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Hello, Doctor. You're muted right now, so we can't hear you still, mutant, Can you hear me now? Perfect. Hello, Doctor. Please introduce yourself and I'll make you co host so you can share your screen as well. Okay. Right. Can I? Because I've joined on the phone because that link is I got to give me two seconds. I just need to send, because I It looks like I had a, uh, a wrong link. Give me two seconds. I'll try and see if I can join. Can I email you my slides? Would you be able to, um, put my stuff? Yes, I can. Um, Would you like my email? No. Yes. Please, just give me to see my slides down. Yes, we can. Thank you. Okay. I'm just going to put it on slide view. That means I might lose some of you, but just give me two seconds. I think if I can get into slide view Yeah, it's on slide view now. Can everybody see? Perfect. Yes. OK, so, um, Good afternoon again, everybody. Um and, um, starting again, my introduction. I'm Sunita Chakrabarti. Um I, um uh, public health consultant. I'm also a gynecologist. and I work in community gynecology. Um, one day, end of the week. Um, but I provide contraception services. The today's, um, topic is an overview of contraception. Now, I have got some slides. Um, Claudia should have them after at the end of the call. So, um, you should be able to get the slides, but there would be some additional material and a website link that I, um I'm going to refer to you. Um, and, uh, then you can have a look at your own, um, in your own free time alongside the slides. And, um, if there's any questions, then you can come back to me. Okay. All right. So very gone. Sorry to interrupt. Uh, sorry to interrupt. This will be this is Rick recorded. So the recording will be available along with the slides in the recording. So there's no need to because it's too complicated to forward people. The slideshow, so Yeah, no problem at all. Yeah, OK, that's absolutely fine. It's a recorded webinar, so you should be able to hear the recording. So thank you, Claudia, for reminding me about that. Thank you. Okay. So, um, so what we've got is we've got an hour. Um and what we're going to do is to familiarize ourselves with various methods of contraception available, and we're going to spend some time to briefly understand how each method works. Okay, So I will not get a lot of time to go into detail about each method of contraception. I will also not be able to go into detail about using specific case studies. But as I'm going along, I will try and and make sure that, um, I try and be as practical as possible so that you get an overview and, uh, sense about contraceptive methods. So why is contraception important? Because, uh, 50% of unintended pregnancies occurring. Women who are not using any contraception in the month that they conceive, and this happens, and it's happening today as we speak. So it's very important that women have a choice to make sure that they do not have a situation where they are have got an unintended pregnancy because the trauma from unintended pregnancies is is is something that women can endure lifelong. So it's very important important for women to have contraception choices. And in spite of the many advances in contraception. We still in? Um uh, in in my town in Milton Keynes. Um, we still have women, um, going in for abortion. Um, and one of the, uh we've got one of the higher areas, actually, where women still have, um, abortions. And I mean, those figures are, um are, uh, kind of old. But I was looking at this yesterday and again. Our abortion rates have gone up quite significantly locally because of the fact that, um, contraception choices not readily available. Um, there is a lot of disruption in our health system here as well for all kinds of reasons, Uh, stemming from the pandemic, which has resulted that women have have not had the opportunity to have all of the choices of contraception. And and and the important thing is, even if women are using the right method of contraception for in 10 women, um, still end up with unintended pregnancy because maybe they're not using the method consistently or they're not using the method correctly. So it's very important when you become the doctors and you're advising your women or even if there's any consultation that you're doing now, um, it's important to know how each method of contraception works when to take it when not to take it, um, or when to take it. And if you missed a gap, or if you had a gap, what to do then? So the average menstrual cycle just a little bit about the physiology. And I'm sure you've learned about this already. The average menstrual cycle last 21 28 days. Um and so the egg is released around the day 14. So this is average, Um so we we know for sure that, you know, some women have longer cycles. Some women have shorter cycles, but as a rule, you are. If you have been having regular periods, then the likely time you're having your ovulation is 14 days before your period, even if that's a longer cycle. Now, some women have irregular cycle, so they don't menstruate every month. And and those, um, in those situations, we're not always able to protect when they've had the population. And I will, as we start to discuss more about the contraceptive choices and you will see why that is so important in in making sure that women have the right right contraception at the right time. The other thing to remember is semen can live in a woman's vagina up to about seven days, and this is important because you might think. Okay, well, you know, I missed a pill, but I've had this unprotected intercourse. Um, it's okay. If I take some emergency hormonal contraception tomorrow, it'll be fine. It may or may not be because the semen can survive up to seven days. So it's important for us to remember that we need to protect around those times as well. And the egg will also will last for about three