Contraception for MRCOG

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Contraception
for
MRCOG
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
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Value of contraception
• Up to one-third of term pregnancies are unintended at conception
in UK
• Unintended pregnancy is associated with poorer maternal and
neonatal outcomes.
• Pregnancy planning allows for general health to be optimised prior
to conception and can be supported by the use of contraception
• Short interpregnancy intervals (less than 12months between
childbirth and subsequent conception) are associated with
obstetric complications
• preterm delivery
• fetal growth restriction and low birthweight infants
• an overall increase in neonatal mortality.
• Increased the rate of uterine rupture in women trying VBAC
• 1 in 13 women presenting for abortion or childbirth in a UK health
board had conceived within a year of a previous childbirth4/16/20 ELBOHOTY 2
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Contraceptive service
• Most types of contraception are available for free in the UK.
• Contraception is free to all women and men through the
NHS.
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Places where you can get contraception include:
•most GP surgeries – talk to your GP or practice
nurse
•community contraception clinics
•some genitourinary medicine (GUM) clinics
•sexual health clinics – they also offer contraceptive
and STI testing services
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Mechanisms of contraception
Primary mechanismContraception method
OvulationCHC
DMPA injection
Implant
FertilizationCupper IUD
Endometrial atrophyLevonorgestrel IUS
Cervical mucousPOP
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Steps
•Assessment of the woman
•Assessing Eligibility
•Counselling
•Prescribe
•Follow up.
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Suitability
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SUITABILITY
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Benefits
Risks
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History and clinical assessment
• Age
• Previous contraception including emergency contraception
• Gynecological history
• Menstrual history including start date of last menstrual period (LMP)
• Sexual history
• Medical History
• Drug history
• Obstetric history including ectopic pregnancy
• Medication – prescribed/non-prescribed/complementary
• Allergies
• Smear history
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Medical history
— Migraine with or without aura & now or past history.
— CVS risk factors (smoking, obesity, hypertension, DVT,
thrombophilia, hyperlipidaemia). Beware multiple risk
factors.
— liver disease.
— FH – DVT, stroke, CHD, carriers of gene mutations known to
increase ca breast risk eg BRAC 1.
— Drugs including enzyme inducers eg carbamazepine, OTC
and herbal eg st John’s Wort.
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Exam
• BP
• BMI
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Information, advice and counselling
• Contraceptive choices discussed/preparation chosen
• Risks/benefits/uncertainties discussed
• Mode of action and efficacy
• Side effects including bleeding patterns
• Teaching about use of method & Leaflets
• Follow-up arrangements
• Record prescription
• Special instructions if any (e.g. additional contraception)
• Any change in personal history or medication since the last attendance should
be recorded
• Any problems encountered, if any, and actions given
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Criteria for excluding pregnancy
• She has not had intercourse since last normal menses
• She has been correctly and consistently using a reliable method of
contraception
• She is within the first 7 days of the onset of a normal menstrual period
• She is within 4 weeks postpartum for non-lactating women
• She is within the first 7 days post-abortion or miscarriage
• She is fully or nearly fully breastfeeding, amenorrhoeic, and less than
6 months postpartum
• A pregnancy test, if available, adds weight to the exclusion of
pregnancy, but only if ≥3 weeks since the last episode of unprotected
sexual intercourse (UPSI).
• NB. Health professionals should also consider if a woman is at risk of
becoming pregnant as a result of UPSI within the last 7 days.
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UKMEC (UK medical eligibility criteria)
—UKMEC 1 – unrestricted use
—UKMEC 2 - benefits generally outweigh
risks
—UKMEC 3 - risks generally outweigh
benefits
—UKMEC 4 - unacceptable health risk and
should not be used
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Fraser Guideline
• If the patient is under 16 and unaccompanied, apply Fraser guidline
• Remember to encourage her to involve a parent in her decision.
And ensure that she is having consensual sex, not being coerced.
Record in the notes.
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Fraser Guidelines.
— The young person will understand the professional’s advice.
— The young person cannot be persuaded to inform their parents.
— The young person is likely to begin, or continue having, sexual intercourse with
or without contraceptive treatment.
— Unless the young person receives contraceptive treatment, their physical or
mental health, or both, is likely to suffer.
— The young person’s best interests require them to receive contraceptive advice
or treatment with or without parental consent.
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Indications
•Contraception
•+ other indications:
•Menstrual irregularities
•Acne/ PCOS
•PMTs
•STDs prevention
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Sexually transmitted infections and testing
•STI screening should be discussed with all
sexually active women attending health
services for contraceptive advice or supply.
•A repeat STI screen should be advised if
necessary after the appropriate window period
•2 weeks for detection of Chlamydia trachomatis
and Neisseria gonorrhoeae
•3 months for syphilis
•for blood-borne viruses refer to local protocols or
British Association for Sexual Health and HIV
(BASHH) guidance.
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First year failure rates of contraceptives (typical
use)
DMPA=depot medroxyprogesterone acetate.
*Estimate in lieu of actual data.
Trussell J. Contraception. 2004;70:89-96.
**Funk S et al. Contraception. 2005;71:319-326.
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Fertility awareness method
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How to use
•Contraceptive options should be discussed
with the woman and specialists involved in the
management of the condition
•Women wishing to use fertility indicators for
contraceptive purposes should receive support
and instruction on the method from a trained
practitioner.
•Women should be informed that combining
fertility indicators is considered more effective
than using single fertility indicators alone.
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Temperature
•No additional contraceptive precautions are
required for sex that has occurred from 3 days
after the temperature rise until the start of
menstruation.
•When sexual intercourse only occurs in the
identified post-ovulatory phase, the failure rate
of BBT as a single indicator is estimated to be
approximately 6.6%.
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Cervical secretions monitoring
•The fertile time starts at the first sign of any secretions and
continues for three full days after peak
•The fertile time ends on the fourth day after peak day.
•It may take women at least three cycles of observing
secretions to be confident in recognising these changes.
•They should use an additional contraceptive method until
three consecutive dry days are noted.
•The effectiveness of changes to the cervix as a sole indicator
for contraceptive purposes is unknown and therefore is not
recommended. Women may be advised that if they are 6
months postpartum.
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Calendar method
• The calendar method requires the user to record their menstrual cycle length for
a minimum of 12 cycles. The length of the shortest and longest cycles is used to
calculate the fertile window.
• To estimate the first fertile day, 20 days are subtracted from the shortest cycle
length.
• The last fertile day is calculated by subtracting 10 days from the longest cycle
length.
• This latter measurement is rarely used when calendar calculations are used in
conjunction with other indicators because it tends to require more days of
abstinence than other methods; for example, the fertile window for a woman
whose shortest cycle is 26 days and longest is 32 days would be from Days 6 and
22 inclusive - additional precautions would be required during this period if
pregnancy was to be prevented.
• Overall failure rate 20 %
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Effectiveness
•Over 1 year, fewer than 1 in 100 women would be expected
to fall pregnant with perfect use of the
symptothermal method [monitoring of
cervical secretions and basal body temperature (BBT) used
with a calendar calculation.
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Fertility Monitoring Devices
•Urine-based test strips with antibodies to estrone-3-
glucuronide and LH are used to identify the fertile
window.
•Women should avoid intercourse or use additional
contraceptive precautions (e.g. condoms or other
barrier methods) when increased levels of these
hormones are detected.
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postpartum
•As the earliest expected ovulation in non-breastfeeding
women is Day 28, contraception is not required until Day 21
postpartum in non-breastfeeding women.
•Locational amenorrhea: Women may be advised that if they
are 6 months postpartum.
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Coitus interruptus
•4-6% of women in the UK may be using withdrawal.
•The efficacy of this method is largely dependent on
the male partner withdrawing before any sperm are
released into the vagina, and relies on the male
being able to accurately identify when to withdraw
and being compliant.
•For perfect use, 4% of women will have an
unintended pregnancy at 1 year; with typical use,
this increases up to 22%.
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•Barrier methods can be considered as an alternative
to sexual abstinence during the fertile window of the
menstrual cycle in women, provided couples have
been properly instructed in their use and accept a
potentially higher failure rate if using barrier
contraception around the time of ovulation (peak
fertile time).
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Not to use
•Difficult to judge the efficacy:
• Women stopping hormonal contraception should not rely on
fertility indicators until regular menstrual cycles have been
established and they have had a minimum of three cycles after
stopping.
•Danger to the fetus or the mother:
• Women using drugs that are known to have a teratogenic effect
should not rely solely on fertility indicators for prevention of
pregnancy.
• In women for whom pregnancy poses a significant health risk,
the reliance on fertility indicators for the prevention of pregnancy
is not recommended.
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Barrier methods
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Types
•Male condoms (latex, non-latex and
deproteinised latex varieties)
• Female condoms (nitrile or latex)
• Diaphragms (latex, silicone)
• Cervical cap (silicone)
• Dams (latex, non-latex).
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•Damsare not a contraceptive but they
can be used to protect against STIs.
• A dam is a thin film of material that provides a
barrier between the mouth and cervico-
vaginal secretions during cunnilingus or
between the mouth and anus during oro-anal
contact.
• Hand-free varieties are available.
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Mode of action
•Prevents fertilization by preventing
sperm reaching the female upper
genital tract.
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Effectiveness
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Depends on the quality and consistency of use
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Suitability
•Medical reasons to exclude hormonal methods
•Barriers are also indicated while a new method
is taking effect
•Male and female condoms can also be used
with another method for protection against
sexually transmitted infection
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Contraindications
•Latex allergy (latex-free condoms are available and the
female condom is made of polyurethane).
•However she may use a silicone diaphragm, cervical cap,
non-latex male or female condoms, or deproteinised latex
male condoms.
•For diaphragm use: Recurrent urinary tract infections,
uterine prolapse and an aversion to touching the genitals
•For women living with HIV or at high risk of HIV infection or
have Toxic shock syndrome the use of either a diaphragm or
cervical cap is not recommended
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•Women with sensitivity to latex
proteins should avoid the use of latex
barrier contraceptives and may use a
silicone diaphragm, cervical cap, non-
latex male or female condoms, or
deproteinised latex male condoms.
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Advantages
