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Summary

Explore the topics of contraception, Fraser guidelines, and patient consent during this engaging on-demand session lead by final year medical students from UCL, Izzy and Maria. This comprehensive guide provides practical advice and coverage of relevant ethics and law. The session starts with a discussion on the Fraser Guidelines, a legal provision concerning contraception advice for under 16s. The instructors use interactive methods, including case studies and Q&A sessions, to bring these guidelines to life. The course also touches on broader themes like domestic and sexual violence. The instructors examine a case involving a 15-year-old patient with abdominal pain, creating a robust guide for client consultation. The practical knowledge acquired in this session will not only help students negotiate their exams but will also apply to daily practice in their professional life. Any medical professional or student looking to deepen their understanding of contraception and associated ethical dilemmas should not miss this session.

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Description

Confused about how each contraceptives works? Trying to get your head around which emergency contraception someone should use?

Join us as we cover ALL YOU NEED TO KNOW ABOUT…CONTRACEPTION! 😍

Perfect for medical students sitting the UKMLA and OSCEs!

Join our final year medics, Izzy and Maria, as they dive into essential topics such as regular and emergency contraception, navigating domestic violence issues, and understanding Fraser guidelines.

This session is crucial for your medical training and will equip you with practical knowledge for real-world scenarios! Understanding various contraceptive methods will allow you to effectively promote patient-centered care by having full insight into the benefits, side effects, and implications of different contraceptives.

🔥🔥 Don’t miss out on the chance to ask questions and engage with your peers! All slides and recordings will be available on our MedAll after the session, and you can check out our full schedule of upcoming sessions! Remember to sign up to the session on MedAll!

💊💉We can’t wait to see you all there! Feel free to reach out with any questions or feedback by DM on Instagram @uclteachingthings 💉💊

👍💙 If you did like this talk on contraception, let our lovely speakers Izzy and Maria know! Drop them and the UCL Teaching Things Team some feedback here:

https://app.medall.org/feedback/feedback-flow?keyword=a85f1013c4a9ac3e74ed3aa0&organisation=teaching-things

and we can continue to produce fun, informative content that gets you all set up for exams! 🩺💊

Learning objectives

  1. To understand the ethics and legal guidelines associated with prescribing contraception to minors, including Fraser guidelines and Gillick competency.
  2. To differentiate between Gillick competence and Fraser guidelines and understand how they apply in a clinical setting.
  3. To be able to discuss and address the concerns and questions patients may have regarding emergency contraception.
  4. To understand how to take a comprehensive sexual history from a patient and appropriately address any potential issues including interpersonal relationships, consent, and previous sexual behavior.
  5. To understand how to handle patient confidentiality and potential challenges in situations of emergency contraception and minor patients, including when and how to involve parents or guardians.
Generated by MedBot

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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.

