Contraception Update

Rachel D’SouzaConsultant in Sexual & Reproductive Health

Margaret Pyke Centres12 March 2020

1. Emergency contraception

2. UK MEC

3. Combined hormonal methodsa) Safetyb) Effectivenessc) Tailored pill regimesd) Missed pill/patch/ring recommendations

4. Cerazette

5. LARC methods

Overview

▪1.5mg LNG

▪ Licensed up to 72 hrs

▪ Little efficacy >96 hrs

>99 % effective

NOT contraindicated by:

1. Young age

2. Nulliparity

3. Previous ectopic preg

4. Risk of STI

Do you always offer an IUD?

Emergency Contraception

▪ 30mg UPA

▪ Selective progesterone

receptor modulator

▪ Licensed up to 120 hrs

▪ Delay or inhibit ovulation

▪ Can use more than once in cycle (unlicensed)

Effectiveness of Emergency Contraception1000 women have a single episode of UPSI

If EC not used

55 of 1000

become pregnant

If all 1000 use EC-

LNG 22 become

pregnant

If all 1000 have

emergency IUD

1 becomes pregnant

If all 1000 use EC-

UPA 14 become

pregnant

OR 0.58; 95% CI 0.33–0.99, p=0.046.

1.4% (22/1617 pregnancies), 2.2% (35/1625 pregnancies).

Cleland K et al Human Reprod 2012

Glasier AF et al., Lancet 2010; 375: 555–62

Cheng et al Cochrane Review 2008

Where in the cycle can I fit an IUD?

www.artiko.co.uk

EllaOne effective up to the point of ovulation

• probability of conception peaks just before ovulation3

• ellaOne® inhibits follicular rupture – even when administered immediately before ovulation

– even if LH levels have already begun to rise1,2

1. ellaOne® SmPC, July 2010.

2. Brache V et al. 2010.

3. Glasier AF et al. 2010

Ellaone – Eligibility/Interactions

Warnings/precautions to use:

NB No contraindications

• Severe asthma insufficiency controlled with oral glucocorticoid

• (Severe hepatic impairment)

• May be excreted in breast milk do not breast feed for 7 days after use

Drug interactions:

• Liver enzyme-inducing drugs

• Drugs increasing gastric pH proton pump inhibitors, antacids, H2 antagonists

• Progestagens…FSRH EC Guidelines2017

Use of Ulipristal Acetate (ellaOne®) in Breastfeeding women Mar 2013

• Women should be informed that higher weight or BMI might reduce the effectiveness of oral EC, particularly LNG-EC

• Cu-IUD efficacy not affected by weight or BMI

• Consider double-dose (3 mg) LNG-EC or UPA-EC if

• BMI >25 kg/m2 or

• weight >70 kg

Oral EC – weight and BMI

Glasier et al. Contraception 2011FSRH IUC Guidelines March 2017

0

1

2

3

4

5

6

7

UPA LNG

Normal BMI

25-29.9

>30

6 (UPA) versus 14 (LNG) pregnancies in each arm of about 230 obese women

Failu

re %

EllaOne – drug interactions with progestagens

After UPA– Progestogens appear to reduce efficacy of prior UPA

– UPA does not appear to effect efficacy of subsequent hormonal contraception

• Do not start any hormonal contraceptives until 5 days after UPA-EC

• Then advise additional methods until they are effective e.g. 7/7 CHC

• Do not give LNG within 5 days of UPA (consider UPA if further UPSI)

Before UPA– Progestogens in the previous 7 days may theoretically reduce efficacy of UPA

• Consider LNG-EC instead if hormonal contraceptives used within previous 7 days (e.g. missed pills)

• Do not give UPA within 7 days of LNG (consider further LNG)FSRH EC Guidelines 2017

FSRH IUC Guidelines 2017

Brache Hum Reprod 2015; 30: 2785-93

CEU enquiry response ED 16/0872016

• Copper IUDs are first line option for EC

• UPA-EC most effective oral EC– caution re possible interaction e.g. progestogens