•Male condoms are widely available without
requiring a visit to a health professional
•Male and female condoms offer protection
against sexually transmitted infections –
diaphragms and caps do not
•No systemic side effects
•No effect on lactation
•Spermicides provide lubrication
•Decreased risk of malignant and pre-malignant
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Disadvantages
•Completely user-dependent so high rates of failure with
'typical use'
•Negotiating condom use may be problematic or impossible
in some relationships
•Barriers can be messy, especially when spermicide is needed
•Diaphragms need fitting at a clinic and the woman needs to
learn to fit them herself
•The size of diaphragm needs to be changed when there is a
weight change of ± 4 kg
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Some precautions
•Women using a diaphragm or cap should be advised to use
the method with spermicide.
•The use of condoms lubricated with nonoxinol-9 is not
recommended.
•When using lubricant with latex condoms, diaphragms and
caps a water- or silicone based preparation is recommended.
•Spermicide should be reapplied if sex is to take place and the
diaphragm or cap has been in situ for ≥3 hours or if sex is
repeated with the method in place.
•A diaphragm or cervical cap should not be removed until at
least 6 hours after the last episode of intercourse.
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When do you recommend Emergency
contraception:
•Diaphragm or cap is dislodged or removed within 6
hours of sex
• Diaphragm has been left in for longer than 3 hours
before sex and no additional spermicide applied
• Condom splitting/breaking
• Condom slippage
• Failure to use condoms as advised when starting or
switching contraception
• If enzyme-inducing drugs are being used alongside
hormonal contraception (combined hormonal
contraception, POP and implant) and condoms are
not used during or for 28 days after.4/16/20 ELBOHOTY 62
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Post sexual exposure STD risks
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Factors increasing the risk of HIV
transmission:
•A high plasma HIV viral load
•Breaches in the mucosal barrier such as mouth or genital
ulcer disease and anal or vaginal trauma following sexual
assault or first intercourse.
•Menstruation or other bleeding—theoretical risk only.
•Sexually transmitted infections in HIV-positive individuals not
on ART or HIV-negative individuals with genital ulcer disease.
•Non-circumcision in males—circumcision has been shown to
significantly reduce HIV acquisition among heterosexual men
in high prevalence countries.
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•Post-exposure prophylaxis (PEP) is a course of
medication administered after potential exposure to
HIV.
•It is only recommended where the individual
presents within 72 hours of risk of exposure.
•Evidence for the efficacy of PEPSE is lacking.
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STI screen
•If it is offered immediately this may only identify pre-existing
infection.
•It is recommended 2 weeks after sexual activity is allow
detection of infections acquired at the time of potential risk
exposure.
•In general, serological tests for HIV, hepatitis and syphilis will
require individuals to wait longer to allow for
seroconversion.
• HIV testing 4 weeks combined test for HIV antibody and p24
antigens (fourth-generation laboratory HIV test) and a
negative result is very resurring
•An additional HIV test should be offered to all persons at 3
months (12 weeks) to definitively exclude HIV infection.4/16/20 ELBOHOTY 69
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STDs
• Chlamydia trachomatis can be transmitted in vaginal or seminal fluids through
vaginal, anal or oral intercourse. Prevalence of infection in partners of those
diagnosed with chlamydia is up to 75%.
• Trichomonas vaginalis (TV), can be isolated from the vagina and urethra in
infected women and the urethra in infected men. It is not transmitted through
anal or oral sex.
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Viral Hepatitis
• Evidence on the use of condoms is limited.
• Sexual transmission of hepatitis B among MSM
• Approximately 25% of the regular sexual contacts of infected
individuals will themselves become seropositive.
• The hepatitis C virus can be transmitted through seminal and vaginal fluids but
the risk of sexual transmission is low.
• <1% per year of relationship or about 2% of spouses in long-term relationships.
• Rates of infection increase if the index patient is also infected with HIV.
• Hepatitis A is spread via the faecal-oral route
• BASHH recommends individuals avoid UPSI until considered non-infectious.
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Combined hormonal contraception
(estrogen and a progestogen)
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Types
•Pills – monophasic, bi/tri
phasic and quadriphasic
•Patches
•Vaginal ring
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Combined Hormonal Contraceptive
•Progestin Derivatives
• 19noretesterone
• 1st Generation
• Norethindrone
• Norethynodrel-derivative of
Norethindrone
• 2nd Generation
• Norgesterl
• Levonorgestrel
• 3rd Generation
• Desogestrel
• Norgestimate
• Gestodene
•Estrogen Derivatives
• Mestranol
• Ethinyl Estradiol
• Estradiol Valerate
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•21OH progeteroene
•Cyprotrone acetate
Spironolactone Derivatives
Drosprinone 75
The majority of combined oral contraceptives
contain ethinylestradiol as the oestrogen
component; mestranol and estradiol are also
used.
The ethinylestradiol content of combined oral
contraceptives ranges from 20 to 40
micrograms.
Generally a preparation with the lowest
oestrogen and progestogen content which
gives good cycle control and minimal side-
effects in the individual woman is chosen.
75
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Mode of action
• Inhibit ovulation
• Alters cervical mucus to reduce sperm penetration
• Alters the endometrium, making it atrophic and unreceptive to implantation
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Classification according to the strength
• Low strength preparations
• containing ethinylestradiol 20 micrograms
• are particularly appropriate for women with risk factors for circulatory disease, provided a
combined oral contraceptive is otherwise suitable.
• Standard strength preparations
• containing ethinylestradiol 30 or 35 micrograms or in 30–40 microgram phased
preparations)
• are appropriate for standard use.
• Phased preparations are generally reserved for women who either do not have withdrawal
bleeding or who have breakthrough bleeding with monophasic products.
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Effectiveness
• 0.3 pregnancies per 100 woman years for perfect use and 9 for
typical use
• Women can be informed that the efficacy of all CHCs is generally
similar.
• Contraceptive efficacy may be decreased in women weighing ≥90 kg,
therefore additional precautions or an alternative method should be
advised.
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Typical use
•1 tablet once daily for 21 days; subsequent courses
repeated after 7-day interval, withdrawal bleeding
occurs during the 7-day interval, if reasonably certain
woman is not pregnant, first course can be started
on any day of cycle
•if starting on day 6 of cycle or later, additional
precautions (barrier methods) necessary during first
7 days, tablets should be taken at approximately the
same time each day
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Indications
•Can provide reliable protection against pregnancy if
consistently taken.
•The method is independent of intercourse.
•The combined oral contraceptive pill (COCP) is
indicated in the treatment of some benign
gynaecological conditions, for example
dysmenorrhoea and menorrhagia.
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contraindications
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Absolute contra-indications to COCP use (UKMEC 4 -
risks outweigh benefits))
Relative contra-indications to COCP use (UKMEC 3 -
risks likely to outweigh benefits))
Past or present cardiovascular disease
History of VTE or current VTE on anticoagulants
Thrombogenic mutations
Familial hypercholesterolaemia
Insulin dependent diabetes with compications e.g.
retinopathy
BP consistently >160/95 mmHg
Smokers over 35 years
Migraine with aura
Stroke
Major surgery with prolonged immobilisation
Active liver disease
Porphyria
Medical condition affected by sex steroids e.g. chorea,
pemphigoid gestationis
Pregnancy
Under 6 weeks postpartum breastfeeding
Under 3 weeks postpartum non-breastfeeding
Undiagnosed genital tract bleeding
Estrogen dependent tumours e.g. breast cancer (ever)
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Family history (first degree relative) of VTE aged under 45
years
Systolic BP 140–159 mmHg; Diastolic BP 90–94 mmHg
BMI >35
Focal migraine with aura > 5 years ago
Conditions requiring drug treatment which may interact
with COCP (some anti-retrovirals, some anticonvulsants,
some anti-tubercular agents)
Medically treated and current gall bladder disease
Ø6weeks but less than 6 months with breast feeding
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EXAM
•A blood pressure recording should be documented
for all women prior to first prescription of CHC.
•Body mass index (BMI) should be documented for all
women prior to first prescription of CHC.
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Advantages
•Reliable
•Reversible
•Independent of intercourse
•Allows manipulation of the time of
menstruation
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•Women can be advised that CHC use does not
appear to have a negative effect on overall mortality.
•A reduced risk of ovarian & endometrial cancer that
continues for several decades after stopping.
•A reduction in the risk of colorectal cancer
•CHC may help to improve acne.
•There may be a reduction in the incidence of benign
breast disease with CHC use.
•CHC may help to reduce menstrual pain and
bleeding.
•Women can be advised that CHC may reduce
menopausal symptoms.
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Disadvantages
•Minor side effects, e.g. nausea, fluid retention.
•There may be a very small increase in the absolute risk of
ischaemic stroke associated with CHC use.
•Unscheduled bleeding
•Up to 20% of COC users have irregular bleeding.
•Bleeding usually settles with time and therefore it is
generally recommended women experiencing unscheduled
bleeding continue their combined hormonal methods for 3
months before considering changing
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VTE risk
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•The relative risk of venous thromboembolism
increases in the first few months after initiating
combined hormonal contraception.
•This risk reduces with increasing duration of
use but it remains above the background risk
until the combined hormonal contraceptive is
stopped.
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So
•Women taking CHC should be advised about reducing
periods of immobility during flights over 3 hours.
•Women trekking to altitudes of >4500 m for periods of more
than 1 week may be advised to consider switching to an
alternative method.
•CHC can be used up until the age of 50 years, providing
there are no risk factors that would restrict use.
•After the age of 50 years, women are advised to consider an
alternative method.
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Medical disorders
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Breast cancer
•There is a small increase in the risk of having breast cancer
diagnosed in women taking the combined oral contraceptive
pill; this relative risk may be due to an earlier diagnosis.
•In users of combined oral contraceptive pills the cancers are
more likely to be localised to the breast.
•The most important factor for diagnosing breast cancer
appears to be the age at which the contraceptive is stopped
rather than the duration of use; any increase in the rate of
diagnosis diminishes gradually during the 10 years after
stopping and disappears by 10 years.
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Cervical Cancer
•Health professionals should be aware that
CHC use may be associated with a small
increase in the risk of cervical cancer
which is related to duration of use.
•the risk diminishes after stopping and
disappears by about 10 years.
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•The possible small increase in the risk of
breast cancer and cervical cancer should
be weighed against the protective effect
against cancers of the ovary and
endometrium.
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Interactions with some drugs
•Women taking lamotrigine (except in combination
with sodium valproate) should be advised that
due to the risk of reduced seizure control whilst
on CHC, and the potential for toxicity in the CHC-
free week, the risks of using CHC may outweigh
the benefits.
•Women should be advised that ulipristal acetate
(UPA) has the potential to reduce the efficacy of
hormonal contraception. Additional precautions
are advised for 14 days after taking UPA (9 days if
using or starting the progestogen-only pill, 16
days for the estradiol valerate/dienogest pill)
(outside product licence).4/16/20 ELBOHOTY 100
100

