Family Planning presentation

Wednesday 30th March
Topics covered
 What to consider with contraception
 Pills
 Implants and injection
 Special circumstances
 Case studies
Not covering
 Surgical methods - no funding
 Natural methods
 Gillick (in too much detail)
 Infertility
General intro
 Common consultation
 Increased choice
 Benefits and risks
 Unwanted pregnancy
Initial consultation
 Personal preference
 Lifestyle
 Medical history
 Family history
 Risk of STI
Before starting
 Confirm not pregnant
 Previous methods
 Current medical problems
 BP
 Migraine?
 Smoker?
 Family history of cancers
 Vary by oestrogen content
 Vary by progesterone type
 21 pills then break
 Aged 35y + smoker
 >50y
 DM
 Focal migraine
Risk greater than benefit
 Female malignancy
 Hormonal problems in pregnancy
 Breast feeding
 Acute hepatitis
 Porphyria
Starter pills
 Microgynon 30
 Ovranette
 150mcg - levonorgesterol (progesterone)
 30mcg – ethinylestradiol (oestrogen)
 £2.99
 £2.29
Progesterone side effects
 Acne
 Headache
 Depression
 Weight gain
 Breast symptoms
 Decreased libido
Alternate options
 Desogesterel – Marvelon
 Gestodene – Femodene
 Norgestimate – Cilest
 Drospirenone - Yasmin
 £6.70
 £7.18
 £11.94
 £14.70
Alternate options
 Cyproterone acetate – Dianette
 £3.70
 Not licensed for contraception alone
 Used in treatment of acne
Oestrogen side effects
 Breast tenderness
 Nausea
 Weight gain
 Bloating
 Loestrin 20 – 20mcg ethinylestradiol
 £2.70
Breakthrough bleeding
 First few months
 Exclude other cause
 Compliance
 New advice on antibiotics
 Enzyme inducers
 Affect all hormonal contraception
Missed COC pills
 Current advice
 Take ASAP
 2 or less
 3 or more
 Older women
 Smokers
 VTE history
 HTN, DM, Migraine
 Breastfeeding <6m post-partum
 Cerazette- desogesterel - £8.85
 Micronor/Noriday – norethisterone - £2.00
 Femulen – etynodiol - £3.31
 Norgeston – levonorgesterel - £0.98
 Start on day 1 of cycle
 Take every day – no breaks
 Missed pill
 D+V
Side effects
 Higher failure rate
 Irregular bleeding
 Risk of ectopic
In summary…
 LARC 23% of primary methods of contraception
 LARC methods
 intrauterine devices [IUDs]
 the intrauterine system [IUS]
 injectable contraceptives
 implants
 all LARCs more cost effective than the COCP even at
1 year of use
 IUDs, the IUS and implants are more cost effective
than the injectable contraceptives (DMPA)
Who can use LARCs?
All LARC methods are suitable for:
 nulliparous women
 breastfeeding
 women who have had an abortion
 BMI > 30
 women with HIV – encourage safer sex
 women with diabetes
 women with migraine with or without aura – all
progestogen-only methods may be used
 women with contraindication to oestrogen
Important points to discuss:
 contraceptive efficacy
 duration of use
 risks and possible side effects
 non-contraceptive benefits
 initiation and removal/discontinuation
 when to seek help while using the
Risks and side effects
Copper IUDs
IUS (Mirena)
Progestogen-only Implants
Altered bleeding
pattern eg.
Irregular bleeding
Ectopic pregnancy
1/20 (lower than
Ectopic pregnancy
Small loss in bone
mineral density,
largely recovered
when stopped.
PID <1% low risk
PID <1%
Weight gain – up
to 2-3kg over a year
No evidence of
effect on
depression, acne or
change, acne
No weight gain
No weight gain
No evidence of
effect on weight,
mood, libido,
headaches, BMD
Benefits – non contraceptive
 Progestogen-only implants/DMPA may
improve dysmenorrhoea and the symptoms
of endometriosis.
 Up to 20% of women using a progestogenonly implant will be amenorrhoeic
 A RTC found a significant reduction in
dysmenorrhoea and menorrhagia with the
LNG-IUS (Mirena) when compared to a CuIUD.
Implants - update
 Nexplanon® is a progestogen-only subdermal
implant (non palpable) - now replaced Implanon®.
 Nexplanon and Implanon are bioequivalent (i.e.
they both contain 68 mg etonogestrel and they
have the same release rate and 3-year duration of
 Nexplanon is radio-opaque and has a different
application device and insertion technique.
When fitting:
Check the woman is not pregnant!
Nexplanon may be inserted:
 at any time
(but use barrier methods for first 7 days if the
woman is amenorrhoeic or it is more than 5 days
since menstrual bleeding started)
 Prevention of ovulation.
 3 years
 No delay
 20% of users - no bleeding
 50% will have infrequent, frequent or prolonged
 Bleeding patterns are likely to remain irregular.
 Not recommended for women taking enzymeinducing drugs eg. Anti-epileptics, St.Johns Wort.
 Useful if high BMI
Copper devices or Mirena coil.
Before inserting an IUD or IUS:
 Test for:
 Chlamydia trachomatis in women at risk of
 Neisseria gonorrhoeae in women at risk of
STIs in areas where it is prevalent
 For woman at increased risk of STIs, give
prophylactic antibiotics before inserting an
IUD or IUS if testing has not been
 Like the implant - an IUD or IUS may be
 at any time
 If the woman has epilepsy, seizure risk may
be increased at the time of fitting an IUD or
 Women with a history of venous
thromboembolism (VTE) may use the IUS.
