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either slights now you never One c should stop. Oh, it went back to I think it went back to my old screen. Yeah. Here. Yeah, that's fine. Just off. Yes, you can thank you everyone for waiting. Okay, So my family started. Sorry, guys, for the delay, Um, quantity on trap the technology and stuff. If you have any questions, just kind of shout out or you make the end if you want, which have write up mind And so my name's and up in one of the f c fools ups and garni ST Fools in Wigan And you could do a quick whistle stop tour through contraception because it is it is a huge subject. And it's not I'm not sure. I mean, there's just so much There's just so much fell trying to pick a few things out that might be important or interesting or something that we could go through. So what we'll go through State is the UK Met criteria, different types, contraception, postpartum conception, emergency contraception and a few drug interactions as well. So does that one. Have anyone heard that you came at criteria? Yes. No. Maybe I open this and see if he plants him on the group, we've got some. Yes, it's in some nose. Okay, so I'm just looking back, you know, if I can get chart on my phone, did you can I hear everyone else in this group and everyone I know they put the microphones off, so it's just going to use the trip, but it to speak to you, right? Let me just get this on my phone. And so I can use a chocolate thing anyway, So you came a criteria is generally what we use in the UK for working out whether contraception is suitable or not suitable. So basically, there's four categories. Number one is one that you can use freely. There's no restrictions and no problem using this conception for this patient Number two there are, you know, you think that they're asked The patient might have a background of some conditions which may make you think, Think twice about contraception, but overall advantages outweigh the risks. Okay, you can make three. Generally, the risks outweigh the advantages. But if you really, really want starts contraception, you should probably get senior adviser consultant advice. And number four is completely unacceptable. Basically Yes, maybe. Yes, yes. Maybe. Maybe yes, maybe No. On the no. Essentially. So you came across, You commit guidelines. A huge there's, like, 11, 12 pages off just of tables and tables of what's appropriate and what's not appropriate to prescribe. But generally the ones the important ones know or what? You can't give him what you kept. Definitely can give just, you know, for your daily practice. And so these are some of the UK McFaul, um, criteria. So, for example, just pick one out at random. You can make for prescribing the combined or contraceptive pill for migraine with aura. That would be you came back for? Absolutely. You should really do that. Any questions? Over? No. Yes. Did your calm surgeon look into the thing on my phone? So you know, you can carry on. We can have. We can have them for all the questions in the group, and then we can see it at the end. Okay, so this is like a set you got 11. 12 pages of you came in guidelines, and this is the You came back. And this examples of how you came back, you set out basically. So you got your conditions and column down the left. And then you got your different contraception stuff. And whether it's 123 or four, there's loads it ranges. Remember, think from postpartum to call your mom pathy. These are some different types of conception, so try to put pictures of ones that actually are not common. M see whether you've seen them before with you know what they are so came out with, um, ounces. Uh, I have not loved into the middle of my phone yet, so I can't see the chance. If you guys were taking my cough and shout out what you might call a shower cap would be great so they won't know what this one is. Are you on no Co? Any answers in the group yet? What's this? NuvaRing? Someone's answered. NuvaRing and vaginal ring? Yeah, absolutely. Is a vaginal ring. Correct. What about this one here? Anyone? This one, Someone's mentioned female condom? Absolutely. Yeah, they don't. These the ones. We don't really see that much, to be honest on about about this one. This one's not as hard. What's that one? We've got several seeing patches yet. And do you think the patches are combined or contraceptive or progestin only contraceptive. We've got Beverly saying combined gap perfect on this one. Always cook. Oh, it's got a name on it. It's died from? Yes. So those are for that, I think are less common. You don't see them as much, basically. But you different types of hormonal. So, guys, take put in my front on, please. On. You just shout out any hormonal contraception. No one, they have no more. Okay, I'll put in a drop in yet. Perfect. Combined. Well, that's what The whole month of my kids. Yep, Yep. Got combined. Got professional appeal. Next one on my arena. Perfect. Yeah. You guys are basically got them all. And then we've got their injection as well as the death of Provera injection. What? Non hormonal contraception couple coil Yet yet? Copy coil condoms. Diaphragms. Perfect. So? So let's put the ring here. Another vaginal ring actually contains hormones is a combined hormonal vaginal ring. So what else we got? Barrier. Couple coil. What's it? What's it? Mm. It's a marker that we don't talk about as much in obs and Gynie natural rhythm method. So that's, you know, Montreal relation and you'll and temperature and things like that. Yet someone mentioned here natural method vasectomy Perfect. You guys have got it. So failure rates. So when the quote failure rates for contraception, we have to look at the typical use in the perfect use. So perfect use. It's quite different. Typically, it's just look at example, for example, the c O. C. P. The most common contraception method using the UK Perfect use actually perfect use. It's no 0.3% failure rate. Okay, so if you use it perfectly, 99.7% effective. However, the average woman uses the combine all concept of pill in a way that gives them a 9% failure rate. So it's very, very different. And if you look here the most, um, the most reliable contraceptives are your lock, your long