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51
Enzyme inducers:
• For a short course (2 months or less) of an enzyme-inducing drug, continue with a
combined oral contraceptive providing ethinylestradiol 30 micrograms or more daily and
use a ‘tricycling’ regimen (i.e. taking 3 packets of monophasic tablets without a break
followed by a shortened tablet-free interval of 4 days [unlicensed use]). Additional
contraceptive precautions should also be used whilst taking the enzyme-inducing drug
and for 4 weeks after stopping. Another option (except for rifampicin or rifabutin) is to
follow the advice for long-term courses.
• For women using combined hormonal contraceptive patches or vaginal rings, additional
contraceptive precautions are also required whilst taking the enzyme- inducing drug and
for 4 weeks after stopping. If concomitant administration runs beyond the 3 weeks of
patch or vaginal ring use, a new treatment cycle should be started immediately, without a
patch-free or ring-free break.
• For a long-term course (over 2 months) of an enzyme- inducing drug (except rifampicin or
rifabutin), adjust the dose of combined oral contraceptive to provide ethinylestradiol 50
micrograms or more daily [unlicensed use] and use a ‘tricycling’ regimen; continue for the
duration of treatment with the enzyme-inducing drug and for 4 weeks after stopping.
• If breakthrough bleeding occurs (and all other causes are ruled out) it is recommended
that the dose of ethinylestradiol is increased by increments of
10 micrograms up to a maximum of 70 micrograms daily [unlicensed use], or to use
additional precautions, or to change to a method unaffected by enzyme-inducing drugs.
• Contraceptive patches and vaginal rings are not recommended for women taking
enzyme-inducing drugs over a long period.
• For a long-term course (over 2 months) of rifampicin or rifabutin, an alternative method
of contraception (such as an IUD) is always recommended because they are such potent
enzyme-inducing drugs; the alternative method of contraception should be continued for
4 weeks after stopping the enzyme-inducing drug.
4/16/20 ELBOHOTY 101
101
Antibiotics and CHC
•Still need to use an alternative method
unaffected by enzyme-inducing drugs (at the
very least good condom use) if using the
enzyme-inducing rifamycins (such as rifabutin
and rifampicin)
102

16/04/2020
52
•Women can be advised that CHC may be
associated with mood changes but there is no
evidence that it causes depression.
103
What are the rules regarding missed pills ?
104

16/04/2020
53
105
106

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54
Timing
•COCs containing EE can be started up to and including Day 5
of the cycle without the need for additional contraceptive
protection.
•When starting COCs after Day 5 women should use
additional precautions such as condoms or avoid sex for the
next 7 days.
•For estradiol valerate/dienogest-containing pill (Qlaira)
should be started on Day 1, with additional precautions used
for 9 days if starting any time after this.
107
108

16/04/2020
55
109
Inform.
• Safer sex/condoms also.
• Consider chlamydia screening (CHLASP) if age less than 25.
110

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56
Follow up
• A follow-up visit 3 months after the first prescription is advised to allow BP to be
rechecked, and assessment of any problems.
• Women may be offered up to a 12 months’ supply of COC or CTP at the follow-up
appointment.
• A yearly routine follow-up visit, plus advice to return at any time if there are
problems, is recommended.
• Follow-ups should involve checking BP, BMI and enquiring about any health
changes.
• After dispensing, rings should be stored at room temperature and used within 4
months.
• Therefore no more than three rings can be provided.
111
Prescribe- summary.
• Monophasic
• Phasic pills eg. logynon. Varying dose in 2 or 3 steps throughout the 21 days.
Need to be in correct order, more complicated. Good for cycle control.
• Qlaira. New pill. Different oestrogen (oestradiol valerate rather than
ethinyloestradiol). Complicated quadriphasic/26 day regime.
Note: generally higher cost of newer pills.
112

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57
Qlaira
• A phasic pill – consisting of a 28-day cycle with a quadriphasic dosage
regimen and a 2-day placebo phase
• The resulting reducing estrogen and increasing progestogen doses are
designed to optimise cycle control
• First COC to contain estradiol valerate, which is metabolised to estradiol (that
also exists naturally in women)
113
Phasic nature of Qlaira
4/16/20 ELBOHOTY
Number of
pills
Colour Estradiol valerate
(mg)
Dienogest (mg)
2 dark yellow 3 0
5 medium red 2 2
17 light yellow 2 3
2 dark red 1 0
2 white 0 0
114
114

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58
Disadvantages
• Complex regimen
• Different (complicated) missed pill rules
Therefore need to be a good pill taker and
prepared to follow the regimen
115
Advantages
• Has recently been licensed for heavy menstrual bleeding in women desiring
contraception
• Dienogest is a highly selective progestogen that produces good suppression of
endometrial proliferation
116

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59
Yaz
• 20mcg ethinylestradiol/3mg drospirenone (20mcgEE/3mgDRSP) is a combined
estrogen and progestogen contraceptive pill licensed for contraceptive use.
• 20mcgEE/3mgDRSP comes in a calendar pack with 24 consecutive active tablets
containing ethinylestradiol 20mcg and drospirenone 3mg followed by four
placebo tablets.
• Drospirenone is a synthetic progestogen that has antimineralocorticoid activity
similar to that of progesterone and mild antiandrogenic acivity.
• There is no pill-free interval: the subsequent pill packet is started the day after
the last tablet of the previous packet has been taken. A four day hormone-free
interval is provided by the four placebo tablets.
117
Combined contraceptive patch
• Evra (apply weekly x3, then patch free week). There is a 48 hour ‘window’ in
which to remember patch application (COC missed pill rules are now similar, but
no need to take daily pill).
118

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60
EVRA: administration schedule
4/16/20 ELBOHOTY
– 20 mcg ethinyloestradiol and 150
mcg norelgestromin
– Apply weekly for 3 weeks
– Apply same day-of-the-week
– 1 week patch-free
Sunday Sunday Sunday Sunday
Patch # 1 Patch # 2 Patch # 3
28-day cycle
Patch-free
Sunday
Start next cycle
28-day cycle
119
119
Nuvaring
•Flexible transparent ring
(54mm diameter; 4mm thick)
•Inserted vaginally
•Combined hormonal contraception
•15 µg/day ethinyl estradiol (EE)
120 µg/day etonogestrel (ENG)
•One ring every 4-week cycle
(3 weeks ring in; 1 week ring free)
If the ring remains outside the vagina for more than 3 hours
or if the user does not know when the ring was expelled,
contraceptive protection may be reduced
120

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Pharmacology
Vaginal administration avoids first-pass metabolism and gastrointestinal interference with drug absorption
Systemic ethinylestradiol exposure is 50% of that of a 30 μg combined oral contraceptive pill (COC)
121
Useful for
• Once monthly dosing – not LARC, but related advantages compared to daily and
weekly methods (good for women who want to remain in control of method)
• Problems with taking pills/COC:
- forgets
- changes in time zone
- difficulty swallowing pills
- nausea on taking pills
- absorption problems
122

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62
Can use with:
•Tampons
•Vaginal thrush treatments
•Diarrhoea and vomiting
•Antibiotics
(but still need extra precautions with liver-
inducing enzymes)
123
Disadvantages
• Cost, 3-ring pack costs £27.00 (BNF)
• Before dispensing, needs to be stored in a fridge at 2-8 ºC; once
dispensed needs to be used within 4 months (so only dispense 1 pack of
3 rings at a time)
• Still have to remember to remove and insert each month
124

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Progestogen-only Pills
125
126

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64
•POPs can also act to suppress ovulation.
•The extent to which this occurs is variable; for
example, up to 60% of cycles in women using an LNG
pill are anovulatory, whereas ovulation is suppressed
in up to 97% of cycles in women using the DSG pill
and they have a 12-hour window for missed pills.
•The DSG pill may offer some benefits in the
management of dysmenorrhoea.
127
UKMEC 4UKMEC 3
Breast cancer current (within the last 5 years)Breast cancer past and no evidence of
current disease for 5 years
Decompansated liver
Liver adenoma or carcinoma
Drugs that affect liver enzymes
Continuation in:
• Current ischaemic heart disease
• Stroke
128

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65
Missed pills
129
Advantages
•The efficacy of POPs (traditional or desogestrel-only) is not
reduced in women weighing >70 kg and therefore the
licensed use of one pill per day is recommended (Available
evidence has not shown an increased risk of pregnancy in
POP users with a heavier body weight or a higher body mass
index).
•There is no evidence of a causal association between POP
use and weight change, depression, headache,
cardiovascular disease (myocardial infarction, venous
thromboembolism and stroke) or breast cancer.
•A woman can continue to use a POP until the age of 55 years
when natural loss of fertility can be assumed.
130