days. So even beyond your ovulation times, if you say Okay, well, I was not quite ovulating then, or I ovulated or it was close to my periods and and it's fine. I I can have unprotected intercourse. That's absolutely fine. As long as you remember even the egg is released and you had an intercourse. After that, there is chance of the fertilization happening even three days later, or to the fact seven days at the semen is already, um, already, Um, uh, they're in the system, so it's as a rule, a conception can occur from seven days before and up until three days after an egg is released from day 7 to 17 on a 28 day cycle. And as we started off by saying average women have a 28 day cycle, so you menstruate every month. However, that's you know, that's if that we take as an average. Then they say they say 7 to 17 is when you're the fertile period, Um, And so that is why it's important for us to make sure whenever we're having contraception advice and counseling to understand it, there's an unprotected intercourse to find out exactly when that's happened. Okay, um, so general principles. So many individual factors affect how a couple choose their method of contraception. So, um, they they are, you know, they could be related to. I have got patient's who are air hostesses, travel different countries, owns in one day. Now, if you give them something to say, you have to take it in the morning, every day. Now they wake up at a different country where morning is different. So they could be in the morning in South Africa and then waking up in a morning within six hours somewhere else because they're traveling across the countries or across the world zones time zones. So it's important for them to then have a choice that it's not reliant on the timeliness of it, or if they can keep a world clock and keep their time. That's great for them, so it's important to make their lives easier. So why this is important is if this is not, if the contraception choices not suitable for the couple in you who are using it, then they're not likely to be using it or not likely to be using it effectively. And then advice should be given to all methods. Um, and and the women should be medically eligible. So, for example, if you've got diabetes, if you've got a heart condition, if you've got a liver condition, if you're obese, then there are certain contraception that are contra indicated for you. And if that is the case, then we can't give you every method of contraception. We have to give you the contraception that is most suitable for you and, uh, to be effective. Contraception also has to be consistently and correctly used, So that means that it has to have, um, you know, the timing that you're using it, um, daily or monthly or weekly or yearly? It has to be consistent. If you if you kind of then lax on it, then that is likely to cause more more problems because you could end up with an unintended pregnancy. And we talk about the long acting methods to be more cost effective than continuation rate and the continuation rate must behind. We'll come onto the long acting methods. A long acting methods are those methods, which is not reliant on the person actually taking a pill on or using apart or using a ring something that the patient has control over The long acting method is an injection that you then have to go and have every three months, or an implant or a coil, which means that it's not within your control. But it's there within your system, um, giving you the giving. You the, uh, you know, contraceptive, uh, support, Um, as you need it, uh, on an ongoing basis. And it's and then you're protected anyway. So this is important going back to the 1st, 1st, sort of point that we went Individual factors affecting a couple's choice of contraception it's quite important. So talking to my patient's or my my clients who are, um, uh, you know, uh, air hostas is if they have something long acting, then they don't have to worry about having to remember to take a pill because they've got something in the system which is giving them contraception choice, as and when, And it's it's they're constantly with them now. This is where, um, a link is important, and, um, at the end of the call, I will put the link in the chat. And it's very important that you might want to look at this document when I put the link in so that, you know, um uh, it's almost kind of a Bible, and it's called U K MEC eligibility criteria, and it's called It's a United Kingdom medical eligibility criteria document. Um, and it's almost the Bible, and it's a very, very helpful document, and what it helps us to do is to go in and see if there's any, um, women presenting to us with their specific condition. It almost kind of gives us, um, sort of the template as to what we can give them and what we can't give them. So it's an evidence based sort of guide for us to, uh, to offer contraception choice and the evidence, uh, falls in four categories, so there might be a condition in which there is no restrictions for the use of a contraceptive method. So, for example, if a woman is breastfeeding and just recently had a baby and 24 year old and otherwise fit and healthy, we can give them all the methods of contraception. There shouldn't be any problem at all, so there is no restrictions at all, so they will fall under category one. Uh um, Category two would be a condition wherein advantages of using the method generally outweigh the theoretical or proven risk. So, for example, if there is a woman who is 24 year old but has had an aunt with who's had a, uh, you know, uh, thrombotic episode or has got varicose veins, um uh, but otherwise fit and healthy, we can then give them any method of contraception that is suitable to them because giving them the contraception is better than not giving them a contraception based on their on their family history. Because the family history might not be that relevant, so the