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Okay. Hi, everyone. Um, just slide up. So hopefully you can see those. My name is Tony Hazel. Um I'm a G P O. Can you, can you see the slides? I'll take it that you can unless I hear otherwise I'm a GP in London with a particular interest in women's health and I'm doing two sessions on contraception sort of basics. One today, I think the next one is in a couple of weeks. Um So today I'm going to talk about quite a sort of general things to think about when you're prescribing contraception. And I'm going to talk about combined hormonal contraception and progesterone only pills. And then next time I'll cover the long acting methods, things like the implant and the interview, trying device and emergency contraception. Thanks for that question. I can certainly, um, certainly talk about that as we go along. Um And I'm more than happy people up to ask questions as you go along. But I, because of how screen sharing, I can't see everyone so I can't sort of see hands up. So I do feel free to just um mute and just shout out if you've got a question Um Can I just sorry to interrupt? Can I just suggest that rather than shouting out people put up their hands? So we don't have people talking over each other? Okay. The only thing is I can't see hands because of how I've got the thing up. But maybe if you put it in the chat because I can see when something new comes into that. So put a question in the chat and then I'll sort of pause when appropriate um to answer it. Um So this is what I do and therefore my sort of declarations of interest. So things to think about when someone comes and asks you for contraception. Um Does the women and I'm going to talk about women wanting contraception, but obviously, sometimes it's a discussion between women and their partners. So I'm sort of using shorthand. Sometimes women are for women and their partners. Um There will also be trans men. So people who are born, female, identify as male, who still have female genitalia and are still at risk of pregnancy. So I'm including them in their this group. Although things are often more complicated for them because of the hormones that they're taking so on. So a woman might want a regular form of contraception. Basically, all medical forms of contraception have to be taken regularly apart from the emergency contraception, which is taken after unprotected sex or you might want just something like condoms, which she can use as needed she might value that. Um, but if a woman does want to use just condoms, she needs to be aware that they have a fairly high failure rate. She might want something that's long acting like the implant or the coil we could just put in and forget about. Or she might want something that she has to deal with every day or every week or like a pill or a patch or every 12 weeks. Like an injection, she might feel more in control of a method like that, that she can stop without having permission from a doctor or other healthcare professions to stop. She might value the side benefits of hormones such as making her periods lighter or she might want something that's non hormonal. She might have come to you for emergency contraception and she might have another gynecological condition like endometriosis or heavy periods. And she's looking for a contraceptive method that can improve that if someone comes to you and says I've just come to go on the pill, then it's always worth just exploring what the woman means by that. She might mean that she's looked at contraception in great detail. She's gone online. She's researched all the options and she knows that the pill is the best thing for her, which is absolutely fine with the even with the push to long acting methods, plenty of women use the pill and like it. But often I find that women come in who come in and say, I'd like to go on the pill. They're using the words the pill as a sort of shorthand for some form of contraception. And actually, if you take them through the whole range of things that are available, it may well be that something more reliable, like the implant or something else will suit them better. So just always double check what the woman means if she comes in and says, I'd like to go on the pill. Is her opening gambits. What is important to her is reliability. The most important thing is it the effect on her periods? Um Is it reversibility and be able to reverse something under her control? So a woman taking the pill can just choose to stop it any day and just stop it by themselves. If one's got an implant in her arm, she needs a doctor or nurse or other health care professional to take it out, that's not under control. And maybe some time until she can get an appointment for that to happen. Convenience means different things to different people. So for some women, convenience means something you can put in and forget about. For other women. Convenience means that reversibility and that being in control. And as I said, she may or may not want hormones. Um put here what's important to her periods, regular, none or light. And I would quite early on in your contraception consultation. Find out what a woman feels about amenorrhea, not having a period. Quite a lot of contraceptive methods can stop your periods. The combined pill can, if taken back to back the progesterone only pill can. The implant can and some of the hormone containing intrauterine devices can. Um, most women I think go yay fantastic periods and nothing but a nuisance that great if they can stop. But I do have a subset of women registered with me, often of a particular cultural ethnic background who get very freaked out by the idea that their periods are going to stop. And I'll talk about it a little bit more in some of the myths. So it's worth being aware of that because if your patient is adamant that she wants to have a regular period that does cut down her contraception two options. And you may as well know about that early on because then you can tailor the things that you offer her. If someone is asking for contraception, then by definition they are or want to be sexually active. And it's always worth taking a sexual history. Who is she having sex with? How many people is she having sex with over a three month or a year period? Does she use condoms as well? Does she have any risk factors for chlamydia? Does she need to particularly be advised to use condoms? So if I see someone that is under 25 I would always advise them to use condoms because that age group has the highest