Cool. I don't think I can hear you. Unfortunately. Can you hear me? Yes, I can hear it. I don't know what's going on there. I can't hear you either. No. Unfortunately, I can't hear you either. Now, do you wanna just like uh rejoin maybe? Ok. I think she's, it's fine. We'll give her a few minutes anyway as people join. Correct. Oh, I think I can hear you now. Say something. You hear me. Yeah. Yeah. Yeah. Perfect. I think, I think it um connected to my iphone microphone and instead of my laptop one for some reason. Uh Yeah. All right. I can't see, I don't know if cameras here. So I think for the people joining we're just going to wait until 605 to start. I think there's a bit of feedback. Yeah. Um OK. We, I might just mute myself when I'm not speaking. Ok. Should we mix up? Ok. So welcome everyone. This is our first teaching things session of the year. Um I hope you can all hear me if not trying to stick something in the chat. So my name is Izzy. Like Maria. I'm a final year medical student. At U CLI really excited to be here. And today we're going to be doing a session on contraception. So all of this is going to be kind of so to go back what we're teaching this as part of teaching things. So teaching things will be running weekly tutorials open to all. There's a mix of those tutors. So that won't be us every week for the most part, we're going to be focusing on the core presentations and kind of diagnostic techniques that you need today. Being contraception is a bit more of a niche topic. So it will be a bit of a different structure. Um Like I said, we're both medical students at UCL. So there's going to be a little bit of a focus for what you need to know for the UCL exams, but kind of the information will be useful for everyone. And importantly, we've got some very kind doctors helping us out who have reviewed all our slides to make sure that they're accurate. Um If you want to, you should be emailed with kind of further teaching thing sessions. But if you want to keep updated, make sure that you're in the group chats and signed up to the email list as well for the two lovely teaching things leads in the session today. So if you've got any questions about that, you can pop those in the chat. But um so to get started, what we're going to cover today is Maria is going to take us through kind of relevant ethics and law that you need to know around the topic of contraception. And I'm going to talk about kind of regular contraception. So what patients might be starting on? We'll talk about emergency contraception. Um, we're going to cover domestic and sexual violence very briefly just because it's a topic that we need to be considering kind of every patient interaction on this subject. Um And then we've got a couple of S EA s that we're gonna go through at the end and then there'll be time for AQ and A as well. So that's kind of what we're gonna cover today. So I'll hand over to Maria. He's gonna take us through the first part. So hi everyone. Um, actually it, I think it might be best to mute for now just so we don't get any feedback. I think, I think that should be fine. Um Hopefully everyone can hear me. Um, so my name is Maria. I'm also, I'm a medical student at UCL. Um, it's nice seeing lots of familiar names in the chat. Um So today we're going to start the session with ethics and law. So it's a very um informal session. So please feel free to ask any questions throughout. Um, and hopefully one of us will be able to answer. Um, and it's also an interactive session. So we rely on people either putting messages in the chats or um taking part in pas throughout. Um and as we said, we have SBA S and we have some sort of ak cases that we're going to discuss. So if you could participate, that would be much appreciated. So, for ethics and law, um as far as what we're going to do today is we're mainly going to discuss fraser guidelines. Um So you should be able to discuss them in an ay setting and answer questions on it. And additionally, um you should be able to discuss and answer questions surrounding emergency contraception um that patients might have. Um So to start with, um we're going to talk about Fraser guidelines mainly in this part of the talk. But um does anyone have any idea what the difference between g competence and Fraser guidelines is? So if you could put it in the chat or unmute yourself, um that'll be great or you could put a message on the chat as well? Ok. If not, um we could just go ahead. So um the difference between gilt competence and for guidelines. So remember, gil competency refers to your assessment of a child, whether or not they're uh mature enough to make their own decisions. Basically, um is a child able to consent to a procedure or implications about um the decisions of their own health care? And that is within Gilli competency, we have Fraser guidelines which are specifically about um contraceptive advice given to under 16 year olds without parental consent. Um So, Fraser guidelines is a subsection of gil competency. Um And this is what involves, so um these come up as S pa S and pamid quite frequently. Um So you might see them anyway. Um but it relies on the fact that the young person's able to understand the advice being given. So that's your consent procedure. Um The young person cannot be convinced to involve parents to allow the medical practitioner to do so on their behalf. So we'll talk through an osk scenario at the end. But essentially, um you would still encourage the young person to involve their parents or have a discussion with their parents. Um If they're under 16, um and 0.3 it's likely that the young person will begin or continue having intercourse with or without treatment. So if you know that um you didn't prescribe, say um contraception to this person and they would leave your clinic and still engage in intercourse, then um you're more likely to prescribe it if that makes sense. Um Fourth point. So their physical mental health is likely to suffer if they don't get contraception. And lastly, it's in their best interests um to get contraception. So this is a document taken from one of the UCL teaching sessions that you get um regarding how you might assess someone who's under the age of 16, whether or not they should receive contraception and is basically um going through those five points that we mentioned regarding the fraser guidelines. And if your answer is yes to any of these, then you may prescribe contraception um to someone who's under the age of 16. Importantly, um remember the age cut off for this is the age of 13 and below. So, um legally, um if a person's engaging in intercourse under the age of 13, then that should automatically be escalated as uh his right. Um So this really is only from the ages of 14 to 16. Um So the case that we're going to discuss, so you're an F two in A&E you're seeing Emily, a 15 year old patient who's come in with abdominal pain, she's already been seen by surgeons who asked you to take a social history to explore possible factors to her abdominal pain. Does anyone have any ideas of what they might want to ask Emily when she's presenting? Um feel free to put it as a message in the chat or am mute yourself? Ok. I've just been told you can't mute. Um So if you could put it as a message, that would be great cause I think you should be able to message Yeah, exactly. So if she feels safe um about having sex by her partner, so um maybe what sort of things would you want to know about her partner? Yeah, exactly. So age et cetera, gender. Absolutely. So consent. Very good. Um So always risk assess patients very good. Um So an ay structure might look something like this. So you'd introduce yourself, you'd explain the purpose of the consultation. Very importantly, you should always talk about confidentiality because um patients in this scenario would be very worried about. For example, will my parents find out about this? Ok. Um Officially, you should keep it confidential and encourage the patient to talk to their parents themselves. Um So you might begin the consultation by talking about why do you want to start the pill? So that includes all the information that you've put on the chat. So you're asking her about her partner, the age of the partner, gender, whether consent. Um So current relationship details. Um So for example, it'd be a very different scenario if she was a 15 year old that for example, is dating someone that's 40 versus a 15 year old that's dating someone in her class that's also 15. Um So how they met is important and how long have their relationship been going on? And absolutely. Um Do you ever feel pressure to something you didn't wanna do? What if there's an S ti then you can't always keep confidentiality in case you have to warn the sexual partners. So, yes, you're right. Um We're talking more in the sense of um I guess the main concern here is whether or not parents will find out. Um Usually it is the question that you get asked in this Osk station. Um It wouldn't be so much an S ti risk. That's also something that I have to keep in the back of your mind. Um But yes, you are absolutely right. And next, you would wanna ask questions about her sexual history. So, including for example, an S ti risk that you've mentioned in the chart. But what are some other questions we might ask someone? What about her sexual history? You're welcome. Oh, it just, it has just disappeared again. Yep. So if they've used contraception, yeah. Are they