Contraception: OSPAP Programme

• OSPAP Programme focuses on Contraception

Objectives

• Understand how hormonal contraception works
• Learn how to choose suitable contraceptive methods
• Know the different types of contraception available
• Understand counselling points in preparation for OSCE

Classes of Hormonal Contraception

• Hormonal contraception divides into two main classes
• Combined hormonal contraception includes both oestrogen and progestogen
• Progestogen-only contraceptives contain only a progestogen
• Non-hormonal methods include Copper-IUDs and barrier methods

Combined Hormonal Contraception

• Combined hormonal methods are available as tablets, vaginal rings, and patches

Progestogen-Only Contraceptives

• Progestogen-only options include progestogen-only pills
• Parenteral preparations like depot injections and implants are available
• Intrauterine devices such as the progestogen-releasing IUS exist

Menstrual Cycle

• Understanding the menstrual cycle is important in understanding contraception

Pharmacology of Combined Hormonal Contraceptives (CHCs)

• The primary mechanism is to inhibit ovulation
• Oestrogen and progestogen in CHCs suppress LH and FSH production
• No surge in LH and FSH, so no stimulated ovaries means no ovulation
• CHCs alter cervical mucus, acting as a mechanical barrier to sperm
• These thin the endometrium, reducing the chance of implantation
• Oestrogen causes the endometrium to proliferate, which progestogen opposes to prevent hyperplasia
• The endometrium is likely thin, fragile, and prone to bleeding
• A 7-day pill-free interval (or inactive pills) lowers oestrogen and progestogen concentrations
• This causes the oestrogen-primed endometrium to slough, mimicking menstruation
• This is the withdrawal bleed

COC Preparations

• Combined oral contraceptive differences relate to progestogen type
• How the dose varies over the menstrual cycle and the dose/strength of oestrogen
• There are four types of combined oral contraceptives
• Presence/absence of a pill-free interval determines COC preparation

Combined Oral Contraceptives (COCs)

• COCs contain oestrogen paired with a progestogen
• The oestrogen component typically uses synthetic ethinylestradiol, and some contain mestranol
• Progestogen components include levonorgestrel, norethisterone, desogestrel, gestodene, or drospirenone
• Progestogen components grouped by 'generation'
• First-generation contains norethisterone
• Second-generation contains levonorgestrel (LNG)
• Third-generation includes desogestrel, gestodene, and norgestimate
• Newer options are drospirenone (DRSP), dienogest, and nomegestrol acetate

COC Preparation Differences

• COC preparations differ in how doses vary over the menstrual cycle
• Monophasic COCs are first-line and have constant oestrogen and progestogen
• Monophasic is the most prescribed option
• Phasic COCs vary oestrogen and progestogen amounts over 21 days
• Biphasic COCs contain two active tablet sets
• Trinordiol and Triphasic COCs contain three active tablet sets
• Quadraphasic COCs contain four active tablet sets
• Phasic COCs used if no withdrawal bleed or breakthrough bleeding occurs on monophasic

Dose/Strength Differences

• COC preparations also differ according to dose and strength of oestrogen
• Low-strength contains 20 mcg of ethinylestradiol
• It is useful with circulatory disease risk factors
• Low-strength can cause disrupted bleeding
• Standard-strength has 30-35 mcg ethinylestradiol in monophasic COCs
• Standard-strength has 30-40 mcg ethinylestradiol in phased preparations
• Mestranol 50 mcg is equal to 35 mcg ethinylestradiol
• Cycle control uses the lowest oestrogen dose
• Most patients use 30-35 mcg of ethinylestradiol
• COC differences relate to the presence or absence of a pill-free interval

Standard Preparations

• Most COCs are packaged in strips of 21 active tablets
• Take one tablet daily for 21 days, then no pill for 7 days in a hormone-free interval (HFI)
• HFI: When no hormones are being taken

ED (Every Day) Preparations

• ED Preparations are useful when compliance is a concern
• Taken continuously with no HFI
• 21 active tablets and 7 inert/placebo tablets are taken from Days 22-28 so a withdrawal bleed can occur

Other COC Preparations: Qlaira

• Qlaira is a quadraphasic pill for heavy menstrual bleeding, starting on day one of the cycle
• Take 28 tablets continuously
• Missed pill rules are different for Qlaira
• Awareness of missed pills is important

