Contraception: Common Problems and FAQS. Dr Christine Roke National Medical Advisor, Family Planning September 2014

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1 Contraception: Common Problems and FAQS Dr Christine Roke National Medical Advisor, Family Planning September 2014

2 ECP failure High fertility risk e.g. few days before ovulation, missed pills 1 st week of COC Subsequent UPSI in same cycle High BMI Slower to reach adequate hormone levels so appears to be ineffective Glasier A et al, Contraception 2011 Taken post fertilisation (LNG ECP doesn t work after fertilisation) Noe G. et al, Contraception 2010

3 BMI and LNG ECP failure rates BMI % failure rate Confidence intervals < or more No ECP 5.6 Glasier A et al, Contraception 2011

4 RISK OF CONCEPTION ON DIFFERENT DAYS OF THE CYCLE Percentage risk M E N S E S Day of Cycle

5 Postcoital IUD Copper IUD inserted within 5 days of fertilisation (by day 19 of 28 day cycle) or within 5 days of single unprotected sexual intercourse Always more effective than LNG ECP Highly recommended when high risk of failure e.g. BMI 30 or more

6 Discussion of emergency contraception with high BMI Discuss LNG ECP may be ineffective Assess whether time of high risk and still within 5 days of ovulation or single UPSI Discuss postcoital IUD If client is at high risk, is within 5 days of above and interested in postcoital IUD, arrange for insertion Provide LNG ECP in case unable to obtain PC IUD or decides not to go ahead

7 Contraception and bleeding disturbances All hormonal and intrauterine methods have potential to disturb bleeding patterns especially initially Need to exclude non contraceptive causes infection, abnormal cervix, interacting medication, pregnancy

8 Oral contraception and bleeding Check re missing pills, diarrhoea and vomiting, running COC packets together COC irregular bleeding more likely with lower dose pills - increase dose or change progestogen - increase oestrogen POP increase dose to Cerazette or 2 pills daily to suppress ovulation -

9 Depo Provera and bleeding Irregular bleeding common initially, occasionally heavy by 1 year most amenorrhoeic Can give Depo Provera at 10 weeks if bleeding when next injection due COC as long as oestrogen not contraindicated NSAIDs for 5-10 days

10 Intrauterine contraception and bleeding Copper IUD can cause heavier, longer and more painful periods usually settles Can use NSAIDs or tranexamic acid Mirena can cause irregular, usually light bleeding initially most amenorrhoeic within 1 st year Hard to manage with medication Check IUS position if persistent spotting

11 Family Planning Jadelle audit

12 Bleeding pattern 6 to 12 months (percentage of sample) Regular periods 34-36% 1 in 3 Irregular bleeding 27-29% 1 in 4 No bleeding 19-23% 1 in 5 Prolonged bleeding 10-11% 1 in 10 Occasional spotting 2-5% 1 in 20 Two weekly bleeding 2-4% 1 in 20 Medication required 6-9% 1 in 10

13 Implant bleeding Discussion of possible bleeding problems essential before insertion Less likely to settle than Depo Provera or Mirena Management of irregular bleeding COC (Ava 30) as long as oestrogen not contraindicated can be used continuously or cyclically throughout the implant lifespan NSAIDs 5-10 days

14 Jadelle and removal because of bleeding Data sheet quotes 14% users (I in 7) had Jadelle removed for bleeding problems before 5 years Family Planning audit removal rate for bleeding at 1 year = 10%

15 Family Planning Jadelle audit

16 Family Planning Jadelle audit 7 Reason for Removal, numbers 6 Bleeding 5 4 Hormonal Effects (wt gain, mood, headache) Bleeding + Hormonal Effects Local Effects 3 2 Not desiring Contraception Medical Reason Pregnant around time of insertion 1 0 Month 1 Month 3 Month 6 Month 9 Month 12

17 Family Planning Jadelle audit

18 Migraine Simple migraines present with: Throbbing or pulsating unilateral or bilateral pain Nausea, vomiting, anorexia Sensitivity to light or sound Severe and not easily relieved by simple pain relief V4.0_2014_0702