vaccinated? Very good. Um And I guess so you, you learn more about this and sexual health but what type of sex you're having? Um Most importantly, remember her admission, she's admitted um with abdominal pain. So she should always rule out pregnancy. Yep. So type of sex. How often are condoms used HPV? Very good. Exactly. Um So that's all summarized here. Very good. And previous S ti screens are always opportunistic. Perfect. Then check for parental involvement explore why um they will not like to tell their parents about this. Um So remember you should always encourage them to tell their parents but um you cannot go to the parents and say anything cos they'll be breaking patient um confidentiality and then would assess the situation using phrasal guidelines that we've already discussed. So, do they understand everything they've told you? So, basic consent, are they willing to tell their parents why not? Um what the patients suffer mental physical health if they don't get contraception or they still engage in intercourse, if they don't get contraception, and then you think about the more um potential contraindications, which I you will go through about regular contraception. If you think it's in the best interest of the patient to get contraception, then um you would be justified to prescribe it. And obviously you'd explore the use of long acting reversible contraception as well. Um So, and again, one Izzy will cover that and then you'll do the rest of the history, pretty much um like regular history taking apart from um menstrual history. So maybe um using that as an opportunity to explore um her periods and her cycle, et cetera. Um Any questions on that. OK. So if questions do pop up, I'll answer um concerning features. So most of these have already been mentioned. So this is for example, when you'd be concerned and you'd escalate to social services. So if a, a young person is too mature, so if they're unable to consent, if there is big differences in age, that's already been mentioned in the chart. Um If there is, is a position of um power or power play that's going on um if there's any pressure. So someone said, if it's consensual, which is very good, so that plays into this, there's any drugs or alcohol being used um as well as any money and if the child is known to place your child protection agencies, so that's sort of like a run through of um fraser guidelines. Any questions on that? OK. I assume no, cause there's no messages. Um So what we're going to do now is we're going to talk about regular contraception. So I'm going to hand over to Lizzy. Perfect. Thank you. So if you can go to the next slide, please. So regular contraception is a huge topic and I think it can feel a bit intimidating when you're trying to revise it because it's great. You know, there's a lot of resources out there for patients, but it's very much like you have a page on the pill and a page on the implant. So it's quite difficult to kind of synthesize all that information. Um So in terms of what you need to know, um you know, it's a very specialist field contraception, which I think people often don't appreciate. But there's a reason why we have community sexual and reproductive health doctors. So you don't need to know everything and there's a lot of online guidelines that you can refer to when you need to. Um But in terms of what I think you do need to know is in detail, you should be able to talk about the oral contraceptive pill, the progesterone only pill also called the mini pill. And then the IUD in the I US. And that's because the pills are very, very common forms of contraception. And then the IUD in the I us both have their own medical uses. So they're really important to know about. Then you should be able to talk kind of more generally about the mechanism of action of contraception, main side effects effects and risks. So what are the common side effects and what are the important ones? You should know a bit about the important contraindications, important drug interactions. And then the missed, also missed pill rules in regards to contraceptive pills and mini pills. So we're going to go through all of these in turn. So next slide, please. So when you're thinking the reason why you need to know the types of contraception is because you kind of need to imagine yourself in an ay station where you sit down with a patient and they go, I want to start contraception, but I don't know what kinds there are. So you need to be able to present kind of all of them as options. And the easiest way to do this is to kind of separate it into like categories. So you have importantly your hormonal types of contraception and then your non hormonal one will have quite strong preferences about whether or not they want um like hormonal or non hormonal hormonal contraception. So within your non hormonal contraception, you have your barrier contraception. So those are your condoms usually external, sometimes internal and then you also have your diaphragm which you you use with or without spermicide. The diaphragm is quite an old form of contraception. The only time I've ever seen it is in call the midwife. So it's not one that you come across that frequently. And it's also not the most effective, but it is something you should be aware of. Then you have your kind of non barrier types of contraception. So this is your natural family planning. When patients track their ovulation cycles in their fertile windows, your copper coil, which is really important to know about. And then also your sterilization, say vasectomies and then tubal ligation over in your hormonal contraception types, you have your short acting and your long acting and this is quite an important distinction. So in your short acting contraception, you have the estrogen and the progesterone types. So that's mainly your contraceptive pill, but also the patch and the ring and you have your mini pill, the progesterone only pill, but going to your long acting types of contraception. So this is your injection, your implant and your I US. The brand name. Most common brand name is Mirena. Combine your injection implant and I us with your copper coil. Those give you your long acting reversible contraceptives, your lark. And this is quite important because if you can ask a patient, if a patient is interested in larks, then you absolutely should encourage that. OK. Perfect Marie just answered the question in the chat. So next slide please. OK. So in terms of how you administer them, you don't have to memorize this whole table. Um, but it is kind of useful if you do know it. Um, so with your contraceptive pill, your combined one, for most of them, there's a few exceptions. But for the vast majority of pills you take it every day for 21 days, followed by a seven day break. Does anyone know why you have a seven day break for the contraceptive pill? Just looking to see in the chart? Any ideas? Yeah. So it is a withdrawal bleed. Absolutely. So it kind of gives time for the patient to have a period. Now, what's really important to know is this is entirely optional. Patients do not have to have this pill break. And in fact, for a lot of patients, it's really beneficial to just take the pills continuously, to not have a break. The reason that I've been told why we have a pill break is because the inventor of the contraceptive pill believes that if it follows the natural cycle and patients still had a period, it might be more acceptable to the Catholic church which is against contraception. Whether or not that's an old wives tale or not. I'm not too sure. But the main point here is the seven day withdrawal bleed is absolutely optional. Some women prefer to use it because it means their bleeding is a little bit more predictable. Whereas if you do just take it continuously, you can have a bit more spotting but patients do not have to take that seven day break. And that's really important to remember going onto your mini pill. You just take that everyday continuously. There's no withdrawal bleed. Most of them is under the brand name Serosa. It's Destrol that has a 12 hour window. So if a patient normally takes it at 10 a.m. they can take it any time the next day up until 10 p.m. However, the old style mini pills, um they have a three hour window. So that means if they're meant to take it at 10 a.m. and then they don't remember until 2 p.m. that counts as a missed pill. And that has really important implications for when you're thinking about the missed pills like later down the line, then you get onto your longer acting ones. So your patch, you replace every seven days, the ring, it lasts for 21 days and then you can follow it with a seven day break. Similar to the contraceptive pill. The injection, you would have that redone every 12 to 13 weeks. The implant lasts for three years and then for the coils depending on the brand and the purpose. The hormonal one will last for 3 to 8 years and the IUD will last for 5 to 10 years. So that's kind of an overview of how long they last. So next slide, please. So this is going to be a table of effectiveness. So again, this is really not something that you have to sit there and memorize on the UCL MARK schemes. It's very much an excellent candidate will be able to tell you the numbers. It's not something that's like high yield. But does anyone know what the most effective contraception method is on all of these, on the table? Vasectomy? Any other ideas? Copper coil. Yeah. So these are