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Contraceptive case studies Dr Christine Roke National Medical Advisor Family Planning March 2013
Case 1 • Anne-Marie comes to see you with her 15 year old daughter, Jo. Anne-Marie wants Jo to have a Mirena because she has used IUDs for years and likes them. • What would you like to know? • What would you advise them about using an IUD and in particular Mirena?
Long Acting Reversible Contraception - LARC • New emphasis because: • Action less often than monthly • All less than 1% failure rate • Fit and forget • IUDS, implant
Intrauterine contraception • IUDs can be used by women who have not had children • No increased risk of PID or infertility unless exposed to STIs • Insertion may be more uncomfortable • Slightly higher expulsion rate
Intrauterine contraception • Now clear that STIs cause infection not IUDs, beyond the initial insertion phase • Ideal to exclude STIs before insertion • If asymptomatic chlamydia found, can treat and insert IUD if reinfection not likely • If STI or PID diagnosed while IUD in situ, treat and only remove if not settling
Mirena • Efficacy not statistically different from copper IUD • Preferable to copper IUDs if periods heavy or painful
Case 2 • Belinda had Jadelle inserted 3 months ago. She has had runs of light bleeding lasting 10-14 days and starting up again after only a week or so without bleeding. • What would you like to know? • What investigations might you organise? • What is your management?
Jadelle bleeding pattern • Irregular bleeding and amenorrhoea common • Settles to long term pattern over first 3 - 6 months • Bleeding less likely to settle with time than Depo Provera or Mirena • Bleeding problems are commonest reason for discontinuation • Spotting and irregular bleeding common – 14% (1 in 7) discontinue for this reason: – 5% for prolonged episodes of vaginal bleeding and spotting – 4% for irregular bleeding – 3% for heavy bleeding
Causes of irregular bleeding on contraception • • • • •
Progestogen only contraception Initiation of hormonal contraception Infection – STIs, chlamydia Medications – interactions, enzyme inducers Abnormal cervix – ectropion, cancer
Management of irregular bleeding
• Exclude other causes if relevant – history, STI check, view cervix • COC as long as estrogen not contraindicated – Ava 30. Can use COC long term for bleeding control while implant provides effective contraception NSAIDs 5 -10 days
Case 3 • Kim needs antibiotics for bronchitis. She is on Ava 30 ED and asks if the antibiotic will affect her pill. • What is the answer?
Antibiotics and hormonal contraception • Numerous studies have shown no drop in hormone levels when various antibiotics are administered during COC use • No need to recommend additional contraception
Case 4 • Angie comes in to get emergency contraception. The condom broke last night. • What would you like to know? • What are the main risk factors for ECP failure? • What will you advise her?
Clinical assessment for ECP • • • • • • • • • • •
Present contraception LMP - Last Menstrual Period Cycle length UPSI – timing of Unprotected Sexual Intercourse Medication: enzyme inducers Coercion Sexually Transmissible Infection risk Serious illnesses: acute porphyria Future contraception Allergies BMI
ECP failure • High fertility risk e.g. few days before ovulation, missed pills 1st week of COC • Subsequent UPSI • BMI 30 or more – Slower to reach adequate hormone levels so appears to be ineffective – Should recommend postcoital IUD if high BMI with UPSI at risky time Glasier A et al. Contraception 2011
Case 5 • Jenny has missed 2 Ava 20 ED pills just before she is due to start the inactive pills. She comes to get an ECP because the condom broke last night. • What would you like to know? • What will you advise her?
Missed pills – for teaching women •
One missed pill, take it as soon as remembered, taking the next pill at the usual time – this may mean taking 2 hormone pills together
•
Any 2 pills missed within a week of each other, follow the 7 day rule
7 day rule •
Not contraceptively safe until 7 hormone pills have been taken in a row
•
Use another method of contraception such as condoms or do not have sexual intercourse while taking the 7 hormone pills
•
If during this time a condom breaks or slips off, the emergency contraceptive pill (ECP) is indicated.
7 day rule – cont.
If there are less than 7 hormone pills left in the pack, finish the hormone pills and start the new pack immediately (miss the 7 inactive pills or the 7 day break)
Missed pills –
what is actually required
FIRST WEEK: Danger of ovulation following pill free week 7 day rule essential Emergency contraception required if additional precautions not taken If any UPSI during the 7 days before missed pills, client needs ECP (may be > 72 hours) SECOND WEEK: No additional precautions required THIRD WEEK: Miss pill free week, no additional precautions required If pill free week taken, emergency contraception may be required.
