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The ideal reversible
contraception

 100% effective after a single simple procedure
 100% safe with no danger or unwante...
The balance of advantage
 The efficacy of the method
 The patient’s wishes
 The advantages and disadvantages of the
met...
Failure rates during the first year of contraceptive use
(USA 1995- National survey)
Method
Female sterilisation
IUD-LNG
M...
Relative popularity with
different methods(U.K.)
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COCP ------------------------ 36%
Barrier methods-----...
Medical conditions which contraindicate the
use of a contraceptive method
(WHO classification 1994)
 A condition in which...
Mechanism of action and
biologic activity of COC
 Inhibition of ovulation through combined action
of progestogen and oest...
Oestrogen induced alterations
in the blood

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Encourages venous thrombo-embolism
Reduced anti-thrombin3
Elevated ...
Effect of COCP on the Liver
 The liver is affected in more ways than any other
extra-genital organ
 Active transport of ...
Absolute contraindications to the COC
(WHO System 1994)
 Cardiovascular
 Venous thrombosis- h/o thromboembolic
disorders...
Absolute contraindication to COC
(WHO System 1994)
Cardiovascular
 Focal migrane or status migranous
 Transient ischaemi...
Absolute contraindications to
COC
Hepatic
 Acute liver disease (whenever LFTs abnormal)
 Chronic liver disease
 Cholest...
Absolute contraindications to COC

Other

 Known or suspected oestrogen dependent neoplasia
 Serious condition affected ...
Relative contraindication to
COC

 Women over 35, who smoke
 Essential hypertension, but controlled on
treatment
 Laten...
Reduced OC efficacy due to
interactions
 Gastroenteritis

  impaired absorption of
OC

 Drugs causing induction
of hep...
Reduced OC efficacy due to
interactions
 Anti- TB:
- Rifampicin

  very potent enzyme inducer
  use DMPA with 8 week
...
Other drugs that may reduce
efficacy of COC
 Cholesterol lowering
agents

 ↓ cholesterol and
triglycerides
 ↓ OC effica...
Drugs that may increase COC
level
 Paracetamol

 Completes in bowel wall
for conjugation to
sulphate
⇒possible more O2
a...
Modification of other drug
action by OC
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Alcohol
Anticoagulants
Aminocaproic acid
Caffeine
Corticosteroids...
Medical disorders for which
COCP prescribed
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Spasmodic dysmenorrhoea
Menstrual irregularities
Premen...
Other non contraceptive benefits
of the COCP
 Prevents ectopic pregnancies
 Reduces incidence of benign breast disease
...
Mechanism of action of POPs
 Inhibition of ovulation in at least 60% and
more often in older women
 Alteration in cervic...
Indications for POP
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During lactation
Contraindications to or side effects with COCP
Hormonal method pre...
Contraindications to POP
 Severe arterial wall disease
or at risk of :– Liver adenoma or carcinoma
– Severe cholestatic j...
Indications for IUCD
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Effective
Safe
Indepent of coitus
No effort required
Motivation necessary only a...
Contraindications to IUCD

 Pregnancy
 Serious related pregnancy related infection
within previous year
 Acute pelvic i...
Relative contraindications to
IUCD
 Past history of STDs
 Multiple sexual partners
 Menorrhagia
 Copper allergy
Subdermal implants
 Jadelle (2 rods) or Implanon are now available
 (Norplant is no more!)
 Work by ovulation inhibitio...
Advantages of subdermal implant
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Efficacy and convenience
Long action
Absence of initial peak dose giv...
Disadvantages of Implants
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Altered bleeding pattern- 18%
Frequent bleeding and spotting
(Treat with cyclical COCP ...
Advantages of injectables
 High effectiveness - > than COCP
 Freedom from fear of forgetting
 Highly convenient- not co...
Disadvantages of injectables
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Irreversible for at least 2-3 months
⇒have to tolerate early side effect...
Implant and Injectables
 Menstrual bleeding patterns are highly
variable among users of implant
contraception.Some will e...
Barrier Methods
 Condom useful – no adverse effects on
pre-existing disease (limited by poor
compliance and high failure ...
General Medical Disorders
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Congenital/Valvular Heart Disease
Venous Thrombo-embolism
Arterial Heart ...
Valvular/congenital Heart
Disease
Valvular/Congenital Heart Disease is the leading medical cause
of maternal mortality in ...
IUCD and Valvular/Congenital
Heart disease
 In patients with valvular and congenital heart
disease IUCD use is limited by...
For completed family or
pregnancy contraindicated
 Surgical method is ideal
 Vasectomy rather than tubal ligation
 Inte...
COC Pill and Venous
Thrombosis
 Oestrogen increases the production of
clotting factors
 Progestogens have no significant...
Factor V Leiden mutation
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Produces changes in structure of factor V
Normally protein C inhibits clotting at level ...
Clotting mechanism
Fibrinolysins
Protein C
Protein S
Antithrombins
Plasmin