 Pelvic infection risk - 20 days following
 risk same as non-IUD-using population
 Irregular bleeding common in the first 6
months after insertion of the LNG-IUS but
by 1 year amenorrhoea or light bleeding is
 Previous endocarditis
 Prosthetic heart valve
 require intravenous antibiotic prophylaxis
 Copper is toxic to ovum and sperm inhibiting
 In addition, the endometrial inflammatory
reaction has an antiimplantation effect and
alterations in the copper content of cervical
mucus inhibit sperm penetration.
 A Cu-IUD inserted when a woman >40 years
can be retained until the menopause is
 >50yrs - 1 year after the last menstrual
 <50yrs - 2 years
 Copper IUDs - 5-10 years
IUS - Mirena
 Prevents implantation.
 Effects on cervical mucus reduce sperm
 Inserted >45 years and amenorrhoeic - may
retain the LNG-IUS until the menopause.
 Randomised trials show that the LNG-IUS
provides effective contraception for up to 7
years – licensed for 5 years.
After fitting:
 At first follow-up visit (after the first
menses, or 3–6 weeks after insertion)
 exclude infection, perforation or
 IUD only: For heavier and/or prolonged
bleeding associated with use of an IUD:
 – treat with NSAIDs and tranexamic acid
 – or suggest changing to the IUS if the
woman finds bleeding unacceptable.
Depo Provera
Injectable contraceptives
Depo Provera or Noristerat (short term use)
Inhibits ovulation.
Check not pregnant!
Can give:
 – up to 5th day of the menstrual cycle
without the need for additional
 – or use barrier contraception 7 days
 Every 12 weeks
 Deep intramuscular injection
 into the gluteal or deltoid muscle or the lateral
 Delay up to 1 year in the return of fertility BUT
 …no evidence of reduced fertility long term
 Amenorrhoea (14.4%)
 Infrequent bleeding (24.2%)
 Spotting (27.9%)
 Prolonged bleeding (33.5%) were all
 Small loss of BMD, which is usually
recovered after discontinuation.
 Women should be advised that there is no
available evidence on the effect of DMPA on
longterm fracture risk.
 Use may continue to age 50 years.
Managing irregular bleeding
 Can try:
 3 cycles of 20-30mcg COC, taken cyclically
– can be repeated
 If COC contraindicated: mefenamic acid
500mg BD until bleeding settles…
 Cerazette 1 tab daily for approx. 3 months
Managing problems with Depo
 Repeat injections may be given up to 2
weeks late.
 DMPA use >2 years, review and discuss the
balance of benefits and risks again eg. BMD
 No evidence of congenital malformation to
the fetus if pregnancy occurs during DMPA
 Good choice if on enzyme-inducing drugs
Follow-up required acc. to NICE
Routine follow-up
 At 3–6 weeks
 Return if problems or time for removal.
Injectable contraceptives
 Every 12 weeks; every 8 weeks for NET-EN
 No routine follow-up
Under 16s and post-partum
Fraser Guidelines and Gillick Competence
Under 16s and providing
 Be aware of the law
 Duty of care and a duty of confidentiality to
all patients, including under 16s.
 > 25% of young people are sexually active
<16 years.
 Least likely to use contraception.
 Confidentiality
 If considering any disclosure of information
- weigh up a right to privacy against:
 current or likely harm
 what any such disclosure is intended to
 potential benefits to the young person’s
 Except in the most exceptional of
circumstances - consult the young person
and offer to support a voluntary disclosure.
The Fraser Guidelines:
 the young person understands the health professional’s
cannot persuade the young person to inform his or her
parents or allow the doctor to inform the parents that he or
she is seeking contraceptive advice;
the young person is very likely to begin or continue having
intercourse with or without contraceptive treatment;
unless he or she receives contraceptive advice or treatment,
the young person’s physical or mental health or both are
likely to suffer;
the young person’s best interests require the health
professional to give contraceptive advice, treatment or both
without parental consent.
The Sexual Offences Act 2003
The Act states that, a person is not guilty of aiding,
abetting or counselling a sexual offence against a child
where they are acting for the purpose of:
 protecting a child from pregnancy or STIs
 protecting the physical safety of a child,
 promoting a child’s emotional well-being by the
giving of advice.
Choices for women post-partum, including
 IUD – copper: from 4 weeks after childbirth
 IUS - Mirena: from 4 weeks after childbirth
 DMPA injection: any time after childbirth, if
>21 days need additional.
 Implants - Nexplanon: any time after
childbirth; if >21 days postpartum need
 Progestogen-only injectable contraception or
implant is appropriate:
 after surgical abortion
 (second part of) medical abortion
 miscarriage.
 If DMPA or Nexplanon within 5 days
 Ideally insert IUD or IUS within the first 48
hours or delay until 4 weeks postpartum.
Emergency contraception
 Less than 72 hours – levenorgesterol - 1.5mg
 Between 72h and 120h – EllaOne
 Most effective is Copper IUD
Emergency contraception
 Advise to return if abdominal pain or next period
 Advice on STI
 Plan contraceptive follow up
TOP - practicalities
 Less than 24w
 Reasons
 Medical and surgical
 Marie Stopes centres
 LARC – offered and coded
 Chlamydia testing – people under 25
Case study 1
 17y
 Only current partner
 BMI 22
 Non-smoker
 Wants contraception
Case study 1
 Comes back 3m later
 Spots over face, some on back
Case study 2
 42y
 Finished family
 Wants something long term
Case study 3
 24y
 New baby
 Unplanned pregnancy
Case study 4
 37y
 Heavy smoker
 BMI 42
 Bed bound
 Diabetic
 Previous DVT
 BP 172/104
 Faculty of Family Planning
 Oxford handbook of General Practice
 Marie Stopes
 Monkgate Clinic

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