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66
131
132

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67
ONGOING USE AND FOLLOW UP
•In the absence of special problems, women can be given up
to 12 months’ supply of POPs at their first and follow-up
visits.
•Women can be advised that a POP can be continued until
the age of 55 years when natural loss of fertility can be
assumed.
•Alternatively she can continue with the POP and have
follicle-stimulating hormone (FSH) concentrations checked
on two occasions 6 weeks apart. If both FSH measurements
are >30 IU/l this is suggestive of ovarian failure.
•In this case she may continue with a POP or barrier
contraception for a further period of 1 year (or 2 years if she
is aged <50 years).
133
Potential risks
•Mood changes have been reported in women using the POP
but there is no evidence of a causal association between use
and mood changes or depression.
•While the overall risk of pregnancy is reduced with use of
traditional POPs, around 1 in 10 pregnancies that do occur
may be ectopic.
•Studies investigating the effects of POP on libido are lacking
and therefore a possible effect cannot be excluded; however,
no association has yet been demonstrated.
134

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68
Side effects: Bleeding
•Indeed almost half of POP users experience
prolonged bleeding and up to 70% report
breakthrough bleeding or spotting in one or more
cycles.
•DSG has 2 times a variable pattern of bleeding than
LNG POPs in the first reference period of 90 days.
•Bleeding problems decreased with increasing
duration of use, and by the fourth reference period
(1 year) almost 50% of DSG users had infrequent
bleeding (1–2 bleeding/spotting episodes) or
amenorrhoea, compared to 10% of the LNG users.4/16/20 ELBOHOTY 135
135
•As a guide, women considering DSG-only
contraception can be advised that after 12 months of
use, over a 3-month period approximately:
• 5 in 10 women can expect to be amenorrhoeic or have
infrequent bleeding
• 4 in 10 women can expect to have 3–5 bleeding
spotting/episodes (regular)
• 1 in 10 women can expect >6 bleeding/spotting
episodes (frequent bleeding).
• 2 in 10 women will experience bleeding/spotting
episode lasting >14 days (prolonged bleeding).
•Traditional POP users can be advised that frequent
and irregular bleeding are common, while prolonged
bleeding and amenorrhea are less likely.
136

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69
MANAGING BLEEDING
•Exclude
•sexually transmitted infections
•pregnancy
•gynaecological pathology.
•After exclusion of other causes, if bleeding patterns
are still unacceptable then an alternative
contraceptive may need to be considered.
• There is no evidence that changing the type and
dose of progestogen will improve bleeding but this
may help some individuals.
137
Breast cancer ?!
•There is a small increase in the risk of having breast
cancer diagnosed in women using, or who have
recently used, a progestogen-only contraceptive pill;
this relative risk may be due to an earlier diagnosis.
•The most important risk factor appears to be the age
at which the contraceptive is stopped rather than the
duration of use; the risk disappears gradually during
the 10 years after stopping and there is no excess
risk by 10 years.
•A possible small increase in the risk of breast cancer
should be weighed against the benefits.
138

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70
Long-acting reversible contraception
LARC
139
LARC
•It is defined as contraceptive methods that require
administration less than once per cycle or month.
•Why:
• It is estimated that about 30% of pregnancies are unplanned.
• The effectiveness of the barrier method and oral contraceptive pills
depends on their correct and consistent use.
• By contrast, the effectiveness of long-acting reversible contraceptive
(LARC) methods does not depend on daily concordance.
•The uptake of LARC is low in Great Britain, at around 8% of
women aged 16–49 in 2003–04, compared with 25% for the
oral contraceptive pill and 23% for male condoms.
•There is no perfect and normal user (Except in DMPA?)
140

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71
Categories
•copper intrauterine devices
•progestogen-only intrauterine systems
•progestogen-only injectable contraceptives
•progestogen-only subdermal implants
141
Discontinuation rates with LARC methods
LARC Discontinuation rates Most common reason
Injectables 50% within one year Unacceptable bleeding
Implant 43% within 3 years Unacceptable bleeding
IUS 60% within 5 years Unacceptable bleeding and
pain
IUD 50% within 5 years unacceptable vaginal
bleeding and pain
142

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72
143
Progestogen-only Implants
144

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73
Forms
•The progestogen-only implant is a single, non-
biodegradable, subdermal rod licensed for up to 3 years of
use.
•Each implant contains 68 mg Etonorgestrel.
•The release rate decreases with time from approximately
60–70 μg/day in Weeks 5–6 to approximately 25–30 μg/day
at the end of the third year.
•Differences between Nexplanon and Implanon
• barium sulphate has been added to Nexplanon to enable
detection by X-ray .
•The applicator has also been modified to reduce the risk
of deep insertion and to facilitate one-handed insertion.
145
Health benefits
•Help to alleviate dysmenorrhoea.
•There is no increased risk of venous thromboembolism,
stroke or myocardial infarction associated with the use of
the progestogen-only implant.
•There is no evidence of a clinically significant adverse effect
on bone mineral density with use of a progestogen-only
implant.
•There is no evidence of a causal association with weight,
mood, headach and libido.
•Women may experience improvement, worsening or new
onset of acne during use of a progestogen-only implant.
146

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74
bleeding patterns
•Fewer than one-quarter of women using the progestogen-
only implant will have regular bleeds.
•Infrequent bleeding is the most common pattern
(approximately one-third); around one-fifth of women
experience no bleeding; and approximately one-quarter
have prolonged or frequent bleeding.
•Altered bleeding patterns are likely to remain irregular.
147
4/16/20 ELBOHOTY
Bleeding patterns
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8
Percentage
Amenorrhoea Infrequent bleeding
Frequent bleeding Prolonged bleeding
148
148

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75
Management
• exclude of other causes.
• women who experience troublesome bleeding while using the progestogen-only
implant, and who are eligible to use combined hormonal contraception, may be
offered Ethinyl estradiol or combined oral contraception (COC) cyclically or
continuously for 3 months (outside the product licence).
• Longer-term use of the implant and COC has not been studied and is a matter of
clinical judgement.
149
Failure rate
•1/2000
150

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76
Factors affecting efficacy
• Concomitant use of enzyme-inducing drugs may reduce the efficacy of the
progestogen-only implant.
• Women should be advised to switch to a method unaffected by enzyme-inducing
drugs or to use additional contraception until 28 days after stopping the
treatment.
151
Follow-up
•No routine follow-up is required.
•Women using a progestogen-only implant
should be advised to return if
•They cannot feel their implant or it appears to
have changed shape
•They notice any skin changes or pain around the
site of the implant
•They become pregnant
•They develop any condition that may
contraindicate continuation of the method.
152

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77
Nexplanon
153
154

16/04/2020
78
4/16/20 ELBOHOTY
Transverse image (deep Implanon)
155
155
4/16/20 ELBOHOTY
Radio opaque implant
156
156

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79
IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE (JUNE 2016):
•There have been rare reports of Nexplanon ®
implants reaching the lung via the pulmonary
artery.
•An implant that cannot be palpated at its
insertion site should be located and removed
as soon as possible
•If unable to locate implant within the arm, the
MHRA recommends using chest imaging.
•Correct subdermal insertion reduces the risk of
these events.4/16/20 ELBOHOTY 157
157
pregnancy
•The progestogen-only implant is not known to be
harmful in pregnancy but women with a continuing
pregnancy should be advised to have the implant
removed.
•Women may retain the implant if they wish to
continue the method after a non-continuing
pregnancy.
158

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80
Progestogen-only Injectable
Contraception
159
Forms
• Both DMPA and NET-EN are long-acting progestogens; the combined
contraceptive injectable is not available in the UK.
• DMPA is formulated for
• deep intramuscular (IM) injection as Depo-ProveraR (150 mg medroxyprogesterone
acetate in 1 ml) 5 and
• subcutaneous (SC) injection as Sayana PressR (104 mg MPA in 0.65 ml).
• NET-EN is less commonly used in the UK.
• It is available as NoristeratR (200 mg in 1 ml), administered by IM injection.
• NET-EN is licensed for short-term use by women whose partners have undergone
vasectomy until successful vasectomy is confirmed, and after rubella immunisation.
160

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Site of injection
•The gluteal muscle in the buttock is the
preferred site for IM DMPA administration
but it can be administered into the deltoid
muscle of the upper arm.
•In women with deep adipose tissue in the
gluteal area, standard-length needles may
not reach the muscle layer and SC DMPA or
deltoid administration of IM DMPA should be
considered.
•SC DMPA should be injected into the
abdomen or anterior thigh.4/16/20 ELBOHOTY 161
161
Efficacy & use
•When administered at the recommended dosing
interval the failure rate of progestogen-only
injectable contraception is approximately 0.2% in the
first year of use.
•With typical use the failure rate is approximately 6%.
•The pregnancy rate with Depo medroxyprogesterone
acetate (DMPA) is lower than that with
norethisterone enantate (NET-EN).
•DMPA should be repeated every 12 weeks and NET-
EN every 8 weeks
162

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Potential harms
• Weight gain (up to 2–3 kg in weight over 1 year).
• A delay in return to fertility of up to 1 year after discontinuation but no
reduction in fertility.
• A small loss of bone mineral density, which is usually recovered after
discontinuation. There is no evidence of an increased risk of fracture.
• Progestogen-only injectables may be used as first-line contraception for women
under the age of 18 years after other methods have been considered.
• Women using DMPA who wish to continue use should be reviewed every 2 years
to assess individual situations, and to discuss the benefits and potential risks.
• There is possibly a weak association between current use of DMPA and
breast cancer.
• There is a weak association between cervical cancer and use of DMPA
for 5 years or longer.
• Women are generally advised to switch to another method at age 50
years.
163
Discontinuation
•Up to 50% of women stop using DMPA by 1
year; the most common reason is an altered
bleeding pattern, such as persistent bleeding.
•A pattern of persistent bleeding associated
with DMPA use can be treated with mefenamic
acid or ethinylestradiol.
•Women attending up to 2 weeks late for repeat
injection of DMPA may be given the injection
without the need for additional contraceptives.
164