Prothrombin

Antithrombins

Protein C & S

Thr...
3rd.generation progestogens and D.V.T.s
 Less androgenic than the older progestogens with a
lesser adverse effect onserum...
Relative risk and actual
incidence of VTE
Population

Relative risk

Incidence

Young femalegeneral population
Pregnant
Hi...
COCP Contraception and
Surgery

 X4to6 fold increased risk of thromboembolic
complications in users of COCP
 COCP should...
Ischaemic Heart Disease and
COCP
 Oestrogen increases the production of clotting
factors
 Progestogens have no significa...
Arterial thrombosis and the
COCP
 Smoking and oestrogen have an addictive effect on the
risk for arterial thrombosis
 Hy...
Incidence of M.I. In
reproductive age women
< 35 years old

Overall increased
Non- smokers
Non- smokers +
OC
Smokers
Non- ...
Contraception and Ischaemic
Heart Disease
– COCP best avoided
– Patients on anticoagulants should not be on

COCP
– IUCD i...
In Ischaemic Heart Disease
 Use alternative contraception to the
COCP:
- IUCD/IUS
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- Barrier method
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- Implant – may b...
 Injectables and Implants are safe method
fir those with heart disease
 Antibiotic cover for the implants may be
necessa...
Incidence of stroke in
reproductive age women
Incidence of ischaemic
stroke

Haemorrhagic stroke
Excess cases/year
~OCs in...
Migraine Sufferers
 Increased risk of ischaemic stroke in
COCP users
 Especially - with other arterial risk factors
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- ...
Risk of Thrombotic stroke in
Migraine
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Background risk for women aged 20 – 2/100,000
Migraine>once a month + COCP ...
COCP contra-indicated in the
following groups of patients
 Migraine with aura during which there are
focal neurological s...
 Stop the COCP
 Consider --- the POP
--- Implant/Injection
--- IUCD/LNG-IUS
Opthalmic Disorders and the
COCP
 Occasional eye discomfort with contact
lenses
---------------------------------- Loss ...
Elevated BP and COC
 ↑ BP reported in some on COCP- occasionally
within a few months of use
 Age is strongly correlated ...
Diabetes Mellitus
– Arterial Disease is a major hazard for diabetics
– Avoid Oestrogen with its thrombotic risks
– POP can...
Possible Use of COCP in
Diabetes Mellitus
 Young <25 : recent DM
 Free of any complications – arteries, nerves,
kidneys,...
Epilepsy and Contraception
 Effectiveness of hormonal contraception is reduced
in women on anticonvulsants which are live...
Epilepsy and contraception
 If hormonal contraception: COCP ----------- 50ugEO should be used with a
reduced pill free i...
Depression
 Patients with a history of emotional disturbance
may be prone to depression on the OC
 If severe – change to...
Smoking
 Smoking produces a shift to
hypercoaguability
 A former smoker must have stopped for at
least one year to be re...
Abdominal pain and COC use
 Thrombosis of major intra-abdominal
vessels
 Gallstones
 Pancreatitis
 Liver adenoma
 Chr...
Gynaecological Problems
 Gestational Trophoblastic Disease
 Ectopic Pregnancy
 Menorrhagia
 Endometriosis
 Fibroids
...
Gestational Trophoblastic
Disease and Contraception
 No evidence of Increased risk in GTD by previous
COCP use
 Close mo...
COCP and menorrhagia
 Low dose pills are as effective as high in
reducing menstrual flow
 COCP can be used to treat meno...
IUCD and menorrhagia
 Inert and copper IUCD a/w increase in
menstrual blood loss (55% ↑ with copper
IUCD)
 But menstrual...
Endometriosis
 The use of COCP is a/w a lower incidence of
endometriosis
 The protective effect is probably limited to
c...
Uterine fibroids
 Uterine fibroids are not a contraindication for low dose
COCP
 There is evidence that the risk of fibr...
COCP and Pelvic infection