acting reversible contraception because there's very little human error involved. For example, once you get your progesterone, are you CD and the typical using perfect use the same because there's no user error involved, and similarly for the progesterone implant is well, which actually has the best. The best success rate essentially. Okay, so you can see here the only knock. That has kind of a very significant difference in typical use versus perfect uses, the progesterone injection. And why do you think that is? Why do you think that is? Just just write down the track box was progesterone injection. What's typical use Got such a high six perfect Victoria? Excellent. So again, with the one of the few locks that has a user dependency. So that relies on the woman going to where she gets her periactin injection done just to go. They're kind of every 12 every 13 weeks. That's the whether you use every comes in because that will make sense. Okay, so let's go through each of the each of the methods of contraception a bit more detail. So the combined hormonal contraception, so that involves the pill, the patch, the vaginal ring. Okay, the most common use method in the UK The peers actually most common use method, but how's it works? It stops ovulation, thins and meet your lining and picking cervical mucus. So there's three things in combination should help prevent pregnancy, and generally, for the combined method, you take it 21 days on and seven days off cm. Seven day hormone free interval Generally, of course, some women in some situations they run, um, that combined form, a little conception back to back. That's, um that's a different places. Anyway, you can see this picture here, the actual effect off the combined conceptive pill. Okay, So, Ms Pill, this is when you get asked a lot. So it's really if you get out a lot in exams in real life, just by generally anyone who you see they were That's what, Mr Pill. So he's just examples off some. They're combined concept of pills. So if you miss a pill anywhere in the pocket all your late starting first part of the new pack it you just take the Ms Pill assume. Remember, even if you have to take two pills the same time you finish packers normal. Okay. Know, imagine conception. No further contraceptions acquired because you only miss war. Okay, so 11 missed a pill. But you remember Take, you know, and take it with the next one is fine. Okay? No, don't any imagine conception. However, if you miss two or more pills in the first seven days, so remember, with the combined conception, you're 21 days on. Then you're seven days off. So you got a seven day hormone free interval, Okay? And then, if you miss two or more pills in the first seven days of the new pack, then he has to take the most recent pill on the plan pill. And you need a medicine conception because you haven't had because you had a whole monthly interval. Somebody had seven days without hormones without conception and then to miss two or two or more pills. After that, your contraception methods are compromised, okay? And you will need to take a medicine conception. And he's very contraception for seven days now, if two or more pills are missed in week two or three. Okay, you take it most recent pill and you take the plant pill, and then you use barrier contraception for seven days. Okay? Now, the reason why you don't need emergency contraception for this case is that you've not just had a hormone free interval. You've not just had seven days hormone free. Okay? You back your you at least day, it's even least had seven days off hormones kind of as a backup. Okay? And and if you miss two more pills in the last week. Just omit the whole month free interval and when you two packs back to back, because that will make sense. Basically, at no point you should be taking more than two pills at any one time. Even if you've missed three, you only take the most recent one on the one for that day. We'll go through it all again if you have any questions at the end. You know, sometimes Ms pills bit complicated. So Mr Patch, so Ms Patch again So you have 21 days off your patch are many seven day hormone free interval. So if you start your patches lakes, you had more than seven days patrimony and some of this hormone free. You have to consider whether you need emergency contraception. If you've had unprotected sex in that hormone free interval, okay, that's first thing. Second thing is get a new patch on straight away and you bury contraception for seven days, so it's very similar to the pill. It's actually the principles now, if your patch has detached for less than 48 hours, or patch has not changed for less than 48 hours, that's fine. No additional action required. So basically, you'll see. Sometimes it's not really. Someone tells you that they notice that their patches for love or the patch has become detached from whatever activity the doing during the day. But I definitely had it on yesterday. That's fine, because it's been less than 48 hours that has been detached, even pop a new one on. Now, if the patch has been detached from or than 48 hours again, it's similar to the pill. So if it's in the first week, you need the most contraception and barrier contraception. And if it's a week to been three, you just vary contraception and stick a new patch on. Okay, so again, similar concept to the pill on the mist rings of that same of the MS Patch rules didn't have a question about Mr Pills. Ms. Patches. Ms. Rings just got it down in their trap box. Hollywood question. What if you have unprotected sex in the hormone free week? Do you need emergency contraception? Okay, so do you mean in general, just in case of Mr Pill Ms Patch. So if you holiday mean, if it's, um, just generally if you're good at taking a pill and you and your hormone free week least are you still protected? What do you mean? If you miss the pill? Okay. I'll just him, um I'll just come back for a question. Is when your price So wrist and benefits of the combined hormonal contraception. So does anyone know and your risk for benefits you can write in the chart. What? The risks of hormone combined hormonal contraception. Oh, yeah. Sorry. Hollywood part if you haven't missed any pills