all, these are definitely the answers that I hear the most. It's like, well, of course, it would be serialization but it's not if you the next slide, please. So what you can see is it's actually the implant, the progesterone only implant, which was a surprise to me as well when I found out, but it's a really effective method of contraception. So what's really important to look at here is the difference between typical and perfect use. So typical use really varies from perfect use quite significantly when there's a degree when the patient has something to do effectively. So you can see the difference is really quite stark for the pills, the oral contraceptive, the combined contraceptive and the mini pill. Whereas for something like the implant and the coil, it's a lot less variable. Um So you do have to remember that when you're talking to patients. So if I was counseling someone on the combined pill, I'd say if you take this at the exact same time every day, only 0.3% of people will get pregnant unintentionally within the first year of yeast. However, the way that most patients take it 9% will. So you have to explain that something else that I think is really important to point out is when you look at the data for the sterilization. So not only is a vasectomy significantly, sorry, not significantly, I'm exaggerating slightly, but it's more effective than female sterilization. It's also far less of an invasive procedure. It's less risky, less time off work. So men, you know, it's a lot easier for men to get a vasectomy than it is for women to have achievable ligation. So that's just something to bear in mind as well. So uh go on to the next slide, please. So while I'm talking, please pop any questions in the chat and I'll either say if we're going to get to it or we can answer it then. So with the mechanism of action, you can go through each of the types of contraception and memorize them all individually, but most of them are quite similar with just a few exceptions. So I think it's easier just to kind of look at what contraception does in general and then think about the exception to it. So, but largely what hormonal contraception does is it inhibits ovulation. It thins the endometrium. It thickens the cervical mucus and it reduces ciliary reaction in the fallopian genes. So the reduction of ciliary reaction and thickening of the cervical mucus that serves to make it harder for sperm to get to the egg thinning of the endometrium prevents implantation. And then if ovulation is inhibited, there's no egg, there can't be any fertilization. So the kind of exceptions to this is most of. So when you look at the mini pill, the progesterone mini pill desogestrel is quite good at inhibiting ovulation. So that's the one so rosette with a 12 hour window, the older style ones less. So they're still good contraceptives because of all of the other actions, they just have less of an action on ovulation. The Mirena coil, it does inhibit ovulation in some women, but it doesn't in others. Now, it's a very, very effective contraceptive method because of its kind of action on the endometrium and the cervical mucus and all of that. Um I think though the reason why I'm pointing this out is because of one of the main side effects of the Mirena coil. So in quite a few women, it will predispose them to develop ovarian cysts. These are not particularly serious in the majority of women, they tend to self resolve after a few cycles. But in some women, they will become large enough to require surgery because they increase the risk of torsion. So to me, it kind of makes sense that if a Mirena coil inhibits ovulation in some women, but we don't really know which ones, then it makes sense that it might make the ovaries go a bit haywire and produce these cysts. It's just kind of how I remember it in my head then looking at the copper coil. So this one's really important because it does kind of obviously it's not hormonal. So it doesn't have the same effects on ovulation in the cervical mucus. And all of that, it's copper itself is toxic, toxic to gametes. So both the egg and sperm cells and it induces an inflammatory response in the endometrium. So this has the same effect as thinning. It, it prevents implantation. But I think it also explains one of the main side effects of the copper coil, which is that it can make periods significantly heavier and significantly more painful. So you kind of have to think if it's causing inflammation on the uterine lining, then that can explain that side effect. So it's a good way of remembering it. Ok, next slide, please. So when we're talking about side effects, you have to think about the common ones and the serious ones. When you're thinking about common side effects, it's really important to bear in mind that kind of the official side effects. So the ones that have been confirmed in research don't always match up to patients experiences. A lot of forms of contraception don't have significant research on them other than its safety, which is really important and its use in certain medical scenarios. So there's a lot of contraceptives that patients will say, for example, oh, it made me gain loads of weight. The research doesn't support that, but you do really have to listen to your patients and you believe in that. So when especially in kind of a GP setting, it's really common that patients will try on multiple forms or even brands of contraception before finding out what works for them, particularly in the combined pill kind of side effect profiles can vary really significantly between the brands but also how women respond to it. There's a complication here because with most forms of hormonal contraception side effects can be worse in the 1st 3 to 6 months and then they kind of settle down as your body adjusts to it. So, one of the real big challenges in practice is kind of balancing patient comfort and how they're doing with the pill with ensuring that they've tried it for long enough to see whether it's going to settle down. And I think you can probably imagine how frustrating that can be for a patient who is trying to find a contraceptive pill and they've given each one of them 3 to 6 months and they're on their third one and it's not worked. So it can be quite difficult, I think, to manage patient expectations there. So it's really important to bear in mind. A patient's experience can be quite different to what the literature reflects. Sign back slide, please. So again, when you're looking at side effects, um you know, just remember, of course, this is mostly about hormonal contraception. Um but the important ones that you need to know about is your kind of general common side effects. It's really frequent that women will report headaches, nausea changes in their mood. They may experience weight gain breast tenderness or even breast growth and then skin changes as well, particularly with skin changes in mood swings. A lot of patients will also go on the pill to try and address those in relation to their cycle. And definitely some forms of the oral contraceptive in particular are really, really beneficial for that. But equally it can go the other way and cause those problems as well. And then more specific side effects that you need to be aware of. So with any form of continuous contraception, so your mini pill, your coil, your implant because you don't have a pill break with a scheduled withdrawal, withdrawal bleed and some patients will experience irregular bleeding and spotting. Um often with these, the periods will entirely stop. So the Mirena coil is the most likely to do that followed by the implant. But in many women, they will just spot or irregularly bleed throughout. Um Depo Provera. So that's the contraceptive injection. That's notable because it's got an increased osteoporosis risk compared to other forms of contraception. So that's really important to consider when you're thinking about prescribing to a young person. And in many clinical guidelines, there will be a time limit on the amount of time, they're allowed to have that for the Mirena coil as we've covered can cause an increased risk of ovarian cysts and the copper coil can lead to increased pain and increased heaviness. So, those are the important ones to remember that. Cool. Thank you. So, if you move on for me, thank you. So then when you're thinking about complications of contraception, there are kind of three main areas that you need to consider. So procedures, vtes of venous thrombo embolism and cancer. So of course, it is not a guarantee that a patient is going to have any of these. And they don't all apply to every form of contraception. But when you're in an OSC station, thinking about what complications do I need to talk about, think about procedure, cancer and VTE. So with procedural complications, this is mainly around the implant in the IUD I US. So you have to think if you're putting a foreign object into the body, then you can get an infection, you can get pain at the site. If you're putting something into the uterus, it's rare, but you can cause a perforation. So those are your main problems there with VT E, we're gonna go through that a bit more, but this is about your estrogen containing contraceptives. So your combined pill, but don't forget it's also your patch and your ring. And then for cancer on the next slide, please. So with contraception and cancer, most research concerns the oral contraceptive pill. Um It's not been looked