– warnings/precautions

• LNG-EC– who have missed pills and want to continue

– quick-starting hormonal contraceptives

– breastfeeding

– using interacting medication: double dose

– severe asthma insufficiently controlled with oral glucocorticoids

EC request –factors to consider when choosing EC option

UKMEC: updated April 2016

• Reordering of categories according to effectiveness

• Now only includes hormonal and intrauterine methods

• Removal of split categories eg 3/4

• UPA included

UKMEC: updated April 2016

• Relates to safety not efficacy

• Drug interactions removed

FSRH Drug Interactions with hormonal contraception

UKMEC: updated April 2016

Bariatric surgery

NB Some procedures may reduce effectiveness of oral methods

Jess, 34yrs

• Jess requests COC:– 34yr receptionist

– Smoker (UK MEC 2)

– BMI 32 (UK MEC 2)

– Mother VTE aged 49yrs (UK MEC 2)

– Superficial thrombophlebitis (UK MEC 2)

Francis, 32yrs

• Frances requests COC to help her endometriosis:– 32yr old doctor

– BMI 38

– UK MEC is intended where use is for contraception

– Where use is for a non-contraceptive benefit the risk/benefit

profile and eligibility criteria may differ

UKMEC: 2016

• SLE– Anti phospholipid antibodies (aPLA) positive

• CHC: UK MEC 4

• POC: UK MEC 2

– No anti phospholipid antibodies

• All hormonal methods: UK MEC 2

UKMEC: 2016

Initial CHCconsultation

Suitable self-

completed

checklists for

medical eligibility

appear to be

accurate &

acceptable to

women.

CHC guidelines FSRH

Jan 2019

CHC guidelines FSRH Nov 2018

Initial CHC consultationAssessing suitability of CHC for individual woman

Is it safe?• VTE• ATE• Breast cancer• Cervical cancer

Will it work?• Compliance• Vomiting or severe diarrhoea• Liver enzyme inducing drugs• Bariatric surgery• Weight >90kg: patch

CHC & VTE RiskRisk of VTE per 10,000 women years

CEC Statement: CHC & VTE 2016

Stegeman et al. BMJ 2013;

EMA/MHRA November 2013

2

5-7

6-12

9-12

29

Immediate Postpartum period 300-400

• Stegeman et al 2013 • meta-analysis of 26 studies

Risk Factors and VTE

4

1821

50

0

100

No risk

factor

BMI>30 Age >40 FH of VTE

No risk factor

BMI>30

Age >40

FH of VTE

Dinger et al, ESC 2008

Per

10,0

00

wom

an y

ears

Dianette

• 35µg EE & 2mg cyproterone acetate

• In UK not indicated solely as contraceptive

• Treatment option for women with:– severe acne, not responded to topical

therapy or systemic ABics

– moderately severe hirsutism

• Withdraw 3-4 months after treated condition resolved

• EMA: VTE warnings, precautions, risk factors

strengthened: VTE risk 1.5 to 2 times higher than LNG COCs

European Medicines Agency – Pharmacovigilance Risk Assessment Committee June 2013

COC & vascular thrombotic events

Weill A et al. Low dose COC & risk of PE, stroke, and MI in 5million French women: cohort study. BMJ 2016 May 10; 353:

CEU response July 2016

Large French observational database study

• 5.5 million woman-years of COC exposure 2010 - 2012

• COC increases venous and arterial thrombotic risk• Absolute numbers very small• Risk of arterial events did not differ significantly according

to the type of progestogen used

• Dose of EE: 20µg COC vs 30µg COC• 0.75 (0.67-0.85) for PE• 0.82 (0.70-0.96) for ischaemic CVA• 0.74 (0.67-0.82) for MI

CVD risk: Practical advice• Risk of VTE amongst COC users is at least twice that of non-users

• Arterial thrombotic risk is slightly increased with COC use

• Avoid repeated stopping & starting of CHC use

• Absolute risk for all CHCs is still very low

• NO increased risk with progestogen-only/non-hormonal contraception

• 1st line COC: ≤30µg EE in combination with LNG or NET

• In addition to considering VTE risk, CHC prescribers should take into account the individual woman’s: – personal preference– other risk factors / contraindications– potential non-contraceptive benefits

CEC Statement: CHC & VTE 2016

Stegeman et al. BMJ 2013;

EMA/MHRA November 2013

Mørch LS et al. Contemporary HC & the Risk of Breast Cancer. N Engl J Med 2017;377:2228-2239

CEU response Dec 2017

CHC & breast cancer

Mørch et al Danish study 2017:

• 1.8 million Danish women aged 15-49 years 1995 - 2012 • Current/recent HC users 20% increased risk breast cancer cf never users

– RR 1.20 (1.14-1.26).