 Pelvic Inflammatory Disease usually a consequence
of STD
 The risk of hospitalisation for PI...
COCP and Pelvic infection
 The mechanism of protection is unknown:
 ? Thickening of cervical mucous to prevent movement ...
Examination and follow- up
 Thorough history and
examination
 BP
 Breasts
 Liver
 Extremities
 Pelvic organs
 Cervi...
Blood tests
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Glucose, lipid and
lipoproteins
Young women at least
once
Women > 35 years old
Strong family hi...
Consider whether the medical
condition would : Increase the risk of venous thromboembolism
 Predispose to arterial wall ...
Remember
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DIMS

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BNF
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
Contraception and medical disorders in pregnancy prof ken
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Contraception and medical disorders in pregnancy prof ken

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Contraception and medical disorders in pregnancy prof ken

  1. 1. The ideal reversible contraception  100% effective after a single simple procedure  100% safe with no danger or unwanted side effects  Independent of the medical professions  100% reversible by simple procedure  Independent of coitus  Not relying on user motivation  Cheap and easy to distribute  Pre fertilisation in action  Used by or visible to the woman  Additional beneficial effects
  2. 2. The balance of advantage  The efficacy of the method  The patient’s wishes  The advantages and disadvantages of the method  Medical problems
  3. 3. Failure rates during the first year of contraceptive use (USA 1995- National survey) Method Female sterilisation IUD-LNG Male sterilisation Implant IUD-Copper T380A IUD- progesterone POP Injectable COC Diaphragm and spermicides Male condom Cervical cap-Nulliparous Sponge- nulliparous Periodic abstinence Female condom Withdrawal Spermicides Cervical cap-parous Sponge- parous No method Ideal use(per cent) Typical use(per cent) 0.05 0.1 0.1 0.05 0.6 1.5 0.5 0.3 0.1 6.0 3.0 9.0 9.0 0.05 0.1 0.15 0.2 0.8 2.0 3.0 3.1 7.6 12.1 13.9 20.0 20.0 20.5 21.0 23.6 25.7 40.0 40.0 85 5.0 7.0 6.0 20.0 20.0 85
  4. 4. Relative popularity with different methods(U.K.)          COCP ------------------------ 36% Barrier methods--------------21% Vasectomy -------------------16% Female sterilisation --------- 10% IUCD ------------------------- 7% O.C. with barrier ------------ 3% NFP --------------------------- 2% CI ------------------------------ 1% No method ------------------- 4%
  5. 5. Medical conditions which contraindicate the use of a contraceptive method (WHO classification 1994)  A condition in which there is no restriction for the use of the contraceptive method  A condition where the advantage of the method generally outweighs the theoretical or proven risks  A condition where the theoretical or proven risks usually outweigh the advantages. But if the patient accepts the risks and rejects or should not use relevant alternatives, the method can be used with caution/ additional care  A condition which represents unacceptable health risks.
  6. 6. Mechanism of action and biologic activity of COC  Inhibition of ovulation through combined action of progestogen and oestrogen  Dominant component is progestogen: Suppresses LH release Creates thick cervical mucous Inhibits capacitation  Oestrogen- suppresses FSH and LH release -Accelerates ovum transport -Alters secretion affecting implantation
  7. 7. Oestrogen induced alterations in the blood      Encourages venous thrombo-embolism Reduced anti-thrombin3 Elevated fibrinogen Elevated Vit.K dependent coagulation factors Increased fibrinolytic activity  In the presence of significant arterial wall disease, oestrogen may also promote superimposed arterial thrombosis  Elevated blood lipids with reduced HDLcholesterol
  8. 8. Effect of COCP on the Liver  The liver is affected in more ways than any other extra-genital organ  Active transport of biliary constituents is impaired by both Oestrogen and Progestogen  The mechanism is unclear, but cholestatic jaundice and pruritus are associated with the COCP  The COCP can cause an increase in cholesterol saturation of the G.B. bile with an increased incidence of gall stones  Benign hepatic adenomas are associated with the COCP  A few cases of hepato-cellular cancer have been reported