the advantages outweigh the risks. Number three is a condition where a theoretical approval in which is usually outweighed the advantage of the method. So, for example, if you've got a liver condition, then the chances are your liver is not functioning well, so it's not going to be meltable izing, um, any medication Well, so if you give somebody with the liver condition something that you've got to take orally, um, then that means it means it means medicalizing and a deliver is already compromised, then that will not be working for them. So we need to look at alternatives for them, which is kind of a mechanical methods such a, such as a non hormonal contraceptive coil or something like that, which could then be beneficial for them and condition for is where there is unacceptable health risks. So, uh, a method cannot absolutely be used and and the reason, um, and there are And so, for example, like you cannot put a coil in a lady who's got active HIV or an active comedian infection, and you can work out for that for yourselves. Can we put a coil in something that's already infected. Know we can't. So that's a condition force. So absolutely not. We cannot do that. So when I push the link in, you'll be able to see the document. And that's the Bible. If you don't get anything to remember from today's message, just read that guidance and read that document. It's not a long document and any contraception advice or uh, consultation that you are going to encounter that will be your your guide and your Bible. So now we're going on to the contraception choices, pills, patches, rings, implants, injections, calls and barriers. Okay, so, um, the combined contraceptive pill, which is the one that everybody is familiar with, and it's got It's estrogen and the progesterone gin, and it's too still the most commonly used contraception. So, um, it's very popular because it gives good cycle control, and it's mostly known about it reduces pain, um, during periods, and it's, uh, and also reduces the bleeding. And it's easy to take because we take one every day. Sorry, my voice is going, so I'm having to have a drink. Apologies. So it's very important to know that the combined contraceptive pill has got an estrogen and a progestin gin, and it has to be taken the same time every day. Um, we sometimes give the contraceptive bill to women who have got heavy menstrual periods or painful menstrual periods because what it does, it just helps them to regulate the cycle as well. So in addition to the contraceptive efficacy, it's also providing, um, uh support with any symptomatic, symptomatic presentations that they're having during menstruation. So it's a really popular and the most commonly used method across the world. Um, so it's a very reliable method, and if it's taken correctly, um um, then it's It's It's a good, good, uh, effective method. But the effect effectiveness is reduced if you don't take your pill every day of your ms your pills, or if you're taking your pills with other medications such as antibiotics, which could reduce the efficacy of the contraceptives or if you've got diarrhea, vomiting. So remember the pill is reliant on your body, absorbing the hormones from the gut. Because you're taking the pill, it's getting into your gut. Your digestive system is working on it. The hormones are being released. Those are then absorbed in your system and then having the systemic effect. Now, if your gut is somehow compromised, then the contraceptive pill is not the method or, for that matter, any, um uh, any any kind of oral method is not helpful. So, for example, women who had bariatric surgery or women who've got sort of, uh, irritable power or Crohn's disease, which means the absorption of um of anything that's taken orally is compromised contraceptive pill or any oral contraception is probably not the best option for them, but that there are other options, and we need to then consider and look into that. The failure rate for the oral contraception. Um, in perfect use is very low. So if you use it regularly, if you use it consistently and if you are careful about not missing your pills, then you're it's very unlikely you're going to have an unwanted pregnancy, our for typical users. And that's what, like the likes of you and me med my medical students so you can see these slides up or University of Buckingham Medical School. So I teach there as well to the medical students. Hectic lifestyles, busy lifestyles, um, you forget to take a pill, you take it as soon as we can. But then, you know, they could be failure rates, and they're the risk is slightly high. It's 1800. How do you normally? How do you take the combined contraceptive pill you take for three weeks and then have no more than seven day break, during which time you get a slight bleed, which is called a withdrawal bleed? Um, And then, um uh and then you start taking again. Now, thing to remember is that I often hear my patient's say, Oh, Doctor, I'm on the pill, Bam! Getting my periods now. The bleeding that you're getting is actually not your periods, although we like to call it a period, but it isn't. It's a withdrawal bleed from the hormones, um, that you stopped taking. So your your system just sheds the inner lining of the womb. And that's the That's the withdrawal bleed. It's not typically after a bleed that you have after ovulation and you release an egg, um, more recent guidance now suggesting moving towards an extended pill regime an extended pill regime means well, does everybody want to see a period every month? Some of us do some of us. Don't. And if you say okay, well, I don't really want to see a period every month. Can I see a period, maybe every three months. Then you can take your pill, pack back to back without a boy break, and then give yourself a break in three months time. Um, if you see, I don't really wanna break. I'll just continuously take it and give it a break