How to be REALLY good at preventing unplanned pregnancy

Dr Angela Cooney 2014

ACTUALLY, NOT VERY MUCH….

BUT

EXTENDED USE COCP REGIMENS

LARC

ONG

CTING

EVERSIBLE

ONTRACEPTION

Condoms “one size fits all….doesn‟t it?”

Withdrawal “no good at all, don‟t even bother”

COCP “the best pill is the one the drug rep just told me about”

POP “you can only use that if you are breastfeeding….”

IUD “don‟t even think about it until you have had 3 children/are over 30”

“If you didn‟t like Implanon, you won‟t like Depo-Provera, cos they are the same…”

Condoms “one size fits all….doesn‟t it?”

“Multiple scientific studies dating as far back as 1993 have all identified that between 40-45% of men have problems finding a condom that fits. Problems like the condom slipping, or falling off. Problems like a condom feeling tight, or uncomfortable, or stopping you being able to orgasm”.

http://www.theyfit.co.uk/pages/about-theyfit

Withdrawal is “no good at all, don‟t even bother”

Withdrawal ◦ Perfect use failure rate 4% per year ◦ Usual use failure rate 18% per year.

Condoms ◦ Perfect use failure rate 2% per year ◦ Usual use failure rate 17% per year….

….AND you never leave home without it…..

COCP…

“the best pill is the one the drug rep just told me about”

Combined pills (oestrogen plus progestogen) on the market in Australia since 1960

A BEWILDERING ARRAY OF DIFFERENT STYLES…..WHERE TO START???

Keep it SIMPLE. ◦ PBS vs Private ◦ „Second generation‟ vs „third generation‟ ◦ Cheap vs expensive ◦ Monophasic vs triphasic ◦ No real difference in side effects as population, only

for individuals, so TRY IT AND SEE, if problems then prescribe new pill to address problem.

All the later generation pills (possibly except Zoely and Qlaira, but not enough evidence yet) have an increased risk of thromboembolism compared to old-fashioned pills….

This includes Diane-style pills, so should only use where there are additional benefits like treatment of acne, hirsuties. BUT ALWAYS SAFER THAN BEING PREGNANT!!

0

50

100

150

200

250

300

No

hormones

Combined

pill

Pregnancy Immediately

postpartum

VTE risk per 10,000 woman years

• What about stopping and starting combined contraception? − “taking a break for 1-2 months”

Faculty of Sexual and Reproductive Health Combined Hormonal Contraception

October 2011 (Updated August 2012)

What about „taking a break from the pill, to give my body a rest?‟

A RECIPE FOR UNPLANNED PREGNANCY!

Women are often already having a break for 1 week every month, and for some women this is too long – ovulation can happen. 4 day pill-free-interval is much safer.

WOMEN MUST HAVE A PERIOD EVERY MONTH, ANYTHING ELSE IS UNNATURAL AND ALLOWS „BAD BLOOD‟ TO BUILD UP

WHICH WAY IS BEST, AND WHY?

2006-2012 US insurance database study Type of COCP pack likelihood of UPP 21/7 7.3% 24/4 6.9% 84/7 4.4% Howard et al. Comparison of pregnancy rates in users of extended and cyclic COC regimens in the United States

Contraception 89 (2014) 25-27

21/7 (eg Levlen) = traditional way, monthly „period‟

24/4 (eg Yasmin) = less chance of ovaries „waking up‟ and

having breakthrough ovulation

84/7 (eg „back-to-back) = previously recommended for

severe dysmenorrhoea, endometriosis etc

120/4 (eg Yaz Flex) = probably optimal for contraceptive

effectiveness and minimising symptoms. CAN DO THE SAME WITH CHEAP PILLS…

What is QuickStart???

Potential advantages ◦ fewer unplanned pregnancies

◦ a higher chance that the woman will initiate the method

◦ minimised chance of forgotten instructions

Potential disadvantages ◦ may not be able to exclude pregnancy for the cycle

◦ pregnancy diagnosis delay

◦ potential for teratogenicity or concern for woman

DON‟T ASK A WOMAN ON DAY 10 OF HER CYCLE TO WAIT FOR HER NEXT PERIOD

What is the worst thing that can happen if she starts the pill now??

Start today on the active pills, and allow 1 week to work, and do a pregnancy test in 4 weeks.

Method

Method is

effective

Effect on

continuing

pregnancy

Method may

mask

pregnancy

Reversible

Comments

Preferred

methods for

Quick Start

Combined

hormonal

7 days

None

known

Unlikely

Yes

Risk of teratogenesis well

studied.

Withdrawal bleed

Implant

7 days

None

known

Yes

Yes

Teratogenesis, unlikely. Long

acting, and effective; rapidly

reversible.

Mini pill

48 hours

None

known

Possible

Yes

Rapid onset, Strict adherence

to timing

Can be used

DMPA

7 days

None

known

Yes

No

Irreversible. Small studies

show no teratogenesis.

Long acting, effective

Can’t be used

(exception

copper IUD

for

emergency

use)

IUD

Copper stat

LNG: 7 days

↑

miscarriage,

esp 2nd

trimester

Yes: LNG

Possible CU

Threads

may

disappear

Possible effect on the outcome

of a pregnancy if the IUD

cannot be removed.

Progestogen Only Pill

“you can only use that if you are breastfeeding….”

