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How to be REALLY good at preventing unplanned pregnancy
Dr Angela Cooney 2014
ACTUALLY, NOT VERY MUCH….
BUT
EXTENDED USE COCP REGIMENS
LARC
ONG
CTING
EVERSIBLE
ONTRACEPTION
Condoms “one size fits all….doesn‟t it?”
Withdrawal “no good at all, don‟t even bother”
COCP “the best pill is the one the drug rep just told me about”
POP “you can only use that if you are breastfeeding….”
IUD “don‟t even think about it until you have had 3 children/are over 30”
“If you didn‟t like Implanon, you won‟t like Depo-Provera, cos they are the same…”
Condoms “one size fits all….doesn‟t it?”
“Multiple scientific studies dating as far back as 1993 have all identified that between 40-45% of men have problems finding a condom that fits. Problems like the condom slipping, or falling off. Problems like a condom feeling tight, or uncomfortable, or stopping you being able to orgasm”.
http://www.theyfit.co.uk/pages/about-theyfit
Withdrawal is “no good at all, don‟t even bother”
Withdrawal ◦ Perfect use failure rate 4% per year ◦ Usual use failure rate 18% per year.
Condoms ◦ Perfect use failure rate 2% per year ◦ Usual use failure rate 17% per year….
….AND you never leave home without it…..
COCP…
“the best pill is the one the drug rep just told me about”
Combined pills (oestrogen plus progestogen) on the market in Australia since 1960
A BEWILDERING ARRAY OF DIFFERENT STYLES…..WHERE TO START???
Keep it SIMPLE. ◦ PBS vs Private ◦ „Second generation‟ vs „third generation‟ ◦ Cheap vs expensive ◦ Monophasic vs triphasic ◦ No real difference in side effects as population, only
for individuals, so TRY IT AND SEE, if problems then prescribe new pill to address problem.
All the later generation pills (possibly except Zoely and Qlaira, but not enough evidence yet) have an increased risk of thromboembolism compared to old-fashioned pills….
This includes Diane-style pills, so should only use where there are additional benefits like treatment of acne, hirsuties. BUT ALWAYS SAFER THAN BEING PREGNANT!!
0
50
100
150
200
250
300
No
hormones
Combined
pill
Pregnancy Immediately
postpartum
VTE risk per 10,000 woman years
• What about stopping and starting combined contraception? − “taking a break for 1-2 months”
Faculty of Sexual and Reproductive Health Combined Hormonal Contraception
October 2011 (Updated August 2012)
What about „taking a break from the pill, to give my body a rest?‟
A RECIPE FOR UNPLANNED PREGNANCY!
Women are often already having a break for 1 week every month, and for some women this is too long – ovulation can happen. 4 day pill-free-interval is much safer.
WOMEN MUST HAVE A PERIOD EVERY MONTH, ANYTHING ELSE IS UNNATURAL AND ALLOWS „BAD BLOOD‟ TO BUILD UP
WHICH WAY IS BEST, AND WHY?
2006-2012 US insurance database study Type of COCP pack likelihood of UPP 21/7 7.3% 24/4 6.9% 84/7 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
21/7 (eg Levlen) = traditional way, monthly „period‟
24/4 (eg Yasmin) = less chance of ovaries „waking up‟ and
having breakthrough ovulation
84/7 (eg „back-to-back) = previously recommended for
severe dysmenorrhoea, endometriosis etc
120/4 (eg Yaz Flex) = probably optimal for contraceptive
effectiveness and minimising symptoms. CAN DO THE SAME WITH CHEAP PILLS…
What is QuickStart???
Potential advantages ◦ fewer unplanned pregnancies
◦ a higher chance that the woman will initiate the method
◦ minimised chance of forgotten instructions
Potential disadvantages ◦ may not be able to exclude pregnancy for the cycle
◦ pregnancy diagnosis delay
◦ potential for teratogenicity or concern for woman
DON‟T ASK A WOMAN ON DAY 10 OF HER CYCLE TO WAIT FOR HER NEXT PERIOD
What is the worst thing that can happen if she starts the pill now??
Start today on the active pills, and allow 1 week to work, and do a pregnancy test in 4 weeks.
Method
Method is
effective
Effect on
continuing
pregnancy
Method may
mask
pregnancy
Reversible
Comments
Preferred
methods for
Quick Start
Combined
hormonal
7 days
None
known
Unlikely
Yes
Risk of teratogenesis well
studied.
Withdrawal bleed
Implant
7 days
None
known
Yes
Yes
Teratogenesis, unlikely. Long
acting, and effective; rapidly
reversible.
Mini pill
48 hours
None
known
Possible
Yes
Rapid onset, Strict adherence
to timing
Can be used
DMPA
7 days
None
known
Yes
No
Irreversible. Small studies
show no teratogenesis.
Long acting, effective
Can’t be used
(exception
copper IUD
for
emergency
use)
IUD
Copper stat
LNG: 7 days
↑
miscarriage,
esp 2nd
trimester
Yes: LNG
Possible CU
Threads
may
disappear
Possible effect on the outcome
of a pregnancy if the IUD
cannot be removed.
Progestogen Only Pill
“you can only use that if you are breastfeeding….”
