W12 Contraception (JD)

Question 1

What is Contraception?

Answer 1

• Contraception refers to methods or devices used to prevent pregnancy by interfering with the normal process of conception (fertilisation of egg and sperm)
• It enables individuals or couples to effectively control if and when they desire to conceive.

Question 2

What are some conditions that expose a woman to increased risk as a result of unintended pregnancy:

Answer 2

Bariatric surgery within the past 2 years
Breast cancer
Diabetes: insulin-dependent, or with nephropathy/retinopathy/neuropathy or other vascular disease
Endometrial or ovarian cancer
Epilepsy
HIV-related diseases
Hypertension (systolic >160 mmHg or diastolic >100 mmHg)
Ischaemic heart disease
Morbid obesity (BMI ≥40 kg/m2)
Organ failure/transplant
Stroke
Systemic lupus erythematosus (SLE)
Thrombogenic conditions
Tuberculosis
Teratogenic drugs – women should be advised to use reliable and effective contraception both during treatment and for the recommended timeframe after discontinuation to avoid unintended pregnancies

Question 3

What are the different methods of contraception?

Answer 3

Broadly categorised into:

• Fertility awareness-based method
  -Avoiding unprotected sexual intercourse (UPSI) during the most fertile period of the menstrual cycle
• Withdrawal method
• Barrier methods
  -Condom, diaphragm
• Hormonal contraception
  -Levonorgestrel Intrauterine System, CHCs, POCs
• Non-hormonal contraception
  -Copper-bearing IUD
• Sterilisation (irreversible)
  -Vasectomy in male OR female sterilisation

Question 4

Sterilisation
What is a Vasectomy?
What is Tubal ligation?

Answer 4

The tube that carries sperm from each testicle (vas deferens) is cut and sealed

The fallopian tubes are cut or blocked to disrupt path normally taken by eggs from the ovaries

Question 5

Methods of contraception: ( extensive-for info)

Answer 5

• Intrauterine Contraception (IUC)
  -Copper-bearing Intrauterine Device (Cu-IUD)
  -Levonorgestrel Intrauterine System (LNG-IUS)
• Progestogen-only Contraception (POC)
  -Progeston only implant
  -Progeston only injectable
  -Progeston only pill
• Combined Hormonal Contraception (POC)
  -Combined oral contraception
  -Combined transdermal patches
  -Combined vaginal rings
• Emergency Contraception (EC):
  -Copper-bearing IUD
  -Oral EM
• Oral Progesterone-only
  -Ulipristal Acetate (UPA)

Intrauterine contraception devices, progeston only implant/injectable are also called Long Acting Reversible Contraception (LARC)

Question 6

Women requiring contraception:
What tests/what to ask?

Answer 6

• History: Take full clinical history (family, sexual, cervical smears, social, medications, previous contraception)
• Check: BP, Weight and BMI
• Exclude: STIs, pregnancy if appropriate
• Determine patient’s preferences for contraception
• Exclude contraindications to a chosen method using the UK Medical Eligibility Criteria (UKMEC 2016)
• Promote barrier methods in addition for protection against STI / Discuss Vasectomy as a potential method of contraception

Question 7

UK Medical eligibility Criteria (UKMEC):
What is this?

Answer 7

The UKMEC for Contraceptive Use offers guidance to providers of contraception regarding who can use contraceptive methods safely.

The recommendations allow for consideration of the possible methods that could be used safely by individuals with certain health conditions (e.g. hypertension) or characteristics (e.g. age) to prevent an unintended pregnancy.

Consists of 4 categories, to see how severe the risks of contraception are

Question 8

Female contraception general guideline:
What is 1st, 2nd, 3rd line offered to patient?