rates of chlamydia. And does she need an HIV test? It's estimated in the UK, that maybe six or 7% of those with HIV are under diagnosed and probably one of the most lifesaving things that you can do actually as a doctor is to pick up someone's HIV, that they didn't know about because that means they can get onto antiretroviral therapy, they can live a normal or near normal length of life and of course, they won't pass it on to someone else. So that's a massively important thing always to think about. And is she up to date with her smear tests? Every country has different regimes for cervical screening. I don't know how, how it's done in Ukraine in the UK, we test for HPV human papilloma virus first because we know that that causes the vast majority of cervical cancers and only if the HPV is positive. Do we look at the, um, do we look at the cells um standard or equal period of three years and that's get short and different woman has an abnormal smear or if they have HPV found on the test, but it's always worth just double checking. So, um basics of how to prevent pregnancy, I'm not going, you, you will know how, you know how babies are made. Broadly speaking, for things need to happen. The woman needs to ovulate, there needs to be sperm in the upper genital tract, the egg and the sperm lee to meet and the egg needs to implant and contraceptive methods can interfere at any of these points. So, the methods I'm going to talk about today, specifically, the combined hormonal contraception and the progesterone only pill um largely act by preventing ovulation. Um but they also thickens the cervical mucus. So that means the sperm is less likely to get into your, less likely to have sperm in the upper genital track and they thin, thin down the endometrium, the lining of the uterus. So that causes problems with implantation. So that, so they act at more than one of these, of these points. Broadly speaking, 85% of women who are having regular unprotected sex will get pregnant in a year. But obviously that that changes hugely with younger women being more fertile than older women. Sperm can live in the female genital tract for five days, but the egg only survives for about 36 hours. So that's important for someone who is wanting to get pregnant to know if they're thinking about trying to time having sex around the time of ovulation. And it's also useful knowledge of those who are not wanting to get pregnant. And fertility usually returns within three weeks after giving birth much sooner after a miscarriage or terminations. So it's really important that contraception is discussed and certainly in the UK, now we're now moving to discussing contraception antenatal when the woman is pregnant because you know, when she's just given birth, she's saw and exhausted and has a baby to deal with and has plenty of other things on her mind. So you're hopefully all familiar with this diagram of the menstrual cycle, which shows the peak of luteinizing hormone and FSH roughly mid cycle which and, and then the ovulation trigger. And you can see at the bottom the changes in the thickness of the endometrium. It's worth remembering that the luteal phase is fixed at 14 days. So someone who has a 21 day cycle won't ovulate halfway through at day 10, which is what you might logically think she will ovulated day seven because the luteal phase is fixed at two weeks. And therefore, there is actually no such thing as a day in the month where you can 100% reliably have sex and not get pregnant. Um And the, the myth that you can't get pregnant when you have your period. Yes, obviously, it's much less likely. But if you think if someone has a very short cycle, maybe 18 days, luteal phase is 14 days, she might be ovulating at day four or five. And if sperm can hang around for five days in the genital tract, there might be no time in the cycle where she can safely have sex. So if we're thinking about effectiveness of contraception, which is, you know, a key thing that women are, are interested in. This is called the Trussell table and this data has been around for years and you can see that there's two columns. So there's perfect use, which is sort of how effective things are in trials. And then there's typical use, which is how effective they are in real life. So if you look say at the implant, the progest a GYN only implant, which is in the fifth row because that is put in and forgotten about the effectiveness is the same in real life as in perfect use. And it is the most effective contraception we have with a 0.5% failure rate. So that's one pregnancy for every 2000 women who use it for a year. If you look at the combined pill, the perfect use failure rate is not 0.3% but the real life failure rate is 9%. That's massive. So 100 women who use the pill for a year, there'll be nine pregnancies. Now, obviously, it is not the case that every woman has a 9% failure risk with the pill. Someone who is a good pill taker, maybe they have to take pills regularly for another medical problem. They don't have to hide the pills. They can keep them somewhere where they'll remember like they can keep next to their toothbrush or something. They probably got a much lower risk, a teenager who lives with mom and has to hide the fact that she's taking her pills is probably going to have a Haider failure at higher failure. Because if she's got to hide the pills as much, she's much more likely to forget them. And therefore you might want to guide her towards a longer acting method. So women often come in and say, what's the best contraception or occasionally go further and say, what do you use? Um If they're seeing a female doctor, I don't think there is any such thing as the best contraception method. It's the best contraception method for that person, which is often the case. You know, there's no such thing as the best school for, for, for Children. It's the best school for the right child. That's and it's the same the best contraception method for that woman. So it's important to get back across that. It's a sort of decision you want to make together with your patient. Ideally using the sort of principles of shared decision making and trying to help her come to the right decision. But a table like this can be useful because it gives you general ideas. So you can see that fertility awareness methods have a very high failure rate of 24%. That's um things like looking at your temperature, looking your cycle mucus, looking at what time it is in your cycle. Um Honda MZs have a very high failure