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CRF PRIMARY CARE DR HAZELL

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Summary

This on-demand teaching session for medical professionals explores contraception for women over the age of 40. Presentation by Tony Hazel, GP in London, will cover topics from the UK Make guidelines including risk classification, when natural fertility can be assumed, checking FSH levels and more. Moderator Hannah will be available to take questions and provide CPD certificates to attendees. Don't miss out on this opportunity to learn more about managing contraception and transitioning to HRT in this age group.

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Learning objectives

Learning Objectives:

  1. Identify and explain the UK medic categorization of contraceptive methods
  2. Describe how comorbidities and loss of fertility can increase in women over the age of 40
  3. Differentiate between hormonal and non-hormonal contraceptive methods
  4. Define how a woman can safely determine when to stop taking contraception
  5. Recognize the implications of giving estrogen only HRT to women with a uterus and the need to provide progesterone as well
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Computer generated transcript

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

Hello. Hi, there. So I'm hoping you all knew that I was going to be 10 minutes late today because I was coming straight off, straight off another talk. Um, So my name is Tony Hazel. I'm a GP in London, and I'm going to be talking to you today about contraception in women over the age of 40. I can see there's some people here, so I will try and share my screen, and Okay, um, hello. Sorry to interrupt. Different nasal. Yeah, I'm Hannah. I'm the moderator. Hi there. Just to let people know, um, the last will take the last 10 minutes or so for questions. If you have any questions with them in the chat at and then after that, we'll post a feedback from that. You have to complete, and right at the end, we'll post them a certificate for this lecture. Oh, I seem to have screen sharing disabled. Can you Can you make you co host one second? Now? Why don't you do it right? Okay. Let's have a go. Yes. Uh, it's just, uh so hopefully you can see this as a as a presentation. Um, so yes. So my name is Tony Hazel. I'm in portfolio G P in London. These are my declarations of interests. So, um, this is the f srh guideline, the faculty for sexual reproductive health guideline which in the UK the the f srh are the people for for guidelines in this area. And most of the information comes in this in This talk comes from this guideline, and I will sign post Where else? It, um I will sign post when, um, I use something else. Um, so I don't know if people are familiar with the UK Make obviously, I realize I'm talking to an international audience. There is a I think, a us A version of this also, and a w h o w h o version, which is more for those who are working in developing countries where the balances of risk and benefit change because childbirth might be more risky. But as I'm based in the UK, I'm largely going to use the UK mech. And so this is how we classify the risks of contraception. So contraception a contraceptive method can be a UK make one, which means there's absolutely no reason not to use it. It can be a UK make four, which is an unacceptable health risk if it's used. So an example of that might be the combined pill in a patient who's had a previous venous blood clot, and then two and three are relative contraindications. So, too, is there is a Contra indication. But on balance, the benefits probably outweigh the risks. And three years on balance, the risks probably outweigh the benefits. Now, as an experienced GP with a particular interest in women's health, I do sometimes prescribe for people who is a UK make three. But I would document very clearly why I'm doing something that I'm aware it's a UK make three. It's probably not appropriate for someone earlier in their career to do that, at least without maybe discussing with a senior. So and these are some abbreviations if you need to come back to them for reference later on. So why is the subject important? Why is the group of women in their forties and over important? So these women were getting to the age where we have an increased risk of medical comorbidities, obesity, cardiovascular disease, cancers, osteoporosis? And then, of course, we have the whole overlap between contraception and the reproductive years and the menopause and H r T years and how we how we sort of manage segue from one into the other. The Marina intrauterine system can be a very useful way to cover that transition. Fertility is reduced, but conception is still possible. And actually, if you look at the late terminations in the UK, a large chunk of them are women in their forties who just didn't think they could get pregnant and put their missed periods down to the menopause when they, they were actually pregnant. If you do get pregnant after the age of 14, you continue with the pregnancy. Then, obviously, you are at higher risk of all sorts of complications and earlier in life. And there is still an STD risk in this age group, many of whom might be divorced or have ended a long relationship. Have found a new partner, possibly not so worried about contraception. So don't think about using condoms, so I don't think we have an actual boating facility here, so I'm just going to ask you to think about this. Molly attends surgery. She's busy working parent got four kids in secondary school and she's 50 and she uses a diese gestural