• Absolute increase small– Never users aged 15-49 : 55 incident breast cancers per 100,000 woman-years– Current/recent HC users: 13 additional breast cancers per 100,000 woman-years– approximately 1 extra breast cancer for every 7,690 women using HC for 1 year

Women should be informed:• small apparent increase in breast cancer risk with current /recent HC• risk reduces with time after stopping HC• weigh this risk against the benefits

CHC & cervical cancer

1. Increased risk x2 with use >5yrs

2. Risk reduces over years after stopping CHC

Non-contraceptive health benefits

associated with CHC use

CHC guidelines FSRH Nov 2018

CHC: Comparison

.

COC Evra Patch CTP

Nuva Ring CVR

Failure rate Similar: 0.3% with perfect use and 9% with typical use

& weight no signif effect higher if ≥90 kg -

Cycle control Better if 30/35µgvs 20µg COC

Similar to COC Similar or better than for COC

Side effects more breast discomfort, dysmenorrhoea,nausea & vomiting

less nausea, acne, irritability & depression more vaginal irritation/ discharge

Adherence 32% discontinue by 1yr for method-specific reasons (USA)

?better than COC ?as for COC

Costper 3 months

£1.80 - £25.18 £19.51 £27

FSRH Guidance Combined Hormonal Contraception Oct 2011

Patch 2

Sunday Sunday Sunday

Patch 1 Patch 3

28-day cycle

Patch-free

Sunday

Start next cycle

28-day cycle

Sunday

Evra• Combined contraceptive patch:

– 33 mcg ethinylestradiol & 150 mcg norelgestromin

• Efficacy: similar to COC• UK MEC: as COC• Side effects (vs COC)

– Site reactions: 20%, discontinuation 2%– Breast tenderness: 1st two cycles (15% vs 4%)– VTE risk

JAMA 2001; 285(18): 2347-2355

NuvaRing• Combined method:

– 15 mcg ethinylestradiol

– 120 µg etonogestrel

• One ring inserted by user into vagina for 3 weeks

– 1 week grace

• Removed for 1 ring-free week

– Hook index finger under ring, or

– Grasp ring between index and middle finger

NuvaRing - advantages

• Highly effective (similar efficacy to COC)

• Low, continuous hormonal levels– Systemic EE exposure 50% of 30µg COC

• Good cycle control with infrequent BTB

– approx half that with COCs

• Avoids first-pass metabolism & GI interference

• >90% women found NuvaRing easy to insert and remove

Hum Reprod 2005; 20: 557-562

Hum Reprod 2006; 21:2304-2311

Contraception 2003; 67: 187-194

NuvaRing – disadvantages

• Side effect profile similar to COC

• Ring related

– expulsion (0.5% cycles)

– Partner feels device 32%

– Vaginitis/discomfort due to device 6%

– Vaginal discharge 5%

• Storage in pharmaceutical fridge at 2-80C until dispensed

• Once dispensed, it can be stored for 4 months at up to 300C

Novak et al. Contraception 67 (2003) 187–194

Estradiol pills: Zoely® and Qlaira®

• Similar efficacy to EE COC

• Same UK MEC as for EE COC

• Different missed pill rules

• Shorter & lighter WTBs

Qlaira

– Estradiol valerate & dienogest 26/2

– Licensed for HMB

Zoely

– First monophasic estradiol pill

– Estradiol, nomegestrol acetate 24/4

CHC guidelines: How is CHC used?

CHC guidelines FSRH Jan 2019

✓

Women should be given information about both standard and tailored CHC regimensto broaden contraceptive choice.

✓

Women should be advised that use of tailored CHC regimens is outside the

manufacturer’s licence but is supported by the Faculty of Sexual & ReproductiveHealthcare (FSRH).

✓

Women should have access to clear information (either written or digital) to supporttailored CHC use.