Answer 8

1.Offer and discuss LARC as 1st line option
2. If LARCs declined or contraindicated/intolerance, consider CHC
3. If CHCs contraindicated or not tolerated, offer Progestogen Only Pill (requires compliance as dose is same time, every day)

Long-acting reversible contraception (LARC)
Combined hormonal contraception (CHC)

Question 9

All Wales Prescribing Guidelines:

Answer 9

• Take full history
• Assess eligibility criteria
• Advise on the available options
• Counsel on the appropriate use of the contraceptive method, adherence, missed pill, SEs, warning signs, fertility
• Offer interim method (e.g., condom)
  LARC-first line
  POP and COC- 2nd line

(see slide on ppt)

Question 10

Combined hormonal contraceptives (CHC) :

Answer 10

Options available :
Combined oral contraceptive pill (COC)
* Monophasic (same dose of oestrogen and progestogen) and multiphasic (variable dose)
* 28-day cycle – with 21 consecutive daily active pills followed by a 7-day hormone free interval (HFI)
* Tailored regimen can be considered – continuous use of CHC without HFI, extended use of CHC (less frequent HFI), or CHC regimens in which HFI is shortened

Question 11

What are the Risks Associated with Combined hormonal contraceptives?
What are the risk factors??

Answer 11

• CHCs slightly increase the risk of cardiovascular disease such as MI and ischemic stroke and risk of VTE.
  Risk of VTE increased with age and presence of other risk factors such as obesity (avoid in patient with a BMI ≥ 35 Kg/m2 – UKMEC Category 3).
• The risk of VTE varies depending on the type of progestogen and oestrogen dose.
  Risk of cardiovascular disease is greater with higher oestrogen doses.

Question 12

What are some contraindications of Combined hormonal contraceptives (CHCs)?

Answer 12

• Current or previous venous thromboembolism (VTE)
• Ischemic heart disease
• Current breast cancer
• Uncontrolled hypertension (blood pressure systolic 160 mmHg or diastolic 100 mmHg or higher)
• Migraine with aura (as risk of stroke is increased)
• Prolonged immobilisation (after major surgery)
• Smoking in patients aged 35 years and over (15 or more cigarettes daily)
• <21 days (3 weeks) post-partum in non-breastfeeding women with other risk factors for VTE or < 6 weeks postpartum in breastfeeding women

Question 13

CHC – Risk of VTE
What is the management strategy?

Answer 13

• All women should be taught how to recognise the signs and symptoms of VTE
• If contraindicated, use alternative contraceptive method such as Copper IUD or Progestogen Only Contraception

Question 14

Missing COC pills- BNF
What are the steps when a patient misses 1 pill?
What are the steps when a patient misses 2 pills?

Answer 14

• You need to use contraception for 7 days to effectively prevent ovulation.

Missed 1 pill
* Take ASAP, even if this means taking 2 pills together) then resume as normal
* No extra precautions are needed

Missed two pills
* Take ASAP, even if this means taking 2 pills together)
* Abstain from sex or use condom for the next 7 days. Skip the pill-free interval if these 7 days run beyond the end of the packet
(if a woman misses 2 or more oills (esp from the first 7 in a packet) she may not be protected.

Question 15

Combined hormonal contraceptives (CHC)-
- combined transdermal patches
How are they used?

Answer 15

• One patch is applied to skin and worn for 7 days to suppress ovulation, then apply new patch for the second and third week. The fourth week is patch-free to allow withdrawal bleeding.
• It can be applied to most area of the body as long as the skin is clean, dry, and not very hairy

Question 16

Combined hormonal contraceptives (CHC)-
- combined transdermal patches
Which patients have a risk of VTE with CHCs?

Answer 16

• Smoking
• Obesity- Very overweight (effectiveness ↓ in women ˃ 90 kg weight)
• Immobilisation (prolonged)
• Migraine with aura
• Family history of heart attack, stroke or blood clot

Question 17

Combined hormonal contraceptives (CHC) - Combined vaginal ring
How is it used?

Answer 17

One ring is inserted into the vagina and left in place continuously for 21 days. A new ring is inserted after a ring-free interval of 7 days to induce a withdrawal bleed.​

Risk of clot
-Lower compared to other forms of CHCs

Question 18

Progestogen Only Contraception
What are the available products?

Answer 18

• Oral Progestogen Only Pill (POP)
• LARCs including; subdermal implant, DMPA intramuscular injection, or IUS

Question 19

Progestogen Only Pills (POP)
Indications?
Examples?