  9. 9. Absolute contraindications to the COC (WHO System 1994)  Cardiovascular  Venous thrombosis- h/o thromboembolic disorders or close family history  Arterial thrombosis- angina, MI  Cerebral thrombosis or haemorrhage  Severe hypertension  Elective major surgery  Leg immobilisation  Hyperlipidemia (Cholesterol > 8mmol/l)  Congenital or acquired heart disease
  10. 10. Absolute contraindication to COC (WHO System 1994) Cardiovascular  Focal migrane or status migranous  Transient ischaemic attacks  Coagulation tendency - thrombophylias • • • • - Fac. V Leiden mutation - Phospholipid syndrome - activated protein C resistance - blood dyscrasias - some autoimmune/ rheumatoid disorders - Post-splenectomy (platelets > 500 x 109) Severe inflammatory bowel disease- Chron’s, Ulcerative colitis Opthalmic vascular disease Exposure to high altitude Combination of risk factors
  11. 11. Absolute contraindications to COC Hepatic  Acute liver disease (whenever LFTs abnormal)  Chronic liver disease  Cholestatic jaundice of pregnancy or OC associated  Chronic idiopathic jaundice  History of liver adenoma, carcinoma  Focal nodular hyperplasia  Galstones causing symptoms  The acute porphyrias
  12. 12. Absolute contraindications to COC Other  Known or suspected oestrogen dependent neoplasia  Serious condition affected by sex steroids - pemphigoid gestationis - Haemolytic uraemic syndromes - Pancreatitis - Hypertrigliceridaemia - Chorea - Erythema multiforme - Thrombocytopenic purpura  Undiagnosed abnormal vaginal bleeding  Pregnancy  Throphoblastic disease  Continuing anxiety unrelieved by counselling
  13. 13. Relative contraindication to COC  Women over 35, who smoke  Essential hypertension, but controlled on treatment  Latent or established diabetes mellitus  Cholelithiasis, but can be used after cholecystectomy  Young, first degree relative with breast cancer  Obesity, if associated with other risk factors  Non- focal migraine when ergotamine not required  Sickle cell disease  Chron’s Disease
  14. 14. Reduced OC efficacy due to interactions  Gastroenteritis   impaired absorption of OC  Drugs causing induction of hepatic enzymes   ↑ metabolite activity & ↑ elimination in bile of both oestrogen and progesterone  Some anti-epileptics: - phenobarbitone - carbamazepine - phenytoin - primidone   use alternative method IUD or IUS or 50µg containing OC
  15. 15. Reduced OC efficacy due to interactions  Anti- TB: - Rifampicin   very potent enzyme inducer   use DMPA with 8 week injection interval or alternate method   wait 8 weeks after end of course before recommencing COC  Antibiotics causing change in bowel flora: - Penicillin - Tetracyclines - Cephalosporins   OC are conjugated in the liver, excreted in the bile and partly reabsorbed. If gut bacteria are inhibited by antibiotics, reabsorption may not occur
  16. 16. Other drugs that may reduce efficacy of COC  Cholesterol lowering agents  ↓ cholesterol and triglycerides  ↓ OC efficacy  Sedatives and hypnotics  Enzyme inducer  Antacids retroviral  ↓ intestinal absorption: take 2 hours apart  Do not use COCs
  17. 17. Drugs that may increase COC level  Paracetamol  Completes in bowel wall for conjugation to sulphate ⇒possible more O2 available for absorption: take 2 hours apart  erythromycin * Potent inhibitor of oestradiol metabolism
  18. 18. Modification of other drug action by OC         Alcohol Anticoagulants Aminocaproic acid Caffeine Corticosteroids Cyclosporine Phenothyzines Sedatives/ hypnotics  Tricyclic antidepressants  Vitamine B12  Beta blockers  antipyretics
  19. 19. Medical disorders for which COCP prescribed            Spasmodic dysmenorrhoea Menstrual irregularities Premenstrual tension Menorrhagia (even with fibroid) and anaemia Endometriosis Functional ovarian cysts Ovulation pain Oestrogen deficiency PCOS Acne Prophylaxis against ovarian carcinoma
  20. 20. Other non contraceptive benefits of the COCP  Prevents ectopic pregnancies  Reduces incidence of benign breast disease  ? Reduces fibroid size and menorrhagia  Protects against ovarian and endometrial carcinoma