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83
Postpartum use
•Troublesome bleeding has been reported in
patients given medroxyprogesterone acetate in
the immediate puerperium; delaying the first
injection until 6 weeks after birth may
minimise bleeding problems.
•If the woman is not breast-feeding, the first
injection may be given within 5 days
postpartum (she should be warned that the
risk of troublesome bleeding may be
increased).4/16/20 ELBOHOTY 165
165
Osteoporosis
•In adolescents, medroxyprogesterone acetate (Depo-
Provera ®, SAYANA PRESS ®) should be used only
when other methods of contraception are
inappropriate
•in all women, the benefits of using
medroxyprogesterone acetate beyond 2 years should
be evaluated against the risks;
•in women with risk factors for osteoporosis, a
method of contraception other than
medroxyprogesterone acetate should be considered
166

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84
167
168

16/04/2020
85
IUD/IUS
169
•Mirena (levonorgestrel-releasing
intrauterine system) contains 52 mg of LNG
•Mirena releases the drug at an initial rate
of 20 micrograms per day.
•This declines to a rate of 14 micrograms
per day after 5 years, which is still in the
range of clinical effectiveness.
170

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IUSIUD
inhibiting implantationpreventing fertilisationMechanism
NotUsedEC
5 years10 yearsLicensed
45 years40retain the device until they no longer
require contraception1.
1sCan cause significant
bleeding problems for up to 6
months
t
choice if heavy periods
Heavier bleeding and/or
dysmenorrhoea.
10 in 1000 over 5 years20 in 1000 over 5 yearsThe pregnancy rate
about 1 in 1000 in years.risk of ectopic pregnancy
1 in 20When pregnant risk of ectopic
pregnancy is
1:1000risk of uterine perforation
1:100risk of developing PID
1:20expelled
60% (the same causes)
Less common to hormonal
50% unacceptable vaginal
bleeding and pain.
within 5 years stop4/16/20 ELBOHOTY 171
171
Risk of infection
•Risk of infection The main excess risk of infection occurs in
the first 20 days after insertion and is believed to be related
to existing carriage of a sexually transmitted infection.
Women are considered to be at a higher risk of sexually
transmitted infections if:
•they are under 25 years old or
•they are over 25 years old and have a new partner or
•have had more than one partner in the past year or
• their regular partner has other partners.
172

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Before insertion
4/16/20 ELBOHOTY
•Testing for the following infections should be undertaken
before IUD insertion:
•Chlamydia trachomatis in women at risk of STIs
•Neisseria gonorrhoeae in women from areas where the
disease is prevalent and who are at risk of STIs any STIs in
women who request it.
• If testing for STIs is not possible, prophylactic antibiotics
should be given before IUD insertion in women at increased
risk of STIs.
•Women with identified risks associated with uterine or
systemic infection should have investigations, and
appropriate prophylaxis or treatment before insertion of an
IUD.
173
173
At insertion
4/16/20 ELBOHOTY
•Provided that it is reasonably certain that the woman is not
pregnant, IUDs may be inserted:
•at any time during the menstrual cycle
•immediately after first- or second-trimester abortion, or at
any time thereafter
•from 4 weeks post-partum, irrespective of the mode of
delivery.
•Emergency drugs including anti-epileptic medication should
be available at the time of IUD insertion in a woman with
epilepsy because there may be an increased risk of a seizure
at the time of cervical dilation.
174
174

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88
Post insertion
4/16/20 ELBOHOTY
•A follow-up visit:
• after the first menses, or 3–6 weeks
after insertion, to exclude infection,
perforation or expulsion.
•a woman should be strongly encouraged
to return at any time to discuss
problems, if she wants to change her
method of contraception, or if it is time
to have the IUD removed.
175
175
Some problems
• Heavier and/or prolonged bleeding associated with IUD:
• use can be treated with non-steroidal anti-inflammatory drugs
and tranexamic acid.
• Women who find heavy bleeding associated with IUD use
unacceptable:
• may consider changing to a levonorgestrel intrauterine system
(LNG-IUS).
• The presence of Actinomyces-like organisms on a cervical smear in a
woman with a current IUD
• requires an assessment to exclude pelvic infection. Routine
removal is not indicated in women without signs of pelvic
infection.
• Women who have an intrauterine pregnancy with an IUD in situ
• should be advised to have the IUD removed before 12
completed weeks' gestation, whether or not they intend to
continue the pregnancy.
176

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Perforation
• Uterine perforation most often occurs during insertion, but might not be
detected until sometime later. The risk of uterine perforation is increased when
the device is inserted up to 36 weeks postpartum or in patients who are
breastfeeding. Before inserting an intra-uterine contraceptive device, inform
patients that perforation occurs in approximately 1 in every 1000 insertions and
signs and symptoms include:
• severe pelvic pain after insertion (worse than period cramps);
• pain or increased bleeding after insertion which continues for more than a few weeks;
• sudden changes in periods;
• pain during intercourse;
• unable to feel the threads.
• Patients should be informed on how to check their threads and to arrange a
check-up if threads cannot be felt, especially if they also have significant pain.
• Partial perforation may occur even if the threads can be seen; consider this if
there is severe pain following insertion and perform an ultrasound
177
4/16/20 ELBOHOTY
Lost Threads
•Causes
• Expulsion / perforation / uterine enlargement
• Exclude pregnancy
•Consider EC
•Recommend additional contraception
•Locate the device
• refer for scan / x-ray
178
178

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Expelling IUD/IUS
•Possibilities:
•Non-fundal placement –no evidence of reduced
effect
•Cervical or below: No knowing for how long may
not have been protective
•Options
•?Remove and replace with IUD if you are confirm a
negative pregnancy test (?excludes very early
pregnancy)
•?Remove and give other contraception method4/16/20 ELBOHOTY 179
179
Removal
•An intra-uterine device should not be removed
in mid- cycle unless an additional contraceptive
was used for the previous 7 days.
•If removal is essential post-coital contraception
should be considered.
180