when I have a bleed. And that's fine, too. So now there is guidance to say that an extended pill regime is equally good. And and for women who forget to take the pill, that might be a better way of managing their contraception. So, uh, we're talking about we're talking about medication Still, so every, um, contraceptive pill. Um, every contraception has got some side effects. Um, the side effects that are for the combined contraceptive pill are weight gain, headaches, mood swings, reduced libido, breast tenderness, nausea and irregular bleeding. Now, the thing is, um, those are important side effects, but not everybody gets them. But if they do get them, then it's important to discuss rather than stopping the pill, what other contraceptive methods would be suitable for them. And then you devise the contraceptive method based on the needs of the client in front of you. Um, so the the side effects usually get better. Um, are minimal after three packets, most women really like it. Um, they are not suitable for women who are overweight. Who've got a high BP who got migraine, who got family history, blood clots and liver problems. So, as I was saying so, then you actually go back and look into you came a guide, which, as I I said, I will share the link with you in the chart. And you will find that when you've got a woman in front of you got a high BP or a significantly overweight or got migraines, then the contraceptive pill is a three or a four, as in, you cannot give it to them. What you then can give is any other method of contraception other than the contraceptive pill combined contraceptive pill. It should also not be given to smokers over 35 unless, um, they've stopped for over a year. And that's quite important to know as well. So, um, command contraceptive pill. How does it work? It works primarily by innovating ovulation by its actions on the hypothalamus pituitary access by reducing LH and FSH. Additional effects on the endometrium and cervical mucus are also noted. So so that is, um, the way it, uh it then kind of, uh makes the reproductive system a little bit hostile for the sperm and the egg to unite. Um, the first seven pills of of the packet are the ones that inhibit ovulation. The rest maintain an ovulation. So when you say when you give your client a pack of pills and say right started today because you know you need contraception and they say also, doctor, does it start working from today, the answer is no. It does doesn't start working from today because the hormone needs to build up in your system so that then it can impact on the hypothalamic pituitary access, which means it can reduce the LH and FSH, which means it can then stop the ovulation or help the ovulation. But the thing is, um, um, unless you have those seven pills, it will not do that. So so it will not start working immediately if you give them a pack of pills they need to use additional, um uh, contraception. And then in seven days time, when you've got enough hormone built in your system, then they can, um They can then start to continue to take it and use it consistently as a method of contraception. Now combined, hormonal contraception comes in the form of a pill, But can it can also come in the form of a part, Um, or also can come in the form of a vaginal ring. So for those who are suitable for the combined pill, but our problems remembering to take it or who get gastric side effects are just nausea. So what we need is the hormones to be absorbed. So we talked about women with bariatric surgery. Crone's disease, who cannot, you know, cannot use the combined hormonal contraception orally. But if you put the if you If you use a patch which delivers the hormone, um into your body parts through absorption in your um through the skin, then why not? And if that's the method they want to use, then absolutely, and we can do that in the form of patches. The patches go on any part of your body. Ideally, the abdomen stays in for a week, and then the every patch you have to change once a week for three. It's once a week for three weeks, and then you give the one week off when you may get a bleed, and then you put them back on. They're pretty discreet. They're very transparent. Nobody can see it if they come off. You just put another one back in. You can go swimming with it. You can have your bath and shower, and it doesn't affect it at all. Um so So again, you know, going back to my patient's My patient's who are PhD students running around all the play all the time and need an effective method of contraceptive, I kind of say, and you want to combine contraceptive? Then I kind of offer the every patch to them, because that takes away the kind of, um, added responsibility of having to remember to take a pill. The NuvaRing is a similar thing. It sits in the vagina and it's delivered. Um um, and and the hormone is absorbed through the vagina, and it's inserted and left for three weeks and then removed for one week. So It's important to make sure that, um, again, if then if the ring is broken, Um, Or if the ring is, um you know, if the ring is, uh, you know, comes off, then you need to have another one put in, and you can leave it in for three weeks, and then you take it out and for a week, and then you put it back in. So basically, you can keep it in for a month. So going back to my patient's who are air hostas is and or or heavy good vehicle drivers, and they need something on an ongoing basis. Um, these are some of the ways that we can give them combined hormonal contraception. Any questions? Is there anything on the chat? We just got a question. Know, Um, okay, that's fine. Please use the chat to put any questions in. All right, So, um, and then I'll keep carrying on Oh, dear. Right. So the next we move on to progesterone only pill. So this is the mini pill, as many people know it. For those who are not suitable for combined pills, they are due to side