  21. 21. Mechanism of action of POPs  Inhibition of ovulation in at least 60% and more often in older women  Alteration in cervical mucous  Inhibits capacitation
  22. 22. Indications for POP          During lactation Contraindications to or side effects with COCP Hormonal method preferred Women > 35 years old who smoke Chronic systemic disease which oestrogen might exacerbate (SLE,Chron’s disease,Ulcerative Colitis) Diabetes Hypertension Migraine Preference
  23. 23. Contraindications to POP  Severe arterial wall disease or at risk of :– Liver adenoma or carcinoma – Severe cholestatic jaundice – Recent trophoblastic disease – Acute porphyria
  24. 24. Indications for IUCD           Effective Safe Indepent of coitus No effort required Motivation necessary only at time of insertion Relatively cheap and easy to distribute Does not influence milk volume/composition Under woman’s control Continuation rates high Nearly always reversible
  25. 25. Contraindications to IUCD  Pregnancy  Serious related pregnancy related infection within previous year  Acute pelvic inflammatory disease  Significant uterine abnormality  Severe dysmenorrhoea  Undiagnosed uterine bleeding  Carcinoma of cervix or endometrium  Previous ectopic pregnancy  Risk from bacteraemia e.g. valvular heart disease renal dialysis immunosuppressive drugs
  26. 26. Relative contraindications to IUCD  Past history of STDs  Multiple sexual partners  Menorrhagia  Copper allergy
  27. 27. Subdermal implants  Jadelle (2 rods) or Implanon are now available  (Norplant is no more!)  Work by ovulation inhibition, supplemented by the usual mucus and endometrial effects  Last 3 years But tissue levels are lower in heavier women especially by 3rd year ⇒re- implant sooner
  28. 28. Advantages of subdermal implant           Efficacy and convenience Long action Absence of initial peak dose given orally Blood level steady HDL/LDL ratio and clotting factors unchanged No concern regarding past history of venous thrombosis Excellent choice for Diabetics No effect on blood pressure Can be used with past ectopic history Rapidly reversible
  29. 29. Disadvantages of Implants     Altered bleeding pattern- 18% Frequent bleeding and spotting (Treat with cyclical COCP therapy) Minor side effects- acne, headache, breast pain,↓ libido  Weight ↑- 35% put on 3 kg  Possible hypo-oestrogenaemia- because ovulation suppressed and no oestrogen supplied  Local adverse effects
  30. 30. Advantages of injectables  High effectiveness - > than COCP  Freedom from fear of forgetting  Highly convenient- not coitus-related  Fully reversible (though some delay)
  31. 31. Disadvantages of injectables           Irreversible for at least 2-3 months ⇒have to tolerate early side effects for a long time Can cause menstrual disturbance ? Risk of hypo-oestrogenism Delay in return of fertility Weight gain (↑appetite +? Anabolic effect) ↑ prolactin and galactorrhoea Acne (surprisingly uncommon, mildly androgenic effects) Enuresis Subjective effects(loss of libido, depression, bloatedness, headache, leg cramps)
  32. 32. Implant and Injectables  Menstrual bleeding patterns are highly variable among users of implant contraception.Some will experience increased flow/bleeding days  Depo-Provera can be used to treat menorrhagia if regularity of the cycle is not a concern.
  33. 33. Barrier Methods  Condom useful – no adverse effects on pre-existing disease (limited by poor compliance and high failure rate)  Protective against STDs  The diaphragm,Femidom and spermicides are alternatives (high failure rate)  Less protective against STDs
  34. 34. General Medical Disorders            Congenital/Valvular Heart Disease Venous Thrombo-embolism Arterial Heart Disease Stroke Migraine Opthalmic Disorder Hypertension Diebetes mellitus Epilepsy Depression Smoking
  35. 35. Valvular/congenital Heart Disease Valvular/Congenital Heart Disease is the leading medical cause of maternal mortality in Malaysia It complicates 1 to 4% of all Obstetric admissions Contraception is all important in management:- from the general health point of view -family should be small and completed early -space between pregnancies will allow for definitive treatment. -There are conditions where pregnancy may be contraindicated.