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• Two IUS devices are currently available; Mirena" or Levosert" (Gedeon Richter Plc.,
Budapest, Hungary), both of which contain 52 mg of levonorgestrel (52 mg IUS), and
Jaydess" (Bayer plc, Newbury, UK) which contains 13.5 mg of levonorgestrel (13.5 mg
IUS).
• Mirena" is licensed for contraceptive use for 5 years; Levosert" and Jaydess" for 3 years.
• However, the FSRH evidence-based guidance supports the use of Mirena" in women
older than 45 years of age for up to 7 years, or to menopause if the woman remains
amenorrhoeic.
Mirena" is licensed for the treatment of HMB, and to give endometrial protection when
used with estrogen-only HRT.
• Neither Jaydess or Levosert are licensed for these indications. The newer and lower
dose-containing Jaydess" has an insertion diameter smaller than the 52 mg IUS, so can be
used in smaller uteri, nulliparous women and older For women of perimenopausal age,
the most important health benefit of the 52 mg IUS is its effect on menstrual bleeding.
Within 3 months of insertion this IUS reduced blood loss by over 80% in women with
HMB
• IUS is more effective than norethisterone for the management of HMB. IUS devices are
equal to ablation and hysterectomy for improving women’s quality of life. IUSs are also
effective for reducing fibroid- associated bleeding, and improve endometriosis-associated
pain.
181
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quick starting contraception
183
• All women of reproductive age are pregnant until proven otherwise’
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Quick Starting Contraception
If a health professional is reasonably sure that a woman is not
pregnant or at risk of pregnancy from recent unprotected
sexual intercourse (UPSI), contraception can be started
immediately unless the woman prefers to wait until her next
period.
185
Checklist for quick starting contraception
If risk of pregnancy cannot be reasonably excluded, the contraceptive provider
should ensure that the woman is:
• Likely to continue to be at risk of pregnancy or that she has expressed a preference
to begin contraception immediately
• Aware that there is a possibility of pregnancy
• Informed that there is a theoretical risk from fetal exposure to contraceptive
hormones but most evidence indicates no harm
• Aware that pregnancy cannot be excluded until she has had a pregnancy test no
sooner than 3 weeks after the last episode of unprotected sexual intercourse
• Offered a supply of condoms or informed of local providers of condoms
• Advised to return if there are any concerns or problems with her contraception
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If pregnancy cannot be excluded (e.g. Following
administration of EC) but a woman is likely to continue to be
at risk of pregnancy, immediate ‘quick starting’ of
• CHC or
• the POP or
• progestogen only implant may be considered.
The woman should be informed of the potential risks and the
need to have a pregnancy test at the appropriate time.
If contraception is quick started in a woman for whom
pregnancy cannot be excluded, a pregnancy test should be
advised no sooner than 3 weeks after the last episode of
UPSI.
187
Women requesting the progestogen-
only injectable should ideally be
offered a bridging method if
pregnancy cannot be excluded, but
immediate start is acceptable if other
methods are not appropriate or
acceptable.
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Quick Starting
Contraception
If starting hormonal contraception
immediately after ulipristal acetate EC,
it is recommended that condoms or
avoidance of sex for 14 days (9 days if
starting POP, 16 days for Qlaira)
189
Emergency
Contraception
•Hormonal
•IUD
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Women who do not wish to conceive
should be offered EC after:
4/16/20 ELBOHOTY
• UPSI from Day 21 after childbirth (unless the criteria for
lactational amenorrhoea are met).
• UPSI from Day 5 after abortion, miscarriage, ectopic pregnancy
or uterine evacuation for gestational trophoblastic disease
(GTD).
• Women who do not wish to conceive should be offered EC after
UPSI if their regular contraception has been compromised or has
been used incorrectly e.g. Missed pills, delay in injections,…
191
191
potential failure of hormonal and intrauterine
methods of
contraception
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193
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• Method
• Situation leading to possible
contraceptive failure • Indication for EC
• Hormonal methods of contraception
• Failure to use additional contraceptive
precautions when starting the method
• UPSI or barrier failure during time that
additional precautions required as
indicated within CEU guidance.
• Combined hormonal transdermal
patch or combined hormonal vaginal
ring
• Patch detachment/ring removal for
>48 hours
• Extension of patch-free or ring-free
interval by >48 hours
• EC is indicated if patch detachment or
ring removal occurs in Week 1 and there
has been UPSI or barrier failure during
the hormone-free interval (HFI) or Week
1.
• If the HFI is extended, a Cu-IUD can be
offered up to 13 days after the start of
the HFI assuming previous perfect use
• If CHC has been used in the 7 days
prior to EC, the effectiveness of UPA-EC
could theoretically be reduced. Consider
use of LNG-EC
• Combined oral contraceptive pill
(monophasic pill containing
ethinylestradiol)
• Missed pills (if two or more active pills
are missed)
• EC is indicated if the pills are missed in
Week 1 and there has been UPSI or
barrier failure during the pill-free
interval or Week 1.
• If the pill-free interval is extended
(this includes missing pills in Week 1), a
Cu-IUD can be offered up to 13 days
after the start of the HFI assuming
previous perfect use
• If COC has been taken in the 7 days
prior to EC, the effectiveness of UPA-EC
could theoretically be reduced. Consider
use of LNG-EC
195
Method
Situation leading to possible contraceptive
failure
Indication for EC
Combined hormonal contraception, progestogen-
only pill and progestogen-only implant
Failure to use additional contraceptive precautions
whilst using liver enzyme- inducing drugs or in the
28 days after use
EC is indicated if there is UPSI or barrier failure
during, or in the 28 days following, use of liver
enzyme-inducing drugs. Offer a Cu-IUD (unaffected
by liver enzyme-inducing drugs) or a double dose
(3 mg) of LNG-EC. UPA-EC is not recommended
with liver enzyme-inducing drugs.
Progestogen-only pill
Late or missed pill (>27 hours since last traditional
POP or >36 hours since last desogestrel-only pill)
EC is indicated if a pill is late or missed and there
has been UPSI or barrier failure before efficacy has
been re-established (i.e. 48 hours after restarting).
Timing of ovulation after missed pills cannot be
accurately predicted. A Cu-IUD is therefore only
recommended up to 5 days after the first UPSI
following a missed POP
If POP has been taken in the 7 days prior to EC, the
effectiveness of UPA-EC could theoretically be
reduced. Consider use of LNG-EC
Progestogen-only injectable
Late injection
(>14 weeks since last injection of DMPA)
EC is indicated if there has been UPSI or barrier
failure:
>14 weeks after the last injection
within the first 7 days after late injection
Timing of ovulation after expiry of the progestogen-
only injectable is extremely variable
A Cu-IUD is only recommended up to
5 days after the first UPSI that takes place
>14 weeks after the last DMPA injection.
The effectiveness of UPA-EC could theoretically be
reduced by residual circulating progestogen.
Consider use of LNG-EC
Intrauterine contraception (Cu-IUD and LNG- IUS)
Removal without immediate replacement; partial or
complete expulsion; threads missing and IUC
location unknown
If UPSI has occurred in the 5 days (the duration of
sperm viability in the upper genital tract) prior to
removal, perforation, partial or complete expulsion.
Depending on the timing of UPSI and time since IUD
known to be correctly placed, it may be appropriate
to fit another Cu-IUD for EC.
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197
Availability
• GP surgery – prescription
• Emergency gynae services
• Accident & Emergency services
• Pharmacy – cost
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Forms
Method Class
Recommended
dose/use
Indications
Copper intrauterine
device (Cu-IUD)
Intrauterine
contraceptive method
IUD retained until
pregnancy excluded
(e.g. onset of next
menstrual period) or
can be kept for
ongoing contraception
Within 5 days (120
hours) after the first
UPSI in a cycle or
within 5 days after the
earliest estimated date
of ovulation
Levonorgestrel EC
(LNG-EC)
Progestogen
1.5 mg single oral
dose*
Licensed for use within
72 hours after UPSI or
contraceptive failure
Ulipristal acetate EC
(UPA-EC)
Progesterone receptor
modulator
30 mg single oral dose
Licensed for use within
5 days (120 hours)
after UPSI or
contraceptive failure
If the client wants the most effective method available to prevent pregnancy, she should
have a copper IUD fitted (which can be removed at the next menses or kept as a long
term method)
EC providers should advise women that levonorgestrel EC (LNG-EC) is licensed
for EC up to 72 hours after UPSI. The evidence suggests that LNG-EC is
ineffective if taken more than 96 hours after UPSI.
199
•Levonelle is a progestogen (1500 µg levenorgestrel)
•ellaOne is a selective progesterone modulator, i.e. acts on
the progesterone receptor (tissue-selective) but is not a
progestogen
•30mg ulipristal acetate
• Both primarily work by
• inhibiting/delaying ovulation
• but may also effect endometrium – inhibiting implantation if
fertilisation has occured
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ellaOne vs Levonelle
• ellaOne more effective (failure rate 1.28% compared to 2.2% with
Levonelle)
• ellaOne can still inhibit/delay ovulation once LH surge started - ie in 48
hours pre-ovulation
• ellaOne is a Progesterone Receptor Modulator and therefore interferes
with ongoing hormonal contraception for the next 7 days.
• Prescription only (i.e. no direct provision available by pharmacists) and
licensed for use up to 120 hours post UPSI and equally effective
throughout that time period
201
Choosing between UPA-EC and LNG-EC
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•The evidence suggests that LNG-EC is ineffective if
taken more than 96 hours after UPSI.
•UPA-EC is therefore the only oral EC that is likely to
be effective if UPSI took place 96–120 hours ago.
Between 96 and 120 hours after UPSI
203
Between 0 and 96 hours after UPSI
• The decision as to whether UPA-EC or LNG-EC (unlicensed after 72
hours) is most appropriate depends on the following factors:
• High risk of pregnancy (If UPSI is likely to have taken place during
the 5 days prior to ovulation) : UPA-EC should be considered first-
line oral EC.
• Low risk of pregnancy (If UPSI is likely to have taken place during
the 5 days prior to ovulation):
• It is more important to protect from future USI by using
hormonal contraception so use LNG-EG + hormonal
contraception
• The ability of UPA-EC to delay ovulation is reduced if a
progestogen is taken in the following 120 hours. It is therefore
recommended that hormonal contraception is not started until 5
days after UPA-EC, whereas hormonal contraception can be
started immediately after LNG-EC.
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Recent use of progestogen.
• It is unknown whether UPA-EC taken when there may still be circulating
progestogen is more or less effective than LNG-EC.
• So LNG-EC may be more suitable
205
BMI/body weight or Enzyme-inducing
drugs.
•The effectiveness of LNG-EC could be
reduced if a woman has a BMI >26 kg/m2
or weight >70 kg or Enzyme-inducing
drugs.
•It is recommended that either UPA-EC or a
double dose (3 mg) of LNG-EC is given in
this situation. It is unknown which is more
effective.
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Use of oral EC if there has been UPSI
and/or use of oral EC earlier in the cycle
•There is evidence that oral EC does not cause
abortion or harm to a very early pregnancy. Both
UPA-EC and LNG-EC can therefore be used if a
woman has also had UPSI earlier in the same cycle.
•Both UPA-EC and LNG-EC can be used more than
once in the same cycle if this is indicated by further
UPSI.
207
Examples of Enz inducers
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The IUD (intrauterine
device) is available from:
•contraception clinics
•Brook centres
•most sexual health clinics (GUM
clinics)
•most GP surgeries
209
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211
Drug interactions
4/16/20 ELBOHOTY
• EC providers should advise women using enzyme-inducing
drugs that the effectiveness of UPA-EC and LNG-EC could be
reduced.
• Women requiring EC who are using enzyme-inducing drugs
should be offered a Cu-IUD if appropriate.
• A 3 mg dose of LNG can be considered but women should be
informed that the effectiveness of this regimen is unknown. A
double-dose of UPA-EC is not recommended.
• EC providers should be aware that the effectiveness of UPA-EC
could be reduced if a woman takes progestogen in
•the 5 days after taking UPA-EC.
•in the 7 days prior to taking UPA-EC.
212
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Limitations
4/16/20 ELBOHOTY
• EC providers should be aware that the contraindications to
insertion of a Cu-IUD for EC are the same as those for routine
IUD insertion.
• EC providers should be aware that UPA-EC is not suitable for
use by women who have severe asthma controlled by oral
glucocorticoids
• Women should be informed that it is possible that higher weight or BMI could
reduce the effectiveness of oral EC, particularly LNG-EC.
213
213
Breastfeeding
4/16/20 ELBOHOTY
• EC providers should be aware that breastfeeding women have a
higher relative risk of uterine perforation during insertion of
intrauterine contraception than non-breastfeeding women.
However, the absolute risk of perforation is low.
• Breastfeeding women should be advised not to breastfeed and
to express and discard milk for a week after they have taken
UPA-EC.
• Women who breastfeed should be informed that available limited
evidence indicates that LNG-EC has no adverse effects on
breastfeeding or on their infants
214
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Repeated use during the same cycle
4/16/20 ELBOHOTY
• If a woman has already taken UPA-EC once or more in a cycle,
EC providers can offer her UPA-EC again after further UPSI in
the same cycle.
• If a woman has already taken LNG-EC once or more in a cycle,
EC providers can offer her LNG-EC again after further UPSI in
the same cycle.
• EC providers should be aware that if a woman has already taken
UPA-EC, LNG-EC should not be taken in the following 5 days.
• EC providers should be aware that if a woman has already taken
LNG-EC, UPA-EC could theoretically be less effective if taken in
the following 7 days.
215
215
When prescribing or supplying hormonal emergency
contraception, women should be advised:
• that their next period may be early or late;
• that a barrier method of contraception needs to be used until the next
period;
• to seek medical attention promptly if any lower
• abdominal pain occurs because this could signify an ectopic
pregnancy;
• to return in 3 to 4 weeks if the subsequent menstrual bleed is
abnormally light, heavy or brief, or is absent, or if she is
otherwise concerned (if there is any doubt as to whether
menstruation has occurred, a pregnancy test should be
performed at least 3 weeks after unprotected intercourse).
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Future contraception
4/16/20 ELBOHOTY
• EC providers should advise women that the Cu-IUD provides effective
ongoing contraception.
• EC providers should advise women that oral EC methods do not
provide ongoing contraception.
• EC providers should advise women that after oral EC there is a
pregnancy risk if there is further UPSI and ovulation occurs later in the
same cycle.
• After taking LNG-EC, women should be advised to start suitable
hormonal contraception immediately. Women should be made aware
that they must use condoms reliably or abstain from sex until
contraception becomes effective.
• Women should be advised to wait 5 days after taking UPA-EC before
starting suitable hormonal contraception. Women should be made
aware that they must use condoms reliably or abstain from sex during
the 5 days waiting and then until their contraceptive method is
effective.
• If a woman and her EC provider estimate that UPSI is unlikely to have
occurred during her fertile period, she may consider the option of using
LNG-EC with immediate start of hormonal contraception rather than
UPA-EC with delayed start of hormonal contraception.
217
217
You can get Levonelle and ellaOne free of charge
from:
• contraception clinics
• Brook centres
• some pharmacies (find pharmacies near you)
• most sexual health clinics, also known as genitourinary medicine
(GUM) clinics
• most NHS walk-in centres or urgent care centres (England only)
• most GP surgeries (find GPs near you)
• some hospital accident and emergency (A&E) departments
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Price
• You can also buy Levonelle from most pharmacies and some private
clinics if you're 16 or over. Prices vary, but it's likely to cost around
£25.
• You can also buy ellaOne from most pharmacies if you're aged 16 or
over. Prices vary, but it's likely to cost around £35.
219
Male and Female Sterilisation
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Sterilization
• female sterilization
• Laproscopic tubal occlusion with Filshi clip (2:1000)
• More than 99% effective, and only one woman in 200 will become
pregnant in her lifetime after having it done
• Hysteroscopic tubal occlusion. (1:500)
• Vasectomy (male sterilization)
• Vasectomy is more than 99% effective. Out of 2,000 men who are sterilised, one
will get a woman pregnant during the rest of his lifetime.
221
Counselling
• include both verbal and written information
• ideally be conducted with both partners together
• highlight the irreversibility/permanence of sterilisation and that sterilisation reversal
is not routinely available through the National Health Service (NHS)
• information on the associated failure rate associated with sterilisation procedures
include information on risk and complications associated with sterilisation
procedures discuss myths and misconceptions associated with sterilisation
• inform individuals that vasectomy is safer, quicker to perform and is associated with
less morbidity than female sterilisation by laparotomy or laparoscopy
• information on other methods of contraception, including long-acting reversible
contraception (LARC)
• assess individuals for known predictors of regret and highlight the possibility of
regret associated with sterilisation
• sterilisation does not confer protection against sexually transmitted infections
• highlight the need to use contraception until sterilisation has been carried out and
the potential need to continue use beyond the procedure
• carried out at a suitable interval prior to the procedure.
• 4/16/20 ELBOHOTY 222
222