New ways of taking COC • Tricycling = taking 3 packets of pills in a row without a break • Continuous = no breaks • Less risk of contraceptive failure • Less breakthrough bleeding with time but some women will find this spotting a problem – take 7 day break • No known medical concerns
Case 6 • Mary is a 46 year old who has come in for a routine cervical smear. She asks when her Multiload IUD should be changed as it has been in for 5 years now? • What would you like to know? • What will you advise her?
Intrauterine contraception • Fertility declines in 40s • Copper IUDs – if inserted when 40 or older, can stay until postmenopausal if no problems • Mirena - if inserted when 45 or older for contraception, can stay until postmenopausal if no problems
Case 7 • Penny comes in 2 weeks late for her Depo Provera injection. • What do you advise her?
Depo Provera • Now internationally recommended that “late” injection is more than 14 weeks since last injection (and even 16 weeks according to WHO) • Still schedule next appointment for 12 weeks
Case 8 • Genevieve has just moved to New Zealand and is using the vaginal contraceptive ring. • What is it? • Is it available here?
Nuvaring • Combined hormonal contraception • Ethinyl estradiol 15mcg and etonogestrel 120 mcg released daily • 3 weeks in vagina and 1 week without • Can be out of the vagina for less than 3 hours without losing contraceptive efficacy • Will become available in NZ this year
Case 9 • Penny wants to “go on the pill” and would like to try Yasmin as her friend likes it. • What would you like to know? • What would you like to discuss with Penny before making a decision?
Risk factors for COC
• Arterial – PH arterial disease, age over 40, smoking, diabetes, obese, hypertension, migraines with aura, hyperlipidaemia • Venous – PH DVT/PE, FH DVT/PE, obese, immobility, smoking
VTE risk • All COCs increase risk of DVT/PE, particularly in first months of use • 2nd generation pills containing levonorgestrel or norethisterone have lowest increase risk • Other COCs appear to have higher risk • MOH recommend women start on 2nd generation pill when VTE risk higher
Case 1 • Anne-Marie comes to see you with her 15 year old daughter, Jo. Anne-Marie wants Jo to have a Mirena because she has used IUDs for years and likes them. • What would you like to know? • What would you advise them about using an IUD and in particular Mirena?
Long Acting Reversible Contraception - LARC • New emphasis because: • Action less often than monthly • All less than 1% failure rate • Fit and forget • IUDS, implant
Intrauterine contraception • IUDs can be used by women who have not had children • No increased risk of PID or infertility unless exposed to STIs • Insertion may be more uncomfortable • Slightly higher expulsion rate
Intrauterine contraception • Now clear that STIs cause infection not IUDs, beyond the initial insertion phase • Ideal to exclude STIs before insertion • If asymptomatic chlamydia found, can treat and insert IUD if reinfection not likely • If STI or PID diagnosed while IUD in situ, treat and only remove if not settling
Mirena • Efficacy not statistically different from copper IUD • Preferable to copper IUDs if periods heavy or painful
Case 2 • Belinda had Jadelle inserted 3 months ago. She has had runs of light bleeding lasting 10-14 days and starting up again after only a week or so without bleeding. • What would you like to know? • What investigations might you organise? • What is your management?
Jadelle bleeding pattern • Irregular bleeding and amenorrhoea common • Settles to long term pattern over first 3 - 6 months • Bleeding less likely to settle with time than Depo Provera or Mirena • Bleeding problems are commonest reason for discontinuation • Spotting and irregular bleeding common – 14% (1 in 7) discontinue for this reason: – 5% for prolonged episodes of vaginal bleeding and spotting – 4% for irregular bleeding – 3% for heavy bleeding
Causes of irregular bleeding on contraception • • • • •
Progestogen only contraception Initiation of hormonal contraception Infection – STIs, chlamydia Medications – interactions, enzyme inducers Abnormal cervix – ectropion, cancer
Management of irregular bleeding
• Exclude other causes if relevant – history, STI check, view cervix • COC as long as estrogen not contraindicated – Ava 30. Can use COC long term for bleeding control while implant provides effective contraception NSAIDs 5 -10 days
Case 3 • Kim needs antibiotics for bronchitis. She is on Ava 30 ED and asks if the antibiotic will affect her pill. • What is the answer?
