things wrong. They can have nausea, vomiting, tell everyone just do a bunch of tests at three weeks to be certain. It's best to find out these things earlier. So you can start, we're going to do about it. Um So just just tell everyone to do that. Um Some, there are situations where no method is suitable if we just quickly go back to the this diagram. If you are, if you are, you're very unlikely to get pregnant if you have sex within the first three days of your, of your cycle. So the likelihood in this window is incredibly rare, you would still give you much of a conception just because there is a small chance, but it's incredibly rare. Now, if you're in this window, if you've kind of past ovulation and you're past the point of being able to put in a copper IUD, there's not a lot that we can do. So that because this ovulation date is very much a guess. We've, they've done comparative studies where they've compared ultrasound scans. And um so biochemical results were LH levels to this method of estimating it. And it's not the best. It's not, it's not 100%. We, it's a guide but it's pretty hidden miss. So this might be here even though the math says it's here. And if that is the case, then as you can then see, yeah, kind of the window is actually later than we think is. So there will be cases where it's, you can't, you can't put these in. But actually it's gonna, gonna solve a problem, which is why even if someone comes in this phase, generally I tell them L1 and Levon L isn't gonna work for them, but there's no real negative to giving it to them because you could just be preventing pregnancy that's occurring later than you expect it to the other times. Think about things like when people come in and they're on sort of multiple medications that interact and they don't want the copper IUD you getting a bit of a come puzzle with that, but it's, it is what it is. Um, or all the mostly conception acts retroactively. So it's covering you for the previous unprotected sexual intercourse. It's not going to cover you for future ones. It's important to tell people they need to use a condom or something else for the next episode because sometimes people think I've had my emergency contraception, like if I have sex today, then it'll be fine. That's not how it works. It's retroactive unless you're using the copper IUD. Uh note about pregnancy again, the copper IUD is, you can't put it in between 48 hours, post delivery to 28 hours, 28 days, post delivery because it's an increased risk of it being expelled or perforating the womb. So that in that window. So if you think about it as post delivery from day 21 onwards, you need emergency contraception, but you can't use the copper IUD into take IUD until day 28 because that's seven day period where you have to use one of the oral oral options. Um And similarly, if breastfeeding, uh this is true for all uh IUD insertions. So even if you're using it for normal contraception, there's a higher risk of perforation with any form of, are you D or R US uh normally for the first couple of months and then it gradually decreases down to the point of a year you need, if you're using elo one in this circumstance, they need to pump for a week and discard because L1 is secreted in breastmilk. Levan. L we think it's fine. We don't have any data suggest that it's excreted in best breast milk. We don't have any data suggests any problems or any risks that increased with both breast breeding. So that's, that might be one to think about that. Um What time is, be on. So we're on, it's about quarter to, that's fine. I've got about a couple of cases, feel free to either shout out what you think or, or stick it in the chat. We'll just go through them quickly. I put some times in a calendar so you can do the math from there. So you've got Amber. She's 27 years old. She's coming to see you in a GP clinic. Her appointment is at 10 AM on the sixth of February, which I've highlighted in blue because when I wrote this slide, um and she had unprotected sex middle of the previous nights. So midnight the previous night, sort of six um midnight of the sixth. So I'm saying she's 10 hours post her unprotected sex day. One of her current cycle was the 25th of January. So over here, just to be clear, I'm sure you guys are all fine with this, but patient's often get confused the day one of your cycle is the first day of your bleeding. Patient's often think day one is the first day of the bleeding stopping. So they do the math slightly differently. So I just need to be clear when you're asking them, when was your the first day of your last bleed as the question that you're looking for? Rather than I think sometimes cycle can be confusing. Um She has an average cycle length of 30 days. That's the information she's giving you off the bat. What else? What else do we need to know? And then she used any other contraceptions? Yes. Perfect. Perfect. Yeah. So that will affect what we can give her. So, if she's already on a combined oral contraceptive pill and we might not be thinking L1 Wells, if she's on any other medications. So she's on anti convulsants or stuff like that. There'll be interactions and taking morning after. Perfect. So, what's the history, is she on any other tablets at the moment? I mean, I think one of the questions I often ask is, do they have a type of uh most conception in mind already? Because a lot of people will come in and go. Oh no, no, I absolutely don't want the, the copper IUD, which is the one that people tend to tend to not want. So then they then you know which way you're heading with that. So if we just do some maths, what day of her cycle is she on? You can't as well. She's on day 12. So assuming that she's got nothing else in her history that complicates the situation. What would you