rate again around 25%. As does the diaphragm and as does the withdrawal method. So those are not great methods. Interestingly. Um female sterilization has a failure rate of 0.5%. So, 200 women who are sterilized and have sex for a year, uh One of those women will get pregnant and that is, I think um higher um than, than some people, than some people think. Um looks good. Right. That, that is higher than some people think. Um And so, um when people come for, come for uh come wanting to be sterilized, then it's important to um to try and understand. What do they, what do they, what do they mean? What do they expect to get from, from their sterilization? Sorry, I'm having a problem with the slides. There we go. Um What do they expect to get from their sterilization? And what sort of um what sort of um effectiveness are they expecting? Because they might be surprised to know that the, the effectiveness of other methods such as the implant is often less, is often more than sterilization. I'm just going to stop sharing and re share for a second because I've lost the Knost the screen for me in a second. Okay. Right. Hopefully you can still see that okay. Um Right. So safety um safety is really important for any contraceptive method. And this is the, this is the UK MEC 2016, which is the gold standard guidelines in the UK. Um It stands for UK medical eligibility criteria. There is a W H O version, World Health Organization version as well, which has slightly different thresholds for sale, that things are not safe, that they're contraindicated. And that is because the risks and benefits of contraceptive methods need to be taken against, against the risks of pregnancy. So if, if you are in a country, for example, where you don't have access to good obstetric care and the risk of pregnancy are significantly more, then you might be prepared to take a bit more of a risk with your contraception because it's more important that you don't get pregnant. The UK make uses four categories. 123 and four. So one is absolutely fine. No problem. So for example, for the combined pill, that might be a young slim nonsmoking person who doesn't have any medical problems, four is an absolute contra indication. So for the combined pill, that might be a previous history of a venous thromboembolism, a blood clot in your legs or your lungs because we know that the pill increases that and two and three are when you need to use your judgment. So two is a contra indication but on balance the benefits probably outweigh the risks and three is a contra indication, but on balance the risks probably outweigh the benefits. Now, um those of you who have Children who went to school will have taught them that two plus two equals four. This is the only time in your life where two plus two does not equal for because to UK Mec twos does not make up before. If a person has to relative contra indications that both come under the category of two, that doesn't mean an absolute contra indication. But it means you need to stop and think and you need to talk to the woman and what the faculty for sexual and reproductive health who wrote this document say is that if there are multiple twos, particularly if they all relate to the same risk, then you might want to think about another method. If another method is better and they talk about a woman who has um A B M I of 30 for is a current smoker has a history of superficial venous, thrombosis has a first degree relative who had a venous from embolism at the age of 50. All of those are UK make twos. So if I have that, we're seeing that woman, I'd probably you came excuse for combined hormonal contraception that has estrogen and progesterone in it. So if I was seeing that woman, I would probably want to encourage her to use someone else because she's got so many relative contraindications. And I put the link there of the UK MEC if any of you want to have a look at it and this is just a screenshot. So you can see roughly how it works. This is the personal characteristics section for combined hormonal contraception. So you can see that if someone comes to you and they tell you that they smoke and you're not sure if that's a risk, you can clearly look at this and you can see that if they're a smoker age under 35 that's a too, so that might be okay. But if they're a smoker aged over 35 then it's at least a three or a four. So you'd probably be thinking against prescribing combined hormonal contraception. You can also see that when someone stopped smoking it takes a year for their, for them to drop back to being a too. So you know, you get people coming. Oh yeah, I spoke for 10 years. I stopped. Now. When did you stop last week? That doesn't count as stopping for the purposes of um of risk of contraception of, of combined hormonal contraception. You can see here that there's, you know, clear guidance for other things like weight and um Pope being postpartum with your breast feeding and things like that. There are certainly more contra indications for estrogen containing methods than progesterone only ones. So there is a big group of women who cannot use estrogen because of a family history or because of obesity or because they have migraine with aura um and things that broadly speaking, um we worry about risk of venous thromboembolism, risk of arterial disease and risk of recurrence of breast cancer. And generally speaking, if you've had breast cancer in the past, that is at very least a three and usually and often or four and, and I would certainly not prescribe a hormonal method of contraception to a woman who's had breast cancer without a proper discussion in writing with her oncologist. Um and, and seeing what their opinion is. So we talked about thinking more broadly when you're prescribing contraception, we've talked about thinking about uh sexually transmitted infections, but it's also really important to think about safeguarding. Now, I'm aware that this is a global audience and laws vary from country to country. So in the UK, the so called age of consent is 16, which is when it's legal to have sex. But in reality, we're not going to go around prosecuting every 15 year old girl who's having sex with her 15 year old boyfriend who's in the same class at school because the police have other things to do with their time. Um However, in the U K, you cannot give consent for sex under the age of 13. So if you find a 12 year old who's having sex, that is statutory rape, even if she thinks she's consented. And certainly I would have a very low threshold