Advances in Contraception. Dr Sarah Pillai Associate Specialist Contraception and Sexual Health Service, Barnet

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1 Advances in Contraception Dr Sarah Pillai Associate Specialist Contraception and Sexual Health Service, Barnet

2 COC and endometrial Ca/COC and early pregnancy Endometrial cancer Meta-analysis shows long term protection continuing for up to 30 years after taking. In high-income countries, 10 years use of oral contraceptives was estimated to reduce the absolute risk of endometrial cancer arising before age 75 years from 2 3 to 1 3 per 100 women. Endometrial cancer and oral contraceptives: an individual participant meta-analysis of women with endometrial cancer from 36 epidemiological studies Collaborative Group on Epidemiological Studies on Endometrial Cancer Early pregnancy Recent study in Denmark showed no increase in birth defects in women taking COCP just before or in early pregnancy BMJ 2016;352:h6712

3 COCP-pill taking regimens 7 day pill free interval- evidence of ovulation All new COCPs 4 day interval or less (Qlaira, Zoely, Eloine ) Tailored pill taking regimen In women familiar with standard use of the COC, switching to tailored COC use or continuing with standard use were both associated with high COC continuation rates and high satisfaction with contraceptive regimen and bleeding pattern. While significant differences tended to favor the standard group, tailored COC use was associated with significantly less bleeding, suited some women very well and can provide a suitable alternative to standard use. Randomized trial of the effect of tailored versus standard use of the combined oral contraceptive pill on continuation rates at 1 year. Stephenson J1, Shawe J, Panicker S, Brima N, Copas A, Sauer U, Wilkinson C, Akintomide H, O'Brien P. Contraception Oct;88(4): doi: /j.contraception Epub 2013 Apr 11

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5 Contraindications to COCP Cardiac conditions

6 Other COC issues Antiepileptics Eloine (Yaz-20mcg ethinylestradiol, 3mg drosperinone) Generics

7 EURAS-IUD Contraceptive efficacy Study of 61,448 women with a newly inserted IUD enrolled in six European countries between 2006 and 2012, over 58,000 studied for 1 year Results were contraceptive efficiency and associated complications Low incidence of pregnancy, with IUS significantly lower than copper IUD Overall Pearl indices of 0.06 [95% confidence interval (CI): ] and 0.52 (95% CI: ) for LNG IUS and copper IUDs, respectively

8 Perforation Perforation Table: Incidence of perforation per 1,000 insertions for the entire study cohort (IUS and IUD), stratified by lactation and time since delivery at insertion Insertion 36 weeks after delivery Insertion >36 weeks after delivery Lactating at time of insertion 5.6 (95% CI ; n= (95% CI ; n=608 insertions) Not lactating at time of insertion 1.7 (95% CI ; n=5927 insertions) 0.7 (95% CI ; n=41,910 insertions) The benefits of intrauterine contraception still strongly outweigh the rare risk of perforation for most women, including those who are lactating or have recently given birth. (MHRA June 2015)

9 Ectopic pregnancies Ectopic 21/118 pregnancies 14/92 IUD, 7/26 IUS pregnancies adjusted hazard ratio for ectopic pregnancy of 0.26 (95% CI: ) Risk of ectopic pregnancy in general population higher overall

10 Jaydess Jaydess LNG-IUS 13.5mg levonorgestrel, Mirena LNG-IUS 52mg levonorgestrel Smaller diameter, lasts 3 years (Mirena 5 years) Only indication is contraception (Mirena menorrhagia, endometrial protection) At three years serum levels 59pmol/l vs 134pmol/l Similar efficacy levels Lower rate of amenorrhoea with Jaydess

11 Levosert generic Mirena? Same size, different fitting mechanism Licence currently 3 years No benefits over Mirena Similar side effect profile Cost 66 vs 88 for Mirena

12 Case study 1 Maryam aged 35 years Postnatal 4 weeks, fully breastfeeding Requests intrauterine contraception She would like a non-hormonal method but had heavy menses and anaemia in the past What are the issues to discuss with her? Would you delay? If so till when? Which device?

13 Vaginal bleeding on LARC, how to manage

14 Case study 2 Sofia aged 31 years IUS since June 2014, regular two day menses Since Oct 2015 has been getting constant nuisance bleeding, sometimes heavy, sometimes light No pain Regular partner 12 years What will you suggest?

15 Case study 3 Mary aged 22 years Implant for last three months, fitted at TOP (was taking COCP but forgot some pills) Demands removal, bleeding every day since fitting She will go back on the COCP What will you advise?

16 Depo-Provera rules-13 weeks

17 Sayana Press

18 Emergency contraception Levonogestrel 1.5mg Ulipristal acetate 30mg (EllaOne ) Copper intrauterine device

19 EC rules Levonelle up to 72 hours licensed, equally effective until 84 hours, no drop off with time Very few contraindications (safer than Smarties) Need double dose with potent enzyme inducers EllaOne up to 120 hours, no drop off with time Interactions-contraindications IUD-up to 120 hours after UPSI OR up to 120 hours after ovulation

20 EllaOne (ulipristal acetate) Progestogen receptor modulator Interaction with hormonal contraception DO NOT USE other contraception for five days after use, then restart and use normal interval before becomes effective Contraindicated in breastfeeding (express for 7 days) Interaction with potent enzyme inducers, not recommended Cannot use more than once per cycle

21 Case study 4 Brooke aged 16 years, nulliparous, new partner for past 3/12 Day 14 of a 28 day cycle UPSI every day since LMP What would you offer?

22 Case study 5 Jemma aged 37 years Erratic menses, cycle normally days Day 17 today UPSI 119 hours ago, casual male partner No other sex this month, desperate not to get pregnant, has a husband What advice would you give her?

23 New technology for women

24 New technology for men

25 Summary EllaOne is effective but has significant disadvantages Tailored pill taking, new pills with shorter pill free intervals New rules for Depo-Provera, 13 weeks Self admininstered MPA New IUS family, be aware of differences Investigate and treat problematic bleeding with LARC Look out for new UK MeC

26 Any questions?