Contraception 2017

Dr Richelle Douglas

Medical Director

SHQ

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Plan

•LARC methods

•Bleeding with progestogen only methods

•Bleeding with combined methods

•Combined methods and mood

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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

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Contraceptive Methods

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CASE STUDY

• Tania is 19-year-old

• G0P0

• No significant medical history

• No medications

• No regular sexual partner

• Uses COCP for contraception

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Tania presents for a repeat combined pill script…

Would you discuss other contraceptive options with Tania ?

• Yes

• No

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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

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(Copper IUD)

What did young people choose?

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0

2

4

6

8

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LARC Pill patch & ring

Year 1

Year 2

Year 3

Cumulative % of women who became pregnant each year

Contraceptive CHOICE study - pregnancies

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IUDs increase infection rates

• True

• False

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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)

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IUDs should not be inserted in nulliparous women

• True

• False

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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

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All hormonal contraception causes weight gain

• True

• False

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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

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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

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MEC 4 and LARC

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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

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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

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Question

• Contraceptive implants should be inserted in the sulcus between the bicep and triceps muscle

• True

• False

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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

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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?

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Whip out a contraception card:

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

Or: no hair or penis pictures

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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

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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

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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

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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.

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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

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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

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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

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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

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Extended COCP regimens

•Shorten or eliminate the hormone free interval

•Decrease frequency of ‘withdrawal bleed’

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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”)

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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

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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!

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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!

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NOW BACK TO SPINY MICE

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THE FUTURE IS WIRELESS BIRTH CONTROL

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Resources – Health Pathways WA

https://wa.healthpathways.org.au Username: connected Password: healthcare

eg.

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Resources

•Faculty of Sexual & Reproductive Health Care

• http://www.fsrh.org/standards-and-guidance/

•Australian Contraception Handbook 4th edition

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Any questions?

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