19 Visual symptoms in migraine with aura In 99% migraines with aura usually before headache Usually symmetrical, affecting one hemifield of both eyes, although subjectively, they may appear to affect only one eye V4.0_2014_0702

20 Visual symptoms in migraine with aura. Typically begins with small bright blind spot which gradually increases in size to assume a C shape Often develop scintillating edges round blind spot which appear as zigzags May include flashing lights V4.0_2014_0702

21 Neurological symptoms and signs of migraine with aura Less common Unilateral sensory disturbance typically pins and needles, spreading up one arm or affecting one side of the face or tongue the leg is rarely affected V4.0_2014_0702

22 Neurological symptoms and signs of migraine with aura Disturbance of speech usually nominal dysphasia Loss of motor function is very unusual These symptoms usually follow one another visual, then sensory, then dysphasia V4.0_2014_0702

23 Headaches Migraines (without aura) - COC OK if no other risk COC contraindicated - migraine with aura - migraine without aura plus additional risk factor for stroke including age over 40, smoking, diabetes, obesity, high BP, hyperlipidaemia Past history of migraine with aura (more than 5 years ago) and no other risk factors WHO 3 V4.0_2014_0702

24 Risk of venous thrombosis (DVT/PE) For non pregnant woman between years old - 2 per 10,000 per year For pregnant woman - up to 10 times risk Low dose second generation pills times risk Most other combined pills and vaginal ring - 6 times risk or more Fatality rate 3% (of DVT/PE) V4.0_2014_0702

25 VTE risk All COCs increase risk of DVT/PE, particularly in first months of use MOH recommend women start on 2 nd generation pill as higher VTE risk initially Risk factors PH DVT/PE, close FH DVT/PE, obesity, immobility, smoking

26 First line COCs second generation pills Oestrogen Norethisterone Levonorgestrel 35mcg *Brevinor 1 *Norimin *Brevinor 30mcg *Ava 30 20mcg *Ava 20 * Government subsidised pills V4.0_2014_0702

27 Tricycling or continuous COC pill taking Advantages Less risk of contraceptive failure - have to miss more than 8 pills in a row rather than just 2-4.4% failure rate vs 7.3% Howard B et al, Contraception 2014 Avoid problems experienced in pill free interval such as migraines, dysmenorrhoea No known medical concerns

28 Tricycling or continuous pill taking Disadvantage Some women experience breakthrough bleeding - take up to 7 day break Encourage continuous pilltaking to improve contraceptive efficacy

29 IUD lifespan Multiparous women 25 years old or more at time of insertion: Multiload 375 can last 10 years CuT380A can last 12 years Mirena can last 7 years CuT380A inserted when 35 or older can continue to menopause Outside license Wu J, Pickle S, Contraception 2014

30 Choice TT380 IUD Copper IUD now subsidised in New Zealand Standard Choice TT380 IUD licensed for 10 years, equivalent to CuT380A Short Choice TT380 licensed for 5 years - thinner copper sleeves (probably unable to recommend longer lifespan)

31 Comparing typical effectiveness of contraceptive methods More effective Less than 1 pregnancy per 100 women in one year How to make your method most effective After procedure, little or nothing to do or remember Implant Vasectomy Female Sterilization IUD IUS Vasectomy: Use another method for first 3 months 6-12 pregnancies per 100 women in one year Injectable Pills Patch Ring Diaphragm Injectable: Get repeat injections on time Pills: Take a pill each day Patch, ring: Keep in place, change on time Diaphragm: Use correctly every time you have sex Less effective 18 or more pregnancies per 100 women in one year Male Condom Female Condom Spermicides Sponge Fertility Awareness- Based Methods Withdrawal Condoms, sponge, withdrawal, spermicides: Use correctly every time you have sex Fertility awareness-based methods: Abstain or use condoms on fertile days. Newest methods (Standard Days Method and TwoDay Method) may be the easiest to use and consequently more effective Source: Trussell and Guthrie 2011

32 Initiating contraception Reasonably exclude pregnancy (remember PT takes 2 weeks to become positive) If contraception commenced by day 7, contraceptively safe straight away Later in cycle. Not contraceptively safe for 7 days May need PT in 2-3 weeks Rate of abnormal baby not increased when taking hormonal contraception

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