• Traditional 21/7 CHC regimen confers no health benefit over tailored CHC use

• Symptoms associated with HFI can be problematic

• Ovulation occurs as early as day 8 in extended HFI

• Vandever et al: oestradiol levels increased more quickly during HFI after extended CHC use

• Ovarian activity during a 7-day HFI could risk escape ovulation

• particularly with lower doses of EE, if use is not perfect and ??if obese

• Tailored CHC regimens with fewer/no HFI &/or shortened HFI can be safely used to

• avoid withdrawal bleeds and associated symptoms

• theoretically reduce the risk of contraceptive failure

7 days

hormone

free

Traditional CHC regimens

21 days

active pills

43

Tailored CHC regimens...

• shorten the HFI

and/or

• reduce the frequency of the HFI

or

• abolish the HFI

44

But it doesn’t have to be like that!

Flexible

extended

regimen

At least 21

days

active pills

4 days

hormone

free

At least 21

days

active pills

4 days

hormone

free

At least 21

days

active pills

If no

bleeding,

keep going

If no

bleeding,

keep going

48

COC: Missed Pill Recommendations 2011(except Qlaira, Zoely)

• Missed if >24 hrs late

• Just keep going

Also

• If missed 2 or more pills

– use condoms or abstain until taken 7 pills in a row

– in addition

• Missed pills in week 1: consider EC

• Missed pills in week 3: omit PFI

Missed pill recommendations May 2011 FSRH

Missed pill rules

(only monophasic ethinylestradiol COC

without placebo pills)

**Under review **Jan 2019

Additional precautions if HFI extended beyond 7 days

Poor cycle control with CHC rule out ..…

• Disease (cervical disease, chlamydia)

• Default (missed pills)

• Dose (low dose pills give more BTB)

• Drugs (enzyme inducers, smoking)

• Disorders of pregnancy (miscarriage)

• Duration of use (in first few months of use)

• D & V (vomiting especially)

• Disturbance of absorption (massive gut

resection)

• Diet (vegetarians)

Poor cycle control with CHC

Other options (if no pathology)

– 35 mcg EE/norgestimate

– NuvaRing

OR

– Another contraceptive method

‘Hormone side-effects’

• Oestrogen side-effects

– Headaches, nausea, leg cramps,

breast tenderness

– Try 20µg pill, estradiol pill or

progestogen-only method

• Progestogen side-effects

– Mood change, loss of libido, bloating

– Try a different progestogen

75 µg desogestrel pillUseful for treating cycle related symptoms

– Dysmenorrhoea/pelvic pain associated with endometriosis

• 50% pain reduction of mild endometriosis after 6 months (P<0.001)

– Migraine headaches • reduction in frequency

• reduction in migraine intensity and/or duration

– Premenstrual symptoms Razzi et al. Eur J Obstet Gynecol Reprod Biol.2007

Georgantopoulou CJ Pediatr Adolesc Gynecol.2009

Nappi et al. Contraception 2011

Ahrendt HJ. Curr Med Res Opin. 2010

Merki-Feld et al. Cephalalgia 2013

Leone Roberti Maggiore et al. Acta Obstet Gynecol Scand. 2013

Pill

IUD

Inje

ctio

n

Impl

ant

Ste

rilis

atio

n

Con

dom

With

draw

al

Nat

ural

FP

0

10

20

30

40

50

60

70%

of w

omen

age

d 16

-49

usin

g co

ntra

cept

ion

Current Use of Contraception by Age (UK)

16-19

20-24

30-34

40-44

Age (years)

Contraception & Sexual Health, Office for

National Statistics 20016-17

LARC

Long acting reversible

contraceptives

Accidental pregnancy in first year of use

0

5

10

15

20

cap

diap

hrag

m

cond

om POP

COC

Dep

oIU

DIU

S

Implan

t

sterilisa

tion

Perfect use

Typical use

Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 17. NY: Ardent Media, 1998;800-801

pe

rce

nt

NICE Guideline 2006(updated 2014)

If 7% of women switched from the pill to LARC methods (doubling current usage to 15%) the NHS could save approx£100million each year by reducing unplanned pregnancies by 73,000

Survey in 5,120 women aged 18-44 years old, in US, Brazil, UK, France, Spain, Germany, Italy, Russia and Australia. Results presented for the age groups 18-24

