Contraception and Emergency Contraception

- Short-acting contraceptives: --> Oral contraception (Combined or progestogen-only --> Combined hormonal patch --> Combined hormonal ring - Long-acting reversible contraceptives (LARC's): What are the 2 types of contraceptives? -->Injectable contraception (progestogen) --> Implant (progestogen) --> Intrauterine system and device: • Levonorgestrel (progestogen) intrauterine system • Copper Intrauterine device - Barrier methods --> Condoms --> Diaphragm & caps --> Spermicides - Periodic abstinence/natural family planning Give examples of other types of contra--> Calendar ception --> Ovulation method --> Sympto-thermal --> Hormone monitoring - Sterilization: permanent method --> Female : Bilateral Tubal Ligation --> Male : Vasectomy Combined Hormonal Contraceptives (contain oestrogen and progestogen) - Oral pill - Transdermal patch - Vaginal ring What are the 3 types of combined Hormonal Contraceptives? 1/9 - Oestrogen and progestogenmode of action - Missed pill advice - Advantages - Adverse effects and risks Give some considerations and advice to give with COC Recap Ovarian Pathology Lecture from Year 1 - Suppression of ovulation --> FSH stimulates ovarian follicular maturation. Oestrogen suppresses FSH production- negative feedback cycle --> LH surge (with oestrogen surge) needed for ovulation. What are the modes of action for ComLH & progesterone- neg. feedback cycle. bined Oral Contraceptive? - Thicken the cervical mucus --> Reduces sperm penetrability - Thinning of the endometrium --> Reduces likelihood of implantation Monophasic Combined Oral Contraceptive pills contain... - Fixed amount of oestrogen and progestogen --> E.g. Ethinylestradiol 30mcg + Levonorgestrol 150mcg --> Microgynon, Rigevidon Phasic Combined Oral Contraceptive pills contain... - Contain varying amounts of oestrogen and progestogen --> E.g. Ethinylestradiol 30mcg, 40mcg + Levonorgestrol 50mcg, 75mcg, 125mcg --> Logynon - Takes 7 consecutive pills to ensure ovulation has been suppressed - Missed pill is one that is more than 24 2/9 hrs late (except Qlaira- 12 hrs late). Missing 1 pill is fine, missing more What is the generalised missed pill ad= not protected against pregnancy vice? - Important to avoid lengthening pill-free week to more than 7 days - Predictable bleeding Menstrual bleeding is usually lighter and less painful - Suitable for healthy, non-smokers up to What are the advantages of the Comage 50 bined Hormonal Contraceptive Oral Pill - Reduced risk of ovarian and endometrial cancer - Reduced risk of colorectal cancer - Easily reversible - Irregular bleeding Nausea, headache, breast pain/tenderness - Increased risk of venous thromboembolism (VTE) What are the disadvantages of the Com- - Very small increase in risk of cardiovasbined Hormonal Contraceptive Oral Pill cular disease and stroke - Possible small increased risk of breast cancer - Increased risk of cervical cancer - Drug interactions Look at slide 16 in ppt Give some points on the Combined Hormonal Contraceptive Patch 3/9 - Weekly application encourages compliance - Unaffected by vomiting and diarrhoea - Similar risks to COC - Less effective in women > 90 - Application site reactions - Inserted for 21 days, removed for 7 days - Contains ethinylestradiol 2.7mg & etonogestrel 11.7mg - Extra precautions needed if in for > 4 weeks - Same risks and benefits as COC Extra precautions needed if in for > 4 weeks - Same risks and benefits as COC Extra precautions needed if in for > 4 weeks Better cycle control Give some points on the Combined Hormonal Contraceptive Vaginla Ring Progestogen Only Contraceptives What are the 3 types of Progestogen Only Contraceptives - Progestogen Only Pill - Injection - Implant Give some considerations and advice to give with COC - Mode of action - Advantages - Disadvantages, adverse effects & risks - Missed pill advice - Less contraindications as no oestrogen - No oestrogen, therefore suitable for use.... Check UKMec - No evidence to suggest a delay in return of fertility 4/9 What are the advantages for the Progestogen Only Pill (POP)? - Side-effects due to oestrogen are absent: nausea, breast tenderness, headaches, unexpected vaginal bleeding... - Can use whilst breastfeeding - Easily reversible What are the disadvantages for the Progestogen Only Pill (POP)? - Strict adherence needed Taken daily with no pill-free interval - Menstrual irregularities - Breast tenderness, depression, mood changes, headaches, changes in periods, acne - Ovarian cysts - Small increased risk of ectopic pregnancy (except desogestrel) - Efficacy affected by liver enzyme inducers Give some points on the progestogen Injection- medroxyprogesterone acetate (Sayana Press, Depo-provera) - Injected every 3 months - Used if oestrogen is contraindicated - No drug interactions - Reduction in bone mineral density - Not rapidly reversible Give some points on progestogen Implants- Etonogestrel (Nexplanon) - Rod inserted into upper arm for 3 years - No oestrogen component - Rapidly reversible 5/9 - Menstrual irregularities - Drug interactions Intrauterine device and Intrauterine system - Releases copper into womb - Inserted into uterus - Copper thickens cervical mucus and stops fertilised egg from implantation - Works between 5 and 10 years Give some points on the Intrauterine de- - Periods can be heavier, longer or more vice (IUD or copper coil) painful - No drug interactions - No hormonal side effects - Suitable when hormonal contraceptives are contraindicated - Emergency contraception - Releases progestogen into womb - Inserted into uterus - Levonorgestrel thickens cervical mucus and thins womb lining - Works between 3 to 5 years Give some points on the Intrauterine sys- Periods can be lighter and shorter, irtem (IUS) regular or stop - No drug interactions - Progestogen-side effects - Suitable when combined oral contraceptives are contraindicated What are the risks associated with IUDs and IUSs 6/9 - Expulsion - Pelvic infections - Perforation - Ectopic pregnancy Women with child bearing potential taking certain When must highly effective contracepdrugs with teratogenic potential: sodium tion be used in valproate for women with child bearing potential? epilepsy, oral retinoids (isotretinoin) for acne Barrier Methods Look at slide 30 in ppt Traditional Methods Look at slide 31 in ppt Pharmacy Contraception Service - Tier 1 --> Ongoing monitoring and supply of repeat oral contraception - Tier 2 --> Initiation of OC via a patient group direcetion (PGD) What are the different tiers? - Tier 3 --> Ongoing monitoring and management of repeat long-acting reversible contraception (LARC), excluding intrauterine systems (IUS) and intrauterine devices (IUD) - Tier 4 --> Initiation of LARCs Umbrella Pharmacy services: - Tier 1 Pharmacy includes Emergency Hormonal Contraception (EHC)- levonorgestrel & ulipristal, condoms, collection of STI kits Umbrella Pharmacy services: - Tier 2 Pharmacy includes As Tier 1 PLUS: - Initiation and ongoing supply of oral contraceptives - Administration of injectable progestogen - Supply EHC- levonorgestrel & ulipristal - Supply antibiotics for positive chlamy7/9 dia test - Supply of STI kits Emergency contraception - Intrauterine device (Copper IUD) - Levonorgestrel (E.g. Levonelle) - Ulipristal (E.g. Ella-One) What are the 3 types of Emergency contraception? - 5 days following first unprotected sexual intercourse (UPSI) in cycle or within 5 days from the earliest estimated day of ovulation - copper toxic to sperm and ovum; primarily inhibits fertilisation (and implantation) Intrauterine device: - Copper IUD can be used up to... - How does it work? - P medicine, prescribed or Patient Group Direction (PGD) - A progesterone; single 1.5mg dose tablet - LNG; interferes with ovulation by inhibiting Luteinising Hormone (LH) surge - Licensed for use up to 72 hours after UPSI or contraceptive failure - Consider Drug interactions Give some points on Levonorgestrel (LNG) - Levonelle - P medicine, prescribed or PGD - A selective progesterone receptor modulator; single dose 30 mg tablet - Delays LH surge and has effect on folGive some points on Ulipristal- ellaOne licular rupture; additional action - Licensed for use up to 120 hours after unprotected sexual intercourse (UPSI) or contraceptive failure - Interactions What are the side effects of the intrauterine device? 8/9 Pain during fitting and few days after What are the side effects of Levonorgestrel? - Vomiting (repeat dose if within 3 hrs) - Altered bleeding pattern, headache What are the side effects of Ulipristal? - Vomiting (repeat dose if within 3 hrs) - Altered bleeding pattern, headache 9/9