A very under-utilised option

Consider where oestrogen contraindicated ◦ Focal migraine, smoker over 35, history DVT

Consider where „every pill makes me feel sick‟ ◦ Nausea is related to oestrogen

Consider where an older woman needs reliable contraception

Reliability of POP vs COCP?

Ideal conditions (drug trials) ◦ COCP 99% effective

◦ POP 99% effective

In real life….. ◦ COCP = POP = 91%

Any pill is only as good as the person taking it

IUD “don‟t even think about it until you have had 3 children/are over 30”

IUDs do not cause infertility

IUDs can be inserted in MOST women, including young, nulliparous or post caesarean, WITHOUT TECHNICAL DIFFICULTY

Other than a small risk immediately post-insertion (1 in 200), IUDs DO NOT INCREASE THE RISK OF PELVIC INFECTION and can be used by teenagers

www.shfpa.org.au/sites/shfpa.drupalgardens.com/files/201310/LARCstatementSHFPAFINAL.pdf

“If you didn‟t like Implanon, you won‟t like Depo-Provera, because they are just the same…”

Implanon ◦ Etonorgestrel 3 year implant ◦ Affected by enzyme inducers eg Carbamazepine ◦ Annoying bleeding comes and goes, does not improve

with time

Depo Provera ◦ Medroxyprogesterone acetate 12 weekly injection ◦ NOT affected by liver enzyme inducers ◦ Bleeding tends to improve with longer use ◦ Has been used as a contraceptive for 45 years!!!

NOT THE SAME!!!!!!!

Resources for health professionals and consumers/patients www.fpwa.org.au/ resourcecentre/

1 WHO IS IT FOR? ◦ Eg 16 year old teen, 24 year old woman-about-town, 35 year old

mother of 3, 44 year old with breast cancer

2 HOW MUCH WILL IT COST? ◦ 16 year olds generally can‟t afford very expensive options

3 ARE THERE ANY CONTRAINDICATIONS? ◦ Eg DVT and migraines for COCP, uterine anomaly for IUDs

4 IS IT ACCEPTABLE TO THE PERSON? “You aren‟t putting that thing in me, it looks like a fish-hook”

5 IS IT ACTUALLY GOING TO WORK? ◦ “I can‟t remember to take pills”, “my boyfriend won‟t use frangers”

16 years old

Comes in with boyfriend, age 17

Wants contraception

Parents don‟t know she is having sex…

Unless she is at risk/coerced/DV, her privacy is protected by Gillick ruling (UK)

Family/parents may surmise that she is having sex, and may be happy that she is caring for herself

„Dobbing her in‟ will lose you a patient

Family can help with accessing more expensive options

1. Age 16

2. BMI of 32

3. Risk of STIs

4. FH of breast cancer – Mum age 47

5. FH of stroke – Dad late 50s

6. None of these

16 years old

Comes in with stepmother Sarah

Periods are unpleasant

SUGGESTIONS??

Combined pill + condom

Vaginal ring + condom

IUD + condom

Depot + condom

Condom only

Withdrawal + diaphragm

Implanon + condom

She is so impressed with how you managed Shannon that she has come to talk to you about contraception for herself

39 years old

2 children ages 10 and 6, both vag. dels

On thyroxine, no other illnesses or medications, ex-smoker 15 years ago

Has been on Yasmin for 5 years until seeing something on TV about DVT risk…

Ceased pill 5 months ago, using withdrawal „at risky times in the cycle‟

Had Implanon inserted by her mother‟s GP in Perth 6 weeks ago

Thinks it doesn‟t suit her, as she feels different, „like when I was pregnant‟

What will you do first?

UCG POSITIVE

Had negative pregnancy test with GP on day 16 of her cycle, prior to insertion of implant…

NOW what will you do?

“Termination of pregnancy is a physically dangerous procedure with long-lasting psychological consequences”

In fact, 5000 procedures per year done in WA alone, most for „social‟ reasons.

With good prior counselling, most women are satisfied with their decision and just get on with life.

Up to day 49 LMP

Offered by freestanding TOP clinics in Perth

Available for use by GPs

MSI 2-step program, online training

NO IMPACT ON SUBSEQUENT FERTILITY

Up to 19 w 6d in WA for „social indication‟

Available in Bunbury Regional Hospital

NO IMPACT ON SUBSEQUENT FERTILITY

Here you can find all the information you need about MS-2 Step™ the use of Mifepristone Linepharma (mifepristone) and GyMiso® (misoprostol) for medical termination of pregnancy up to 49 days of gestation.

To become an MS-2 Step™ certified prescriber or dispenser please select from one of the following options:

Option 1:To become an MS-2 Step™ certified prescriber you need to complete the online training program.

Option 2:Current TGA Authorised Prescribers of mifepristone and medical

practitioners with a Fellowship (FRANZCOG) or Advanced Diploma (DRANZCOG Advanced) of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) can waive the requirement for training and go straight to register as an MS-2 Step™ certified prescriber.

Option 3:If you are a pharmacist or specialty medical clinic, you can go straight to register as an MS-2 Step™ certified dispenser You are not required to complete the online training but have access to it if you would like to know more about the process.

She talks to her husband and they decide to continue the pregnancy

You remove the implant for her

You insert an IUD for her when her little boy is 6 weeks old