effects. So, you know, we talked about the side effects. If they've got a heart condition in the obese, if they got a liver condition we provide and they still want to take something orally, but they want to take something hormonal, then we can offer them the progesterone only pill. Um, and the progesterone only pill is a very safe method of contraception because it only has one hormone. And that's progest Rogen. Um, the newest preppers. There's a gestural and you take it every day. So like, unlike the combined hormonal contraception that you take it every day, you take it for three weeks and give yourself a break. This you take it every day, and there is no pill free week, and you just continue to take it. And that's how it provides contraception. Um, if you take, if you've forgotten to take your pill, then you can take it within the 1st 12 hours. Um, and with some of these pills, it might work. It might not work with all of them, but you've got that opportunity to take it within the 12 hours, um, but still use added precaution. Now, after taking it for a while. A percentage of women don't have any periods. Um, or some women have irregular bleeding to start off with, and then it tails off, and it becomes, uh, sort of, uh, kind of a little tiny bleed every month or no bleed at all. So that's the way the progest Rogen only pills, um, kind of, um are known to women. Oops, right. So then we move on to Depo Provera. Now this is an injection, and again, it's delivering a progesterone only method, and it's given every 12 weeks, so it's given every three months. It's a very reliable method of contraception. Um, the failure rate is less than four in 1000 over two years, and it's a possible introduction of a newer sub cup preparation, um, of of actually the women delivering the injection to yourself. So if you you have to get an injection, you need to find a doctor. Um, and you have to find a doctor, um, to give you the injection every three months. I mean, in the situations you are in, where will you find one? How do you find one really reliably, but you want to use your injection as a method of contraception so you can give you the vials, and you can teach you how to inject yourself. And then they sign a press. You can just use it and inject yourself so that you don't have to worry and be reliant on a doctor, and you take, we'll show you how, when and how to take it. So this is another long term method of contraception. So what it is is it takes away that responsibility from the patient. If you forget to take a pill, remove a patch to remove a ring. Then the injection is in you, and it's, um, and it's delivering the method of contraception constantly, um, taken regularly. So every three, um uh, every three months. Then often the periods stopped completely after the after the first year of use, and some women like it and they think, you know, that's great. Fantastic. Um, and And this. However, if you are one that you want to start a family in a year or two, then this is probably not the best method. Why? Because, um, after you stop taking the injection, it takes about a year. Um, to start to, um kind of, um, have your periods back and get your reproductive cycle into gear. So if you're one that you want to start a pregnancy maybe in six months time, but not just yet. Then maybe the depo is not the The injection is probably not the best for you. You might choose one of the other methods of contraception. The Depo Provera injection can be associated with some weight gain and some mood swings. So it's important to just alert women about that. So, you know, if you are somebody who's already obeys and you're watching your weight, then this might not be for you. Um, and then and mood swings also is something that can accompany this method of contraception. Now, we don't want to give this method of contraception to, um those who are under the age of 18, preferably or over the age of 40. And this is because, um, they're both the bone. It has estrogen, um, feeds our bones and estrogen looks after our bones. Once you're giving a lot of progest rogen, and that is kind of limiting. Um, the estrogen, um uh, release from your ovaries because that's the way it's working. Then, um, your bones are likely to be affected. And if that happens, um, then you know your bone mineral density will be affected, which means that for under 18 years old, where their bones are still developing, it probably is not the best, um, an effective choice. And over the age of 40 when women are coming up to their menopause years when because of the lack of estrogen, the bone density is is getting worse anyway, um, than due to concerns about loss of bone, mineral density, we do not give them the injection. We offer them other methods of contraception and there are quite a few, as you can see. So you never say to a woman. There isn't a method of contraception that is suitable for you because they're always is. So how does the Depo Provera injection work? It works primarily by inhibiting the ovulation. It thickens the cervical mucus innovating sperm penetration into the upper reproductive track. It also changes the endometrium and makes it unfavorable, unfavorable for implantation. So basically what it does then it is just sort of, um, um you know, the cervical mucus is thick so the sperm can't go in and no egg or the fertilized egg can get implanted on the endometrium because it's very thin. We now move on to contraceptive implant. Now, contraceptive implant is a little tiny, um, uh, sort of a match like, uh, contraceptive device. And it goes into your arm, just sits underneath the skin and can stay for three years. And it only releases prot estrogen. And it needs, uh, somebody who is a trained fitter to fit it in because otherwise it can go deep. It can go into the arteries, it can go anywhere else. So, um, those of us who are trained to deliver it, we have had to go through a lot of