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Counselling
•Individuals should be informed that vasectomy
carries a lower failure rate, in terms of
postprocedural pregnancies, and that there is less
risk associated with the procedure than sterilization
carried out by laparoscopy or laparotomy.
•Individuals should be informed of the method of
access and tubal occlusion being recommended in
their case, the reasons for preferring it over other
methods, and the method to be used if the intended
procedure cannot be performed.
223
4/16/20 ELBOHOTY
Vasectomy
224
224

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113
• In a small proportion of men non-motile sperm will persist following
vasectomy. In such cases special clearance can be given to cease using
additional contraception when less than 100 000 non-motile sperm/ml
are observed in a fresh semen sample post-vasectomy.
• If motile sperm are observed in a fresh sample 7 months post-
procedure, the vasectomy should be considered a failure.
• If more than 100 000 non-motile sperm/ml are observed in a fresh
sample 7 months after vasectomy, clinical judgement and/or local
protocols may be used to determine whether or not the procedure
should be deemed a failure.
• pregnancy can occur several years after vasectomy. The contraceptive
failure rate should be quoted as approximately 1 in 2000 (0.05%) after
clearance has been given.
• vasectomy is associated with a risk of postoperative testicular, scrotal,
penile or lower abdominal pain that is rarely severe and chronic in
some men.4/16/20 ELBOHOTY
Risks
225
225
Post vasectomy
• contact their health care provider if they have any concerns following the
procedure: for example, persistent bleeding, pain, possible infection, or rapidly
enlarging one-sided scrotal haematoma that would indicate being seen as a
matter of urgency
• use non-steroidal anti-inflammatory drugs (NSAIDs) for pain/discomfort
following the procedure, unless contraindicated
• rest following the procedure and refrain from strenuous activity
• abstain from sexual activity for between 2 and 7 days post-procedure
• wear tight underpants/athletic support for the first few days following the
procedure, including at night for the initial 48 hours or longer according to
symptoms
• Evidence suggests that 12 weeks post-vasectomy is the optimal timing to
schedule the first PVSA. Earlier or later testing is acceptable taking into account
that earlier testing increases the probability of additional tests and later testing
prolongs the need for additional contraception.
• Postal semen samples can be used for PVSA; however, such samples will not be
suitable for the assessment of sperm motility.
• A routine second PVSA is not required if azoospermia is found in the first sample.4/16/20 ELBOHOTY 226
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4/16/20 ELBOHOTY
Tubal occlusion
227
227
• During laparoscopy, the fallopian tube can be occluded with a Filshi clip (the
standard method)
• a modified Pomeroy technique can be performed using endoscopic sutures; or
diathermy (either unipolar or bipolar) can be used to destroy a segment of the
tube.
• Topical application of local anaesthesia to the fallopian tubes may be used
whenever mechanical occlusive devices are being applied as short-term
postoperative pain is reduced.
4/16/20 ELBOHOTY
How
228
228