progesterone only pill. And she hasn't had a period for years, probably because of the pill, which can give Amenorrhea as a side effect, and she wants to know how much longer to take them. So just have a think. If Molly was in front of her in front of you, would you say, Yeah, you're 50 that's fine. You're done. You can stop your contraceptive pill. Or would you tell her that she needs to continue with it? So I would answer no to this question. She can't safely stop her contraceptive pill. So if a woman is not on any hormonal contraception, then it's fairly simple to know when they can stop, for example, using condoms or when they can take their copper coil out. They just wait for the last period. And if they're over 50 when that last period comes, they use contraception for one year more, and if they're under 50 they use contraception for two years more. And that's because you can have a random ovulation in that period of time, and therefore there is a very small risk of falling pregnant, even if you are say six months from your last period. Um, but of course, if you are on a contraceptive method, which causes amenorrhea, then you have no idea whether your amenorrhea is just because of the pill, for example, and therefore, when you stop it, you will be fertile again, or whether you have, in fact, gone through the menopause. Um, so it depends what method the woman's using. If she's on the combined pills, you just can continue if she wants to, assuming no other contraindications until 50 and at that point switched to a non hormonal or a progesterone only method. The depo injection again can also be continued to 50 and we usually stop from there. And that's the same whether it's the intra muscular depo injection or the subcutaneous depo injection. We've got both available in this country. If you're using an implant or a progesterone only pill or an intrauterine device, then again, you can continue them. You can continue to age 50 but you can continue them beyond 50. So that brings up the question for women like Molly. She's happy on her pill. It gives her amenorrhea. She doesn't want to get her periods back But how does she know when she can stop taking it? So she's got two options which really depend on how proactive she wants to be. If she's not that fussed and she's happy taking the pill, she can just carry on till 55 then stop. So the F Srh says that at 55 natural loss of fertility can be assumed even if a woman is still having her period because it is so vanishingly rare for someone to get pregnant. If she would rather stop taking it just doesn't like the idea of the hormones, which is causing her side effects. Then at the age of 50 if a woman is not taking a a estrogen based contraception, then she can check her FSH level follicle stimulating hormone level. Um, and if it is in the menopause range, then you can take the date of that blood test as being akin to the date of the last period. So then she's over 50. So if the FSH is in the menopausal range, she uses contraception for a year, and then she stops. And if she's and if the FSH is not in the menopausal range, then she needs to carry on with her contraception, and you can check it again in a year or two if she wants to. I sometimes use this for women, Um, where I'm putting in a new implant towards their 50th birthday. If I'm putting in an implant that, say, age 48 then I might suggest that they have an FSH done at 50 because then, at 51 when the implant runs out, If I know that the FSH a year ago was in the menopause arranged, then they don't want to have another one. Remember that for women who use any kind of coil or intrauterine device, if they have it too, but in later in life, then it can often stay in longer. So a marina, which is being used for contraception and that is put in over the age of 45 can stay till the age of 55. That's not the case if it's been used as part of HRT when it still has to be changed at five years, and a copper coil that's inserted after the age of 40 can be left in until until 55 until the menopause. So Molly decides she's busy. She can't really be bothered to go for a blood test. So she's going to carry on with her pill, and a year later she comes in with very clear menopausal symptoms. She's having hot flashes, night sweats. She can't concentrate. She got joint pains. She's anxious and she's done a lot of research, and she knows that she wants to start HRT. So we need to think, How are we going to maintain contraception for Molly, as well as starting on her on some HRT and protecting her endometrium? Because, obviously she still has her uterus. So have a think again about these. You don't have to click anything. So are we going to swap to a sequential combined HRT? So that's the kind where you have estrogen only for two weeks and estrogen and progesterone for two weeks and stop her desogestrel because she's going through her menopause now doesn't need contraception. Are we going to add in estrogen tablets on their own and keep her desogestrel as the progesterone form of the HRT? Are we going to add in a continuous combined HRT? So that's estrogen and progesterone all the time and get her to keep going with her desogestrel. Or are we going to swap to a marina and to an estrogen only? Um, h R. T. So I think what I'll do is let's go through those options first and explain why two of them are right and two of them are wrong. So this isn't really an HRT talk, but broad principles are that women with the uterus need estrogen to counteract the menopausal symptoms and progesterone to protect their endometrium from the estrogen. If you give estrogen only H R T two women with the