which need contraception a week? No. So you're you are protected in that week. And because you got you had the hormone on board for 21 days. So, actually, that seven day hormone free interval, you'll have a withdrawal bleed. Okay, so you know you're protected because your endometrial lining sure is shedding essentially in that seven day. So you remember. Your seven day hormone free interval is also when you get your period not taken. Compare it because you're not ovulating, but but ah, withdrawal bleed. Do that make sense? So we've got some answers here, but clot yet which is a very endometrial bowel cancer. Correct. Can improve acne. Perfect can potentially increase in breast cancer risk yet, um, treat heavy periods? Absolutely. The regular menstruation PMS perfect. So absolutely the treatment menorrhagia Dysmenorrhea PMS Endometriosis and PCOS. These things that all the help by the combined hormonal hormonal contraception. So it can be life changing for some women, and you're actually right in the reduce risk of endometrial ovarian and colon rectal cancer. Now you risk the risk of ET see you back for Mr CT is about 1 to 2 in 10,000, generally depending on what preparation used. But generally you SGBT is increased 9 to 10 in 10,000, which is quite a significant jump. And it's about 53 times higher than background risk and and also, you know, with enzyme dosing drugs like the family see. And like carbamazepine, you're the effectiveness off the combined or contract to pull. It reduces. You have to think about whether this is the right medication or whether actually, the risk of pregnancy is a lot higher with the enzyme and juicing drugs, and it also reduce the effectiveness effectiveness of lamotrigine, the lowest Caesar seizure threshold. So anyone on lamotrigine should not be given the combined or contraceptive pill because there are high risk of having seizures going forward and effectiveness of combines or concept produces. And women have had bariatric surgery last year. The absorption. Any questions about the combined pill? So So what's wishing here S t I Z? What do you mean by ST I? Because they're not doing it because we're not. We're not using barrier contraception, so you're still on to the progesterone only conception. So how does this work again? Inhibits ovulation for the most part. Sick and cervical mucus and correct implantation. And you got three types. You got your progesterone only pill. You got your implant which is your Implanon or your next one on on day You're listening. Only injection, which is your Depakote Provera injection was taking for 13 weeks. And I know the coil is in there, but we'll talk about the oil separately is into you tried device? Don't worry. So you take a pill to take it once a day around the same time. Now, the traditional pills you have to take, you know, within three hours of So if you took it at 12 o'clock today, the later she could take it tomorrow is three PM and that's like a push. Okay, it has to be at the same time every day. However, with the new newer and progesterone pills like the suggestion, the windows 12 hours, you got bit more. A bit more flexibility there. So the most common p o ps available the UK you got norethisterone levonorgestrel desogestrel. But they all have different brand names. There's a load of remains in Silicon Party reason, just some examples of brand names that are out there. But we will have the same mechanism. Okay, now the suggestion, actually the best It's suppressing ovulation. Was it? The pills are are 67% and success. It's at suppressing ovulation. I got a question here on the group of having a look. I was just wondering in week three, if you're taking the pill correctly for the 14 days before, why would you need to then use other contraception for seven days? Following is they're not 14 days of hormone on board that you have taken so would be protected. Okay. Yeah, yeah. So and yet you can you take you technically right? So we generally, if you've got seven days of hormone on board. Technically, you should be covered, but just for kind of to cover you. Because, remember, sperm can last in the in the AM in the female genital tract for 5 to 7 days. So if you then stop taking it and you're and you actually got sperm, the genital tract, you run the risk of actually getting pregnant after you've had intercourse. Does that make sense? Okay, so, Miss Pill. So this is we'll go through it again. So you, if you miss one pill that's more than three hours or more than 12 hours, you take miss a pill it soon as you remember, and you only take one pill. So with the mist progestin only pill, you don't take two pills at one time and you just take the only you just take that woman you've missed on. Then you have to use barrier contraception for two days after getting back on track with your Ms Pill on the use of murder conception. If you're if you've had unprotected sex after the missed a pill within 48 hours of restarting. Okay, so you've got a lot less time to play with, basically, with you missed a pill You're talking about 48. I was great. So risks and benefits off your progesterone only contraception. So it's very good in treating dysmenorrhea and menorrhagia. But it can, um it can cause a bit of irregular bleeding. Okay, Now it's got no association with increased risk of breast cancer on fertility. Comes back extremely quickly when you come off the pill. Okay, Um, now, the big thing is that it can be given to women up to 55 years old. Where is with combined all combined hormonal contraception. You wouldn't generally like to give it to someone who's over the age of 50. Just because you know your risk of ET increasing increasing sorry increases significantly as you get older plus giving you issues in the risk of ET the risk outweighs the benefits of off it. And now what people sugar with progesterone is. Sometimes you have quite significant new changes in weight game. Now, no causal link has been has been established with weight gain and progesterone only pill. But lot of people do report and do struggle with it, and then your risk temps a risk of that topic. Pregnancy full in, pregnant on p o p. Um, But message here. Are there any reports for contraceptive guidance? And