Other COC Preparations: Dianette

• Dianette combines cyproterone acetate and ethinylestradiol 2000/35
• Dianette is not only an oral contraceptive
• It is for women needing oral contraception who have acne or hirsutism
• Dianette carries an increased risk of venous thromboembolism (VTE)

Monophasic CHC Initiation

• Initiate Monophasic CHC within the first 5 days of the menstrual cycle
• No additional contraception is needed if started within 5 days
• Ideally, start on day 1 of the cycle
• If starting on day 6 or later, use extra precautions for 7 days (9 days for Qlaira)
• Start Monophasic CHC up to day 21 postpartum with no additional contraception
• If not breastfeeding and with no VTE risk

CHC Regimens

• Monophasic COCs are either standard or tailored, based on individual choice
• Standard use involves 21 days of active pills (21 days), and 7 days without
• ED prep uses 28 days of active pills (21 days) and 7 inactive pills
• Shortened hormone-free interval lasts 21 days using pills for 4 day
• Extended use (tri-cycling) consists of 9 weeks (3x21 active pills), for 4 or 7 days
• Flexible extended use includes continuous use of active pills until breakthrough bleeding for 3-4 days
• A continuous use of active pills involves no pill-free period

Tailored Regimens

• Standard 21/7 cycles are designed to make withdrawal bleeds each month, like the natural cycle

FSRH Tailored Regimens

• FSRH has found no health benefit from a seven-day hormone-free interval
• Fewer/no hormone-free intervals are safe
• The hormone free interval can be shortened to 4 days or continuously taken
• Continuous use avoids monthly bleeding
• It reduces headache and mood changes
• It reduces the risk of escape ovulation and pregnancy
• Continuous use is still safe and effective
• Unscheduled bleeding is common to use
• Tailored regimens are outside the license but are supported by FSRH and CCGs

Missed COC Pill Rules

• A missed COC pill is more than 24 hours late
• CHC effectiveness counts on consistent and correct use
• Perfectly used CHC results in less than a 1% pregnancy risk
• 9% failure rate, or 91% effectiveness overall from typically used CHC
• Action for missed COC pill depends on when the pill was missed
• It also depends on, how many pills missed, where in the cycle (pack), and which pill

Action for Late or Missed COC Pill: Basic Rules

• If one active pill is missed, no extra precautions are needed
• If two active pills are missed, take additional precautions for 7 days
• Increase the chance if pregnancy if pills are missed early in the cycle or the end (extends the hormone-free interval)
• Multiple missed pills can also increase the risk of pregnancy
• Refer to fsrh for more detailed guidance

COC Counselling Advice

Advantages of COC

• More effective than barrier methods at preventing pregnancy
• Menstrual bleeding is usually regular, lighter, and less painful
• Reduced risk of cancer in the ovary, uterus, and colon.
• Reduced severity of acne in some women
• Reduced incidence of premenstrual tension (PMT)
• Reduced risk of ovarian, endometrial and colorectal cancer
• Normal fertility returns immediately after stopping the COC

Disadvantages of COC

• Temporary ADR's, such as headaches, nausea, breast tenderness, and mood changes
• Changing the COC type after some months could address the ADR effects
• Blood pressure may increase.
• No STI protection so use condoms if at risk
• Less effective than long-acting reversible contraceptive (implants, injectables, IUDs)

COC: Drug Interactions

• Enzyme-inducing antibiotics eg. rifampicin or rifabutin, reduce COC effectiveness

Medication Action

• Both reduce effectiveness and failure may occur
• Change to alternative contraception method which include switching to condoms (short term)
• Avoid sexual intercourse, or using a barrier method up to 28 days (4 weeks) after stopping
• Breakthrough bleeding indicates low serum oestrogen conc
• A longer term treatment (>2 months) requires an alternative contraceptive method

Non-enzyme Inducing Antibiotics

• Broad-spectrum antibiotics are non-enzyme-inducing and do not require any precautions
• Extra contraceptive precaution is only needed if antibiotics result in vomiting or diarrhoea
• Article by the BMJ suggested this guidance should change
• Current advice says findings from study are robust enough to change FSRH CEU guidance