(799 answers), for all countries excluding US

Hooper DJ. Clin Drug Investig. 2010

57% of women surveyed missed at least 1 pill in the

previous 3 months

High % of women miss the pill

Contraceptive offering is impacted by lack of time, funding and training

• Only 2% of HCPs offer a full range of methods

• >50% said not enough time in consultation to talk about all options

• 20% do not offer IUD or IUS

• 23% do not offer subdermal implant

1.FPA YouGov survey 2016

Myths and misperceptions

• 39% think hormonal contraception makes you gain weight

• 17% think long term use of contraception increases infertility

• 87% did not know that the IUD can be used as emergency contraception

• 21% think emergency contraception is only effective the day after sex

1.FPA YouGov survey 2017

Difficulty of insertion of IUS in 216/224 nulliparous women

Marions L, et al. Eur J Contracept Reprod Health Care 2011;16:126−34

Extremely difficult 6%

Easy72%

Moderatelydifficult 22%

IUC insertion: Will it hurt? Counselling

Equipment – ? gynae couch with leg rests

Confidence of HCP

Explanation to patient

Accurate bimanual

Team interplay between assistant and HCP

Analgesia: oral / instillagel/ misoprostol/ intracervical block

Verbal anaesthesia

Calm atmosphere

Bahamondes L, et al. J Fam Plann Reprod Health Care 2014;40:54-60

IUC - Counseling

1. Complications:

i. Perforation (< 2in 1000)

ii. Expulsion (1 in 20)

iii. Failure (< 1%)

iv. Infection

2. Side Effects:

i. Bleeding

ii. Hormonal SE (IUS)

3. Interim contraception 4. STI screen

Perforation: 1-2 in 1000, related to skill of inserterBreastfeeding: risk of perforation x 6

IUC complications: perforation

Heinemann K, Reed S, Moehner S, et al. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine

devices in the European Active Surveillance Study on Intrauterine Devices. Contraception 2015; 91: 274–297.

IUC- Infection • IUC does not cause pelvic infection

• Risk higher than background only in first 3 weeks after insertion

• If asymptomatic: no need to

– wait for STI screening results

– provide antibiotic prophylaxis

providing can be contacted & treated promptly if result positive

• Infection with IUC in situ

– treat as PID, no need for routine removal

Actinomyces like Organisms

• Actinomyces Israelli are commensals of the female genital tract

• Very very rarely = pelvic actinomycosis

• Inform patient

• Assess for symptoms & signs of pelvic infection

• If no PID

– leave IUC

– no need for routine F/U unless symptoms occur

• If PID is suspected refer for specialist advice

FRSH Intrauterine contraception 2015

• HIV– Subconditions changed from use of ARVs to CD4 count as

these relate to safety

• CD4 ≥200: all UK MEC 1 except IUC UK MEC 2

• CD4 <200: all UK MEC 1 except IUC UK MEC 3 (I)

because of possible infective risk

– Effectiveness: link to HIV drug interaction checker

UKMEC: updated April 2016

UKMEC: updated April 2016

• Postpartum IUC

up to 48hrs UK MEC 1

Safe after caesarean or vaginal delivery

48hrs - 4 weeks UK MEC 3 ≥ 4 weeks UK MEC 1

postpartum sepsis UK MEC 4

Extended use of Mirena IUS

• Mirena IUS can be used for contraception until the age of 55 if inserted at age 45 or over

– even if the woman is not amenorrhoeic

– but just 5yrs if being used as part of HRT

• Women <45 yrs at insertion & who present for replacement of the device 5-7 yrs after insertion may have immediate replacement if PT negative– Repeat PT after 3 weeks

• As the risk of pregnancy is extremely low once a woman reaches age 55, contraception can be stopped at that age even in women still experiencing menstrual bleeding

Cardiac disease and IUC fitting

• Vasovagal collapse may be triggered by IUC insertion

• Risk is increased in women with:– Arrhythmias

– Pulmonary hypertension

– Pre-existing bradycardia

• Discuss with a cardiologist & fit in hospital setting

IUB

•Single semi-rigid rod 40x2mm

•Releases 30-40µg etonogestrel daily

•No skin incision required

•Lasts 3 years

•Radio-opaque (Xray, CT as well as USS, MRI)

Nexplanon

Nexplanon

• During the 4th year of use of Nexplanon the pregnancy risk is low – emergency contraception is unlikely to be required

– the implant can be replaced provided a pregnancy test is negative• condoms then should be used for 7 days

• pregnancy test repeated after 4 weeks.