what do you mean, reports? Okay, now it's going to the implant. So your implant is your long acting reversible contraception? You can see how big it is there It's like, Looks like a little matchstick. And it's licensed for three years. Um, it's about eight. It's inserted eight centimeters proximal to me like a condo of the humor. So about there in the picture, basically, you can see where it's inserted on DA Generally, they used to give implement, But now that they give next pill, Um, because if we weren't, if you can no longer feel your implant anyone of make sure it hasn't migrated or gone anywhere else, then actually, the next time, um, is radio opaque would be able to do some imaging for it. Initially, you released quite a bit of progesterone 60 70 marker once a day, then obviously it decreases as it as you get on. And by the time you get two year three, you're on 25 micro today, which is why we have to then, um, replace it so the risks and benefits implement, implement so it's reversible because he can take out easily when you take out fertility returns fairly quickly. It's also a very good option for dysmenorrhea, So progression really does help. Painful periods 20% of people don't have here is anymore. They become a Mandaric. Okay, however, 20% also have the implant removed because they have irregular bleeding that they just want it unacceptable. And generally that's the case for most professional only conception. It's the same for the coil, the pill, the implant and the injection. Some people have no periods, and some people have been accepted irregular being periods, and some people have regular light periods. Basically, just one has a little or no risk of ET, which is a major. Plus, if you're looking at someone who's overweight as a family, history is a smoker, any risk factor that might predispose and for VT, and you can also give the progesterone implant of four people who would be sub 250 kg, where is actually with the combined or combined hormonal you probably wouldn't get. You wouldn't give it someone who was that overweight because of the risk of Et Like I said before. If you're not able to palpate the implant, the new next, the lawns. You could do imaging and work out where it is. And if you can't see on imaging, he takes in each knee. Gestural. Okay, so you take a blood sample test each ogestral, which is the hormone in the implant. And if it's negative, the implant is, you know it's not in the body. It's migrated outside the body somewhere. It's made of the way out. And if it's positive, you have to think about doing MRI's to have a little look where this implant might be okay next. Progesterone only conception of got the injection. So that's generally we give the Depakote Provera, which is your iron injection. Okay, and it's given every 13 weeks. It's very good for treating endometriosis and again, like I said, like the other progesterone, only contraceptives. It can induce him and amenorrhea for a lot of women, it's also the best on the most frequently used contraception for sickle cell sufferers. Okay, because it reduces, it reduces pain and severity off sickle cell crises. So it's it's it's what's recommended for women with sickle cell disease now again can cause a regular baby parts. About the same with all these progesterone, only contraceptions. Okay, that's interesting about the injection is that we generally don't like giving it in adolescence. Teenagers. Young women less sedating years old because it can cause loss of bone mineral density, which means that it can affect kind of bone growth in those teenage years. Generally, don't not started the injection very young. Okay, now this is the only one that cause a delay in infertility to return to. It can be up to a year after you stop your injection that your fertility comes back. So it's that's important question. If you want to start when the injection, we ask them if they're planning on getting pregnant anytime soon, because if they are in the next 12 to 18 months, the progestin injection probably isn't for them. So here we go late injection rules, so actually, you can go up to 14 weeks generally every 13, which have your injection, but really, you got to every 14 weeks and and then if you go to 14 weeks bank on, that's absolutely fine now. 14 weeks plus one day you give you injection and the U seven days. Barrier contraception. Okay, now, if you have unprotected intercourse, you need emergency contraception on barrier contraception. Now, the interesting thing about Morrissey conception is that your l a one c Your unit crystal may be less effective because you got a residual restroom. You shouldn't really give l a one if you've been taking progesterone contraception generally anyway. But we'll go to that slides time. So we'll do. We'll jellicle behind hormones. We've done progesterone hormones. Let's go into the interview trying devices. So Copa Couple coil has it like so the copper coil. It's the effect of the copper itself on the over the sperm and the copper causes an inflammatory reaction in the endometrium, which prevents that them it prevents implantation. Basically, copper is also, uh, it's the copper content in the cervical mucus stops the sperm from getting through. Okay, now the couple calls last 10 years, it's radio opaque against. If you lose it, become image and see what see where is pedestrian progesterone in three trying system. So that's this four out there on the market. They all use levonorgestrel, and there's forcing. Or in my Rena believe also you, JDS and the Kyleena Now the way they differ is basically an amount of progesterone. They're having them. So my Rena has my reader leave also have the most 52 mg off, leaving Ogestral on the both license for five years. I think the Merina is slightly, um is license for a few more things than leave us, for example, menopausal and Amitril lining protection. But don't worry about that. And now my reader is very good for someone if they want conception. They also have heavy periods because it actually can call. It causes a lot of women to have very light periods or a become a mandaric. Okay, now your J destiny Kyleena haven't have a lot lower concentration of levonorgestrel, so they're actually