training and then we've we've had to do this. It's a very reliable method of contraception, and it caused, um it contains etonogestrel. Um So, um, again, it's It's a very sophisticated progest. Rogen and one of the third generation Progesterone Jin's, um So, um, it has less side effects, but it's a very reliable method of contraception. So this little rod sits underneath your skin in your arm and releases a hormone every day. So basically, it then head helps with kind of again working on that hypothalamus, particularly access to effect on your ovaries, but also on your on on your sperm penetration because it thickens the mucus around the cervix, Um, and also inhibits the normal endometrial development. Which means there is, uh, there is no place for an egg and, uh, to kind of lodge or or, uh, or an early pregnancy to lodge. So what are the side effects of contraceptive implant? We get minimal weight gain, breast tenderness and mood changes. Because, remember, it's a progesterone, only contraception. Um, the periods can be stopped altogether very infrequent and regular or regular, period or uh is kind of the known, uh, most women who don't want to see a period and particularly my young ladies. Um, school goers. Six formers need a bit of contraception that they don't want to have periods, but they need contraceptions on board. And they also, um, and they also have sort of, uh, something, um, that is reliable for them. Um, then then they choose the implant. Irregular bleeding. Most likely to occur in the first 3 to 6 months and then often settles. Um, but that is one to caution your patient or or your client that you're talking to to say bear up for the first 3 to 6 months. After that, you're bleeding. Will settle. If a woman is, um of a high B m I, then you might want to change the implant in two years rather than wait for the three years and and we are really looking at that guidance. We don't always do it now. Um, but it's one that can be advised because, of course, if you're overweight, you need more hormones in your system to really shut down your hypothalamus pituitary access. So it's kind of logical. Okay, moving on swiftly. And we are moving on quite quickly, actually. So that's good. We are moving on to the intra, you try and contraception devices and the entry you trying contraceptive devices are of two types. One is a hormonal device, and then other one is a nonhormonal device. And this is what you probably know as, um, copper T or people call it the coil. I don't know what it is called in your country, but you might want to look it up. So there is two methods. There's a hormonal method, and there is a non hormonal method. The non hormonal method is a tea safe, and it's a copper based cop contraceptive. It can stay up to 10 years, or or there's one that can also stay up to five years, and it's a very safe method of contraception. It stays in your room, and again, you need a trained fitter to fit it. In the hormonal contraception, there are a couple of them. The more common one is called Mirena, and there is one called Kyleena as well, which is got a little less hormone. And there is one that's tiny, and it's called JDS, which can last for three years. So the hormonal coils last for five years. Um, and the importance of that is, uh, you know, uh, of course, the hormones that in the coil runs out. So that's why, then has needs to be replaced. So let's talk about the copper coil, then the copper coil. It's got no hormones, so no side effects. It keeps the keeps, your cycles normal. So, you know, I have clients who tell me I don't want any hormones in my system or, you know, my young lady. So I like Doctor, I want something I don't want to pollute the environment with all these hormones? Um, I want something that's got no hormones at all, uh, and the so Then I advise them to have the copper coil fitted. And because you don't have any hormones in your system, your normal PSA reproductive cycle is going properly, and so you get your periods regularly. The periods can become a bit heavier and pain more painful, but as time goes by, they settle and most women tell me it's usually okay, Doctor. It's a very good method of contraception. However, it still has wanted to send failure rate, and the way it works is that copper is toxic to the album and the sperm, and therefore it inhibits the sperm penetration, and it kind of immobilizes the sperm. That's the way it works. Um, it works primarily by inhibiting the fertilization, so it just basically immobilizes the sperm, immobilizes the overwhelms, the sperm and the ovum become dysfunctional so they can't meet and and, uh, and produce an unintended pregnancy. And because it's sitting inside the womb, it also produces an endometrial implemented the reaction, which is an anti implantation effect. So basically, um, it makes the inside of the warm quite hostile. Which means there is. Um, no, um, you know, no way for a for an egg, uh, and and a sperm to actually implant the marina. Us is the hormonal method of contraception. The Mirena coil contains a small amount of daily progest Rogen, which is released directly into the uterus. So it's it's It's like it's like a T shaped, um device. And it's got, like, a little capsule. Uh, and the capsule has the hormone in it, which is really released inside the womb. It is a five year method of contraception, and it's reliable, and it's being sterile. Uh, and it's as reliable as being sterilized. So the evidence has shown that, you know, when women go and have surgery to have sterilization, the contraceptive, uh, the the efficacy of that can be relatable to the marina calls. The Marina Marina call has similar efficacy. Now again, then, because the marina coin has got an irregular Um, uh, it's got a hormone, it's and it's got a progesterone, only hormone. Um, it it can cause your bleeding to become irregular, but then, as time goes by, it delivers