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Contraception Dr Sarah Smith

Jo, 15

• Wanting ‘the pill’

• How might we respond?

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Long Acting

Reversible Contraception

LARCs

Contraceptive choice study • Almost 10,000 US women, not wanting to be

pregnant for 1 year, offered choice of contraceptive method, free

• 2/3 chose LARCs • LARC continuation high

– 86% at 1 year, compared to 55% using other methods • LARC satisfaction greater at 1 year

– Over 80% compared to 50% for other methods Ref: The Contraceptive Choice Project: http://www.choiceproject.wustl.edu/studyfindings.html

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Contraceptive choice study - pregnancies

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2.5

5.

7.5

10.

LARC Pill patch & ring

Year 1Year 2Year 3

Cumulative % of women who became pregnant each year

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LARC vs pills

LARCs 20 times more effective

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Talking with patients about options

http://shq.org.au/download/contraceptive-card/

Contraception card

Option 2 (no hair, no penises) side 1

http://familyplanningallianceaustralia.org.au/wp-content/uploads/2014/11/FPAA_Efficacy_SCREEN.pdf

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Contraception card 2 side 2

Myth?

• IUDs are risky for young women…

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IUDs and young women

Infection? – 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)

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IUDs and young women

• Pain? – Studies quote average pain for nullipara 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

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Risks of IUDs (all ages!)

Approx Incidence /100 insertions

Expulsion 5

Vaso vagal 2

Non-insertion 2

Pelvic infection 0.3

Perforation 0.2

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Back to Jo

• Why does she want ‘the pill’? – Contraception? – Other purposes? – A combination of reasons?

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Jo • Take thorough history including specifically:

– Migraine with aura – Severe liver problems – Cardiovascular risks – VTE risks – Past cancers – PID, current STI risk

• No contraindications identified for any method

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Discuss options • LARCs first line

– Most effective, safer, easier, cheaper, last longer • Brief summary of main pros & cons of each

method, eg. – Implants

• Very effective, easy to insert and to remove, lasts 3 years • Main difficulty is unpredictable irregular bleeding • Other hormonal side effects uncommon, such as acne,

breast tenderness, headache, mood changes

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Jo decides on the combined pill, while she thinks about an IUD

• “Can I have the one that doesn’t cause weight gain please?”

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Myth?

• Hormonal contraception causes weight gain

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Weight and hormonal contraception

• Depot contraception is the only method associated with weight gain – only in already overweight women

• Women using other methods do 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

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Effectiveness of combined pills

• Real-world (in contrast with research-world) efficacy of combined methods is 91%

• If combined methods chosen, discuss how to get BEST effectiveness: – Daily reminders – Skip inactive pills as often as possible!

Ref: Trussell, J. (2011) Contraceptive failure in the United States. Contraception, 83(5), 397–404

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Quickstart

Adapted from: www.fpv.org.au

Method When does the method become effective?

What is the effect on existing pregnancy?

Can the method mask pregnancy?

Is it reversible?

Preferred methods for Quickstart

Combined hormonal, starting with active pill

7 days None known Unlikely Yes

Implant 7 days None known Yes Yes

Progestogen only pill

3 days None known Possibly Yes

Acceptable method

Injection DMPA

7 days None known Yes No

Unacceptable method

IUD Copper: Immediately Hormonal: 7 days

Increased risk miscarriage

Copper: possibly Hormonal: yes

Yes

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Combined pill

• “Can I skip my period?”

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7.3% 6.9% 4.4%

Howard et al. Comparison of pregnancy rates in users of extended and cyclic COC regimens in the United States Contraception 89 (2014) 25-27

Effectiveness of extended regimes

0.2.4.

6.

8.

21/7 pack 24/4 pack 84/7 pack

% Likelihood unplanned pregnancy

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Options for skipping bleeds 1. Any monophasic pill: take active pills

continuously: – For 3 months at a time, then 4-7 days of no active

pills OR – Until spotting occurs, then 4 days of no active pills

(provided at least 21 active pills taken before this) 2. Use a particular brand set up for extended

use….

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Extended regime - Seasonique

• 84 days of 30mcg EE/150mcg LN • 7 days of 10mcg EE

EE = ethinyloestradiol LN = levonorgestrel

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Flexible regime - Yaz® Flex • Yaz tablets (20mcg EE/3mg

drospirenone) • Can choose 4-day pill-free interval

every 28 days, or wait for breakthrough bleeding

• If breakthrough bleeding (after the first 24 days), take a 4-day pill-free interval

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Which pill to begin with?

• Lowest oestrogen dose = lowest risk of VTE & cardiovascular disease

• Cheapest • Progestogen choice

– Older types (levonorgestrel & norethisterone) probably have lower VTE risks

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One pill meets all criteria…

• Lowest dose, monophasic, older progestogen AND PBS listed…

• ….unless there’s a good reason to use another

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Short acting contraception: Mention Emergency Contraception options

• Copper T

• Levonorgestrel 1.5mg – Single dose (eg Norlevo-1) OR – 50 x 30mcg POP (eg Microlut)

• Ulipristal (EllaOne )

– Single dose 30mg – Available in Australia since May 2016 – prescription no longer required

(Feb 17)

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Emergency contraception Access Cost Mechanism Other issues

Copper IUD IUD skilled health professional

$70-$200

Prevents implantation

Most effective method; insert within 5 days; may be retained for ongoing contraception, or removed after next menses

Ulipristal Pharmacists or Dr script

$45 Blocks or delays ovulation

Take within 5 days; approx 85% effective; lessened by starting hormonal contraception within 5 days

Levonorgestrel Pharmacists or Dr script

$15-$40 Blocks or delays ovulation

Take within 5 days; approx 85% effective; ?less in overweight women

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Susanne wants an Implanon

• Day 10 of cycle • Regular periods every 32 days • Unprotected sex days 2 and 4 of cycle

• When to insert Implanon? • … remember to discuss emergency

contraception as well!

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Further questions?

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