mainly licensed for contraception. They're not licensed for treatment of heavy heavy periods was marina is your gold standard first line treatment of menorrhagia, and they differ slightly by like half a centimeter in size. Between them, it's enough not to use it difficult. That's just pictures of my really here, which looks slightly longer and slightly thicker in the body here and the others, and you put your J death, which is just smallest amount, which is your lowest concentration of progesterone and any Kyleena. So you can see that the large one Kyleena then JDS. But you cannot not too different size. So go through risks and benefits of the intrauterine devices. So you copper copper coil is very good for contraception because of the copper toxicity to the sperm in the old um, Onda. Lot of people choose it because they don't want hormones. A lot of people don't want exogenous hormones in the body, so then they go for the copper coils. However, the copper coil is not good for periods essentially, so it causes very heavy bleeding on quite painful bleeding and can cause irregular bleeding. So if someone comes to your clinic and tells you they're bleeding really, really heavily, the periods got so much heavier the last year on. Then you find out that using the copper coils contraction. There you go. There, that could be a cause. Take try it on. Offer them something different. Um, on with the progesterone intrauterine device you. But you got a lot fewer side effects than any systemic progesterone. But it can sometimes cause irregular bleeding like we discussed can also cause acne breast pain headache but to a lower extent than thesis temic progesterone on the surveillance that it can cause functional cysts in some women. Okay, now, like I said, the copper call people that use it with hormonal methods of country indicated So that starts in the bottom after both copper and marina, copper and Colleen or whatever. So it's general risk of expulsion is one in 20 however, and that's mainly in the first month also. Ah, first month also. And after insertion Okay, you ask a P I. D is 100 repair afraid who's one twenties? Well, okay, sorry. That's wrong. Your risk of perforation. One of thousands of not one and 20 I think, just written that twice risk of expulsion 1 20 p. I. D. 100 freshens 1000. So that was a kind of a whistle start. Really whistlestop tour through the basics of conception. What they do on be kind of which one is suitable for woodshop people. So let's go through postnatal conception because it's a really big issue. Lot of women, um, a lot of women get pregnant both soon after they have a child. And actually wh show commends into pregnancy interval of 12 months because Prevacid of a lot less than that actually increases both in the Natal on maternal mortality. Sorry. Morbidity, not mortality. And start to preterm birth. Fetal growth restriction. Still there on the nasal mortality. These are these are all increased em by having getting pregnant very quickly. You get after giving birth. So one in 13 women conceive in the first year of childbirth and 13 term pregnancies were unintended. Pregnancy is so that's those interesting to statistic cycle. And these are this is some of the UK meccas. Well, so well, can we can look through these so you can make set out very clearly. You've got postpartum women and it's broken down into breast feeding and non breastfeeding. Okay, Now, in breast feeding women, implant is also fine. Cry generally, progesterone is fine. Okay, but in breast feeding women within the first six weeks, the combined hormonal contraceptive is you came back four, which means absolutely not allowed. Okay, because your risk of ET is much higher. And then it kind of gets downgraded to two before six months and then a one after six months. Okay, you can have a little look through that. That kind of works through everything. Um, important one snows are you're combined. Hormonal contraception. So what's so I would advise you to look up the difference between a breast feeding and a non breastfeeding woman. Okay, but the combined hormonal contraceptive and and also intrauterine devices and post partum. Okay, So intertwined devices come out to be inserted immediately after giving birth within 48 hours all four weeks. Okay, that period, after 48 hours but between but before four weeks. And your risk of perforation is extremely high because you've got very soft uterus that is trying to involute. Okay, so it's either immediately or wait for weeks. Essentially on this is a image off a coil being put in that section. Look, can one still see this link bed with me a second? Just from this video on there. We also do you What size kind of Want to see this delivery of the baby removed the placenta, as you would normally on massage the uterus to eight. Contraction. Apply green. Armitage is to ensure hemostasis of uterine angles, ensure the uterus is empty of placenta and membranes. You do not need to exterior rise the uterus, but this is an option if you prefer, removed the IUD from the inserter and grasp it with sponge holding four sets or with your sterile gloves. Hand place the IUD at the fund. It's pressing on the top of the uterus with the non dominant hand in the same manner as applying bundle pressure. Once the IUD is in place, died the threads of the device down the cervix using sterile forceps if necessary. Then suture the uterus as you normally would. Do not suture the device. You're not super device, so that was a cool being putting that section and and this is just that's what looks like a section. I'll just show you a quick devil of what? What you what? How you put a coil in either immediately post partum after a normal vaginal delivery, obviously in outpatient clinic setting. So it's fine that okay or other contra indication fictions or other contraindications for the insertion of Mirapex and then cleansed discs and then cleanse the cervix and vagina with a suitable antiseptic solution. Cervix supplies the survey. Visualize to speculum, visualize the cervix and then cleanse the cervix and vagina with a suitable antiseptic solution. Grasp the anterior lip of the cervix with the tenaculum to stabilize the uterus. If the uterus