Vasanthy Ravichandran Woodland Avenue Surgery

 Every 10 seconds 44 births and 18 deaths = net gain of 26.

 Every week extra 1.5 million people need food and shelter  WHO (NOV 2006): 180 million conceptions (80 million unwanted) each year. 45 million abortions - 19 million performed unsafely. Still 540 000 die each year!

 99% of population growth in developing world but planet is affected everywhere- Environmental crisis due to population explosion and no suitable second planet available to escape

          Effective Convenient (non-forgettable, non-coitally related) Reversible Safe, minimum / no side effects Maintenance- free (no provider/medical intervention- pain or discomfort free) Acceptable to culture, religion , political view Other contraceptive benefits Protective against STIs Cheap and easy to distribute, store Visible to women eg. male condom

       Better deal for women Education and Literacy Availability of family planning information and services Better health and fewer child deaths More employment and opportunities Later marriages, Migration to Towns and cities Rising Living standards and more equal distribution of wealth

    Age of consent in the UK is 16.Although mutually agreed sexual activity between two under 16 year olds would not generally lead to prosecution unless there is evidence of abuse, exploitation.

Under 13 is considered unable to legally consent to sexual activity Consent, confidentiality and safeguarding young people Competence to consent to treatment should be assessed

     

Fraser Guidelines / Gillick competence Contraceptive advice for young people- UPSSI

It is considered good practice for doctors and other health professionals to follow the criteria outlined by Lord Fraser in 1985 in the House of Lords' ruling in the case of Victoria Gillick v West Norfolk and Wisbech Health Authority and Department of Health and Social Security. These are commonly known as the Fraser Guidelines: the young person Understands the health professional's advice.

the health professional cannot Persuade the young person to inform his or her parent 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 Sexual activity 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.

UKMEC

1 2 3 4

Definition of Category

A condition for which there is no restriction for the use of the contraceptive method A condition where the advantages of using the

method generally outweigh the theoretical or proven risks

A condition where the theoretical or proven risks generally outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable A condition which represents an unacceptable risk if the contraceptive method is used

History

Medical conditions and medications including OTC Family history Life style( sexual,work,home situation) Cervical screening STI risk Examination- BMI, BP Discussion about choices- Hormonal/Non hormonal -Short or Long acting - user dependent or non-user dependent

         Health professionals can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy: Has not had intercourse since last normal menses.

Has been correctly and consistently using a reliable method of contraception.

Is within the first 7 days of the onset of a normal menstrual period Is within 4 weeks postpartum for non-lactating women Is within the first 7 days post-abortion or miscarriage 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 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 and undertake pregnancy testing where appropriate (≥3 weeks since last UPSI).

 A 25 year old who smokes 15 cigarettes / day with BMI 32 is requesting the combined pill?

 A 35 year old smokes 15/day with BMI 33, requesting the combined pill?

 A 22 year old mother of 2 (had uneventful pregnancies), with factor V Leiden mutation would like to discuss her contraception?

 A 22 year old suffers from acne and would like to go on the pill?

 A 20 year old with a family history of breast cancer, has been having heavy painful periods is requesting contraception?

 A 34 year old nulliparous treated for breast cancer five years ago, in a new relationship, and would like a reliable contraception?

 A 27 year old whose mother had DVT at 48 years, is requesting contraception?

 A woman on coc, what advice should be given when you prescribe Amoxicillin for chest infection?

 A young woman on the combined pill has been diagnosed with Pulmonary TB and is going to be started on Rifampicin, how would you advice her?

 A 26 year old on coc has been recently diagnosed with epilepsy and the neurologist recommends her to go on Lamotrogene. How would you counsel her?

 A woman develops migraine with aura on POP? What will you do?

         A number of factors should be considered when informing women about EC options. These include: Medical eligibility Efficacy of method Last menstrual period and cycle length Number and timing of episodes of UPSI Previous EC use within cycle Need for additional precautions/ongoing contraception Drug interactions Individual choice.

TRADITIONAL POPs

(Micronor®, Noriday®, Norgeston®, Femulen®)

DESOGESTREL-ONLY

(Cerazette®)

>3 hours late

(>27 hours since the last pill was taken)

>12 hours late

(>36 hours since the last pill was taken) Take a pill as soon as remembered. If more than one pill has been missed just take one pill.

Take the next pill at the usual time. This may mean taking two pills in one day. This is not harmful. An additional method of contraception (condoms or abstinence) is advised for the next 2 days (48 hours after the POP has been taken).

If ONE pill has been missed (48–72 hours since last pill in current packet or 24–48 hours late starting

first pill in new packet)

Continuing contraceptive cover

The missed pill should be taken as soon as it is remembered. The remaining pills should be continued at the usual time.

Minimising the risk of pregnancy

Emergency contraception (EC) is not usually required but may need to be considered if pills have been missed earlier in the packet or in the last week of the previous packet.