uterus, then they will get hyperplasia excess growth of the endometrium and, um, that can lead to endometrial cancer. So she needs estrogen and progesterone. Desogestrel is a progesterone only contraceptive pill, but it doesn't count as a progesterone part of HRT because it doesn't have a license for that. There isn't the data to clearly show that it protects the endometrium, so we know that we can't do number two. We can't add in estrogen tablets and keep her desogestrel and leave it at that because then she will effectively be on estrogen, only HRT. And we're putting her at risk of endometrial cancer. looking at number one, swap two sequential combined HRT and stop her desogestrel. Well, there's two reasons why we shouldn't be doing that. Firstly, HRT in itself is not contraceptive. And so if we stop her desogestrel and start her on HRT, we're leaving her unprotected. Her risk of getting pregnant at 50 is pretty small, but it's not nothing. Secondly, she's had no period for 12 for over 12 months, which means, but that she can go straight onto a continuous HRT. She doesn't need a sequential one, which would give her her periods back, and she probably wouldn't thank you for it. So one or two are not right. Number three. Add continuous combined HRT. Yep, that is sensible because she hasn't had a period for ages, so she can go straight into a continuous HRT and keep her DC gestural. Yes, great. Everyone's happy. She's got her HRT. She doesn't have to have a period, and she's protected from pregnancy and number four swapped to a marina and estrogen. Yes, that would work. So the Marina coil has a license as the progesterone part of HRT, and it is also contraceptive. And then, obviously she could stop her diese gestural. So three and four would both be reasonable things to do for Molly. So as of alluded to so far, HRT in itself is not contraceptive. I know that seems kind of counterintuitive, but women do have to use contraception at the same time, and so many women will need both contraception and HRT at the same time. In their early years of using HRT At the time of speaking, the only intrauterine system on the market in the UK with a license for HRT is the marina obviously abroad. You might be using different um, different devices with different licenses, so it's worth checking what you have available to you. And if you're not using a marina, then it's absolutely fine to give another contraceptive method, Um, such as the progesterone only pill or the implant as well as the HRT, and to explain to the woman that even though that's two lots of hormones, that's absolutely fine. So I think I've covered most of this, but I thought it was useful to have it in a table form. Um, the depo injection is not recommended as the progesterone component of HRT. Logically, you would think it would probably provide endometrial protection because it's a big dose of, but it hasn't got a license for it. And also we try not to use it past 50 just because we're slightly concerned about the effect on bones. The implant and the progesterone only pill are really good methods for contraception in this group, but they don't work as endometrium protection. And the combined hormone contraceptive pill or patch or ring is a UK MEC four after the age of 50 so we shouldn't be using it at all, and women who are using it in their late forties need to know that at 50 they're going to need to change to something else. So let's talk a bit about some of the different methods that we use and how useful they are and what pros and cons they have in women who are in their forties. So combined hormonal contraception. It's great, isn't it? It's great for women who don't have any contraindications, and you get on with it because it sorts out your periods, which are like and regular unpredictable. Often now we suggest that women do extended pill taking so they might only have a couple of periods a year, or even no periods at all. And it's used in the management of all sorts of women's health conditions such as endometriosis. Dysmenorrhea, um uh can be used in people who get things like migraine during their periods, because if we abolished cycle, then often lots of those things go away. There's a significant reduction in ovarian and endometrial cancer, which outweighs any increased risk of breast cancer for the vast majority of women, has a positive effect on bone density. Now this quote is from the F srh guidance on combined hormonal contraception. And it says that women who are using the combined pill for non contraceptive benefits, for example, to control endometriosis ma might consider using it over the age of 50 when it's usually a UK MEC for personally. I've never continued combined hormonal contraception above the age of 50. Um, and I think if I was doing so, I'd probably want the woman to be under care of a gynecologist as well, just to check that the other thing she was using it for there wasn't a better way to manage it, because you do get increases in the risks of uh, particularly vascular disease after the age of 50. So what are the risks of combined hormonal contraception are the main ones that people worry about our venous thromboembolism, vte breast and cervical cancer and cardiovascular disease. So let's talk about vte. So you can see there. What issues and in terms of things like family history, weight, um thrombophilia is and so on would put you in the four UK Met categories. One being it's fine to being. Benefits outweigh risks. Three. Being risks outweigh benefits and for being, uh, don't use it. Um, I think these numbers are quite useful for women, so this is a number of blood clots per 100,000 