is retroverted, it may be more appropriate to grasp the posterial it of the cervix. Gentle traction on the forceps can be applied to street in the cervical canal. The forceps should remain in position and gentle. Counter traction on the cervix should be maintained throughout insertion procedure. Advance uterine sound through the cervical canal to the funders to measure the depth and confirm the direction of the uterine cavity. If difficulties encountered, consider dilatation of the canal insertion First opens. There are package completely, then use sterile technique and sterile gloves. The rain is provided within an inserter consisting off the marina itself, already in the correct or is a little position, an anatomically curved insertion tube with a double sided centimeter scale and a plunger inside the flans and the handle containing the mark, the slider and the threads inside push the side of forward in the direction of the arrow to the furthest position to load Mirena into the insertion tube. You know, pull the slider downwards. As this may prematurely release Mirena. Once released, Mirena cannot be reloaded holding the slide in the furthest position, said the upper edge of the Flandy, to correspond to the sound measurement of the uterine depth while holding the slide in the furthest position, advancing certain through the cervix until the flanges, approximately 1.5 to 2 centimeters from the uterine cervix. Do not force the inserter. Delayed the cervical canal if necessary. While holding the insert a steady Pull the slider to the mark to open or is ontological of Mirena. Wait 5 to 10 seconds for the horizontal arms to open completely. Advance inserter gently towards the funders of the uterus until the flank touches the cervix. The rain is now in the funding. Is it in holding the insert in place? Released Mirena by pulling the slider all the way down while holding the slide all the way down. Gently remove the inserter by pulling it out. Cut the threads to leave about 2 to 3 centimeters visible outside of the cervix. The rain insertion is now completed. Removal replacement. The rain is removed by pulling on the threads with forceps. You may insert a new Mirena immediately following removal. Oh, Yeah, that's your insertion. It's very different. Disney after a section on down outpatient setting. So that's your intrauterine devices. Now, let's look at the lactation. Allow amenorrhea method. So this is a method that lot of women use when they're breastfeeding. So they have this three criteria that have to be met Teo, to provide adequate conception. So you need to be exclusive. Best being that means regular feeds, no bottle top ups and know dummies. Okay, You need to be a memory extremely to not had a period since delivery. I need to be within six months. Postpartum. Okay, Because if you if all these characteristics are fulfilled, you got really high levels of product prolactin, which inhibits the issue. If you look at the heart pump pituitary axis on, if if that's the case, then it's 98% effective. So it's 200 to 100. Women will get pregnant using this method. So imagine conception. So the general postpartum conception was the three medicine for exception. So when is most contraception acquired? So anyone who's got a risk of pregnancy after it'll protected sex needs 30 conception, okay. And so anyone who is not using any hormonal contraception should be offered a most conception. Anyone who is three weeks postpartum. Okay, so your risk of getting pregnant is back from day 21 on from day five after termination, miscarriages, topic. Anything like that. Okay. Have any regular contractions been compromised? Still do a minute. The conception Emergency contraception. So there's three types of medical exception. You've got your copy coil. Okay. Which obviously we talked about how copies toxic to spend on the specimen that you cite and prevents Implantation is the copper cool can actually be given up to 100 20 day 120 days supreme up 120 hours after unprotected sex. And it's a most effective method on only one in 1000 people get pregnant. Okay, Now, if we can't compare this to you know it crystal, which is your l a, which is brand name with a one. I'm not delays ovulation. Okay, that could also be given homes and 20 hours after impacted sex. But I want to have 100. Women will still get pregnant after this, and then third, we'll look at levonorgestrel, which is common known hours 11 l. This could be given 72 hours after unprotected sex on 2 to 300 women get pregnant after taking this. Okay, you can see that the copy coil is most effective. Emergency contraception. And then it got to be one. Once you got a copy oil in place. It commanded to be used as regular contraception if the woman wants. So this is just a diagram to explain the kind of timing off the different medicine contraception. So let's go through it. So your maximum risk of pregnancy is population on day, six days after ovulation. That's your maximum risk on a day or two. Either side, basically. Okay, so here you can see that, um, a maximum risk population and six days after, Okay, Now you're a copper coil can be given at any point because the copper is toxic to the sperm and that you cite and prevents implantation. Okay, because the earliest time that's the little implant in the uterus is six days after fertilization. Okay, Now you're getting crystal can be given up to the onset of the late surge to hear, But once the LH surge, once you got the peak of the LH serve, but it ovulations gonna happen. I'm going to press. Still can't. Don't think about it. It can prevent ovulation. At that point, you can't delay ovulation. Okay, now lean ogestral again delays ovulation just like you do crystal. But it needs to be given before the age surgeon started. Okay, so that's why it's really important that good history of women, if it acts asking for emergent conception toe work out when the last central period was when they're probable. Data. Ovulation is there's 14 days after your last menstrual period. Yeah, to work out what the best method of contraception is because if they've already ovulated and they're already a few days past ovulation, then they're best best that is. Actually combine the