• Local analgesia: – For insertion consider ethyl chloride spray

• s.c. lidocaine should be used eg where insertion follows removal, if cuts to the skin.…

– For removal use subcutaneous lidocaine as the analgesic effect of the ethyl chloride spray may be lost after 1 minute.

Ethyl chloride spray

▪ Position the canister 10-20 cm away from the skin

▪ Spray for approx 7-8 seconds until a thin white

film forms (max 10 seconds)

▪ Insert implant ideally within 30 seconds

(numbing effect lasts for up to a minute)

▪ Avoid contact with the eyes

If this occurs, rinse thoroughly with water & seek medical attention

Deep Implant

• Palpable – ‘Pop-up’ sign

• Non – Palpable Is it there? X - ray if SDI fitted after Oct 2010

Deep Implant Clinic for USS / if wishes removal

Assess pregnancy risk

More than 1 rod ……

• Do not attempt to remove if implants look/feel like this:

Jadelle – available in Europe Norplant

SDI - failures

0

10

20

30

40

50

60

70

80

failure to

insert

liver enxyme

inducer

untimely

insertion

true method

failure

not enough

data

expulsion

France

Australia

UK

Bensouda-Grimaldi et al Gynecol Obstet Fertil 2005

Harrison-Woolrych et al Contraception 2005; data on file, Organon UK

%Unintendedpregnancies

SDI - Bleeding patterns

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8Three-monthly assessments

Pe

rce

nta

ge

Amenorrhoea Infrequent bleeding

Frequent bleeding Prolonged bleeding

FSRH 2003

Depo-Provera & BMD

1. May be first-line in young people if other methods unsuitable/unacceptable

2. Review risks / benefits at 2 years

3. Consider other methods if significant risk factors for osteoporosis

4. Long-term carbamazepine, phenytoin, primidone & sodium valproate associated with loss of BMD & fracture

Sayana Press®

• New delivery system - Unijet ™

• Pre-filled injector – shake vigorously

• Point needle downwards

• S/C injection thigh / abdomen

• Repeat every 13 weeks +/- 7 days

• Bio equivalent to Depo-Provera

• Similar side effect profile to Depo-Provera ®

Sayana Press®

Compared with im DMPAAdvantages:• May be self administered (now licenced)• May be less likely than DMPA to cause haematoma

eg if bleeding disorder/anticoagulated• In very obese, no concern as no need to reach muscle

Disadvantages: • Cost £6.90 vs £6.01• Local skin reactions/lipid atrophy about 10%

Subcutaneous Depot Medroxyprogesterone Acetate (Sayana Press®) Jun 2013

Sayana Press and a case of likely lipoatrophy

J Bush BMJ Sexual & Reproductive Health July 2018

Stacey, 34 years old

• requests further DMPA:– Well controlled NIDDM UK MEC 2

– BMI 36 UK MEC 1

– Smoker 20/day UK MEC 1

– Hypertension 135/85 with amlodipine UK MEC 2

Sophie, 48 years old

• Using DMPA for past 6 years, last injection 15 weeks ago• Keen to continue as likes the amenorrhoea• Will you administer a further DMPA today?

• LSI 7 days ago• No other risk factors for low bone density

Sophie, 48 years old

Continued……• Reports having menopausal symptoms

• Can you check her FSH?• Can you give her HRT?

Contraception after pregnancy

UKMEC: updated April 2016

• Postpartum IUC

up to 48hrs UK MEC 1

Safe after caesarean or vaginal delivery

48hrs - 4 weeks UK MEC 3 ≥ 4 weeks UK MEC 1

postpartum sepsis UK MEC 4

UKMEC: updated April 2016

• Breastfeeding– No differentiation between

full and partial

– CHC:

<6 weeks postpartum: UK MEC 4

6 weeks to 6 months postpartum: UK MEC 2

No evidence of adverse effect of CHC on breast feeding

– POP, SDI: UK MEC 1 for from time of delivery

UKMEC: updated April 2016

• Non-breastfeeding• VTE risk returns to baseline 6 weeks postpartum

• UK MEC 1 for POP, SDI from time of delivery

www.contraceptionchoices.org

Dr Julia Bailey & Professor Judith Stephenson

https://sexwise.fpa.org.uk

Any questions ?