women per year. Background risk is, too, because, of course, we must remember that these bad things do happen to women who are not taking whatever the medicine is. We're talking about shoots up to 29. If you're pregnant, you start a second generation pill. That's, for example, one with levonorgestrel as the progesterone. Then it's 5 to 7, and if you start a third generation pill with one of the third generation Progesterones, then it's 9 to 12. So you're talking about you know, maximum, maybe an extra 10 cases of VITI per 100,000 women per year. And John Gilbert, who was the contraception guru in the U UK for many years. He used to say that the risk of taking combined pill for a year for most women is probably around the same as driving a car on the motorway for two hours. So you might want to try and put this in context for a woman. You might want to put this in context with her other personal risk factors, particularly if she is a smoker. If she has obesity, other risk factors that are potentially modifiable so the cancer risk the background risk of breast cancer is the relative risk of breast cancer. Over the background is 1.24. Now, the risk of a woman in her twenties or thirties getting breast cancer is almost zero. Not many young women get breast cancer, and 24% of almost zero is still almost zero. So the risks when a woman are younger is younger are very small. There's very limited evidence over the age of 40 but it is still a very small risk, a very small number, absolute number of increased cases. You know, nice. Our main guidelines committee in the UK does suggest taking a breast cancer family history when you're starting the pill or HRT. And I always do that because every now and then I pick up a woman who's got really strong family history, and I might refer her to a genetics clinic to see if she needs testing for the BRCA genes. Generally speaking, before you refer to those clinics, you need a complicated. You need a full family history. You need to know about other cancers, um, as well as breast cancer. So I will often end up sending the woman away to gather a bit more information from her family and then come back or maybe fill in the questionnaire. There's a very small increase in cervical cancer, but it's back to the baseline within 10 years of stopping, as is the increased risk of breast cancer. And as I said, there's a massive reduction in the variant and endometrial cancer and this, um, you know, certainly equalizes out the increased risk of breast cancer if not outweighing it. What about cardiovascular risk? So, um, smokers over 35 don't tend to get combined hormonal contraception from me. Although they are only a UK make three if they're smoking less than 15 cigarettes a day. But I tend to think that's probably the time to move to progesterone Only, um, when you stop smoking, it takes a year for you to become a nonsmoker as far as the UK MEC is concerned. So you know, we've all we've all seen. Patient. Oh yeah, Doctor, I'm an ex smoker. I spoke for 20 years and I'm an ex smoker. That's fantastic. Well done. When did you stop smoking? Yesterday. You know you're not quite an ex smoker yet. Not for the process and purposes of the UK MEC. You can see there what BP levels would make you concerned as well. Um, and the risk arises with the dose of estrogen. So if you've got someone who's maybe a bit borderline but you are using an estrogen contraceptive method because maybe she's tried everything else and nothing works. Then you might want to think about using a lower estrogen pill. So let's talk about the levonorgestrel intra uterine system. So I'm aware that these are UK brands and I don't know where you'll be practicing. There are the same brands, but in this country we have, uh, rus systems at three different doses. Um, only the higher dose can be used as the progesterone component of HRT. Um, the levonorgestrel entry uterine system is fantastic. I fit them all the time. It's got loads of benefits other than contraception in terms of reducing period pain, heavy bleeding pain associated with endometriosis and Adam Aosis. And a lot of our gynecologists use it when we refer people with irregular bleeding and they diagnosed endometrial hyperplasia. Then they will put in a levonorgestrel intra uterine system and use that as the treatment. So it's fantastic, and I use it a lot. Um, and it is worth trying to have a quick chat with those group of women who don't want amenorrhea, which you can get with the levonorgestrel I us and just reassure them that Amenorrhea just means that the device is working. It's thinning down the endometrium. There is often this sort of urban myth that if your period stopped, then the period blood is building up and up inside you and making you fat and causing you problems and that is not the case. So it is worth just trying to just trying to to bust those myths. Um, and as I alluded to the Marina, is a really useful way to bridge the gap between contraception and the menopause, because then you don't have to have any of these discussions about Well, I'm going to put you on HRT. But you also need some contraception because the marina does a double duty for both. So if I've got someone who's maybe in her early forties and she has a copper coil which needs replacing, then I'll certainly have a discussion with her about whether it would be better to put in a levonorgestrel coil because she might then want to use it for, um, for the for H R T uh, in the UK we have another brand called Lever Search, which is the same coil but doesn't have a license for HRT. But we're hoping that things might even up about that in the near future. It's