A very under-utilised option
Consider where oestrogen contraindicated ◦ Focal migraine, smoker over 35, history DVT
Consider where „every pill makes me feel sick‟ ◦ Nausea is related to oestrogen
Consider where an older woman needs reliable contraception
Reliability of POP vs COCP?
Ideal conditions (drug trials) ◦ COCP 99% effective
◦ POP 99% effective
In real life….. ◦ COCP = POP = 91%
Any pill is only as good as the person taking it
IUD “don‟t even think about it until you have had 3 children/are over 30”
IUDs do not cause infertility
IUDs can be inserted in MOST women, including young, nulliparous or post caesarean, WITHOUT TECHNICAL DIFFICULTY
Other than a small risk immediately post-insertion (1 in 200), IUDs DO NOT INCREASE THE RISK OF PELVIC INFECTION and can be used by teenagers
www.shfpa.org.au/sites/shfpa.drupalgardens.com/files/201310/LARCstatementSHFPAFINAL.pdf
“If you didn‟t like Implanon, you won‟t like Depo-Provera, because they are just the same…”
Implanon ◦ Etonorgestrel 3 year implant ◦ Affected by enzyme inducers eg Carbamazepine ◦ Annoying bleeding comes and goes, does not improve
with time
Depo Provera ◦ Medroxyprogesterone acetate 12 weekly injection ◦ NOT affected by liver enzyme inducers ◦ Bleeding tends to improve with longer use ◦ Has been used as a contraceptive for 45 years!!!
NOT THE SAME!!!!!!!
Resources for health professionals and consumers/patients www.fpwa.org.au/ resourcecentre/
1 WHO IS IT FOR? ◦ Eg 16 year old teen, 24 year old woman-about-town, 35 year old
mother of 3, 44 year old with breast cancer
2 HOW MUCH WILL IT COST? ◦ 16 year olds generally can‟t afford very expensive options
3 ARE THERE ANY CONTRAINDICATIONS? ◦ Eg DVT and migraines for COCP, uterine anomaly for IUDs
4 IS IT ACCEPTABLE TO THE PERSON? “You aren‟t putting that thing in me, it looks like a fish-hook”
5 IS IT ACTUALLY GOING TO WORK? ◦ “I can‟t remember to take pills”, “my boyfriend won‟t use frangers”
16 years old
Comes in with boyfriend, age 17
Wants contraception
Parents don‟t know she is having sex…
Unless she is at risk/coerced/DV, her privacy is protected by Gillick ruling (UK)
Family/parents may surmise that she is having sex, and may be happy that she is caring for herself
„Dobbing her in‟ will lose you a patient
Family can help with accessing more expensive options
1. Age 16
2. BMI of 32
3. Risk of STIs
4. FH of breast cancer – Mum age 47
5. FH of stroke – Dad late 50s
6. None of these
16 years old
Comes in with stepmother Sarah
Periods are unpleasant
SUGGESTIONS??
Combined pill + condom
Vaginal ring + condom
IUD + condom
Depot + condom
Condom only
Withdrawal + diaphragm
Implanon + condom
She is so impressed with how you managed Shannon that she has come to talk to you about contraception for herself
39 years old
2 children ages 10 and 6, both vag. dels
On thyroxine, no other illnesses or medications, ex-smoker 15 years ago
Has been on Yasmin for 5 years until seeing something on TV about DVT risk…
Ceased pill 5 months ago, using withdrawal „at risky times in the cycle‟
Had Implanon inserted by her mother‟s GP in Perth 6 weeks ago
Thinks it doesn‟t suit her, as she feels different, „like when I was pregnant‟
What will you do first?
UCG POSITIVE
Had negative pregnancy test with GP on day 16 of her cycle, prior to insertion of implant…
NOW what will you do?
“Termination of pregnancy is a physically dangerous procedure with long-lasting psychological consequences”
In fact, 5000 procedures per year done in WA alone, most for „social‟ reasons.
With good prior counselling, most women are satisfied with their decision and just get on with life.
Up to day 49 LMP
Offered by freestanding TOP clinics in Perth
Available for use by GPs
MSI 2-step program, online training
NO IMPACT ON SUBSEQUENT FERTILITY
Up to 19 w 6d in WA for „social indication‟
Available in Bunbury Regional Hospital
NO IMPACT ON SUBSEQUENT FERTILITY
Here you can find all the information you need about MS-2 Step™ the use of Mifepristone Linepharma (mifepristone) and GyMiso® (misoprostol) for medical termination of pregnancy up to 49 days of gestation.
To become an MS-2 Step™ certified prescriber or dispenser please select from one of the following options:
Option 1:To become an MS-2 Step™ certified prescriber you need to complete the online training program.
Option 2:Current TGA Authorised Prescribers of mifepristone and medical
practitioners with a Fellowship (FRANZCOG) or Advanced Diploma (DRANZCOG Advanced) of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) can waive the requirement for training and go straight to register as an MS-2 Step™ certified prescriber.
Option 3:If you are a pharmacist or specialty medical clinic, you can go straight to register as an MS-2 Step™ certified dispenser You are not required to complete the online training but have access to it if you would like to know more about the process.
She talks to her husband and they decide to continue the pregnancy
You remove the implant for her
You insert an IUD for her when her little boy is 6 weeks old
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