  36. 36. IUCD and Valvular/Congenital Heart disease  In patients with valvular and congenital heart disease IUCD use is limited by the risk of bacterial endocarditis  The IUCD may be used when other options are restricted  -- insertion under antibiotic cover  Absolute contraindications in those with prosthetic valve and those with a past history of endocarditis  Injectables and Implants are safe methods  COCP contraindicated in valvular/congenital heart disease
  37. 37. For completed family or pregnancy contraindicated  Surgical method is ideal  Vasectomy rather than tubal ligation  Interval Ligation is preferred to immediately post-partum  Minilaparotomy is ideal but laporoscopy in selected cases
  38. 38. COC Pill and Venous Thrombosis  Oestrogen increases the production of clotting factors  Progestogens have no significant impact on clotting factors  All low dose COCPs have an increased risk of venous thromboembolism  Smoking has no effect on the risk of venous thrombosis
  39. 39. Factor V Leiden mutation     Produces changes in structure of factor V Normally protein C inhibits clotting at level of factor V In Factor V Leiden mutation, this does not happen The entire clotting cascade is then resistant to the Protein C system --------------------------------------------------------------- The most common inherited form of venous thrombosis  Heterozygotes for Factor V Leiden mutation- x8 ↑ risk of thrombosis  Homozygotes for Factor V Leiden mutation- x80↑ risk of thrombosis  Highest prevalence of Factor V Leiden mutation is in Europeans(34%)  Very rare in Africans/Asians (0.4%)
  40. 40. Clotting mechanism Fibrinolysins Protein C Protein S Antithrombins Plasmin Prothrombin Antithrombins Protein C & S Thrombin Factor V + other clotting factors Plasminogen Fibrinogen Fibrin ← Plasmin
  41. 41. 3rd.generation progestogens and D.V.T.s  Less androgenic than the older progestogens with a lesser adverse effect onserum lipids  Women on 3rd. Generation progesterones have a higher circulating conc. of HDL and lower conc. of LDL  Considered therefore that risk of MI and Stroke would be lower – but not possible to prove  BUT – 3 studies(95/96) suggested a x2-3 increased risk of venous TE with pills containing gestodene or desogestrol compared with levonogestrel or norethisterone  CSM advised – all women at increased risk of thrombosis(BMI>30),VVs,FH of DVT,PIH,should change to a 2nd.generation pill
  42. 42. Relative risk and actual incidence of VTE Population Relative risk Incidence Young femalegeneral population Pregnant High dose OC Low dose OC Leiden mutation carrier Leiden carrier + OC Leiden mutation homogenous 1 4.5/100,000 12 6-10 3-4 6-8 48-60 24-50 12-20 24-40 30 120-150 80 320-400
  43. 43. COCP Contraception and Surgery  X4to6 fold increased risk of thromboembolic complications in users of COCP  COCP should be discontinued at least 4 weeks before major surgery or prolonged immobilisation  Can be recommenced on the first day of the next period but at least 14 days after the operation  No need to discontinue for minor surgery/laparoscopy  No need to discontinue if taking POP/other progesterone preparation
  44. 44. Ischaemic Heart Disease and COCP  Oestrogen increases the production of clotting factors  Progestogens have no significant impact on clotting factors  Past users of OC do not have an increase incidence of CV disease  POP pill has a negligible impact on lipoprotein profile - no increase risk of venous or arterial thrombosis  Avoid if hypercholesterolaemia
  45. 45. Arterial thrombosis and the COCP  Smoking and oestrogen have an addictive effect on the risk for arterial thrombosis  Hypertension is a very important additive risk factor for stroke in the COCP patient  Almost all M.I. and strokes in OC users occur with high dose products or users with cardiovascular risk factors and more than 35 years old.  Arterial thrombosis has a dose- response relationship with oestrogen but insufficient data to determine whether there is a risk difference with 20, 30 or 35µg ethinyl oestradiol
  46. 46. Incidence of M.I. In reproductive age women < 35 years old Overall increased Non- smokers Non- smokers + OC Smokers Non- smokers + OC 5/100000/year 4 4 8 43 > 35 years old Non- smokers Non- smokers + OC Smokers Smokers + OC 16 40 88 485
  47. 47. Contraception and Ischaemic Heart Disease – COCP best avoided – Patients on anticoagulants should not be on COCP – IUCD is an excellent form of contraception – (LNG-IUS ---- very useful)