copper copper coil, so that's just which one you should give basically. So let's go through drug interaction of the murder contraception. Another great thing about the copper call at the most conception, it's not affected by any concurrent drugs. Doesn't matter what drug, sure, whereas women who are using enzyme inducing drugs should should. So women who use the enjoyment using drugs should be offered a copy coil. Okay, now some people say that you can give a double dose off the level now if they use the enzyme inducing drugs. However, there's very little evidence to support how effective this is preventing pregnancy with this. And you cannot give it a bulldozer. You crystal. So any enzyme in juice is such a copy. Last peen your family to win, they should have called quill. Okay, now we mentioned I mentioned briefly earlier that your yearly crystal so your l A one can delay ovulation for least five days. However, any progesterone. So if you start restaurant immediately, have to take a day. Or if you really have been taking progesterone before the emergency conception, it can, um it can affect how how good this is that playing population. So you don't generally use protection on the pill within five days of the universe to emergency contraception. Okay, so don't regards to nearly nearly. They're breastfeeding, breastfeeding, image, conception, conception. So the unit pristall enters breast milk. So if you'll breastfeeding and he taking you depressed, you've taken your crystal emerged conception. You pump and dump for a week, okay? It's a discarded milk for a week. Yeah, there's a theoretical risk of of increased perforation, like we discussed earlier. When you're breastfeeding eso, it's meant to consider if you're thinking about the copper coil on breast feeding has no limitations with levonorgestrel. So with breastfeeding woman, your best bet is probably actually levonorgestrel. Okay, so any questions about three case studies will go through it together and get involved with some questions about anything that the minute you want to go through, I know we've done a very quick whistle stop for and there's lots to talk about contraception. Well, try just crack home with the case. It is. Yeah. Okay, Studies yet? Okay. So case one in 18 year old para one to shut. She's got one year old child, had a normal delivery. She turned her local sexual reproductive health clinic in question conception. Her first pregnancy was unplanned, and she wants a reliable matter of contraception at the same time, coming for further pregnancy and 12 to 18 months. Okay, so she's in a steady relationship. Has been with the same partner for two years. Appears are irregular, heavy and painful. I have got worse over recent months with cycle of five bleeding and bleeding for 5 to 7 days. And then there has cycle the last 21 to 30 days. She's also noticed increased facial hair required electrolysis. She's previously been diagnosed with PCOS. She has no relevance from the history and examination those numbers, so movements like conception for her. What factors, first of all, are are what faxes are seeming important to you so far from this case, ate yet one stable relationship. Good. So we're thinking absolutely heavy periods. Need to consider this is considered PC less good. He's us perfect facial hair. What else? Well, her plans for family. What do you think? Deny. Next. Exactly. So that's key We've actually earlier, delaying next year for 12 to 18 months. So which one of these can we just rule out straightaway direction? So you guys mentioned the factors, so she's in a stable relationship. So should we take condoms out them? Wait, what do you think about her weight? So let's say condoms out because it says she's in a steady relationship has been the same partner for two years. Let's take that one out. What else could we exclude out this list? Rule out depot, So why don't rule out hepatorenal Perfect. Yeah, So it was actually right you want to rule out death because weight gain. But also, she wants to start a family to remember. We discussed that, Depot, once you stop taking it, that can be delay infertility for 12 months. So what do we think? The answer is what do you think she should be started on? Been a lease. Factors that you guys mentioned in mind. So we need something that's gonna help with conception. Yeah, is not gonna I'm not going to, um, affect your fertility long term. Might help her heavy, painful periods, maybe regulate his cycle and help with her facial hair. So we've got a couple options. One anyone else agree? Disagree What we all think I think five. So why do you think? Five Zarah. Yeah. So I can actually see we coming from as in safer because of her weight, in the risk of BT. However, And I would say, um c o c p m because so some people pee is being my too high for C o. C. So let's look at her being my Actually, that's what kind of a minute and we'll go through the You came back. Yes. So Oh, yeah. There you go. You guys are all right. So Absolutely So you worked out her B m. I was You came back three. So her be a miser over 35? Absolutely. So you could it dependence, Whether you would in clinic is very difficult to say. You know, hard and fast rule, but in clinic, you could offer weight loss advice on the C o C. P. Okay, all you could start her on the P. O. P. You're absolutely right. However, certain that's clear in this in this history is that she struggles with MPC rest of facial hair on also regulating her cycles. So her cycles already irregular. Um, so P o. P probably wouldn't help with cycles. And so yeah, So basically, this question is show. There's numerous, numerous different answers for this. So we managed to rule out that we don't need condoms and we don't need to check your injection. Yeah, but it depends in thistle. Do patient consultations. You'd have to discuss the patient whether she would be happy to try a progesterone only conception like the marina, or like the P O. P. Because she's already having irregular irregular periods. And there's a risk. 20% risk of having further irregular periods with this. Okay, So if we want to start the c o. C. P, we would have to ask the senior advice and whether this was appropriate. Every wants to