Antibiotics and hormonal contraception • Numerous studies have shown no drop in hormone levels when various antibiotics are administered during COC use • No need to recommend additional contraception
Case 4 • Angie comes in to get emergency contraception. The condom broke last night. • What would you like to know? • What are the main risk factors for ECP failure? • What will you advise her?
Clinical assessment for ECP • • • • • • • • • • •
Present contraception LMP - Last Menstrual Period Cycle length UPSI – timing of Unprotected Sexual Intercourse Medication: enzyme inducers Coercion Sexually Transmissible Infection risk Serious illnesses: acute porphyria Future contraception Allergies BMI
ECP failure • High fertility risk e.g. few days before ovulation, missed pills 1st week of COC • Subsequent UPSI • BMI 30 or more – Slower to reach adequate hormone levels so appears to be ineffective – Should recommend postcoital IUD if high BMI with UPSI at risky time Glasier A et al. Contraception 2011
Case 5 • Jenny has missed 2 Ava 20 ED pills just before she is due to start the inactive pills. She comes to get an ECP because the condom broke last night. • What would you like to know? • What will you advise her?
Missed pills – for teaching women •
One missed pill, take it as soon as remembered, taking the next pill at the usual time – this may mean taking 2 hormone pills together
•
Any 2 pills missed within a week of each other, follow the 7 day rule
7 day rule •
Not contraceptively safe until 7 hormone pills have been taken in a row
•
Use another method of contraception such as condoms or do not have sexual intercourse while taking the 7 hormone pills
•
If during this time a condom breaks or slips off, the emergency contraceptive pill (ECP) is indicated.
7 day rule – cont.
If there are less than 7 hormone pills left in the pack, finish the hormone pills and start the new pack immediately (miss the 7 inactive pills or the 7 day break)
Missed pills –
what is actually required
FIRST WEEK: Danger of ovulation following pill free week 7 day rule essential Emergency contraception required if additional precautions not taken If any UPSI during the 7 days before missed pills, client needs ECP (may be > 72 hours) SECOND WEEK: No additional precautions required THIRD WEEK: Miss pill free week, no additional precautions required If pill free week taken, emergency contraception may be required.
New ways of taking COC • Tricycling = taking 3 packets of pills in a row without a break • Continuous = no breaks • Less risk of contraceptive failure • Less breakthrough bleeding with time but some women will find this spotting a problem – take 7 day break • No known medical concerns
Case 6 • Mary is a 46 year old who has come in for a routine cervical smear. She asks when her Multiload IUD should be changed as it has been in for 5 years now? • What would you like to know? • What will you advise her?
Intrauterine contraception • Fertility declines in 40s • Copper IUDs – if inserted when 40 or older, can stay until postmenopausal if no problems • Mirena - if inserted when 45 or older for contraception, can stay until postmenopausal if no problems
Case 7 • Penny comes in 2 weeks late for her Depo Provera injection. • What do you advise her?
Depo Provera • Now internationally recommended that “late” injection is more than 14 weeks since last injection (and even 16 weeks according to WHO) • Still schedule next appointment for 12 weeks
Case 8 • Genevieve has just moved to New Zealand and is using the vaginal contraceptive ring. • What is it? • Is it available here?
Nuvaring • Combined hormonal contraception • Ethinyl estradiol 15mcg and etonogestrel 120 mcg released daily • 3 weeks in vagina and 1 week without • Can be out of the vagina for less than 3 hours without losing contraceptive efficacy • Will become available in NZ this year
Case 9 • Penny wants to “go on the pill” and would like to try Yasmin as her friend likes it. • What would you like to know? • What would you like to discuss with Penny before making a decision?
Risk factors for COC
• Arterial – PH arterial disease, age over 40, smoking, diabetes, obese, hypertension, migraines with aura, hyperlipidaemia • Venous – PH DVT/PE, FH DVT/PE, obese, immobility, smoking
VTE risk • All COCs increase risk of DVT/PE, particularly in first months of use • 2nd generation pills containing levonorgestrel or norethisterone have lowest increase risk • Other COCs appear to have higher risk • MOH recommend women start on 2nd generation pill when VTE risk higher