lighter periods with less pain and less PMT. So premenstrual tension as well is reduced. So in many of my patient, where, um, it's not just contraceptive use, but they've come to see me because they've got heavy periods or they've got, um, uh, painful periods or they've got P. M. T. This is something that I give to them. Even if they're contraception is sorted so it can give that dual protection. It can give you contraception, uh, support, but also can give you these other additional benefits of lighter periods and less period pain. Okay, um, so just going back. So the Mirena is a five year coil, so you you have to replace it in five years time. So in five years time again, you have to find somebody who is trained to take one out and put another one in. Jadiss is a smaller version of the Mirena, and it's tiny and it's licensed for three years, and it's got a lower daily hormone dose, and it's targeted most at my young women who want something. Um, but they don't want an injection or they don't want something any wrong, but they can't remember to take a pill. Then this is something that I advise to them. They're likely to maintain a regular but lighter cycle similar to the, um, combined contraceptive, the pill. But they will start off with an initial irregular phase. Okay, so so that's important to know. Um, recently, we've had another another coil introduced, called Kyleena, which also has the lower daily hormone dose, but is a five year version. So as women want longer time on their contraception, um, you know, we prefer the Kyleena now over anything. Um, these days, Okay. Moving onto emergency hormonal contraception. Now, why is this important? This is important. Um, for those situations, you know, it's the morning after the night before you had a great time, Uh, and you wake up in the morning, and Prince's charming, who was supposed to be prints charming, is no longer looking like prints, charming anymore. Operas charming has disappeared. Um, and you kind of think OK, well, did I actually use contraception? And then I realized I haven't used contraception, and then you kind of think right? Where am I in my so cycle. And, um, I now at risk of an unintended pregnancy, which is kind of quite a scary place to be in. So the emergency hormonal contraception, then, is for for those situations. And it can be given, um, as Levon L or Ella one. These are the two oral methods of contraception. Again, we talked about the fact that they might not be suitable for everybody but want to be considered. And then if, uh the most, uh, most effective method, which is a non hormonal, longer lasting method, is the copper coil as well. The copper coil can be used as an emergency. Hormonal contraception. Why remember, we talked about the fact that the copper immobilizes the sperm. So you've now in a situation morning after the night before you've got active sperm in your system. You realize, um, in my ovulation stage, I might be able I might be ovulating today or tomorrow. So now that's a difficult situation to be in. But if we can get you a copper coil in, then remember what we talked about. The copper immobilizes the sperm. Uh, and it also deactivates the ovary, um, deactivates the ovum, which is the egg, which means then then you have less risk of an unintended pregnancy. But again, this is Reliant of you finding somebody who is trained to put a copper coil in and the Lebanon on the L. A. One are oral hormonal methods, and we'll talk about them in a minute. So the level in El is, um, is a one tablet and it can be given up to 72 hours post ups, I unprotected sexual intercourse. So this is sexual intercourse where you haven't used any protection, so this can be given within 72 hours, and it can be given after this time. But the patient's need to know is unlikely to be affected. So most most of the time, we give it within the 72 hours if the woman presents to us in the correct time. Um, if we can't give it to 72 hours, then we If we can't give it to them in the 72 hours and they don't want to coil, um, and they're beyond their 72 hours, then we prefer L1, and we'll talk about that. That's the other oral method. Now there is no limit to how many times a patient can have leaven l in one cycle. So remember, in one cycle, you're releasing one egg. If you have one or two episodes of unprotected intercourse, Um, in the one cycle, then you know for sure that, um, that, you know, you can have a couple of you know you can have level now more than once. Um, and it doesn't prevent quick starting of a new contraceptive method, which is not affected by recently taken progest Rogen. So I think it's important to know that, um, you know, once you have an emergency method of contraception, you have a discussion about starting something, um, straight after, which can give you that ongoing contraception support. Okay, um, you're in the situation today. We are in this situation today because, you know, we've not had any contraception on board. And we have We've we've just discovered that we've had around unprotected intercourse, so the level Nell can be given, and then on top of it, you can also give some progesterone only contraception if you want them to start that method straight away. There's some new guidance suggesting that women who are obese need a double dose. Um, so they need two tablets of the LeBon l if they're seeking, um, emergency hormonal contraception and then the newer Well, it's not that new anymore. The newer emergency contraception that has now been launched. It's called L1, and it has a license up to five days, 120 hours. Okay, And the original data steps. It is as effective as the level L in the 1st 72 hours, but more effectively at the level l from 4 to 5 days. But new data suggest now better just overall. So we basically prefer the L1 for everything these days. Interactions with the progest Rogen before and after used to reduce the efficacy, uh, can