into so much of the others. And remember your Mirena coil is used to help prevent endometrial cancer. But most of the questions you get asked will be around the oral contraceptive pill. So, what you need to remember is the oral contraceptive pill, increases your risk of breast and cervical cancer and decreases your risk of endometrial and ovarian cancer. So, a good way to remember that is it's alphabetical BC goes up, eo goes down and with that increased risk. After 10 years without taking that form of contraception, the risk will go back down to normal. Um So that's for breast and cervical cancer. After 10 years of not taking the pill, it will go back to a baseline. But once you've been taking contraception, your decreased risk of endometrial and ovarian cancer that stays because it decreases the number of times you've menstruated and ovulated. So that decreased risk persists. So that's something important to counsel patients on. OK. So moving on, please. So you have your contraindications. Um So if you want to look at this in detail, you need to look at the U KMC grid. This has a huge list of all of the possible contraindications, but there's some really important ones. So these are very frequent ay questions or in particular SBS, they can try and catch you out. So remember with BT, we're thinking about the estrogen containing contraceptives here. Um So the important ones, I've underlined the ones that are absolute no nos, they're absolute contraindications and then the non underlying ones are like it's relative. So, if a patient is under six weeks postpartum and they're breastfeeding, you cannot prescribe the pill if they are, if they're a smoker over 35 years old. And in particular, if they're smoking more than 15 cigarettes a day cannot prescribe for if a patient is obese. So their o their BMI is over 35. That's a relative contraindication. If they have a personal history of VTE E, you absolutely cannot prescribe it if they've got a first degree history. So their mum or their sister had it under a certain age, then you should think about alternatives. Very, very common is migraines with aura. You cannot prescribe or um combined contraceptives to patients that have migraines with aura and if they are hypertensive and it's not under control. Um So in particular, if their BP is over 100 and 60/100 you cannot prescribe with cancer. If they have current breast cancer, then you absolutely cannot prescribe the oral contraceptive pill. If they've had it in the past or they're a known bracket carrier. It's a relative contraindication. In some rare cases, it may be permitted, but most patients would prefer not to anyway, especially with so many other forms of contraception available. Ok. Same anything. So, drug interactions. Um This is not the most exciting part you have to remember. But again, it can be quite a good s va question. Hormonal contraception can be affected by enzyme inducing drugs. Um The ius in the injection aren't really affected by this. So patients on these drugs can have a Mirena coil and in some cases debe injection. Um in particular common ones that will come up in exams, your anti seizure drugs. So, carBAMazepine, topiramate pterin some antibiotics. So your rif antibiotics, rifampicin some HIV medications. So ritonavir and then Saint John's wort as well, kind of just Saint John's wort interacts with everything. It's important to consider is the medication Teric. So if patients on topiramate, for example, then that's another important consideration and they need to be on like a very effective form of contraception such as the copper coil. Ok. Moving on. And the last thing I'm going to talk about is that your missed pill rules. So for this, we're going to start off with the mini pill. You need to think about which pill is the patient taking. So most patients are going to be on desogestrel and remember that's got a 12 hour window. But the other one, the traditional ones, there are a three hour window. You need to ask, has the patient had unprotected sex? So this is how you evaluate whether or not they need emergency contraception. Say if um if you find that emergency contraception is not needed, then what you need to do is take the missed pill ASAP and then you take the next pill at the usual time. So it's not, it's fine if you have to take pill on the same day, you then just continue with the rest of the pack like usual um taking extra precautions. So you're using condoms for the next 48 hours. It's really important to remember. You have to apply these rules when patients are in there and diarrhea and vomiting as well. So general rule, if a patients vomited within three hours after taking the pill or if it's persisted for over 24 hours apply these same rules. So these are your rules for the mini C and then moving on to the combined pill. So this is slightly more complex. That's still very doable. But a very common question, if you've missed one pill, it's fine. It's due, you just take it straight away and then you carry on as usual. If you've missed two or more, you take one immediately and then carry on as usual. But you have to take extra precautions for seven more days. So your body is con ons for seven days and then there's additional rules depending on what week of taking the pill they're in. So if it's a week one, then you have to consider the use of emergency contraception. If they've had unprotected sex in that week, or if they're taking it with the pill free interval in the previous pill, free interval. In week two, you don't have to take any additional precautions. It's fine if it's in week three, all you have to do is advise them to run the next pack straight away to take it continuously. Skip the pill free interval. Theoretically, patients would be entirely protected if they just take the contraceptive pill week on week off, week, on week off, patients don't do that. But that's why in week two, you don't need any additional precautions. So we're gonna have some SDA s on that at the end. Um But if not, I'm gonna hand back to you Maria, but please pop any questions in the chat and I can answer them as we go. Ok. Thank you, Izzy for going through that. Um So we're now going to do emergency contraception. Um So what do you need to know about emergency contraception? We're going to go through all of this today. The main thing you need to know is that it's very examinable. OK. So there will be questions that would come up in your written paper and there's a very high chance it'll come up as an AUS station, especially when you're doing your specialty year, which is fifth year in UCL um for our mocks last year in MOD B, we had a emergency contraception counseling station which we're going to go through at the end as well. Um So this is very examinable just to emphasize that. So we're gonna begin by talking what are the three types of emergency contraception? And which one is the most effective? So, if you can in the message, write down what are the three types of emergency contraception? And in a way it's much easier than regular contraception cos there's only three things you need to know. So, feel free to pop it in the chat, either one or all three. Yep. Good. So, the copper IUD. Brilliant. That's one. Yeah. Very good. Exactly. So you have your Luprisol and your Levonorgestrel. I'm not gonna call those names. So I'm just gonna say LA one and Levanil. So these are your three types. Very good. Also known as morning after pills in the case of the pills or the copper IUD. The gold standard is your copper IUD. So you should always encourage your patients if they can get a copper IUD to get one because that's the best way of protecting yourself against pregnancy. Um But otherwise, obviously, it depends on many factors and as well as personal preference. Um You can also give oral um morning after pills. Good. So let's talk about how these work. So in a way it's quite easy. So the oral contraceptive pills, they work by delaying ovulation by five days. So, um and what we'll talk about why that is later on and the IUD work by preventing implantation. I think Izzy's already mentioned that as well. So um important to note that oral emergency contraceptive pills do not work. If ovulation has occurred, you cannot delay ovulation if ovulation has already occurred in that cycle. So bear that in the back of your mind when we're going to be going through questions on emergency contraception. And if someone's presented to you in clinic and they've already ovulated, they cannot get oral contraception anymore. So the only thing you can recommend to them is a copper IUD. Hopefully, that makes sense. And lastly, this is a quote from um Jane, one of her lecturers who teaches us contraception at UCL. So she said you can have unprotected sex immediately when going home after getting a copper IUD. So um the mechanism of action and how long it takes for these to work um is slightly variable. And um but just to kind of emphasize that copper ID is the gold standard. And if theoretically if you wanted to, you could go and have unprotected sex on the way home after getting one fitted. So when can you give or fit emergency contraception? So for oral emergency contraception, the Levanil pill, you can give it up to three days after an unprotected sexual encounter. Um La one is five days. The way I remember that is LA, one A is four letters plus one makes it five days. Um Levanil, unfortunately, I haven't thought of a mnemonic for that one. But