Dr Richelle Douglas Medical Director SHQ€¦ · •The Netherlands abortion rate of 8.7 per 1000...
Transcript of Dr Richelle Douglas Medical Director SHQ€¦ · •The Netherlands abortion rate of 8.7 per 1000...
Contraception 2017
Dr Richelle Douglas
Medical Director
SHQ
1
Plan
•LARC methods
•Bleeding with progestogen only methods
•Bleeding with combined methods
•Combined methods and mood
2
3
Why do we care?
• 50% pregnancies in Australia are unintended
• Teenage fertility rate of 87 births per 1000 in some rural & remote areas
• The estimated abortion rate at 19 per 1000 women
• The Netherlands abortion rate of 8.7 per 1000 women
4
Contraceptive Methods
5
CASE STUDY
• Tania is 19-year-old
• G0P0
• No significant medical history
• No medications
• No regular sexual partner
• Uses COCP for contraception
6
Tania presents for a repeat combined pill script…
Would you discuss other contraceptive options with Tania ?
• Yes
• No
8
Contraceptive CHOICE study
• US prospective cohort study of 9256 women age 14 – 45yo
• Participants read a script regarding long-acting reversible methods of contraception to increase awareness of these options:
• Copper intrauterine device
• Hormonal intrauterine device
• Contraceptive Implant
• www.choiceproject.wustl.edu/studyfindings.html
9
(Copper IUD)
What did young people choose?
11
0
2
4
6
8
10
LARC Pill patch & ring
Year 1
Year 2
Year 3
Cumulative % of women who became pregnant each year
Contraceptive CHOICE study - pregnancies
12
13
IUDs increase infection rates
• True
• False
14
False
• Exclude Chlamydia & gonorrhoea at time of insertion
• Risk of PID is only at time of insertion
• Presence of IUD doesn’t increase later PID risk
Ref: Faculty of Sexual & Reproductive Healthcare (UK) Clinical Guidance - Intrauterine Contraception April 2015 (Updated October 2015)
15
IUDs should not be inserted in nulliparous women
• True
• False
16
False!
• Pain? • Studies quote average pain for nulliparous women from 3-7/10
at insertion (similar to multiparous women)
• Recent US study suggests 20% young nulliparous women have moderate-severe pain a week later
• Same study - 83% satisfied or very satisfied with IUD
Ref: Hall AM, Kutler BA. Intrauterine contraception in nulliparous women: a prospective survey J Fam Plann Reprod Health Care: 2015
17
All hormonal contraception causes weight gain
• True
• False
18
False
• Depot contraception is the only method associated with weight gain; only in already overweight women
• Women using other methods gain weight…at the same rate as women not using hormonal contraception
• Cochrane Reviews: Lopez LM, Ramesh S, Chen M, Edelman A, Otterness C, Trussell J, Helmerhorst FM Effects of
progestin-only birth control on weight 28 August 2016 &
• Gallo MF, Lopez LM, Grimes DA, Carayon F, Schulz KF, Helmerhorst FM
Effect of birth control pills and patches on weight 29 January 2014
19
USING MEC – can she use this method?
MEC 1 Yes e.g. nulliparous and IUD
MEC 2 Probably e.g. personal history venous thromboembolism and progestogen only method (e.g. contraceptive implant or injection, hormonal IUD)
MEC 3 Probably not – consider other method Needs careful consideration and good reasons why other methods inappropriate
e.g. a women aged ≥35 y who smokes less than 15 cigarettes per day and combined hormonal method
MEC 4 No
e.g. history of migraine with aura within last 5 years and combined pill
20
MEC 4 and LARC
21
Copper
IUD
Hormonal
IUD
Implant Injection
To initiate:
current PID,
purulent cervicitis,
asymptomatic chlamydia
or gonorrhoea
To initiate:
current PID,
purulent cervicitis,
asymptomatic chlamydia
or gonorrhoea
Current breast cancer Current breast cancer
Current breast cancer
Unexplained vaginal
bleeding (suspicious for
serious condition)
Unexplained vaginal
bleeding (suspicious for
serious condition)
Copper IUD Hormonal IUD Implant Injection
Past breast cancer >5 years
ago
Past breast cancer >5 years
ago
Past breast cancer >5 years
ago
Liver: Severe
decompensated cirrhosis,
hepatocellular adenoma,
malignant hepatoma
Liver: Severe
decompensated cirrhosis,
hepatocellular adenoma,
malignant hepatoma
Liver: Severe
decompensated cirrhosis,
hepatocellular adenoma,
malignant hepatoma
Uterine fibroids with
distortion of uterine cavity
Uterine fibroids with
distortion of uterine cavity
Continuation: if IHD or
stroke develop during
hormonal IUD use
Continuation: if IHD or
stroke develop during
implant use
Cardiovascular disease,
stroke and risk factors,
diabetes with
nephropathy/retinopathy/n
europathy
To initiate: severe
thrombocytopaenia
Unexplained vaginal
bleeding (suspicious for
serious condition)
Unexplained vaginal
bleeding (suspicious for
serious condition)
MEC 3 and LARC
22
23
Reproductive ‘stage’ of life; frequency of sex
Accessibility Affordability Ease
of use
Effectiveness Invasiveness
Discretion
Side-effects
non-contraceptive benefits
Contraceptive Choice: one size does not fit all
24
25
Question
• Contraceptive implants should be inserted in the sulcus between the bicep and triceps muscle
• True
• False
26
FALSE: AVOID THE SULCUS!