happen. So you need to avoid progest Rogen seven days before and five days after taking the, um, taking the L1. So if you wanted to start somebody on Hormonal Contra exception again, post emergency hormonal contraception, then it's likely unlikely to work. Um, if they've had L1. so it's important that we give them other methods of contraception rather than, um, uh, progesterone only method of contraception. And in the neither oral effect, methods are as effective as copper IUD, the emergency copper IUD, and we just discussed why that is the case at the copper IUD. Um, the copper T works best as an as an emergency method of contraception. But if you can't get any of those, at least you can buy, or you can get over the counter. Uh, oral. Uh, Levon l or the oral? Um, l a one. So, um, how so? The copper IUD, the copper i d. Can be inserted up to five days post unprotected sexual intercourse or five days after expected date of ovulation. So remember when we started off, we started to talk about why it's important for us to actually remember the remote reproductive cycle. Um, cycle and make sure that we've got, um, uh, some idea of as to when the woman has ovulated. Um, it's a more reliable method. And we talked about why that is That is the case, because it immobilizes this form and it immobilizes the egg as well, and it provides a good method of ongoing contraception. So any form of emergency on a conference hormonal contraception we gave we asked the woman to do a pregnancy test in 10 days time if they do a pregnancy test in 10 days time and then negative. Um, and they don't have any contraceptive on board. Then we obviously have given them some methods. If you're given the ministry and progesterone on a progesterone, only contraception. Um, but if they've got a copper coil on board, then they can continue to use the use it for ongoing contraception beyond the time. But of course, if they if their pregnancy test comes back as positive, then they're, uh they have to remove the copper coil unfortunately, and then decide what? Whether they want to keep the pregnancy or if they don't want to keep the pregnancy, they can't go to abortion services. Uh, doctor, we're running out of time. Unfortunately. Okay, three. Okay, I think I'm almost done. Most patient's declined to the invasiveness of the procedure. So again, as I said, we need to find somebody who's trained. So I'm almost done in spite of all the contraceptive methods. Um, there is still unwanted pregnancy. And, um, if there is unwanted pregnancy, then we, um, sign post them to determination services. Um, their determinations can happen as medical terminations, which is a different lecture altogether. Mifepristone, misoprostol are oral tablets that are used. Um they can come by opposed these days. Or if you're over nine weeks, then you end up with a surgical terminations, which means sedation. And I think that was the end of my lecture. Sorry. No problem, Doctor. Thank you. Very informative and clear. We had one question about the contraceptive pill, the combined one. And I was saying that because ovulation is stopped, can this be a preventative treatment for infertility in the future? Or how would that work? Because if you're not using the think conservative pill, we're blocking the ovulation. Therefore, we are in a way, preserving the Varian results. So the question is, can we also consider it as a no, unfortunately, not because your your ovaries are aging from the time you're in your in your mom's womb. Okay, so the eggs, even if they're not being released, they are degenerating. So it doesn't mean that if you are not releasing your eggs, your eggs are staying as fresh and can be released when you're ready to for them to be released. No, it cannot be used as a preventative around infertility because your eggs are constantly aging, even if, um as as you're as you're growing older in your reproductive cycle. That's a normal physiology. Thank you, Doctor. And just for me, Um, you know, the other contraceptive, like the coil and whatnot. Are they going to be a real period per se, like whether egg is actually released or that question again, Will the egg actually be released in the coil and other contraceptives? No. So, um, when you're taking the copper coil, that's not got any that hasn't got any hormones in it. So that doesn't affect your hormonal cycle That doesn't shut down your ovaries. So for that your eggs will be released, so copper coil with no hormones will release your eggs. But any of the other methods they are working by shutting down your ovary and, you know, making sure that you're it's taking over your reproductive cycle. So that's the way it works, so your eggs won't be released if you're taking any other method of contraception. And that's what we're wanting to do. Because if your eggs are released, then of course, you've got unintended pregnancy. Um uh, as the complications. So that's the way it works by not releasing your egg. Does that answer your question? Yes, Very clear. Thank you, Doctor. And thank you, everyone for listening and thank you for your time as well. No problem at all. So, um, I am quickly going to put the link, um, that I was talking about on this, um, chat and so that people can get it. Um, sorry about that. Give me two seconds. Um, thank you. Thank you. Guys. Please fill in the feedback form and download a certificate. You hope to see you soon. And Doctor will also be having other lecture series. Yes. Also put my email address on the chat. If anybody wants to ask me any questions that they haven't been able to ask today, then please feel free to write to me. And I'm very happy to answer them. Thank you, Doctor. Thank you. Everybody, please don't know. Certificate this Corby ending shortly. Okay? Just give me two seconds. Let me just quickly pose that two seconds. I had it open, but then it's suddenly gone blank. Sorry about that. No problem.