if you know, the LA one is five days, you can kind of work out the other one as long as you remember, one of them, the IUD is slightly more um annoying to remember. And that has these two rules which you can give or fit an IUD to someone if first of all, um they are, um they had an oopsy or an unprotected sexual encounter up to five days after the earliest ovulation predicted date. And we're gonna discuss that later or up to five days after the encounter has occurred. Um And we'll talk about that. Also another thing to keep at the back of your mind before we start going through questions is the earliest predicted ovulation date as your last menstrual period date minus 14 days. So if someone doesn't have a 28 day cycle, um which is often the case, for example, if you have 30 day cycle, then remember your earliest predicted ovulation date will not be 14. Um So take that into account when you do written questions and exams. And another sort of reminder implantation takes five days to occur after fertilization because um fertilization occurs. Remember, it goes through the tubes and it takes roughly five days to implant. So a lot of the basis of emergency contraception and how you might discuss this with a patient who has questions about it um is all based on these sort of considerations. So with that in mind, the boring, slightly boring things first. So just like any medication, there are special considerations for any medication. So, levanil is slightly easier. There's no medical considerations. You need to know you can breastfeed when you give someone levanil. Um The only thing you do need to know about is if they are taking enzyme inducers or if they're over 70 kg, you need to give them a double dose. That's the only consideration. Really la one. So remember this is the one that you can take five up to five days after. Um you cannot give, if someone is taking enzyme inducers or if they're asthmatic, you cannot give if they are breastfeeding and you need to wait for a week um before taking other forms of hormonal contraception, such as long term hormonal contraception, which as you talked about. So this is a slide from one of her lectures which has helped me to remember this. So if in doubt, love and just to rule it out, but I EDS have more clout. OK. So if you're ever in doubt, if you have a patient who, for example, um if it, if they fit within that three days and they prefer to have oral contraception, then it's very much safe to give loven L. Remember lo one has more special considerations, but you should always encourage conversation about I EDS if you can cause it's the gold standard. Um and just as a pneumonic for enzyme inducers, so scars. So smoking, chronic alcohol use antiepileptics, not all of them, but most of them rifampicin. So atb drug and Saint Johns. W which as he's already mentioned, all of these um should not be prescribed. Um Sorry, lo one should not be prescribed if a patient fits any of those categories. So, with that in mind, um yes, this is the other thing I wanted to say, oral contra um emergency contraception can be taken more than once per cycle. Um And a lot of people actually don't realize that. Um So this is something that you should be very open to with your patient and you can discuss this as well. Um The acu station that comes up the most um integrating all of this together is you being able to talk to your patient about the pros and cons of getting emergency oral contraception or an IUD. Um So a lot of it's self explanatory, you should always sort of promote IUD S if possible because they are the gold standard and they're the most effective. So if a patient wants the most effective method, but they don't mind doing a procedure, then IE D is perfect. Um And there's lots of other positives, for example, as, as you already said, it provides a 10 year contraceptive cover, that's what they would like. Um And however they can get it removed in the next cycle. Um Oral emergency contraception, it's obviously a one off tablet easy to take. There's no procedure involved, but it is less effective and you do need to always talk about um long term contraception and bring that up in patients and ask you if this is something they'd consider taking, if they present it to you with for a need for emergency contraception. Um IE D figures. So because it's a small procedure, um it comes with all the side effects which is is already covered. But also remember procedural sort of more surgical side effects. So, infection expulsion, perforation and ectopic pregnancies. That is something that you need to quote um in an OS you not so much, but mentioning a few of these would be very helpful to help your patient decide. Um So, uh because it's a PDF, unfortunately, um the box is slightly off but red flags. So always think about risk assessments. Um So always ask about S ti risk alongside um prescribing emergency contraception. So we've already um someone's already mentioned it in the chat, which is brilliant and also always assess risk at home. So that ties into our last topic of today as well. Um So in and ask you always think, you know, do what um you're told to do, but at the back of your mind, always think what sort of extra kind of nuggets can I put in? Um just to cover all my bases. I know I'm going quite quickly. Um So if you do have any questions, please pop in. As we said, this is a very interactive session. So feel free to ask. I'm rattling through quite quickly. But hopefully it all makes sense. So with that in mind, a bit more interaction. So if anyone can tell me what are the two things we need for pregnancy to occur? And this is not a trick question. I'm just testing to see if people are still awake. I don't think ha ha ha is. Yes, very good. So, sperm and an egg perfect. So when we're thinking about emergency contraception, first of all, two points, we need to consider um the sperm can survive for five days in the uterus. Ok. Whereas an egg has a 24 hour window in which it can get fertilized. So those are the two things that we're gonna be thinking about when we're answering questions regarding emergency contraception. Um and just as a reminder as we said, ovulation occurs at L and P minus 14 days. So with that in mind, if a patient presents to your clinic and is asking if they can get emergency contraception, what are the sort of questions you might want to know? Might want to ask um what information would you like to know about this patient to help you assess what kind of methods of emergency contraception they could get? Yep. Good. So, when did they last have sex? So, yep. So we want to know the date of the unprotected sexual intercourse. But also um if it's already happened more than once in the cycle, remember. So we need to know every single time it happened? Good. When was the last menstrual period? How long the cycles are very good. When do they last? Have it good? Do they use contraception? Very good. So, are they on long term contraception already? Um have they had emergency contraception during the cycle? Good. Although remember, we can get it more than once in a cycle anyway. Um but yes, absolutely. But that might um encourage you to have a more thorough exploration of, for example, long term contraception that might work for that patient. Um So, yes, very good. Most of these have been mentioned already. So are you on any contraception currently date of your last menstrual period which remembers the first day of the bleed other things about um their cycle. So, cycle length is a regular. Um Usually, how long is it, is it heavy? Is it painful? Is this one particularly heavy? Is this one particularly painful um within this cycle? How many times have you had unprotected sex and the date they're presenting today in relation to their last menstrual period date? So, what that allows you to do is to plot this line? So what I want you to do is get a piece of paper and a pencil because we're gonna be plotting a few of these and this is the best way to answer these questions. So hopefully you have it on hand. So essentially you're plotting a number line which the end number is. Um So the 20 here is the their cycle length. So remember, not everyone has a 28 day cycle. So you might have to change that accordingly. From that. You can calculate their ear earliest ovulation predicted date, which remember is their cycle length minus 14. So in this case, it's 14, you want to know the date today. So that's in green and day 1 L MP. And once again, opportunistically always ask about red flags. So any intramenstrual bleeding is this current cycle heavier than usual, more painful than usual. Do you get any postcoital bleeding or pain? Um Always ask about smears. So, first of all, um have you ever had a smear test before? What was the result of your previous smear test? And has it ever been abnormal? Um Additionally, risk assess. So, um do you feel safe at home? Do you feel safe in your relationship? Ok. So always use opportunistic questions through acies to gain extra marks. And as we said, always consider long term contraceptive discussions. So um to give you a better insight into copper IUD D rules cos I found them really confusing at first, remember, um you can give a copper IUD D in these two instances. So up to five days after the earliest ovulation date or up to five days after the sexual encounter. So if I'm drawing this on this line, then it'll be I can cover someone with a copper IUD D if they present within