POP Flashcards
What types of POP are available? (4)
- Desogestrel (DSG) 75mcg
- Levonorgestrel (LNG) 30mcg
- Norethisterone (NET) 250mg
Coming soon: 4. Drospirenone (DRSP) 4mcg
How is the POP taken?
Continuously at 24h intervals without HFI
Apart from the new pill drospirenone which has 4 HFI days. Some will have a bleed.
How do the POPs prevent pregnancy?
Desogestrel and drospirenone (the D’s) inhibit ovulation.
Levonorgestrel & norethisterone (the “traditional” POPs) do not reliably inhibit ovulation, they rely for contraceptive effectiveness on their effect on cervical mucus, endometrium and tubal motility.
Age limitations POP
All POPs can be used between menarche and age 55 in medically eligible individuals
What UKMEC is it for POPs for those individuals with a history of ectopic pregnancy and ovarian cysts?
1
List the UKMEC 3’s for the POPs
UKMEC 3
- Current and history of ischaemic heart disease (UKMEC 2 for initiation, UKMEC 3 for continuation) [UKMEC 4 in CHC]
- History of stroke (UKMEC 2 for initiation, UKMEC 3 for continuation) [UKMEC 4 in CHC]
- Past breast cancer [UKMEC 3 in CHC]
- Severe (decompensated) cirrhosis (associated e.g. with ascites, jaundice, encephalopathy or GI haemorrhage) [UKMEC 4 in CHC]
- Hepatocellular adenoma or carcinoma [UKMEC 4 in CHC]
List the UKMEC 4’s for the POPs
- Current breast cancer
NB. For individuals with a history of breast cancer, any decision to initiate hormonal contraception may be best made in consultation with their oncology team.
How does the new POP drospirenone work? What is the risk of this.
It is a potent progestogen with a similar pharmacological profile to progesterone. A spironolactone derivative [aldosterone antagonist], it has anti-mineralocorticoid and mild anti-androgenic activity. Drospirenone is an aldosterone antagonist thus there is a risk of hyperkalaemia in susceptible individuals.
Who should drospirenone not be used by?
Patients:
- with severe renal insufficiency or acute renal failure
- with known hyperkalaemia or untreated hypoaldosteronism (e.g. Addison’s)
- using K sparing diuretics, aldosterone antagonists or K supplements
Who should drospirenone be used with caution by?
Patients:
- with mild/ moderate renal insufficiency
- with treated hypoaldosteronism (e.g. treated Addison’s)
- using ACEi’s and ARBs
What investigations might be considered before starting drospirenone and in who?
U+Es & BP
In those who have risk factors for CKD e.g. HTN, CVD, DM, particularly if over 50
How effective is the POP?
- Contraceptive effectiveness of the POP relies on correct use
- If used perfectly, POPs may be more than 99% effective
- Estimated typical failure rate is about 9%
What potential drug interactions are there?
- POP effectiveness reduced during use of the enzyme-inducer and for 28 days after stopping the enzyme-inducer. Offer alternatives: DMPA, the Cu-IUD or the LNG-IUS are suitable options if the individual is medically eligible.
- POP could reduce effectiveness of UPA for EC. The ability of UPA-EC to delay ovulation could be reduced if a POP is started within 5 days of taking the UPA. The ability of UPA-EC to delay ovulation could theoretically be reduced if a POP has been taken in the preceding 7 days. Advise use condoms for 5d after UPA + 2 days while POP takes effect (7d for drospirenone)
Weight / BMI with POP
Contraceptive effectiveness not affected by body weight or BMI
What could effect the absorption of POP
Vomitting
Severe diarrhoea
Bariatric surgery
Bleeding patterns to warn people of with:
Traditional POPs
Bleeding pattern is unpredictable
As a guide, over a 3 month period ending at about 12 months of use:
- <1 in 10 (2%) amenorrhoeic
- 1 in 10 = infrequent bleeding (1-2 bleeding/spotting episodes)
- 8 in 10 = normal frequency bleeding (3-5 episodes)
- 1 in 10 = frequent bleeding (6 or more episodes)
- <1 in 10 = prolonged bleeding for >14d
[<1, 1, 8, 1, <1)
Bleeding patterns to warn people of with:
Desogestrel
Bleeding pattern is unpredictable
As a guide, over a 3 month period ending at about 12 months of use:
- 2-3 in 10 = amenorrhoeic
- 3 in 10 = infrequent bleeding (1-2 episodes)
- 4 in 10 = normal frequency bleeding (3-5)
- < 1 in 10 = frequent bleeding (6 or more)
- 1 in 10 = prolonged bleeding >14d
[3, 3, 4, <1, 1]
NB this is similar in the new Drospirenone pill
What should be done in first consultation?
- Check medically eligible [PMH / Meds Hx / check specific UKMEC 3/4s]
- Check no interacting meds
- Check no allergies to pop content - note some DSG preps contain soya and may case cross reaction to individuals allergic to peanuts
- Check any existing risk of pregnancy, requirement for EC / additional precautions / f/u testing
- Give individual info on:
a) contraceptive effectiveness (perfect 99% and typical 91%)
b) how to take pills
c) any requirement for initial contraception
d) management of late/ missed pills
e) interaction with medicines / herbal remedies
f) potential bleeding patterns
g) alternative contraceptions incl LARC
h) STI risk assessment / screen
i) cervical screening status - Send them link to online resouce eg sexwise
How much can you prescribe at once
12 months
Advice to seek advice if any change to med history
some may require r/v before 12months eg those on new DRSP pop with rfs for hyperK
NB specific approved brands of desogestrel POP can now be bought by the user from a pharmacist
When can you start a POP?
Day 1-5 of period without need for extra precautions
[DRSP POP can only be started on day 1 without need for extra precautions]
Quick start - any time if 1. PT negative or certain no UPSI 2. Use condoms for 2 days [7d for DRSP] 3. F/U PT at 21d if appropriate
Missed pill windows
Traditional POPs - 3 hours
Desogestrel - 12 hours
DRSP - 24 hours
What follow up arrangements needed?
- Annual review
- Can usually be done without an in person r/v
- At follow up recheck:
Medical eligibility
Drug history
Method adherence and method satisfaction
Alternative options - LARC if appropriate
What happens with fertility when stop POP?
- immediate return to underlying fertility
- need alternative contraception immediately if dont want to get pregnant
- options for ongoing contraception
When is a traditional POP considered missed
3 hours