for involving social services. If a 13 year old is having sex, the older the child gets and the less other concerning factors there are there than the less likely I would be to involve social services. But it is something that you need to think about if a child is having sex and you know, they're in a healthy relationship and, and, and so on then it is undoubtedly in their best interest to be able to access contraception. And certainly the legal framework in this country allows for this without a doctor being at risk of being prosecuted, for breaking the law, anything like that. Again, this is the framework that we use in the UK. So it may not be relevant legally wise in other countries. But I think it's quite a useful way to think about things. Um It's called Gillick competence after a lady Mrs Gillick who took doctors to court's to do with contraception for her daughters. And, and Lord Fraser was the judge in the case. That's where the name comes. And these are five useful principles to think about and maybe to document in the notes. So can the young person be prepared to tell their parents or carers that they're having sex to get some support? And I would, and I would widen that actually if they can't tell their parents and they may have very valid reasons not to. Is there an older sister? Is there a cousin? Is there an aunt? Is there a trusted adult friend who they could tell? Does a young person understand the advice you're giving is their physical or mental health or both likely to suffer unless they receive the advice of treatment that they're seeking. And I think we can probably all agree that a teenage pregnancy will damage a teenager's physical and all mental health over and above having contraception. Is it in their best interest to receive the treatment? And are they likely to continue having sex with or without contraceptive treatment? And I don't know how many of you have teenagers at home, but it seems very unlikely that a teenager who's having sex with her boyfriend or wanting to, if the doctor deny some contraception she's going to go. Oh, yeah. You're absolutely right. I'll wait till I'm married. Um, you know, mostly they are going to go on and have sex and therefore it is in their best interest to have contraception. Why does safeguarding principles to think about? So, it's not just the age, if you think about, say a 15 year old girl having sex with her 15 year old boyfriend who is in her same class at school and then you think about maybe a 15 year old girl having sex with a 17 or 18 year old boy who's a few years ahead of her at school. You're starting to think that, you know, that may be, the dynamic is just slightly different. Doesn't necessarily mean there's a safeguarding issue, but you certainly think about it. And then if you think about that same 15 year old girl who's having sex with a 30 year old man, you're going to get, you're going to be much more concerned. And then maybe that 30 year old man is her teacher in a position of power is this really going to ring alarm bells? So you've got to think about the whole situation and these are just a load of things to consider alcohol, drugs, coercion. Obviously, these days, we have to think about online grooming. Um You can never promise absolute confidentiality really to anyone because there are always situations in which we might have to break confidentiality. Think of the person with uncontrolled epilepsy who refuses to stop driving, for example, and particularly for under sixteens. Um You know, if you think there are safeguarding issues, you may have no choice but to break confidentiality. But the form of words I tend to use is something along the lines of, you know, you have a right to secrecy and to confidentiality within your medical consultation. And I will not and cannot tell anyone what you say to me and what I say back to you unless I think that you also want an else is in really serious danger or risk of harm. And, and people will usually understand that um always get a proper interpreter. If you and the patient don't speak the same language, don't let the partner or a parent interpret. I always see teenagers on their own. Um If mom has come with the teenage girls get contraception, that's great. That's fantastic that the girl has got that sort of support and I will see them together. And then I'll say to mum, you know, just as a matter of principle. I always see teenagers on their own. Would you mind having a seat in the waiting room and then I directly say to a teenager, is there anything you want to tell me that you don't feel you can say in front of your mom? And then, and then I'll get the, um, back in when appropriate and think about safeguarding in remote consultations. If you're consult, consulting on video or by phone, you don't know who else is in that room. And if you are concerned, if it's making your antennae twitch, then have a low threshold for bringing the patient in face to face. So we talked quite a bit now about sort of teenagers who need contraception. And then of course, there's a group of women at the other end of their reproductive life who need contraception in their menopausal years. Um So broadly speaking, everyone can stop contraception at the age of 55. So the F Srh Guidance says that it's exceptionally unlikely to get pregnant after the age of 55 even if you're still having regular um regular periods because ovulation is so unlikely. Although the occasional woman who is still having a regular period, if they want to carry and using contraception, that's, that's absolutely up to them. Um The menopause is defined as 12 months since the last period. And so if a woman is over 50 and she's having normal regular periods, then once they stop and they have stopped for a year, she can stop using contraception. If her last period is under the age of 50 then she can stop two years after a last period. And the reason for saying you need contraception for for that longer time is obviously, firstly, the last period is a retrospective diagnosis. You don't know that that was the last period until normal have happened after that. And also just because in that perimenopausal period, you can have the odd spontaneous ovulation. So if you said, you know, once you've gone three months without a period, say you can stop, then, then there would be a risk of pregnancy. Women who have a very young menopause under the age of 40 should usually usually use contraception for a bit longer. Um It is slightly trickier for women whose periods are affected