start option three of five. We would have to discuss the patient whether she felt the risk of irregular periods. Waas acceptable for her. Okay, so sorry, guys. That was a trick question. You have any questions about this case? Because this is more. This is the most likely cation to come across. Not over there with a straightforward answer. Okay, so case to miss it. Why is a 22 year old really Paris young woman who presents it a local sexual sexual reproductive health clinic having had unprotected sexual intercourse and a 16 of a regular 28 day cycle? She's in a new relationship, having her intercourse last night with her boyfriend. She's not had any other episodes off protected intercourse this cycle. She suffers from epilepsy and takes carbamazepine twice a day. She's otherwise well, with no relevant from history. And those are her measurements below. So what are we thinking? What jumps out at you straight away about this woman. So she looking for emergency conception. Absolutely different. So she's she's taking carbamazepine. So what do we think is not suitable for her than taking carbamazepine today? Succeed? Absolutely. So she's obviously, doesn't she? Yes, a homeowner will have interaction. So do we think 11 l suitable? Well, my double those 11 now? Yeah, exactly. So what would you think, Would you say? Actually, so there's no image to contraception suitable. You have to have a termination Or would you go for a copy? Coil discussed popcorn. Absolutely good. The cop call with him would be the most effective one for her. For a couple of reasons. She's on carbamazepine, so she's She's on an enzyme inducer. Okay, so you do Crystal is not appropriate left. Now there's a little evidence that that's gonna work, especially in Congress. Double the dose. There's again very little evidence for that. She's also a day 16 of a regular cycle, which means that she has Operation Day 14. Okay, so she's really ovulated. I remember the mechanism of action off Levin L under a one is to delay ovulation. So already past that point, we can't. Deliberations happened already and the only one that is suitable after ovulation has occurred is the copper coil. Okay, last case, guys. I know it's half a mg. Probably tired. Um, Mrs P. A 30 year old para fall. So she got four babies, has just delivered a baby boy Spontaneous vaginal delivery following an unplanned pregnancy. Having recently separated from my husband and and into new short term relationship, she's one week postpartum and requesting reliable form contraception. She's a family history of e. T. In a first degree relative, but has never had a CT episode herself. She's bottle feeding her Perparim. So that time around, giving bear has been uncomplicated and she's keen to start contraception as soon as possible. On those are her numbers, height, weight and BP. So what do you think? What factors are what factors you need to consider in this case? Absolutely. Ct breastfeeding relationship history VT Good. One week postpartum Excellent. So, looking at the fact that you've listed so far for me, what do you think we can rule out the shore? We can rule out a couple of options already, Conway. So, yes, it can go up the combined or conceptive Why can't rule out already gave you? Absolutely. Absolutely. You can make four so only a week postpartum. So it's way too soon. Stopped C O C p. Perfect. So we'll get that. We'll get rid of that one. What else can we take out? Rule out carpet coil? Exactly why we want that copy coil. When can you not get up for a while? We ruled out perfect. Yeah, so we can rule out copy call because she is more than 48 hours post partum in less than four weeks. So we have to wait four weeks for that. Perfect perforation. Risk. Good. So the rule out couple coil well ruled out their combined pill. What else to move out? Welcome rule on that list. There's another one we can definitely rule out. She can use barrier methods, especially if you say if it's got a a new partner. Yeah, definitely. Barrier methods. Is it definitely option. So we're left with a lactation, a layman, a re a method on the p o. P e slash in clumps. Excellent. Thank you. So we can rule out Latisha Amenorrhea because she's bottle feeding, So she's not really fit. The criteria of exclusive breastfeeding. The shape so we can take out. So barrier methods. All the p. Okay, what's record either? All is one. Do you think one is better than the other for this lady? Yeah, both of both. Absolutely suitable. It will be up to the woman. And some women like to leave a postnatal ward with something in situ. So, like they like to live with implants or the pill in the bag or something Definite. Rather than having to rely on trying to go and get barrier methods. Absolutely right. Discuss shared decision. So they're absolutely So I think this copper cases here that really needs to be shared decision making. Either with yourself in the patient or the South Patient and senior colleague. Yeah. So Sleep case is just to show that conception isn't always straightforward. Just one answer. Okay. So sorry. Thank you for listening. Thank you for being patient with me starting late. 11 technical issues. But you have any questions? I know the concept is a massive topic on. You could talk about each of those little subsections for ages, but please do not get the UK Met criteria is very expensive. so don't feel like I have to remember all one day. Um, on D v a. Has my email address it when it wants to get in touch with specific questions about contraception or about generally obscene gynie training or whatever. But you have any questions right now? Yeah. No problems. Um, do you? How does feedback work on this? And so they'll get the feedback link directly to the email. So what? They'll fill that out, and then they'll get death certificates. Great. And I will send them to you later. Great. Thank you. S. So if nobody has any questions, then, um get in touch with you if you're if you want my email address for anything. Cops and granulated. No problem, Guys. I believe we don't have any questions then. Thank you very much. Sign up. It was really good. Very good session and very engaging one. So we hope to see you soon. Thank you. Bye. Thank you. Bye, everyone