be offering her as first line Lebon? Oh, why? Tell me you're thinking uh because it's before the day of ovulation. So yeah, so yes, you can offer 11 L. So in this situation, I would say L1 might be a better option. Level is absolutely fine. Officially assuming she doesn't say no to it. The copper IUD would be the first line offering because she's prior to ovulation, but it's still the most effective methods. That's what you'd say first. She might say no to that. And the reason I would say L A one in this situation over Levin L is because she's day 12. Um So assuming 30 day cycle, we would assume that ovulation occurs day um 16. So because she's in the five days leading up to the ovulation, any date that but if we go back to that chart that we heard him to look, so you go back to here. If we think that she's, she's kind of in the five days pre ovulation, the chances of Levon L working just slightly lower than L1. If she started the LH surge already, then L1 will be more effective. So generally think if they're five days pre pre ovulation, ideal yellow one, but Lebanon would probably work as well. We just, we just don't know in that window. But yeah. So I think with this one, any, any of the options you're doing an oral, ideally L1. Sorry, that's my dog barking a squirrel. Um So with the leaven L, would you do it if example is not data a bit a bit sooner. So I think if it's sooner than that absolutely fine to use either one. So you could just, you could do either one or Levon L in that situation, the leaven L you would be better in a sense because with Levon L, you could then immediately start her on some kind of other contraceptive if you could give her a projection only pill or a combined or contraceptive pill to start the next day. So she's covered for any future episodes. Um, was with the one you got that delay period. So she was dig sort of earlier than 11, 11. Oh, absolutely. Fine. Sorry. Can I ask a really out of order? Like, really weird question because I work in pharmacy, um qualified in pharmacy and stuff and we've never like come across this. It's like you either if she's three days into sexual intercourse or before three days prior sexual intercourse, you give her levonorgestrel and then if it's five days, you give her the one that we've never really asked these or find out where and how ovulation cycle is. So does it mean that, I mean, yeah, you always tell them to take a pregnancy test, 2 to 3 weeks, post taking the pill? Does it mean that there would be a higher failure rate? Is that? Yeah, so, so I used to, so I'm a G P now, but I used to work on sexual health clinic. And one of the most common things we have is when you go to pharmacy and you can get asked for emergency perception, they're not your, I mean, it's just the way different training works. They don't explain the maths behind it. So often people end up with the wrong kind of emergency contraception when they go to a pharmacy and I've seen that happen repeatedly where people have come in and said, oh, they're coming from ST ice cream, for example, because they had the, um, period sex two weeks later. And they told me this and then we have done the maths. They've had the wrong type because the problem, the most common problem I see tends to be that they were given L1 11 L and it was post the estimated date of ovulation. And that is the most common problem. I see and they weren't necessarily told that actually is not gonna be effective because we think you've probably already ovulated because no one's done that math. Does that make sense? Yeah, thank you. So would it be more, would it be wise? I'm going back into practice like if you were in a community pharmacy? So if I was still working there like to just kind of promote L1 or just or doing the maths and working out? Because how would I mean, taking that time out, I guess? Right or? Yeah. So I would honestly, I mean, the options are ideally do the maths because it might be the yellow one doesn't work either. So it might be that the only option in this window is the copper IUD in which case you can send it to sexual health school. And I can say just, just go walk into any sexual health clinic and wherever you are. And I mean, most of them have phone numbers that you can ring for emergency appointments and, and that's, but you can still give them L1 at the same time. The, the ideal, if you're going to give either L1 11, L normally I tend to prefer L1 if I can't find a contra indication just because L1 has that extra couple of days where even if you've kind of done the maths a bit wrong or, or something's gone wrong because you can get it in just off the LH LH surgeon, it still be effective. And because Leila one is more effective up to kind of 100 and 20 hours and it's more effective at the same time window as Levon L L 01 is just better. It's just ideally the math needs to be done because otherwise you might be giving them something that is kind of pointless. Thank you so much. Um Just, is that all the questions I have to take other questions if, if there's more because I know we're running low on time. You can look at the cases later if you want us, that's actually fine. Any questions? No, we're good. We'll do, we'll do Betty then I think we've got enough time for Betty. Oh no, I've gone off. So Betty is 23. She, her appointment is two pm at them the same day because I couldn't be bothered changing the calendar. She's had operated sex three times over the last two days. She's got Polycystic Ovarian syndrome. So she hasn't had a bleed in 42 days and she doesn't know how long her cycle is because it varies every month. What else do we need to know about her? Ignore my dog thoughts. Wow. I just go through it cause I haven't got much time. So if we think we should do the maths here, so