fine to leave in, uh, I us a marina I us for five years as part of HRT, even though the license is only for because the F srh guidelines are very clear that you can use it for five years, and and that's what we all go by. Um, I'm a very experienced coil fitter, and I will sometimes fit ones where colleagues of mine have had ago, and I haven't managed to get it in. But I wouldn't fit a coil of any sort in a woman who's had an endometrial ablation in the past, which she might have had for heavy periods. Because this group is at high risk of perforation, and I would always refer and suggested it be done on the direct visualization at risk or a hysteroscopy. Um, there's no increased risk of cardiovascular risk or blood clots with the IU IU s, and there's very little evidence about any increases in cancer. If there are any, they're fairly small. So the implant, the implant is the most effective form of contraception we have. The failure rate is around 0.5%. Um, it lasts for three years. If a woman is happy with her implant, she can come back in three years. You can take it out and put another one back in the same arm. I've got women now who are on their fourth or fifth implant in the same arm. Theoretically, you have to watch out for skin thinning or stra in the arm if you're putting in a third or fourth or subsequent implant, but I've never actually seen it. I always have a look, and it's never been an issue. There's no age restriction in in real life, there's no issues with cardiovascular disease or thromboembolism, and it can be used with HRT. And there are very few contraindications. Um uh, past or current breast cancer is probably the main one Now. The most common side effect of the implant is altered bleeding, and I've put the actual statistics here. But I don't think these are terribly memorable for a patient. I think if you're throwing 22% and 7% and 18% of them they're going to forget, then you know, we we know that there's there's lots of evidence about what percentage of stuff that we tell a patient do they remember, and it's quite a small percentage. So what I tend to do is to simplify this. I tell my patient to think of five typical win who are using the implant, and I say one out of those five women will find that her periods stop while she's taking the implant. Now this is no problem for your future fertility, and your periods will come back after the implant comes out. Would this bother you because this is a good time to find out what her thoughts are about amenorrhea. And hopefully, she says, Oh, that would be amazing not to have my periods, and then you can move on. So one in five women will have no periods at the other end of things. Approximately one in five. I think 18% is close enough will have bleeding that is heavy or prolonged or both, and we'll probably have the implant taken out early, so there is a risk that this won't be for you, and then the other three women in five will either have irregular bleeding or normal periods or frequent bleeding in terms of start stop. But it's usually light. Um, and I can't know which group you're going to be in until you have the implant fitted. I usually suggest that women who have an implant and have difficult bleeding carry on with it for three months unless it's really, really problematic, because just anecdotally, I do find that often someone will ring a after six weeks and say all my bleeding is a real problem. But by three months it's settled down. So it's a shame if you rush to take it out after, maybe you know, 4 to 6 weeks, because it might have been better at three months and then she's got a reliable method of contraception for three years. But of course we do have to respect our patient's bodily autonomy. And if someone comes back after a month and says I cannot take this, I'm bleeding every day. I must have this thing out. Then I will remove it for them. So the Depo Provera is an intra muscular brand of the Depo Contra contraception, and the scion oppresses a subcutaneous brand. These are the two brands we have in the UK Um, so the subcutaneous brand, I think, became a little bit more popular during Covid because people could give it at home. There's a video on the manufacturer's website, and it's fairly straightforward to give it to yourself. Just by looking at that, you don't necessarily even need a nurse to to teach you. Um, but in general, I would say that the popularity of the depo as a method has dropped. Um, I've been a G P since 2004, and in my early years as G P, I always had a few depots in the cupboard in my room because I would give them relatively often. And now if someone comes in and they want one straight away, I have to go and find a nurse and see if they can if they know where they kept these days and who's got the right keys and so on, because I hardly ever give them. And if they if they stayed in my room, they just go out of date. There is a delay in return to fertility. So most women in their forties who are using contraception probably don't want more kids or don't want Children at all or don't want more Children if they've got them already. But you do have to let the person know, and you've got to be careful how you counsel them about them. So on average, it takes about a year or so for fertility to return. But that is an average figure. I have arranged terminations for people who were told that there was a delay in return to fertility. And what they heard is I don't need to use contraception for a year after my last depo. Oh, I'm pregnant. So it is on average figure. So, for example, I wouldn't give the depo to someone who was saying 36 wanted still wanted a baby at