Answer 19

• Suitable for older women, heavy smokers, and for those with hypertension, valvular heart disease, diabetes and migraine (risk of VTE)
• It is the preferred hormonal method for use in the breastfeeding as there is no
  impact on lactation
• Desogestrel 75mcg – 12 hrs missed pill window, should be used if compliance is likely to be a problem
• Norethisterone 350 mcg (Noriday®) – 3 hrs missed pill window

Question 20

Missed POP
What are the steps?

Answer 20

• The Faculty of Sexual and Reproductive Healthcare recommends emergency
  contraception if one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours late and unprotected intercourse has occurred before 2 further tablets have been correctly taken.

Missed Progesterone Only Pills:
* Northisterone POPs
- >3 hours late (>27h since the last pill was taken)

• Desogestrel POPs
  >12h late (>36h since the last pill was taken )

-The missed pill should be taken as soon as remembered. If more than one pill has been missed, only one pill can be taken.
- The next pill should be taken at the usual time. This may mean that two pills are taken in one day.
- Additional contraceptive precautions (condoms or avoidance of sex) are advised for 2 days (48h) after restarting the POP.
- EC is indicated for unprotected sex occurred after the missed pill and within 48h of restarting the POP.

Question 21

Emergency contraception
Who is this considered for?
What are the options? (3)

Answer 21

• EC can be considered for any women who does not wish to conceive if there is a potential risk of pregnancy after unprotected sexual intercourse.
  -Women not using hormonal contraception
• After pregnancy
  -UPSI from Day 21 after childbirth (unless the criteria for lactational amenorrhoea are met)
• Women using hormonal contraception incorrectly

EC Options:
* Copper IUD
* Levonorgestrel – Upostelle or Levonelle (POM)
* Ulipristal – EllaOne (Pharmacy Only Medicine)

Question 22

Emergency Contraception:
1. Within 72h of intercourse
2. Between 72-120h after intercourse

Answer 22

1. Copper IUD- Use first line due to low documented failure rate. Copper IUD is particularly useful if a woman intends to continue to use an IUD as long term contraception.
   Levonorgestrel Upostelle (cost effective)
2. Ulipristal: EllaOne unsuitable with enzyme inducing drugs because they can reduce efficacy of hormonal contraception.

Question 23

Role of pharmacist – EC

Answer 23

Patient education:
* Safety
-ECs are safe regardless of age – information about age should be sought to fulfil the pharmacist’s professional obligations to the patient
* Risk:
-There is ˂ 1% risk of ectopic pregnancy
-No evidence that EC interfere with implantation of a fertilised egg neither cause abortion of an existing pregnancy
* Dose

• Advice and information about ongoing contraception
• Information on STIs and how to get tested
• Arrangements for review by a medical practitioner should there be a delayed
  period following EC use

Question 24

Drug-drug interaction

Answer 24

• Use of medication may ↑ or ↓ serum levels of contraceptive hormones.
  Likewise, hormonal contraception may ↑ or ↓ serum levels of other medications.
• D-D interaction can result in reduced efficacy or potentially cause adverse
  effects.
• Pharmacists should ask women about their current and previous drug use
  including prescription, OTC, herbal, recreational drugs, and dietary supplement.

Question 25

Anna, a 30-year-old woman, comes into the pharmacy presenting a repeat
prescription for the COC pill that she uses for contraception. She tells you
that she has started new job that is quite demanding and that requires
frequent interstate travel. She is worried that she might forget to take her
tablets. She ask for your advice on how to manage her COC pill.

What advice should you provide Anna in relation to missed pills?

Answer 25

• If the COC pill is less than 24 hours overdue, it is a ‘late’ pill. If Anna has a late pill, she should take it as soon as she remembers (even if this means taking two pills within 24 hours). She is covered for contraception.
• If the COC pill is more than 24 hours late, it is a ‘missed’ pill. In this case, Anna
  should take the pill most recently missed straight away (even if this means taking
  two pills within 24 hours)
• If Anna missed more than 1 pill, she should take the pill most recently missed
  straight away and use a barrier method of contraception such as condoms until
  she has taken active pills for seven days in a row. If the missed pill was in the last
  seven days of the active pills, she should finish the active pills in her current pack
  and start the active pills in a new pack without any break.
• Anna could use EC if 2 or more pills missed from the first 7 tablets in a packet and unprotected intercourse has occurred since finishing the last packet.