she has had three episodes of prevent sex in the last um two days. So we say over the weekend she's had 300 sex. We don't know what date is we is. We don't know if she ovulated. We don't know when she ovulated. Um So because of that, we cut the all ones may not be effective. They might be. But we don't know. So realistically for her, we would want to be giving her the copper IUD. She's fine to have the copper IUD even though we don't, even though we don't know if she's ovulated already because all of the episodes were in the last two days. So she falls in the, within five days of first episode window, even if she doesn't fall into the five days post ovulation window. So that for her ideally copper IUD if you can't put it in cause you're in a pharmacy, give her L1 just in case and tell her to go to uh to uh someone to have it put in if this would be more complicated, if she said that she had three episodes of unprotected sex in the last two days and another episode sort of 30 days ago because then you're wondering if you're pregnant because then you're not sure. In that case, you can't do not copper IUD. So in that case, you'd kind of be saying do a pregnancy test now have an L1 and then do another pregnancy test in three weeks time because we can't, we can't put in a copper IUD if you could be pregnant, um we'll just whip through the last one as well. So Caramel is a, forgot what age of her. She's 32. She, her appointment's at four PM on the same day having a lot of emergency contraception appointments this day, she had sexual intercourse on the third of February at 10 PM. So that's three days ago. She missed, sorry, she missed two doses of her combined oral contraceptive pill on the 4th and 5th. So she had sex on the third and then didn't take the pills over the weekend. She wants to get pregnant in six months time. The I just, I'll just say it because I was the things I wanted to highlight in this case where the fact that she's Timewise were the maths of the time. Um So we've done. So four PM is 16 hours in that day and then we've got the previous day, which is 24 hours, which is what, 40 hours and then 10 PM. Uh So you've got two days of 48 plus 16 is when the mask gets me. 64 plus two is so she's 68 hours. So she's fine for either, either type of pill. Um But what she's what we do need to know is does she actually need emergency contraception? So she's only missed two pills. If this was in her second or third week or she's back to backing packs of the contraceptive, she won't need extra cover. She's still protected for up to seven days in the 2nd, 3rd weeks or if she's back to backing, she's in the third week and she's missed this many pills. She shouldn't take the gap. She just, she should just continue with the combined contraceptive pill. Um straightaway after finishing this pack so that she doesn't have a elongated gap if we say she doesn't get to say she's in the first week of starting the combined contraceptive bill. So say she does need motive contraception. The, the ideal here would again be the copper IUD because that's first lyme, they're planning to get pregnant in six months. I've just put that there to make to kind of profess the point that even if you have the copper IUD put in, you can get it taken out, doesn't have to stay in for five years and there's no delay to fertility. So she, even if she wants to get pregnant in six months, she can still have the copper IUD have it taken out in five months time and then immediately twice getting pregnant. That's absolutely fun. Um With her, you could theoretically give either of the two pills because she's in the time window still with Ella one. However, she can't restart that contraceptive pill for five days. So then she, she's being left unprotected with Levon L, which would be a better option here because she could then immediately start taking her, her combined contraceptive pill as normal from today. Um I'll stop there because we're running quite close to time. Any final questions that I'm happy for you to email me or whatever afterwards. If you think of something, anything else with the IUD, um Is it, can you, can that be taken out after a month then or is it when the patient wants or is that a joint decision? Yes. So you can be taken out after a month often. I'm asking in that case, why the answer is usually because my last period was horrific. Uh And that's covered known side effect. You want to wait until the next bleed to take it out and you can't take it out if they've had unfriended sex within the last seven days. So tell them if they think they're going to have it out soon that in the week prior when you want it out, use Condors or something else to take a pill or something. Just so that otherwise if they've got sperm sitting in the vaginal tract from three nights before taking it out, take the copper IUD out and, because there's no residual effect, but there's the directly acting agent, they could immediately get pregnant. There's no, we don't definitely know that they wouldn't ovulate and then get pregnant straightaway. So, the only caveat taking out after a month is use something else for a week prior to taking out. Uh huh. Yeah. Anything else? Nope, we're good. Hannah. Anything from your in writing to do. Um, there's nothing in the chat. So if no one's got any more questions, um, grand. Ok. Well, in that case, have a nice day and I hope the less rest of your lectures go. Well, I'm doing one on sexually transmitted infections in a couple of weeks, so I might see some of you for that otherwise. Good luck with everything. Thank you. Thank you very much. Um, and we do have a few minutes. Um, if you haven't done the feedback here, everyone. Um, so please do complete the feedback form and then I'll post the certificate in the chat.