  48. 48. In Ischaemic Heart Disease  Use alternative contraception to the COCP: - IUCD/IUS  - Barrier method  - Implant – may be used in heavy smokers  - those older than 35yrs.  - hypertensives  - hypercholesterolaemia
  49. 49.  Injectables and Implants are safe method fir those with heart disease  Antibiotic cover for the implants may be necessary  Failure rates are low(PI 0-1.0) and these methods provide long periods of contraception
  50. 50. Incidence of stroke in reproductive age women Incidence of ischaemic stroke Haemorrhagic stroke Excess cases/year ~OCs including Smokers & HPT 5/100,000/year 1-3 under 35 10 over 35 6/100,000/ year 2/100,000/year in low dose OC users 1/100,000/year in low dose OC users <35 8/100,000/year in high dose users
  51. 51. Migraine Sufferers  Increased risk of ischaemic stroke in COCP users  Especially - with other arterial risk factors  - focal neurological symptoms (asymetrical)
  52. 52. Risk of Thrombotic stroke in Migraine     Background risk for women aged 20 – 2/100,000 Migraine>once a month + COCP - 10/100,000 ------------------------Background risk for women aged 40 – 20/100,000  Migraine >once a month - 56/100,000  Migraine > once a month + COCP - 100/100,000
  53. 53. COCP contra-indicated in the following groups of patients  Migraine with aura during which there are focal neurological symptoms  Status Migrainosis>72 hours  All migraines treated with ergot deriveratives  Moderately severe migraine without auras but with other additional arterial risk factors
  54. 54.  Stop the COCP  Consider --- the POP --- Implant/Injection --- IUCD/LNG-IUS
  55. 55. Opthalmic Disorders and the COCP  Occasional eye discomfort with contact lenses ---------------------------------- Loss of vision: Retinal artery/vein thrombosis  Transient cerebral ischaemia  Benign intracranial hypertension
  56. 56. Elevated BP and COC  ↑ BP reported in some on COCP- occasionally within a few months of use  Age is strongly correlated with ↑ BP in COCP users  Women with previous HPT in pregnancy may be more likely to develop ↑ BP on COCP  ↑ BP that developes on COCP usually returns to normal after stopping  Women < 35, otherwise healthy and with BP well controlled can be prescribed the lowest oestrogen dose medication under close supervision  In any patient BP rises markedly stop
  57. 57. Diabetes Mellitus – Arterial Disease is a major hazard for diabetics – Avoid Oestrogen with its thrombotic risks – POP can be a method of choice – Alternatively – Implant – – – – - Injection - IUCD/IUS - Barrier method - Sterilisation
  58. 58. Possible Use of COCP in Diabetes Mellitus  Young <25 : recent DM  Free of any complications – arteries, nerves, kidneys, retina.  Non smoker, normotensive, BMI<30  Perceived to need maximum protection against pregnancy  No satisfactory alternative ------------------------------------------ Can use an ultra-low COCP using only a lipid friendly progestogen –mercilon with only 20ug. Oestrogen  But COCP for the shortest possible time  Encourage family as soon as circs. Permit
  59. 59. Epilepsy and Contraception  Effectiveness of hormonal contraception is reduced in women on anticonvulsants which are liver enzyme-inducers  (phenobarbitone, phenotoin,  carbamezapine, primidone)  Sodium valproate, lamotrigine,vigabatrine,benzodiazepine, do not have this effect.  Liver enzyme inducing drugs also increase the metabolism of progestogens and double the usual dose may be required
  60. 60. Epilepsy and contraception  If hormonal contraception: COCP ----------- 50ugEO should be used with a reduced pill free interval  POP ----------- Only to be used if no other acceptable method  Depot Provera – Reduce dosing interval  From 12 to 10 weeks  ------------------------------- Alternative non hormonal methods are better used
  61. 61. Depression  Patients with a history of emotional disturbance may be prone to depression on the OC  If severe – change to alternative form of contraception  Women with PMS may have a varying response to OC – ranging from symptomatic improvement to a worsening of the condition