by their contraception. So, so if you have a contraceptive method that stops your period, that doesn't mean you're infertile if you stop that contraceptive method. But obviously, it means that you can't use the date of your last period to judge when you can stop using contraception. So what these women can do is they can either just keep using contraception to the age of 55 or they can do an FSH follicle stimulating hormone test at the age of 50. If that is in the menopausal range, which usually for our labs is above 30 then um you can take that as effectively like the date of the last period. And then the woman can just use contraception for one more year and then stop. It's important to remember that hormone replacement therapy for the menopause is not in itself contraceptive. So some women will be using HRT and a means of contraception at the same time. And generally speaking, over the age of 50 combined hormonal contraceptions contra indicated and the depo injection is not, is not generally recommended. And of course, when we're prescribing contraception in these women, we've got to think about the fact that in your forties, obesity is more likely and risks of things like blood clots and cardiovascular disease are going up. So being 40 is a UK MET two for combined hormonal contraception just on its own. So if you've got someone who say has obesity and that might author be a, you came back to then already you've got two contraindications. If there are any more, then you might need to think about moving her to a different method. So, um we always typically used to stay start the pill on the first day of your pregnant of your period. But the problem is if you're seeing a woman quite early in her cycle and you say here's some pills starting on the first day of your next period, you might be leaving her unprotected for a few weeks and she might not come back because her next period might not come because she might get pregnant in the meantime. So there's increasing interest in this concept of quick starting. So there are clearly some situations in which it's mid cycle, but you can be reasonably certain that the woman is not pregnant. So she hasn't had sex since her last period, for example, um, or she's had a terminations, she hasn't had sex since then. She's within the first five days of a normal period because it is extremely unlikely to get pregnant in that time. Although, as I said before, you have to caveat that for women who have very short cycles. So if you, if you can reasonably exclude pregnancy, using this criteria, then you can start a method at any time. There will be some women who for whom you can't reasonably exclude pregnancy. Um, but you can't diagnose it either. So let's say you've got a woman who had multiple episodes of unprotected sex in the first half of her cycle and now she stayed 21 of a 28 day cycle. It's too early for a pregnancy test because they only become positive when the period is late, but she might be pregnant and she wants some contraception. It is reasonable and it is backed by guidelines to still quick start most methods of contraception in that situation. As long as the woman understands that you cannot exclude a pregnancy and you are starting on that basis. And it's really important that she needs to do a pregnancy test, at least three weeks after her last episode of unprotected um sex, you can never guarantee that any child is going to be born without abnormalities. But for the vast majority of um of contraceptive methods, all the data we have suggests that if you inadvertently take the pill for a bit in early pregnancy and then you stop and you continue with the pregnancy, this doesn't confer any increased risk of a congenital abnormality. But you have to explain this woman quite carefully because there is a background risk of about 2% of congenital abnormalities. And if a woman takes the pill for a couple of weeks and then finds she's pregnant, keeps the baby and then it turns out to have a cleft lip or something. You don't want her to feel guilty that she has caused that the depo is less suitable for quick starting in that situation just because it's an injection. It last three months, you can't take it out and hills containing cyproterone, which is an anti androgen should not be quick started because they are an anti androgen. So they can feminize a male fetus. Um The oops are one the wrong way, right? So myth busting. So I'm just going to give you a second. Two of these seven are true and the other five are false. So I'm just going to give you a second to read about them and try and think in your mind, I won't ask people which you think are true and which you think our fault. These are common, common things that women discuss with us. I'm going to move on now. So those two are true, you can get pregnant the first time you have sex and a breast feeding, women can get pregnant before she has her first period to have protection for pregnancy. Um from breastfeeding, you have to be in the first six months, you have to be fully breastfeeding day and night and you have to be a man a rig. So someone who is mixed feeding, her period might not have come back, but she cannot rely on her breast feeding for her period. I talked a little bit about women who are not happy with their periods stopping. And so the first one is a myth that if you, if you don't have a period every month, this is unnatural and you won't be able to get pregnant in the future. If you think about women in the Victorian Times, um they probably spent most of their reproductive lives pregnant or breastfeeding. So they would have had many less periods than us. Um And so it's a modern thing to have a lots of periods during, during a reproductive life. If you don't have a period, the blood does not build up inside and make you fat. This is another common urban myth. The methods that stay stop the periods generally do so by thinning down the lining of the womb so that the just the blood isn't there. Um Someone asked about Polycystic Ovarian syndrome. It does affect fertility, but it doesn't completely stop, doesn't completely reduce the risk of fertility to zero. So it is important that women with pcs who don't want to be pregnant still use contraception. The pill does not make you gain weight. Um And for those who are using condoms, this is quite persistent urban myths. It, it's a good idea to use to. That's a really bad idea because they rub against each other and could cause holes in them. So now I'm just going to talk about a