some point in the future because, you know, time is not on her side and she doesn't want to delay in return to fertility. There is some initial loss in bone density and that recovers on stopping. We don't have amazing evidence, and no one's ever going to do a massive trial because it would be expensive and the drugs are off patent. Um, but the evidence that we have is is for two years use, and that and it is that your bone density recovers when you stop. The concern, of course, then, is that if you go into your menopause on the depo injection, so your bone density is going down going into your menopause, and it may never have the chance to go up again. if you go straight into the menopause and is that going to put you at a greater risk of osteoporosis in later life? We don't really know. But the advice is to stop at 50 at the other end of the age spectrum. It's not considered, ideally, to be a first or second line method for teenagers, because again, the concern is that if we drop their bone density, maybe they'll never reach their sort of predestined peak of bone density. And will that predisposing to osteoporosis in later life? So if they are at one end of the reproductive years or there are other risk factors for osteoporosis, such as they're heavy smokers or have a very strong family history, then you might want to consider an alternative. There's no increase in cardiovascular disease, probably a trivial only increase in blood clots. A very weak association with breast cancer and possible reductions in a variant and endometrial cancer again because it stops ovulation and it does after a few months often cause amenorrhea, so it's useful for those with heavy bleeding. But as I said before, if someone comes back at a month after an implant, says I'm having terrible bleeding. I can't take this. I can take it out. You can't take out an injection. And a small minority of women will have real catastrophic bleeding for the first three months, which we can't often do much about. So I certainly would not put an input put, give someone a depo If, for example, they're about to get married or they're about to go off trekking in some remote area, you might want to suggest another method. The progesterone only pill by which I'm basically talking about the Desogestrel pill. The more old fashioned pills with hormones like northeaster and we don't use very much, they're much less effective, and you have to take them within three hours at the same time every day. Which is can be difficult. Um, where is the progesterone only pill? You have a 12 hour window for this pills? Um, it's great. You can prescribe it on the phone because you don't need a recent bm I or BP doesn't affect your bone. Mineral density doesn't cause any increase in risk of cardiovascular disease or blood clots. It's quite a useful bridging method. So if someone wants an implant or a coil, But there isn't an appointment for a few weeks or they can't get to you for a few weeks. Um or they don't want to have it till the next period. You can just give them the progesterone only pill in the meantime to cover them to bridge them until they get to their final contraceptive method, which obviously reduces the risk that they never have their implant because they come back for the appointment. And actually, they're pregnant. Um oh. Sorry. I've moved on to the next slide by mistake. But the PSA gestural pill is, um it does stop ovulation so it can be useful for endometriosis and heavy bleeding. I think most gynecologists in most GPS would probably go for a combined preparation first line. But there is a reasonably sizable group of women who can't take combined pills because they have a risk factor or another. Um, and so they can use these a gestural um, there is a risk if you're starting it. That's abnormal bleeding, which you can have in a similar way to the implant might prompt investigations in a woman who's over 40 but I think we can probably get around that by just taking a good history. So, you know, for 43 year old women say suddenly starts having a load of bleeding in between her periods for absolutely no reason. Then I'm going to be concerned and want to investigate that. If that same woman had started the Desogestrel pill two weeks ago and suddenly they're having a load of irregular bleeding, I might say, Well, this probably could be the pill. Let's see if it settles down over three months or should we stop the pill, See if it gets better before rushing to investigate? Because the temporal the time relationship with the pill would suggest that a side effect is probably the most common cause. And there are very few contraindications. Um, uh, I think cirrhosis of the liver and, um, uh, current or previous breast cancer. But but there aren't many at all. There are many more contra indications to the combined pill until the progesterone only pill for the group of women with breast cancer. I would never start any hormonal method, including the intra uterine, um, progesterone device, um, without speaking to their oncologist and getting advice from their oncologist in writing because the oncologist will have more information about the cancer about whether it was hormone sensitive, whether it had progesterone receptors, estrogen receptors and so on. You don't want to. You know, uh, there is always a risk that breast cancer will recur even without, uh, a pill. And you don't want to find yourself in the legal firing line. If that happens, um, and you have started the method off your own back sterilization. So in the UK, um, some areas restrict access because of funding. I'm never convinced that sterilization is a fantastic