  62. 62. Smoking  Smoking produces a shift to hypercoaguability  A former smoker must have stopped for at least one year to be regarded as a non smoker  Women who have nicotine obtained from patches or gum in their blood stream should be regarded as smokers
  63. 63. Abdominal pain and COC use  Thrombosis of major intra-abdominal vessels  Gallstones  Pancreatitis  Liver adenoma  Chron’s disease  Acute porphyria
  64. 64. Gynaecological Problems  Gestational Trophoblastic Disease  Ectopic Pregnancy  Menorrhagia  Endometriosis  Fibroids  Pelvic Infection
  65. 65. Gestational Trophoblastic Disease and Contraception  No evidence of Increased risk in GTD by previous COCP use  Close monitoring is required after hydatidiform mole by serial hCG levels  Must avoid pregnancy until after 6 months of normal levels (may mask a rise in hCG due to malignancy)  Must not take COCP until after hCG levels have returned to normal  (prolongs high hCG status  increases risk of requiring chemotherapy after HM)
  66. 66. COCP and menorrhagia  Low dose pills are as effective as high in reducing menstrual flow  COCP can be used to treat menorrhagia a/w DUB among teenage and perimenopausal groups  COCP used to treat menorrhagia reduces menstrual blood flow by 50%
  67. 67. IUCD and menorrhagia  Inert and copper IUCD a/w increase in menstrual blood loss (55% ↑ with copper IUCD)  But menstrual blood loss ↓ if device impregnated with progestogen  LNG-IUS- 20% amenorrhoeic after 1 year  Menorrhagia a/w inert/ copper IUCD can be treated with NSAIDs
  68. 68. Endometriosis  The use of COCP is a/w a lower incidence of endometriosis  The protective effect is probably limited to current or recent use  Consistent with the belief that hormonal treatment of endometriosis should be viewed as suppressive not curative  Use progestogen dominant COCP on a‘tricyclic’ regime
  69. 69. Uterine fibroids  Uterine fibroids are not a contraindication for low dose COCP  There is evidence that the risk of fibroids is decreased by 1/3 in women who used higher dose of COCP for 10 years  Case controlled studies with lower dose have found neither a decrease nor an increase in risk although Nurses Health Study reported a slightly increased risk when COCP was used in early teenage  The administration of low dose COCP to women with fibroid does not stimulate fibroid growth  COCP is a/w reduction in menstrual bleeding
  70. 70. COCP and Pelvic infection  Pelvic Inflammatory Disease usually a consequence of STD  The risk of hospitalisation for PID is reduced by about 50-60% in COCP users - but at least 12 months of use are necessary & protection is limited to current users  If the patient does get pelvic infection, the severity of salphingitis found at laparoscopy is reduced (gonococcus)
  71. 71. COCP and Pelvic infection  The mechanism of protection is unknown:  ? Thickening of cervical mucous to prevent movement of pathogens and bacteria laden sperm in uterus and tube  ↓menstrual bleeding ↓ movement of pathogens into tubes  ↓ in culture medium  But suggested that chlamydial infection may be enhanced- 15 of 17 studies showed an association of COCP and chlamydial cervicitis (? Due to ectropion)  But COCP users are protected against symptomatic PID and there is no evidence for ↑ tubal infertility
  72. 72. Examination and follow- up  Thorough history and examination  BP  Breasts  Liver  Extremities  Pelvic organs  Cervical smear Follow- up visits  First 3 months after OC  Thereafter yearly if no risk factors  If risk factorssee 36 monthly by trained personnel
  73. 73. Blood tests        Glucose, lipid and lipoproteins Young women at least once Women > 35 years old Strong family history of heart disease, HPT, DM History of gestational DM Zanthomatosis Obese women Diabetic women Coagulation screen  Personal/family history in young first degree relative of idiopathic thrombophilia  Check for: Antithrombin III deficiency Protein C deficiency Protein S deficiency Factor V Leiden mutation Prothrombin gene mutation Antiphospholipid syndrome
  74. 74. Consider whether the medical condition would : Increase the risk of venous thromboembolism  Predispose to arterial wall disease  Adversely affect liver function  Be influenced by sex hormones  Require treatment with an enzyme inducing drug  Risk of exacerbating pelvic sepsis
  75. 75. Remember  DIMS  BNF

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