Enzyme-Inducing Drugs

• Such as antiepileptics -carbamazepine, phenobarbital, phenytoin and
• Herbal remedies like St John's Wort which is available OTC
• Switch contraceptive method to and IUD or depot
• Take 50 mcg of ethinylestradiol with COC to avoid getting pregnant
• Avoid sexual intercourse and take continuous/tricycling regimen up to 28 days after
• The effectiveness can not be guaranteed because it is a high risk of thrombosis

Lamotrigine

• Oestrogen reduces serum levels of lamotrigine
• Increases risk of of seizures
• It also increase lamotrigine toxicity during pill-free intervals
• Avoid combination and use IUS/IUD/depot instead
• If unavoidable, increase lamotrigine dose and using COC in continuous fashion

Vomiting and Diarrhoea

• Absorption of the oral contraceptives can be affected!
• If vomiting occurs within 3 hours, take another pill immediately
• If vomiting or severe diarrhea continues for >24-hours follow instructions
• Follow instructions for missed pills, and count missing/ diarrhea
• To avoid intercourse use a barrier such as condoms during
• If this happens with the last 7 tablets, just skip and use a new cycle

Risks: MI and Stroke

• There may be an increased risk when combined with multiple risk factors and conditions
• If the patient smokes, has diabetes, avoid hypertension if > 160/100mmHg
• Avoid those with BMI>30, migraines with aura, or CVD

Increase VTE

• Risk depends on progestogen and oestrogen levels
• Use appropriate dose but discontinue should any issues arise

Breast Cancer

• Small risk but returns to normal after ten years
• CSM advice should be against the evidence against cancer
• Test for history
• Smoker or someone 35+ should not use, and avoid those >50
• Can be used for those no other risk factors

Migraine

• Increases risk of venous of arterial
• Increases risk of stroke
• Be cautious of those with aura

Cautions and Contraindications:

• Prescibe base on patient type and UK (medical criteria - categories
• Category 1; no restriction of use
• Category 2: advantages of use generally outweigh the harm use
• Category 3: risks are greater
• Category 4: Avoid use and dangerous for health to continue (COC etc

Conditions when needed to avoid:

• Severe disease, migraines with aura, smokers

Risks increased

• 1st degree
• BMI
• Symptomatic bladder disease, hypertension, diebetes
• Stop COC if there is severe chest pain, breathlessness, or severe heel pain etc

Combined Contraceptive Patch

• There is only one in the UK
• Evra patch - ehtinylsradual and nogestrel
• Should not apply to breast, inflamed or broken skin
• Designed for sauna,exercise etc
• Change the patch weekly

Instructions to change/remove

• Apply once every three years within patch interval
• If partially detached use
• If 48 hours or too long use a new one

Progesterone only pill POPS

• Used because estrogen is contraindicated

• Older women, VTE, smoker etc

• Take one with no break

• 12 hour withs windows if more than pop

• Iniatie pops on Day 1, if not use a barrier

• higher rate of failure, must be taken every 24 hrs

• Menstrual irregularities are common and will become better with time

• Smaller risk of breast cancer, or ovarian cysts

• Must be careful to see if they are vomiting or having diarrhea

POP Interactions:

• Enzyme - similar, watch out can cause issues
• Short term can cause contraceptive cover to be reduced or affected
• Can take two pills or start a new schedule
• Progestogen pills are available via
• They are licensed and recommended to see the doctor when buying

Switching

• Important if and where pill cycle is in the patients
• Do not start until after traditional cycle
• Important not to engage as much and must be using condoms or protection
• Start POP on the last day

Progestogen Injectables

• Administered usually to prevent ovulation
• Given after very 12 weeks
• Failure rate is very low (7 %
• Can be weight gain or density gain
• Discontinuation should be addressed in a certain time

Implant

• Inserted by a dermatologist with training
• Very in effective
• Irregular bleeding and some issues

IUS

• Has levonogestrel
• Very effective
• Low fail rate
• Effective up to 5 years

IUD

• Non hormonal and also contains copper
• Prevents fertilization
• Some issues and cause bleeding etc

Trans genders

• Contraception is recommends for trans
• Gonadotrophin is used