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Postpartum or abortive
• possible. Should tubal occlusion be requested either postpartum or
post-abortion, women should be made aware of the increased rate of
regret and the possible increased failure rate.
• For postpartum sterilisation, both Filshie clips and modified Pomeroy
technique are effective. Filshie clip application is quicker to perform.
229
complications
• Major complications associated with laparoscopic surgery are injuries to the
bowel, bladder and blood vessels that require laparotomy.
• The risk of laparotomy as a consequence of a severe complication reported in a
large prospective study was 1.9/1000 procedures.
• Two other practice surveys reported laparotomy rates of 1.4–3.1/1000 cases.
• The risk of death associated with laparoscopy is reported as being 1/12 000.
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Risks
• The lifetime risk of laparoscopic tubal occlusion failure is estimated to be 1 in
200.
• The longest period of available follow-up data for the most commonly used
method in the UK, the Filshie clip, suggests a failure rate of 2–3 per 1000
procedures at 10 years.
• Evidence suggests that there is an association between tubal occlusion and an
increased risk of subsequent hysterectomy but there is no evidence of causation.
• Women may report worsening menstrual symptoms following tubal occlusion
but there is no evidence to suggest a causal effect.
231
Hysteroscopic sterilisation
• Transcervical sterilisation is usually performed without the need for
anaesthesia and involves a hysteroscope being inserted into the vagina
and cervix vaginoscopically or by using a speculum.
• Flexible micro-inserts (Essure®) are then passed through the
hysteroscope and inserted into the proximal section of each fallopian
tube.
• The micro-inserts elicit a benign tissue response (fibrosis) resulting in
the permanent occlusion of each tube after approximately 3 months.
• Additional contraception is required until successful placement of the
micro-inserts and tubal occlusion is confirmed by imaging at least 3
months after the procedure.
• The incidence of unsuccessful placement of intra-fallopian implants is
reported as ranging between 0% and 19%, following up to two
attempts in an outpatient setting.
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•Available evidence suggests that tubal occlusion by intra-
fallopian micro-insert has a low associated failure rate which
is approximately 1 in 500 at 5 years of follow-up; this
includes cases where luteal-phase pregnancy or non-
adherence with post-procedural instructions was
documented.
•Available evidence suggests that the use of intra-fallopian
micro-inserts for tubal occlusion is a procedure that is well
tolerated by the majority of women and results in good long-
term satisfaction in terms of comfort and tolerance of the
insert.
•Hysteroscopic sterilisation with micro-inserts is
contraindicated if there is documented proven patch test for
nickel allergy.4/16/20 ELBOHOTY 233
233
•A confirmatory imaging test should be undertaken 3
months after the insertion of intra-fallopian micro-inserts.
•This may be via X-ray or transvaginal ultrasound scanning
(TVUSS) in the first instance, followed by
hysterosalpingogram (HSG) in selected patients where X-ray
or TVUSS cannot confirm satisfactory placement.
•HSG should be used as a first-line test where the
hysteroscopic procedure was considered suboptimal,
according to local protocols.
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Ectopic
• Women should be informed that if tubal occlusion fails, the resulting
pregnancy may be ectopic.
235
Timing
• A pregnancy test must be performed before sterilisation to exclude the
possibility of a pre- existing pregnancy. However, a negative test result does not
exclude the possibility of a luteal- phase pregnancy.
• Tubal occlusion can be performed at any time during the menstrual cycle,
providing that the woman has a negative pregnancy test and is not at risk of
luteal-phase pregnancy [no unprotected sexual intercourse (UPSI) in the past 3
weeks].
• If this is not the case, the procedure should be deferred and contraception used
until at least 3 weeks from the last instance of UPSI.
• During tubal occlusion, curettage should not be performed for the purpose of
preventing luteal-phase pregnancy.
• Following sterilization via hysteroscopy and the insertion of intra-fallopian micro-
inserts, additional contraception must be used until either successful insert
placement and/or tubal occlusion are confirmed, depending upon the
confirmatory test employed.
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Reversal
• Vasectomy reversal involves complex surgery that can result in high
postoperative patency rates, but may not result in pregnancy or a return to
fertility.
• Fallopian tube reanastomosis following sterilisation can result in high
postoperative patency rates, but may not result in pregnancy or a return to
fertility.
• To date, reversal of sterilisation with micro-inserts cannot be achieved via
fallopian tube reanastomosis, therefore consideration should be given to in vitro
fertilisation.
237
Special groups
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Miscarriage or ectopic
• Women who wish to conceive after miscarriage can be advised there
is no need to delay as pregnancy outcomes after miscarriage are
more favourable when conception occurs within 6 months of
miscarriage compared with after 6 months.
• Women who have been treated with methotrexate should be advised
that effective contraception is recommended during and for at least 3
months after treatment in view of the teratogenic effects of this
medication
239
Recurrent miscarriage
• Combined hormonal contraception (CHC) should be avoided by
women with REM until antiphospholipid syndrome (APS) has been
excluded.
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Previous ectopic
• Women should be advised that the absolute risk of ectopic pregnancy
when contraception is used is extremely small and that the risk of
pregnancy is lowest with LARC.
• Women should be advised to seek medical advice if they suspect they
may be pregnant and have symptoms suggestive of ectopic pregnancy,
even while using contraception.
• Women who have had an ectopic pregnancy should be advised that
the IUC is one of the most effective methods of contraception and so
the absolute risk of any pregnancy including ectopic pregnancy is
extremely low.
• Women should be informed that if pregnancy occurs with an IUC in
situ, there is an increased risk of ectopic pregnancy and therefore the
location of the pregnancy should be confirmed by ultrasound as soon
as possible.
241
Post molar
• After complete molar pregnancy, women should be advised to avoid subsequent
pregnancy for at least 6 months to allow human chorionic gonadotrophin (hCG)
monitoring for ongoing GTD.
• After partial molar pregnancy, women should be advised to avoid pregnancy
until two consecutive monthly hCG levels are normal.
• Women who have had chemotherapy for GTD should be advised to avoid
pregnancy for 1 year after treatment is complete.
• IUC should not normally be inserted until hCG levels have normalised after GTD.
Insertion of Cu-IUD as EC may be considered in a specialist setting for women
with decreasing hCG levels following discussion with a GTD centre
• IUC insertion at surgical evacuation where GTD is suspected but not confirmed
should be made on an individual case basis based upon the individual woman’s
risk for GTD, clinical findings and her preference for IUC insertion at this time
• Hormonal contraception can be started immediately after uterine evacuation for
GTD.
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Abortion
• Clinicians should be aware that women who choose to commence
LARC immediately after abortion have a significantly reduced
likelihood of undergoing another abortion within 2 years, compared
with women provided with medium-acting, short-acting or no
contraceptive methods.
• Progestogen-only contraception can be safely started at any time,
including immediately, after medical or surgical abortion.
• Women should be advised that implants can be safely initiated at the
time of mifepristone administration.
• Women should be advised that there may be a slightly higher risk of
continuing pregnancy (failed abortion) if DMPA is initiated at the time
of mifepristone administration.
• Women should be advised that scant or absent bleeding should not be
attributed to a hormonal method of contraception that has been
initiated, but that it may be due to failed medical abortion. Under such
circumstances, urgent medical review should be sought.4/16/20 ELBOHOTY 243
243
Postnatal contraception
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Benefit
•Women should be advised that an
interpregnancy interval (IPI) of less than 12
months between childbirth and conceiving
again is associated with an increased risk of
preterm birth, low birthweight and small for
gestational age (SGA) babies
245
Time
•Women should be advised that although contraception is
not required in the first 21 days after childbirth, most
methods can be safely initiated immediately, with the
exception of combined hormonal contraception (CHC).
246

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Choice
• The choice of contraceptive method should be initiated by 21 days after childbirth.
• A woman’s chosen method of contraception can be initiated immediately after
childbirth if desired and she is medically eligible.
• Women should be advised that intrauterine contraception (IUC) and progestogen-
only implant (IMP) can be inserted immediately after delivery.
• Clinicians should be aware that insertion of IMP soon after childbirth is convenient
and highly acceptable to women. This has been associated with high continuation
rates and a reduced risk of unintended pregnancy.
• Clinicians should be aware that insertion of IUC at the time of either vaginal or
caesarean delivery is convenient and highly acceptable to women.
• This has been associated with high continuation rates and a reduced risk of
unintended pregnancy.
• .
247
• The rate of device expulsion with immediate postpartum vaginal
insertion is slightly higher than for intra-caesarean insertion.31
Expulsion is also observed more frequently with immediate versus
delayed vaginal insertion.
• All women who receive PPIUC (by either intra-caesarean or vaginal
insertion) should be advised to attend a follow-up appointment at
around 4–6 weeks, to confirm appropriate location of the device.
• PPIUC insertion is associated with a higher likelihood of non-visible
threads at initial check, with up to 50% of women experiencing this
after intra-caesarean insertion
• Women should also be advised about the expected bleeding pattern,
particularly as women choosing the LNG-IUS may notice a reduction
in lochia following immediate postpartum insertion
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249
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• For breastfeeding women, the risk of uterine perforation during
interval insertion may remain elevated for up to 36 weeks following
birth, with a six-fold increase in the relative risk of this complication
compared with non-breastfeeding women.
251
•Women who are breastfeeding should be informed that the
available evidence indicates that progestogen-only methods
of contraception (LNG-IUS, IMP, POI and POP) have no
adverse effects on lactation, infant growth or development.
•Women who are breastfeeding should wait until 6 weeks
after childbirth before initiating a CHC method.
•Women who are breastfeeding should be informed that
there is currently limited evidence regarding the effects of
CHC use on breastfeeding. However, the better quality
studies of early initiation of CHC found no adverse effects on
either breastfeeding performance (duration of
breastfeeding, exclusivity and timing of initiation of
supplemental feeding) or on infant outcomes (growth,
health and development).4/16/20 ELBOHOTY 252
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LAM
•Women may be advised that, if they are less than 6 months
postpartum, amenorrhoeic and fully breastfeeding, the
lactational amenorrhoea method (LAM) is a highly effective
method of contraception.
•Women using LAM should be advised that the risk of
pregnancy is increased if the frequency of breastfeeding
decreases (e.g. through stopping night feeds, starting or
increasing supplementary feeding, use of dummies/pacifiers,
expressing milk), when menstruation returns or when more
than 6 months after childbirth
253
EC
•Women who breastfeed should be
informed that available limited evidence
indicates that LNG-EC has no adverse
effects on breastfeeding or on their
infants.
•Women who breastfeed should be advised
not to breastfeed and to express and
discard milk for a week after they have
taken UPA-EC
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Contraception for Women Aged Over 40 Years
255
Suitability
• extended use of the copper intrauterine device until menopause when inserted at age
40 or over.
• extended use of a Mirena® levonorgestrel intrauterine system (LNG-IUS) for
contraception until the age of 55 if inserted at age 45 or over, provided it is not being
used as the progestogen component of hormone replacement therapy (HRT) for
endometrial protection.
• progestogen-only implant (IMP) is not associated with increased risks of venous
thromboembolism (VTE), stroke or myocardial infarction (MI) and has not been shown
to affect bone mineral density (BMD).
• Women over 40 using depot medroxyprogesterone acetate (DMPA) should be
reviewed regularly to assess the benefits and risks of use. Women over 50 should be
counselled on alternative methods of contraception.
• Compared to non-DMPA users, women using DMPA experience initial loss of bone
density due to the hypoestrogenic effects of DMPA
• Women can be informed that the progestogen-only pill (POP) is not associated with
increased risks of VTE, stroke or MI and has not been shown to affect BMD.
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CHC
• Combined oral contraception (COC) with levonorgestrel or norethisterone
should be considered first-line COC preparations for women over 40 due to
the potentially lower VTE risk compared to formulations containing other
progestogens.
• COC with ≤30 μg ethinylestradiol should be considered first-line COC
preparations for women over 40 due to the potentially lower risks of VTE,
cardiovascular disease and stroke compared to formulations containing higher
doses of estrogen.
• Combined hormonal contraception (CHC) can reduce menstrual bleeding and
pain, which may be particularly relevant for women over 40.
• Practionars can offer an extended or continuous CHC regimen to women for
contraception and also to control menstrual or menopausal symptoms.
• Women aged 50 and over should be advised to stop taking CHC for
contraception and use an alternative, safer method.
• COC is associated with a reduced risk of ovarian and endometrial cancer that
lasts for several decades after cessation.
• CHC may help to maintain BMD compared with non-use of hormones in the
perimenopause.
• There is a slight increased risk of breast cancer among women using COC,
but with no significant risk of breast cancer by 10 years after cessation.
• Women who smoke should be advised to stop CHC at age 35 as this is the
age at which excess risk of mortality associated with smoking starts to
become clinically significant.
257
When to stop contraception?
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Contraception along side HRT
259

Contraception for MRCOG

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