W12 Navigating contraceptive methods (JD)

Question 1

Birth control for Anna:
“Hi there, you must be the pharmacist. I’m Dr Michael and I need your advice. I would like to start my patient on a combined oral contraceptive.
Can you please check if Mercilon
Ⓡ (ethinylestradiol 20 mcg, Desogestrel 150mcg) is a safe and effective option for her?”
What questions do you need to ask the doctor before you make any
recommendation?

Answer 1

• Reason for admission
• Past medical history – to determine eligibility for COC use using UKMEC
• Patient age
• BP, weight, and BMI
• Pre-admission medication (to confirm eligibility and identify IDD)
• Use of OTC, supplement or herbal product (to identify DDI)
• Other medicine used in the wards
• Reason for using oral contraception
• Patient preference

Question 2

• Upon further questioning, you determine that Anna was admitted last night with PV bleeding. A transvaginal ultrasound confirmed spontaneous miscarriage at 8
  weeks gestation associated with foetal chromosomal abnormalities.
• Furthermore, she was diagnosed with tuberculosis 3 months ago and she is
  currently taking Rifinah® 300/150mg two tablets once daily and Pyridoxine 20 mg
  tablet daily.
• Anna is nonsmoker, her weight is 68Kg, and her family history is not significant.
• All other investigations are normal including BP measurement.

This morning, she has communicated that she has chosen to delay parenthood until she is emotionally ready. She prefers a method of contraception that is convenient.
* Is Mercilon the most appropriate contraceptive choice for her?

Answer 2

• Inform doctor that Mercilon® is not the best choice for Anna.
• Reason
• Concurrent use of Mercilon and Rifinah may result in contraceptive
  failure, spotting and breakthrough bleeding
• Rifampicin is a potent CYP3A4 inducer and concomitant use with Mercilon can results in a decreased in plasma concentrations of ethinylestradiol and desogestrel

Question 3

What are other contraceptive options available to Anna and why?

Answer 3

• Options can be considered
• Barrier methods (e.g., condom)
• Levonorgestrel IUS
• Copper IUD
• These methods do not have DDI* with Rifinah – Anna needs to take Rifinah for
  another 4-6 months.
• IUDs are extremely effective (success rate range: 99.5 – 99.9%)
• Both IUDs are convenient
• levonorgestrel-releasing IUD - every 5 years
• copper IUD - every 5 or 10 years
  (Drug-Drug Interactions*)

Both IUDs are immediately effective when it is inserted for Anna
* Copper IUDs are immediately effective regardless of when they are inserted.
* Levonorgestrel IUDs are immediately effective if inserted within 5 days of an abortion or miscarriage.
* Anna should be advised to continue taking Rifinah to avoid developing of
resistance strain of Mycobacterium tuberculosis and to cure the infection

Question 4

What are the follow up requirement for the contraceptive method chosen?
(IUD)

Answer 4

Educate patient
* Regularly check for the presence of the threads and to seek medical attention if the threads cannot be felt or thread length has changed because this may indicate
abnormal positioning of the IUD.
* Altered bleeding patterns can occur with both IUDs
* Breakthrough bleeding may occur in the first few months of use.
* With levonorgestrel-IUDs, unscheduled light bleeding is common during the first 3 to 6 months, after which the usual pattern is amenorrhoea, or light regular bleeding or spotting.
* Nothing should be inserted in the vagina for 48 hours after IUD insertion (avoid
penetrative intercourse, tampons, menstrual cups, swimming or baths).
* Ask if they have any questions

Question 5

Mrs A, a 45-year-old female, with a BMI of 35 kg/m2 and would like to start a long-acting contraceptive method. Which of the following contraceptive methods is NOT appropriate for Mrs A:

A. Noriday® (norethisterone)
B. Nexplanon® (Etonogestrel) 68mg implant
C. Copper T380 A intrauterine contraceptive device
D. Depo-Provera® (medroxyprogesterone acetate)
E. Microgynon® (ethinylestradiol with levonorgestrel)

Answer 5

= A & E
* CHC should be avoided
* All other options can be considered
* Noriday® (norethisterone) is a POP – it is safe but it is not long acting

Question 6

Mrs D, a 25-year-old female, wants emergency hormonal contraception. She had unprotected intercourse 48 hours
ago. Which of the following contraceptive is appropriate for Mrs C:
A. Levonelle® (levonorgestrel)
B. Noriday® (norethisterone)
C. Qlaira® (estradiol valerate with dienogest)
D. Nuvaring® (Ethinylestradiol with etonogestrel vaginal ring)
E. Depo-Provera® (medroxyprogesterone acetate)

Answer 6

=A
* Levonorgestrel is effective if taken within 72 hours (3 days) of UPSI and may also be used between 72 and 96 hours after UPSI [unlicensed use], but efficacy decreases with time.

Question 7

Mrs C, a 28-year-old female, currently breastfeeds her 12 weeks baby girl and would like to start a contraceptive method.
Which of the following contraceptive methods is NOT appropriate for Mrs C?

A. Noriday® (norethisterone)
B. Zoely® (estradiol with nomegestrol acetate)
C. Copper T380 A intrauterine contraceptive device
D. Nexplanon® (Etonogestrel) 68mg implant
E. Depo-Provera® (medroxyprogesterone acetate)

Answer 7

• Answer – B
• CHC should be avoided because
  oestrogen can reduce milk production in breastfeeding women.

Question 8

Mrs E, a 37-year-old female, with a 20-pack-year history of smoking and hypertension and would like to start a contraceptive method. Which of the following contraceptive method is appropriate for Mrs E?

A. Noriday® (norethisterone)
B. Zoely® (estradiol with nomegestrol acetate)
C. Copper T380 A intrauterine contraceptive device
D. Nexplanon® (Etonogestrel) 68mg implant
E. Depo-Provera® (medroxyprogesterone acetate)

Answer 8

=C
Patient with multiple CVD risk factors
CHC should be avoided