those five days from their ovulation, um which is the first red arrow and then the second red arrow is five days after whenever their unprotected sexual encounter was, um which remember can also occur after ovulation too, which is not the case with oral contraceptives. OK. So, um let's discuss this case. So hopefully you have your pencil and paper on hand. So case one, what would you do here with regards to a copper IUD? So for example, a patient has presented today stage 26 they have a 28 day cycle. Therefore, their ov predicted ovulation day is day 14 and they had their unprotected sexual encounter on day three of the cycle. So what options do we have here with regards to copper ID? Remember bearing this in mind? So have a have a think about what you might do. Um Is she eligible for a Cooper ID? And if yes, then why? Yes and if not, then why not? So yes, a copper ID can be fitted immediately. But remember um the two times you can um fit them in is either five days after the cancer or five days after her ovulation day. In this case, she is not taking any of those rules, right? So she's not fitting into both of those boxes. Unfortunately, so the only thing that you could say in clinic is unfortunately, you are not eligible for emergency contraception. So in this case, we would ask you to do a pregnancy test in three weeks, you might um then ask, you know, um potentially if she has any thoughts, any feelings on that. Um What would she do? Um If she has any thoughts about what would she do if either outcome was the case? Um So remember at this point, implantation has already occurred because um copper IUD DS, they prevent implantation. And remember it takes five days for implantation to take place, which is why these are the five day rules of copper IUD s So unfortunately, in this case, we cannot prescribe her a copper IUD. So hopefully, that makes sense. Um So just generally, now, let's think about this next scenario. Um If you do have any questions, feel free to pop in the chat and I'll answer as we go along. So this again as a patient who has a 28 day cycle. So her ear earliest ovulation predicted today is day 14. She's presenting to you today at day eight and her unprotected sexual count was on day six. So what options do you have here? And what could you prescribe? So have a think about it, draw it out if that helps draw your copper IUD arrows. Consider other forms of contraception if for example, she did not want to get procedure. Yeah, so good. Definitely. Um Copper ID can be prescribed. Very good. Exactly. So you can give Copper ID because if it's that first rule, absolutely right within five days. Um, perfect. So, as long as if it's 11 of those rules of the Copper ID, um, if they're happy, they can get a Copper ID in clinic. And remember if they wanted to, they can have unprotected sex on their way home. Um, but absolutely. Right. You can also get, um, oral contraception, um, because remember they still haven't ovulated yet. Um, and with regards to what kind of oral contraception. So we're thinking about the two options, Levanil. So that is three days. So technically, it's day two when they're presenting. So that would be eligible or it could be lo one within five days. So very good. Um So spot on how would this change if they presented on day 10? So in that case, what would you be able to give them? So imagine this green sort of today pillar, it's just day 10 rather than day eight. So in the interest of time, I think I'm gonna move on. Um But basically, if it's day 10 and the encounter was on day six, so they no longer can get the leel pill. Ok. So they can still get the copper IUD and they can still get LA one because remember L1 is four plus one, which is five days. Um So they can get two forms of emergency contraception. Hopefully, that makes sense if they have a past medical history of asthma. So remember if in doubt um Leel it out. Um, so if they have asthma, they can get leel but they can't get lo one. Ok. So my first SBA um, is here, what I would like you to do is using your piece of paper, draw out your timeline with this information. I'm going to put this out as a pool. Um, and if you can vote on the poll, I think you need to exit the full screen in order to see the poll. So I'll start the poll now and hopefully you could see it. So please vote when you have a chance and I'll set a timer for 30 seconds. Ok. So um I'm going to go on when I get 10 responses. I'm seeing seven at the moment. Ok, perfect. So, um this would be your timeline. Ok. So first of all, you need to draw every instance of um unprotected sex. So in this case, it's day seven and day 13. So, um this is a bit confusing cos it's 28 to 31 day cycle. I'm not sure why. Sorry. And she's presenting day 18. So in this case, um you can fit an IUD because this rule is covered here in this case. Um You do not need to give emergency contraception cause remember, sperm um stays alive for five days, but they haven't ovulated yet. So there's no way that that perfect um pregnancy recipe can occur. So you only need to cover for this instance at day 13. Hopefully that makes sense. Um So last but not least a case, this was our mock station in Module B last year and it was about um counseling someone on emergency contraception. So, Stella age 30 has requested emergency contraception. She's been seen by the nurse. So she's had unprotected sex four days ago. No other sex in the cycle. Last menstrual period was 14 days ago of a regular 28 day cycle. One male partner of three years negative SDI screen, usual contraception is condom. So, automatically you're thinking of um maybe some long term contraception um discussions if that's what the patient might be interested in. No past medical history and weight below 70. So you scan this through. So what I want you to do is based on this paragraph, draw your um timeline of on your piece of paper of how this might look and what options does Stella have. So once again, I'm gonna say 30 seconds. Ok. So hopefully, um that should look something like this. So, um Stelle is presenting today technically of day 14, which is the same day as um her earliest predicted ovulation date. Um The unprotected sex was four days ago. So day 10, she has a regular 28 day cycle. Um So remember the two IUD rules. Um So she is eligible for an IUD because it's within five days of um yes, f sorry, five days of the unprotected sexual encounter. So you're rule number one. So you can talk about IUD S. But additionally, um what other forms of, of contraception might they be eligible for? So it's yes, very good lo one. So they're presenting um four days after. So remember the five day rule. So this is your ay um this was our Osk Mark scheme here. So you'd open the consultation as normal. What if Stella asked? I really don't want to get pregnant. The nurse said you'd be able to discuss options I have. So that would just um explaining to Stella the two options that she has from based on what you've figured out. So that would be an IUD or an L1 and explaining that she's too late for a NL now because that has a three day limit. And then she asks, I would like to know more about the most effective method. So what might you say to that? Which one's the most effective out of the two of those? Yes, very good. So your copper IUD D is your gold standard? If you quote um feel your rates that would be even better. Um But good. So lots of copper copper coils coming through in the chat and then if she asked, um can you tell me more about the coil, please? Are there any side effects with it? So you should all be experts by now because Izzy is giving you a fantastic lecture on um copper ids already. So you talk about how it works. So remember copper I EDS work by preventing implantation, oral contraceptives work by delaying ovulation. So you only have two routes. You could go down. It works for 10 years. You could use it as a long term contraceptive as well. So you're taking two boxes there if you want to start talking about long term contraception too. Cos remember they only use condoms with their partner main side effects. So all of this is, is covered already and then addressing concerns. So thanks for all of that, isn't having a coil fitted the same as an abortion. Can I come get it fitted the next day? So, is getting the coil fitted the same as an abortion and why Cha's very silent? Ok. So, um exactly. No, because it prevents implantation, very good spot on. So, absolutely, it prevents um implantation from occurring. So therefore, um usually, um the consensus is is that it's not an abort efficient um procedure. Um And remember when she's presenting, so, can can I get it fitted the next day? So she needs to get it fitted within five days and she's presenting in four days. So that might be a little bit of communication skills to explain that actually, you have this time limit which you can get it fitted. Um But if you want us to speak to your partner or if you have any more information, obviously give you leaflets, et cetera, et cetera. So, hopefully that's given you an idea of how this would come up in a, a scenario. Um Yeah, that's me. If you have any questions, feel free to pop in the chat, but otherwise Izzy is going to speak now and I can answer in the background. Thank you very much. Thank you so much. Um, so I'm aware we're going slightly over time. It's quite a big topic if you do need to go, that's completely fine. Um But you will have been emailed a feedback form. So