If TWO OR MORE pills have been missed (>72 hours since last pill in current packet or >48 hours late starting first pill in new packet) Continuing contraceptive cover

The most recent missed pill should be taken as soon as possible. The remaining pills should be continued at the usual time.

Condoms should be used or sex avoided until seven consecutive active pills have been taken. This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed.

If pills are missed in the first week (Pills 1–7) EC should be considered if unprotected sex occurred in the pill-free interval or in the first week of pill-taking.

Minimising the risk of pregnancy

If pills are missed in the second week (Pills 8–14) If pills are missed in the third week (Pills 15–21) No indication for EC if the pills in the preceding 7 days have been taken consistently and correctly (assuming the pills thereafter are taken correctly and additional contraceptive precautions are used).

OMIT THE PILL-FREE INTERVAL by finishing the pills in the current pack (or discarding any placebo tablets) and starting a new pack the next day.

Situation

Extension of patch/ring-free interval Patch/ring detachment/removal Extended use of patch Extended use of the ring

Timefram e

≤48 hours >48 hours ≤48 hours >48 hours ≤9 days >9 days ≤4 weeks >4 weeks

Additional contraceptive protection required?

No Yes (7 days). Consider EC if UPSI occurred in patch/ring-free interval No (providing there has been consistent and correct use for 7 days prior to removal/detachment) Yes (7 days). Consider EC if patch/ring was detached/removed in Week 1 and UPSI occurred in patch/ring-free interval or Week 1 No Yes for 7 days No (ring-free interval can be taken) Yes. However, if the woman has worn the ring for >4 but ≤5 weeks, efficacy could be maintained by starting a new ring immediately without a ring-free interval

 A woman has regular 32 days cycle presents on day 14, following an accident with the condom 4 days previously. How would you advice?

 A woman using CVR (Combined vaginal ring) has forgotten to change the ring at the end of 3rd week and is approaching the end of the 4th week. She had UPSI 2 days ago.

 A woman who had her first episode of UPSI 7 days ago but did not seek help, and had another episode 50 hours ago is requesting emergency contraception. How would you advice? What options she has?

 She would like to go on a reliable contraception as soon as possible Nexplanon or oral contraceptive. Would you be happy to offer it to her?

 Woman forgot to start the new pack of COC > 48 hours and had UPSI during PFI (pill free period)?

 Woman using the CTP (combined transdermal patch) noticed her patch detached > 48 hours in week 2. What would you do?

 Missed > 27 hours pop pill (Noriday) and had UPSI? What if it was Cerezette?

 Woman came for her DMPA. The nurse called you to say that the lady was 2weeks and 1day overdue. What would you do?

 A 40 year old lady would like to discuss about LARC methods in your 10 minute consultation?

 Patient concerned  Clinical history- correct use, inter-current illness, medications.

 Other symptoms (pain, dyspareunia, abnormal discharge, PCB, HMB)  Exclude STI  Check cervical screening history  Rule out pregnancy  Manage any issues identified

COC

Increase dose of EE.

Try different COC

POP

Try different POP.

IMPLANTS, MDPA, IUS

Try COC (continuous or cyclical) HRT (Oestrogen only) patch.

Mefenamic acid.

Tranexamic acid.

? Doxycycline

 Receptionist rang you to say that a lady who had an IUD inserted the previous day is experiencing pain and bleeding?

 A 46 year old had Mirena IUD inserted 5 months ago, she is worried that she is no longer seeing her period?

 A lady who had a sub-dermal implant inserted 8 weeks ago, hasn’t had her period and is now concerned?

 A 25 year old would like her Implanon/ Nexplanon removed due to irregular heavy bleeding for 4 months. How would you manage her problem?

 A 45year old with a Copper IUD inserted 2 years ago is experiencing pain and bleeding? How would you manage her problem?

 A lady 46 years of age has a LNG-IUS for 6 months has irregular bleeding and discharge?

 An 18 year old had the first DMPA injection and is troubled by heavy irregular bleeding?

 A 50 year old who had a Copper TT 380 for 8 years and didn’t see her period for 12 months, consults you regarding the IUD?

 A 50 year old had a Mirena IUS 5 years ago for heavy periods, now amenorrhoeic for 2 years. Her husband had a vasectomy?

 A healthy mother 4 weeks postpartum, fully breast feeding would like to know her contraceptive options.  What if not breast feeding and would like to go back on the coc - could she start?

 35 year old on DMPA experiencing irregular heavy bleeding?

 35 year old experiencing breakthrough bleeding on Loestrin?

 13 Year old came alone to surgery to discuss contraception, says she would soon start sexual activity? What would you do

 Actinomyes like organism( ALO) was reported in routine cervical smaer in a woman has an IUD?

 Lost threads?

 Pregnancy with the IUD?

 Pelvic infection?

Any questions?