method, because, of course, we have to consider it as irreversible because attempts to reverse often fail. And, um, they're not they, they're they're often not funded in many health systems. Um, it's got a reasonably high failure rate. Maybe about half a percent. Um, and so many of the long acting reversible methods like the implants, actually have less of a failure rate. And they have non contraceptive benefits, as we talked about and they can be reversed. But there will be some women who have, over the course of their life, made their way through all the reversible methods. And they're not happy. Um, and they want to be sterilized. Women, after they are sterilized, do often get heavier periods now. Sometimes that is a sort of false impression because they've been on the combined pill before and the combined pill has made their periods artificially light. And, of course, when they get sterilized, they come off the combined pill and therefore their periods appear to get heavier. But there is some data that even women who haven't been on the combined pill before do get heavier periods afterwards, so women need to be counseled about that. That, and for women who are in a stable relationship, it is always worth asking if their male partner would consider a vasectomy, because that carries a lot less morbidity than a laparoscopic. Sterilization, which is a laproscopy, always carries the risk of potential conversion to open surgery, um, and is a bigger procedure than a vasectomy. Emergency contraception. There's no massive issues to do with age, except that periods are often more irregular in your forties, So a copper coil being used for an emergency contraception can be used for up to five days after the date of ovulation. If you know when it is so If someone has a regular 28 day cycle and they have unprotected sex on days 38, 10, 11, 13 and 15, then you know that they're going to ovulate on day 14. You could still put in a copper coil up to day 19, which would cover all those episodes of unprotected sex. Um, in a way that none of the oral methods available would do. Um, but obviously, if a woman has irregular periods, then you can't do that. And then you're limited to just five days after the unprotected sex. Um, you can see the effectiveness there. The copper coil is more effective than ulipristal, which is more effective than levonorgestrel. Um, you shouldn't use any other progesterone method for five days after using ulipristal because there is a risk that doing so might cause the ulipristal itself to fail. So if someone wants to start the pill, for example, you can give them the ulipristal emergency contraception. You can give them the prescription for the pill, but they must wait five days before starting it. And we can no longer do what we used to do before we knew about this, which was give someone an ulipristal pill and put in an implant at the same time. They have to come back at least five days later for their implant. There is some risk that if you've used a progesterone method in the seven days beforehand, that that might also cause ill a crystal to fail. So if I was giving it to someone who wanted emergency contraception because, for example, they were on a desogestrel pill and, um, but they've been a bit rubbish about taking it, Um, and therefore they thought they weren't covered. Then I might think about giving them a levonorgestrel pill or trying to persuade and have a copper coil instead. Um, I always do offer a copper coil because it is the most effective emergency contraception. But in my experience, I don't tend to find that it's, um, that it's terribly, terribly popular. People people don't tend to take me up on it. So other methods barrier methods do have a high failure rate. And, um, as we get older men are more likely to have issues with erectile dysfunction women to have issues with prolapse and that can cause difficulties using barrier methods. Natural contraception is also obviously much harder if you're tracking your cycles, it's got a high failure rate at the best of times as the joke. What do you call someone who uses natural contraception? You call the A parent, so it's not something you should ever encourage. And neither is withdrawal, which also has a high failure rate. But it's used by probably 4 to 6% of women in their forties, so it's always worth checking if someone says, Oh, yes, I'm using protection. Find out what? Because they might mean that they're using natural family planning or they're using the withdrawal method, neither of which are really methods that have any huge success rate. So take her messages, and I'm happy to answer any questions if you want to stick them in the chat. Contraception still needed over 40 and indeed, over 50. For some women, think about the interaction between contraception and the menopause and HRT, and how you're going to smoothly move your women from her reproductive years to hand on reproductive years, the progesterone only pill and the implants of good safe options for contraception over 40 and consider. As women get older, consider bone health with the Depo injection and venous thromboembolism risk with the combined hormonal contraception, be it a pill, a patch or a vaginal ring. And that's it. I'm happy to. I can't see any questions in the chat. Um, but I'm Oh, yeah, we've got one. So, um, what about the risk of liver disorders in women who are using contraception? Yep. So if you have a look at the UK MEC, there are some conditions that are contra indicated. Uh, so I As I said, I think the cirrhosis is usually a four. Um, I always double check it because it's such a massive document. You can't