couple of specific methods and then I will come back to the questions that we've had. So combined hormonal contraception, you've got pills, you've got a patch which you don't stick on the palm of your hand. That's just to show how big it is. And you've got the vaginal ring, which is newer and I think much less commonly used. Um So it prevents ovulation. It thickens the cervical mucus and thins. The endometrium is fully reversible. And under the women's control, the women's control, which makes it popular. It was obviously the first uh contraception method available. When contraception first became available in the 19 sixties, it was the combined pill. It's usually pretty well tolerated. Actually, I find that most women just stick with the first round of pill. I give them sometimes you can get side effects. So headaches tend to be a side effect of the estrogen. And so dropping down on the estrogen dose can help things like nausea and breast tenderness can be a side effect of the progesterone. So changing to appeal, that just has a slightly different balance, the two hormones can help and irregular bleeding does happen particularly in the first three months. And I'm not terribly worried if it's in the first three months of starting a pill. Um If it's light, I would just usually tell a woman that unless it's too troublesome, she should carry on because it might well settle down. Um The pill has significant other benefits in that. It makes your periods lighter and less painful and it's used to treat endometriosis, um and dysmenorrhea and menorrhagia. So, the traditional use of these contraception is that you have one week off them in every month and in that week you have a period. So you take the pill for three weeks on one week off, you use one patch per week for three weeks, on one week off or you use one ring for three weeks and you have one week off. But there's no medical reason for having this week off and it is the weak points um week W E A K that the less strong point in the contraceptive protection because every woman will metabolize estrogen at a different level. And we know that for those women who are very rapid metabolizers of estrogen towards the end of a seven day period without a pill, they are getting perilously close to a low enough level of estrogen that might make them ovulate. Um And so, um uh so we, we now use the pill and the other methods of combined hormonal contraception in a slightly different way. So you've got here, the standard use which is three weeks on and one week off. I never tell anyone to use a pill like that anymore. Haven't done for years, an absolute minimum. If the woman wants to have a break every month, I tell her to have a four day break because that means that even if she's a fast metabolizer, metabolizer of estrogen, she's not going to drop her level enough to low enough to ovulate and crucially if she forgets um to restart, if you have a seven day break and then you forget to restart and suddenly you've had an eight or nine day break in court got quite high day, high chance of ovulating. But if you routinely only have a four day break and you forget to restart, then you're still only on a five or six day break in your less light ovulate. Um You can take it on step further and suggest that she takes two or three packets in a row and then have the four day break or you can just use continue the pill continuously, either continuous until you have some breakthrough bleeding at which point, you stop for four days or continuous, you just carry on taking it. And that is not a licensed use of the pill, but it is in all the guidelines. Every woman is different in terms of how much her endometrium can take before she will start to bleed. So some women will find that, let's say if they together 10 weeks of the pill, they're always going to start to bleed unpredictably. So actually, they might prefer to take eight or nine weeks and then stop and have a bleed when it suits them and then continue. But it is another benefit, the pill that it's very flexible. So if a woman is meant to be going on a beach holiday or something as she was you to have her period, she can just continue the pill without a break, so she won't have a bleed. Um This is a useful illustration about how you tell patient's about risk. So there were some big press campaigns in previous years, 10, 15 years ago in the UK, the pill doubles your risk of having a blood clot all over the front pages. The newspaper loads of women start stopped taking their pills. Predictably a few months later, the terminations rates increased. So the pill actually roughly troubles your risk of having a blood top. But if you look at the absolute risk, it's about 3 to 9 extra cases per 10,000 women per year. And if you think about that in terms of the risk of your, to your life, compared to the risks that you might take by driving a couple of hours on the motorway or going on an airplane or even crossing the road, then it's relatively small. So it's always important to explain to him in the difference between absolute and relative risk. And I tend to say, look, if I buy a lottery ticket, I can double my risk, my risk of winning the lottery by buying two tickets. But I'm probably not going to give up my job on, you know, on the grounds that I've doubled my risk of winning the lottery. And therefore I'm going to win the lottery. Um, the risk of course, of blood clots is higher when you're pregnant or in the post partum period, much higher than when you're taking the combined pill. Its highest when starting the pill, the combined pill or any combined method. And, um, there's probably an element that we are uncovering some women who have throm affiliates and don't know about it. Um, but interestingly, it's also high when you restart. So women who want to sort of give their body a break from the hormones for a few months, that's a really bad thing to do because when you start the combined pill, you have a little bulge in your risk of venous blood clots again. And of course, obviously, if you stop, stop starting your increase your risk of pregnancy too. Um So really just the way to prescribe this safely is to look at the UK met contraindications because a lot of them are related to the risk of blood clots. And, and if you're clear there, then it's a fairly safe method to use. There's a very small increase in risk of breast cancer. The relative risks about 1.19. the risk of a 25 year olds say getting breast cancer is so tiny has to be almost zero. How many? It's not quite