please do fill that out. It's really important and it's really useful for us. Um Just before, so I've only got a couple of slides on this and then we've got three Bs that we can do. And just before I move on though, just kind of a point for when in practice something, I've seen a lot from kind of speaking to women in clinic is when you ask, how long is your cycle? Sometimes you get a really short answer like it's 20 days or it's 18 days. Some women do have cycles this short. But a lot of women for some reason think that when you're asking how long their cycle is, you're asking how many days do they not bleed for? So if you are asking this question, you get a short answer, just follow up with a clarification. And so how many days is your period? How many days do you not bleed for? So, from the start of your first period to the start of your next. Is it this many days? That's something I found really useful while I'm kind of talking on the walks in an ay they'll know. So, moving on to domestic and sexual violence. So the reason why we've put this in is because it's a huge topic, it's a massive issue, but it also comes up in UCL exams, you'll get some really useful teaching on it. But it was one of our actual stations last year. So would recommend going to the teaching and revising it. So I'm just going to talk about it quickly. So next slide, please. So domestic and sexual violence is, it's a horrifically extensive issue. So one in four women in the UK who have experienced rape or sexual assault um and domestic violence stats are, I think it's about one in seven. Um Part of the reason why it's important is because women who are experiencing domestic violence, they're at higher risk of sexual violence and they seek emergency contraception more frequently than other women. So in any kind of sexual health or s and going in consultation, you have to ask about whether they feel safe at home and whether or not the intercourse was consensual, it can be a really difficult thing for a person to say it without being asked. So they make sure that you're asking it sensitively but directly to the next slide, please. So when it comes to kind of thinking about why it's important in practice. Remember that the effectiveness of the combined pill and the mini pill, it relies on the patient being able to take that pill every day. Contraception, in abusive relationships, it can be controlled, it can be restricted, it can be tampered with for multiple women. The first time they ever hit by a partner is when they are pregnant. So pregnancy is a really, really vulnerable time for a lot of women. And so if a patient wants to make sure they have contraception, but they are worried that that access might get blocked or it might get tampered with, then it can be a really, really good idea to consider offering a lock. So an injection, an implant IUD or I US as well as signposting to further support. So that further support includes referring to charities ensuring you're talking it through with a senior. If there's Children in the mix, you have to consider referring to safeguarding as well, it's difficult to help someone that you know, that refuses help. You have to consider whether or not you're meeting the threshold to get the police involved. But for the most part kind of just make sure you're contacting that senior. And if you ever get told something along the lines of domestic or sexual violence as a medical student, make sure you are telling the doctor and that you're not keeping that to yourself. So, um that's kind of all we needed to say on this topic. Sorry to kind of end it on a heavy note, but it is really important to consider. So if we go on to the next slide, we've got a few sbs that we can go through to kind of refresh your memory of the regular contraception part that we were talking about at the start. So I'm just going cool. Thank you so much, Emery has just launched the poll. So if you put that in and then we can go through just waiting for a few more responses. Perfect. So you're absolutely right. Um The correct answer is the Mirena coil so well done. Um So that's the Mirena coil is the method that is the most likely to stop menstrual bleeding. Um The contraceptive implant would be a good alternative. It's slightly less likely to, but it can help with severe period pain and very understandably, some patients are quite nervous about the idea of the procedure that goes along with the coil, continuous use of the um kind of contraceptive pill, it certainly can work. But like I said earlier, if a patient is interested in the lark, never dissuade them otherwise. And it would be a little bit more irregular at inducing amenorrhea and the copper IUD while it's very useful would avoid in severe period pain because that will get exacerbated. So, moving on to the next one. So if you have a look at this one pale will just come up. So we're 5050 at the moment. Copper copper, IUD Justin, you had so perfect. You're absolutely right. So the copper IUD is the correct answer here. So the reason is you kind of there's a few different things you have to look for here. So the patient experiences migraines with aura. So that immediately rules out the copper, the contraceptive pill, there's a bit of a mismatch. One of the poll answers has been uploaded as a patch, but on the side, it says implant. So the contraceptive patch would absolutely be incorrect because that's also contraindicated with migraines with aura. So then that leads you to the other answers. So the progesterone only pill. So you can use this in migraines with aura. However, she is taking topiramate for migraine prophylaxis, topiramate is an enzyme inducer. So that's um it's an enzyme inducer and it's teratogenic. So you have to be really careful in these patients. So enzyme inducers affect the mini pill, the progesterone mini pill. So you can't give the mini pill in this patient. You could consider giving the contraceptive implant. Uh No, sorry, you can't, you can't also give the implant with enzyme inducers. Remember, you can give the copper coil because it's non hormonal and you can give the Mirena and you can give the injection, you can't give the implant. So, therefore, the best option for this patient in terms of the options given and overall is the copper IUD. So next question please. And the last one, so I have a go at this one just waiting for a couple more answers to see if they come in. Perfect. So we've got a bit of a split, split answer set here. So next question, please got one for all four. So the correct answer is D emit the pill free interval. So what we need to look for here is she missed day 17 and 18 of her combined oral contraceptive pill whilst on holiday. So it's a combined pill. So you know that the the missed pill rules, you have to apply differ for the weeks. Now, week one is from um day well, 1 to 7, sorry, this patient is in week three of her pill. Um So what you would want to advise would be to admit the next pill free interval. Uh No further advice would be needed if the patient had um was in week two. You would want to consider the use of emergency contraception if she had had unprotected sex in her first week or in her previous pill free interval. Um taking a pregnancy test in three weeks time. I mean, it's entirely harmless. So you absolutely can kind of tell the patient to do it um if they're worried, but this is a single best answer question and the single most important piece of advice would be to emit the next pill free interval. So that's why that's the correct answer. So uh next slide, please. So if you saw this patient in your clinic, what else would you need to consider? Well, really important whenever emergency contraception might be needed, you have to assess sti risk. So make sure that you're considering that as well because it's very easy to kind of get stuck in one line of thought and forget about the rest. OK? So that's all of the S VA S that I had. Um So next slide. So thank you so much for watching everyone. We hope that you found this useful and that you enjoyed it. Please fill in the feedback form for us that also me, Maria will be hanging around for the next few minutes just so you can ask any questions that you might have as well. Yeah, thank you so much for spending your Thursday evening with us. Um When you fill out feedback, um you need to indicate the name of the tutor. So it's Isabelle and Maria. Um That'd be great. Thank you. You've got a question here. So why do you need to assess risk when giving emergency contraception? It's a really good question. Um The reason is if a patient is wanting emergency contraception and it usually means it's because unprotected sex has occurred. Um So when there's been unprotected sex, there's an ST risk. So it's also just getting you in the mindset if it's because a patient has forgotten to take their pills when they've been having sex with their husband and there's no sex outside of that relationship. They're much less likely to need any ST I cover. But it's good practice to always be considering it to make sure that you're not missing any cases. Um So that's the reason why they, I just had to say it. Please fill out the feedback form you're putting in the chart. It's really helpful. If you put it in the feedback form. There you go. Do you guys wanna stop broadcasting now? Yes, thanks. All right. Thank you so much. Have a good Thursday evening. Thank you guys for attending. Um How do I stop recording?