remember everything off the top of my head. I think that well controlled hepatitis B or C is okay, but it's something to always double check. And if you're concerned, obviously, if a woman has got has got a liver disease such that she's under the care of a liver consultant, then it's perfectly reasonable, um, to talk to them. Um, I don't think it's an issue for women who have fatty liver, which is obviously an increasingly common condition with the increase in obesity and metabolic syndrome. So I think it's really only cirrhosis that is an absolute contra indication. We've got about 10 minutes left. So if anyone wants to put in some questions and then they're more than welcome to what I'll do while we're waiting for for questions. Just on the more general contraceptive front is I touched a little bit on extended pill taking for the combined pill, so I will waffle on about that for a little bit. While any of you think about whether you want to go on. Sorry to interrupt. I just want to encourage everyone to fill in the questionnaire because it's really important. We have feedback for the medical school to keep going. Um, so I've put the link in the chat. I'll send it again now and you have to fill in the date the name of the lecturer and the lecturer name and just answer. It's one or two questions, Um, and then at the end, like one minute before we finish, I'll put in the certificate for this lecture. Fantastic. Yeah, please do feel in the questionnaire because it's also really useful for us to know. You know what in the talk was useful and what wasn't so we can adapt. It for the future, so we haven't got any questions at the moment. Do feel free to put them in and I will stop and answer questions. But in the meantime, I'll quickly talk a bit about extended pill taking, which is a relatively new thing. Um, so when the combined pill first came along in the sixties, you took it for three days, Um, for three weeks and then you stopped for one week. It it was quite controversial, Um, in terms of, you know, women having having control over their own fertility, and and, um, some religious organizations weren't terribly happy and so on, and it was sort of designed to mimic the normal cycle where you might have a week's worth of a period within a month. Now the problem with that is we know that we we say to women, you you can't get pregnant within that week off because your hormone level doesn't drop low enough to allow you to. But there is a small subgroup of women who metabolize estrogen very quickly, and there is evidence that that group are perilously close to the level at which they might ovulate by the end of a seven day gap. And certainly if they were to forget their first pill back then, they are at high risk of ovulating. And I think human sort of normal feelings is we don't necessary. We wouldn't necessarily think about starting the break, starting the next packet late as being a mist pill. People are often more concerned about missing a pill in the middle of a packet, which isn't such a big deal. But if you start the next pack it late, then that is significant in terms of being at risk of pregnancy. So the first thing to due for any woman who is taking the pill now is I always tell them to have a four day break instead of a seven day break. That's not licensed. But it's It's certainly, uh, backed up by guidelines in the UK, and I would imagine elsewhere around the world. So for women who do want to have a break and a period every one month, I would say take it for 21 days and then stop for four days and then start again. But actually there's a there's no reason why you have need to have a period every month. Um, lots of women who use the pill will run a couple of packets together to take advantage so they don't have to have a period if they're going on a beach holiday or something. Um, and you can do that normally, so it's absolutely reasonable to run two or three packets together and then stop for four days. So you have a period every six or nine weeks. Or you can do what we call extended pill taking, which when you just take the pill and you keep taking it and you keep taking, you keep taking it. And when you have a bleed, you just stop for four days. Everyone's endometrium is different in terms of how much of the pill it will tolerate before you start to have a bleed. So some women will find that always after three packets they start to bleed. And actually, therefore they would rather stop proactively and have a break before that because then they're in control of the timing up so women can go for six months or a year or or longer with no bleed, and that's absolutely fine to do. The endometrium is thinned by the contraceptive pill, and that's fine. So do look up extended pill taking. And when you are giving the combined pill to women do do encourage them to shorten that gap to four days and and that they don't have to have a gap every month. It makes the pill a much better and easier method to use. We've got a few more minutes If anyone wanted to ask, um, any more questions? Um, don't be shy. I'm just double checking through the chat, but I think it's all about people so far giving their names and names of that medical school. So if no one's got any questions, then we might need to wind that wind it up. But I'm happy to carry on. If anyone has anything that they wanted to ask, Final chance? No. Okay, well, I will leave it there. Then. I hope you found this useful. Um, and yep, that you enjoy all the future talks to come. Thank you very much. Bye bye. Thank you so much for an excellent lecture. Thank you very much, Doctor. You're welcome. You're welcome. Bye.