serious about how many women in their twenties do you see with breast cancer? Not very many and therefore an extra 19% of almost zero is still almost serious. A tiny risk there. And the risk has gone 10 years after you stop it. There is no restriction to prescribing for those with a family history of breast cancer. But it is felt that the risks outweigh the benefits if there is a known gene mutation such as the Bracha gene that that runs in the family causes breast cancer. So for women who have such a strong family history that I might be thinking about referring them to the genetics clinic, I would probably have a conversation about look, if you turn out to have a breast cancer gene, then this will be contraindicated. So maybe something might, might be better for you, but just a bit of a family history is fine. And um one first degree relative over the age of 50 having breast cancer actually puts you at no higher risk than back ground. So often people come in and they say I'm really worried because my mom had breast cancer when she was 65. They are at normal background risk of breast cancer. The relative risk is too for invasive cervical cancer, but that is less common and the risk only increases after five years of use and it goes within five years of stopping. So, in a move on, I think this is the last slide or last but one. So talking about the progesterone only pill and then I'll come to the question. So um the progesterone only pill is good for people who can't take e student for whatever reason, they're contraindicated because maybe they have migraine with aura or A B M I over 35 or they're a smoker over 35 or they just don't get on with it. Modern pills largely contained, these are gestural and they have a 12 hour missed pill window the same as the combined pill. So if you normally take your pill at nine in the morning and you forget as long as you remember before nine at night, then you're absolutely fine. And this is compared to the older style what were called mini pills which contain hormones like Northeast drone, which only had a three hour pill window and we're less reliable. They work in the same way. They stop population thicken the mucus and thin the endometrium and you take them every day without stopping. So, a pack of combined pills has 21 pills in it and a pack of progesterone only pills takes has 28. And I do find them easier to explain how to take. The MS pill rules are more straightforward. There are less contra indications than the combined pills. As I said, people who with things like migraine with aura who can't take the combined pill would take the progesterone only irregular bleeding is quite a common side effect. Um And but it often does settle down with time. So again, I would always tell people to give it three months unless it's really terrible because it might improve. And they can also be used as the treatment for um medical conditions such as endometriosis. So I will go back through the questions have been asked already and then if anyone else wants to put more in the chat. So can you advise about safe contraception in patient's with Polycystic Ovarian syndrome? And those who've had a past history of venous thromboembolism or subarachnoid hemorrhages. Um So past history of venous thrombo embolism is a UK MEC for, for combined hormonal contraception. It's an absolute contra indication but these patient's can have I think pretty much anything else. So progesterone only implant coil intrauterine device, things like that. Um patient's who have Polycystic Ovarian syndrome. Um It really depends what issues they're having. So PCOS is associated with obesity. Um for the combined pill having a B M I, over 30 is a UK MEC to and over 35 is a UK mec three. So if they have obesity, then that might be an issue. People with PCOS often have hyperandrogenism. So they may have lots of spots or hair growth where they don't want it. Um There is a pill, the pill I mentioned about being not suitable for a quick starting which contains cyproterone, which is an anti androgen instead of the progesterone. It's called die Annette in the UK. I think it's called Diane in quite a lot of uh Europe in countries. Um We sometimes use that because it does stop, it reduces acne and it stops hirsutism, but it does carry a higher risk of blood clots than other pills. So it's just worth thinking about. And I think actually I'm just going to uh go back because I I um I passed over this table without really discussing it. Um I don't think that at medical school level, you need to know about this in detail. I think it's more close graduate thing, but it's just to make you aware that there are different generations of pills that carry different risks of venous thromboembolism and pills with uh cyproterone is not mentioned on here, but would probably be in that third, that 3rd, 3rd group of, of having a higher risk. Um Let me look at the rest of the question. Um So bright night hemorrhage. I don't know that off the top of my head actually, but the UK MEC would probably have something to say about it. I mean, a subarachnoid hemorrhoid hemorrhage, it's a hemorrhage, not a clot. So the, the increased coagulopathy is probably not such an issue and obviously it's, it's a congenital thing. So I'm not aware of it being a contra indication. Um But don't hold me to that because if I had someone come in, I would certainly look that up in the UK neck. Um So the next question was in which content, congenital heart conditions is pregnancy dangerous. And if abstinence is unlikely, what contraceptions are the next best um to congenital heart conditions is a massively specialist topic. And so I wouldn't presume to tell a patient with congenital heart disease, whether or not they should get pregnant. I would certainly leave that to their consultant. But logically, you would think that the more serious things like fallows and hyperplastic left heart and things like that would be more likely to cause pregnancy related problems than a simple ventricular septal defect or something like that. Um Certainly in the UK, the pediatricians are quite good at doing the transfer from child to adolescent to adult care. They have a, um the adult cardiologists have clinics called Grown Up Congenital Heart Disease clinic, which obviously a relatively new thing because 50 60 years ago these kids didn't survive and it's in the recent decades that they are surviving into adulthood and they are pretty switched on actually about contraception and pre pregnancy counseling. So I