• June 2016: FSRH Clinical effectiveness unit: AVOID the sulcus
• Risk of intravascular insertion (rare)
• Inner side non-dominant arm about 8-10cm above the medial epicondyle of humerus
• OVER the triceps muscle posterolateral to sulcus
27
Initiating a LARC conversation:
• Explain methods briefly
• Highlight key benefits of:
High efficacy
Convenience
Reversibility
• Show a picture or use a model of the implant and IUD
• How/when she can access LARC insertion?
28
Whip out a contraception card:
29
http://shq.org.au/download/contraceptive-card/
Or: no hair or penis pictures
30
http://familyplanningallianceaustralia.org.au/wp-content/uploads/2014/11/FPAA_Efficacy_SCREEN.pdf
Hormonal IUD Copper IUD
Cost PBS Non PBS ($100)
Mechanism of action May thicken cervical mucus
Effects sperm/oocyte motility
Thins endometrium
May inhibit ovulation
Toxic to sperm
Endometrial effect
Duration 5 years 5 or 10 years
Effect on bleeding Significantly reduces menstrual
bleeding
Can increase menstrual bleeding
and pelvic pain
Hormonal side effects Can occur None
Other benefits Protects the endometrium in
women requiring hormone therapy
(HT)
Provides highly effective
Emergency Contraception
IUD comparison
31
Explaining bleeding with progestogen-only LARCs
• Provide accurate information about expected bleeding patterns, emphasising that troublesome bleeding is likely to improve with time
• Be proactive in offering management advice for troublesome bleeding • Actively encourage review of troublesome
bleeding
32
Implanon bleeding - “unpredictable”
• 1/5 amenorrhoea (explain that this is safe and is caused by a thin endometrium)
• 3/5 infrequent, irregular bleeding
• 1/5 frequent or prolonged bleeding (explain around half will improve after 3 months)*
• Explain that management is available for troublesome bleeding and actively encourage review
• *The effects of Implanon on menstrual bleeding patterns Mansour et al, The European Journal of Contraception and Reproductive Health Care June 2008 Jun;13 Suppl 1:13-28
33
Depot and progestogen IUD – “often to begin with, but it settles”
• Hormonal IUD: frequent spotting/bleeding common in first 3-5 months; either amenorrhoea, light irregular or light regular bleeding common after six months.
• DMPA Injection: ½ amenorrhoea, 1/6 infrequent irregular bleeding, 1/3 frequent/prolonged bleeding; amenorrhoea increases over time.
34
Expected bleeding – progestogen only pill
40%
40%
20%
Bleeding pattern
Regular
Irregular, sometimesfrequent
Amenorrhoea
Source: Guillebaud J Contraception: Your Questions Answered 4th ed 2004
Managing bleeding - Implanon, Depot, POP, progestogen IUD
•Consider & exclude abnormal causes
• infection
•polyps
•cervical and endometrial cancer
•pregnancy
36
Managing bleeding
•First line Rx
• A combined hormonal contraceptive continuously or cyclically for three months
• Five days of NSAID eg mefenamic acid 500mg bd-tds
• Five days of tranexamic acid 500mg bd
Ref: Australian consensus statement: https://www.fpnsw.org.au/health-information/contraception/guidance-
management-troublesome-vaginal-bleeding-progestogen-only
37
Managing bleeding
•Less evidence for effectiveness:
• Norethisterone 5mg tds for 21 days
• Levonogestrel progestogen only pill, 30 mcg bd for 20 days
• Early removal and replacement of implant or hormonal IUD, or shortening interval between injections from 12 to 10 weeks
38
COCP
•Start with lowest oestrogen and progesterone dose for the individual women which:
is well tolerated
has the best safety profile
is affordable
offers additional non-contraceptive benefits if desired
39
40
Extended COCP regimens
•Shorten or eliminate the hormone free interval
•Decrease frequency of ‘withdrawal bleed’
41
3 methods
•Tricycling 21/7 methods, avoiding HFI
•Flexible extended use using drosperidone, 120 days, then 4 days “placebo” (“Yaz Flex”)
•Extended regimen 84 days Prog/est, then 7 days of 10mg oest (“seasonique”)
42
Starting hormonal contraception
Start Days 1-5
Contraception immediately
effective
(no need for extra measures)
Start later than Day 5
Expect contraception to be effective
in:
• 48 hours (POP)
• 7 days (other hormonal
methods)
Use extra
measures 7
days
Consider pregnancy test in 3-4
weeks Consider pregnancy risk
43
What do you think?
• Deborah is 20
• Happy on the COCP for 2 years
• Has considered LARC, tried implanon and depo but had bleeding issues
• Stopped the pill yesterday because she heard on TRIPLE J that the pill causes depression!
44
Danish National Database study
• Association found between hormonal contraception and first use of an anti-depressant medication
• Observational, cannot prove causality
• Absolute risks small
• Seek advice from doctor if mood changes occur, but don’t stop if happy!
45
NOW BACK TO SPINY MICE
46
THE FUTURE IS WIRELESS BIRTH CONTROL
47
Resources – Health Pathways WA
https://wa.healthpathways.org.au Username: connected Password: healthcare
eg.
48
Resources
•Faculty of Sexual & Reproductive Health Care
• http://www.fsrh.org/standards-and-guidance/
•Australian Contraception Handbook 4th edition
49
Any questions?
50