would generally seek their advice. But if abstinence is unlikely, then um decisions about contraception would probably really be based on what is considered to be the risk of arterial or venous disease. And if it was considered to be significant and you'd want a progesterone only method or an in future and device rather than a combined method. What about cultures, cousins in cultures where people marry their first cousin? It's not really an issue for contraception. Um The issue is obviously can congenital diseases because if you've got the same recessive condition hanging around in both sides of the family, then it's more likely that you're going to have a child with that condition. We did. I I have dealt with a few families who have had a series of Children with some quite nasty congenital conditions. And the genetics clinic have said that this is because you are cousins because you're in a consanguine this marriage. But obviously all you can do is council people. So they know the risks and then you know, they have to make their own decisions. Um How can post menopause will hr Tea formulation be influenced by what contraception was previously used and any gestational complications and cardio oncological risk factors. Um That's probably a lecture in itself broadly speaking. Transdermal HRT. So a gel or a patch or a spray does not increase your risk of venous combo embolism. So, if a woman has risk factors for VTE such as a raised BME or family history or she's had one in the past and she's desperate for HRT, then I would certainly always give her a transdermal form rather than an oral one. And in the UK, we've moved so much a transdermal HRT that we're actually having shortages of some because so few women are taking the tablets, everyone's on the gels and the, and the sprays and so on. Um influenced by what contraception was previously used, not massively much. Although if a woman tells me that she was very, very sensitive to the progesterones in her contraception, she got lots of spots and bloating and breast tenderness. There's always a risk she might be sensitive to the progesterones in H R T. Um if she has a marina, which is a type of intrauterine device with hormones in it, that can be used as the progesterone form of HRT. So that's helpful. Um Gestational complications probably not really relevant to HRT unless the woman had a blood clot and um oncological risk factors. Again, this, this is a talk in itself, but broadly speaking, the increased risk of breast cancer with modern formulations of HRT is pretty tiny. You're probably saying a maximum of four extra cases per 1000 women over five years. So less than one extra case per 1000 women per year. And there is no in increased risk of dying from breast cancer. And the best evidence we have is actually that HRT acts as a growth factor. So it probably makes a cancer that was already there, grow quicker and therefore it gets diagnosed earlier and there's no increased risk of mortality. How is breast cancer risk worsened by having young male relatives with aggressive prostate cancer? I my understand, I'm not an oncologist, but my understanding is that um, prostate cancer is made more common by the Brook A gene. So obviously, if you have a lot of prostate cancer in your family, that just might mean you should be assessed for having the BRACA gene. Um If you have a family history of subarachnoid, when would you investigate for Berry aneurysm? I would certainly pump that decision up to the neurologist. It's quite a, it's quite a difficult decision because investigating for a Berry aneurysm obviously does does good because if someone has one and it gets clipped and their life gets saved because they're not going to have a subarachnoid, that's great. But if you diagnose a very tiny berry aneurysm, which is much too small to operate, then that person is living with the anxiety their whole life. And of course, if you do go in and operate and you cause a catastrophic bleed, you could cause a lot of damage in a woman who's aneurysm might never have popped and she might never have a bleed. So that's quite a complicated discussion and it's one of the neurologists, so I will probably leave it there. I'll stop. Share ing, got two minutes if anyone else. Oh, thank you very much. If anyone else has any. Yes, I do have a question. Hi, Doctor. I don't know if you can hear me. Yeah. Yeah. So my question is that, um, in regards to contraception, why is it that, um, has a risk of causing blood clots? And what's the pathway, how does it lead to, to a blood clot? I'm trying. Yeah, it's an, I'm not, to be honest, it's a very good question. I'm not sure exactly which, which coagulopathy methods, uh, they cause, but basically it's, it's an effect on the coagulopathy of the blood. It just makes, it makes it, uh, slightly more likely that you have a blood clot. That is a really good question actually. And I don't have the sort of precise hematological answer, but there is a slightly increased risk of both venous and arterial blood clots. And that's why we are concerned about women who have migraine with aura because they have a very slight increased risk of stroke. And obviously stroke is uncommon at a young age. But it's very, um, but it's very catastrophic. So we've got to be careful with that group. Okay. And also, um, does it matter, um, does it, um, matters at what age like, or is it in general, regardless of your age group that you will be at risk of having blood clots if you're taking, if you're on contraception. Yeah. Absolutely. So, it goes up with age. So being, it's mainly for combined hormonal contraception being 40 or over, um, increases your risk of both arterial and venous clots. And so, being 40 or over in itself is a UK MEC two. And therefore, if you've got other risk factors, you're adding them onto the risk factor for your age. Um And so it might be that, let's say you've got someone who's, um, you know, you've got someone who smokes a little bit and they're a bit overweight, but they're 25 you might be quite happy. Whereas if they're a smoker and they're overweight and they're over 40 then you're probably not going to want to give them the combined pill because the risk factors are just adding up. Okay. Thank you. You're welcome. Okay. Fantastic. It is 12 o'clock. So I will leave you to it. Thank you very much and I'm back, I think a fortnight from today um, for the second half when I'll do long acting contraception and emergency contraception. Thanks very much. Bye. Thank you. Thank you.