Overview of Contraception and Reproductive Health

Frankie Brown 2020

Programme for the course

SESSION ONE - 18th May (11th June)

◼ Introduction and assessment of needs

◼ Quiz around the physiology of the menstrual cycle

◼ Understanding hormones

SESSION TWO – 19th May (12th June)

◼ Quick overview of all contraceptive methods

◼ What is UKMeC and its role in delivery?

SESSION THREE – 1st June (18th June)

◼ Thinking through a good review

◼ CHC – the rules – contraindications and work on

doing regular review

SESSION FOUR – 2nd June (19th June)

◼ POP – the rules – contraindications – case

study

◼ Depo – the rules – contraindications - case

study

SESSION FIVE - 8th June (25th June)

◼ Emergency contraception - How and when? –

case study

SESSION SIX – 9th June (26th June)

Lets bring it all together and consider some very

generic basic reviews you may do or suprises you

might get in other consultations

Training issues - what’s available? Local and

national

Extras

What will you be receiving?

◼ Quiz on Session one

◼ All presentations throughout

◼ Reading list plus online resources

◼ Faculty guidance on new regimes for

CHC

◼ Competency framework

◼ Evaluation form

What do I want from you?

◼ To try to obtain condom

demonstrator for practice.

◼ Get used to templates in your

practice

◼ Ask to see updated protocols etc

within practice

◼ Find out referral pathways for EC

IUD if not available in your practice.

◼ Over next few months try to get

your competencies signed off

◼ Evaluations

Programme for Session 1

Frankie Brown

Lecturer in Womens’ Sexual and Reproductive Health –

Contraception

MSc Cert Ed in Higher Education

Session One

• 10.00am Introductions to the day• Exploration of practice problems•• 10.30am Quiz of prior knowledge

• COFFEE break to suit all 10 mins at some time•• 11.00am Feed back from quiz

• 12.00md Understanding hormomes• 12.30pm Fini

Any questions ?

◼ Then lets have a quiz -just a quick 10

mins to answer all you know or think

you know

◼ Then we will go through together

HormonesThe Picture

Frankie Brown

2020

• Hormones are produced primarily in endocrine glands

• BUT

• Can also be produced in endocrine cells that are part of other organs

Metabolism and elimination of sex hormones• Inactivation takes place mostly in the

liver

• Excretion takes place mostly via the kidneys, but also through the biliary tract into the intestine

The hormonal cascade

GnRH Hypothalmus

(Pulses every 90 minutes)

FSH and LH Pituitary

Prolactin(controlled bydopamine) Anterior pituitary

Oestradiol and progesterone Ovaries

and Inhibin, (hormone secreted by the granulosa cells

in the ovaries of women that acts primarily to

inhibit the secretion of follicle-stimulating

hormone by the anterior pituitary gland.)

The Menstrual Cycle

Principal functions of the female reproductive

system

Produce ovum and ensure it is fertilised, nurtured and

allowed to grow to term, and to expel it safely into the

external environment (Endocrinology at a Glance (2011)

Functions of oestrogens

• Principle function is to bring about the development of the female sex organs, the breasts, the pattern of body hair in women and the distribution of fat around the body

Functions of oestrogens

• Many stages of the menstrual cycle are directed by oestrogens

– It encourages growth of the endometrium

– Makes the fimbria of the fallopian tube move towards the follicle

– It helps to make muscles contract

– Mid-cycle it is responsible for increased libido

– and makes cervical mucus sperm friendly

Functions of oestrogens

• Makes the skin supple and elastic all over the body (particularly important in the vagina)

• Cause retention of salt

• Helps maintain the structure of bone

• Stimulates the liver to produce a number of hormones e.g.– High density lipoproteins(HDL) (increased)

– Sex hormone binding globulin(SHBG) (increased)

– Various factors which are involved in blood clotting

Functions of progesterones

• Responsible for preparing the body for pregnancy

• Therefore particularly in 2nd half of cycle - maintains thickness of endometrium

• In conjunction with prolactin it also stimulates breast milk production

Functions of progesterones

• Thickens cervical mucus

• Leads to loss of salt from body

• Contraceptive pills contain progestogens, derived from testosterone, not natural progesterone

Types of Oestrogens in

contraception

Ethyniolestradiol

And

Estradiol Valerate

Types of progestogens in Contraception• 19-Nortestosterone derivatives

– Norethisterone

– Norethisterone acetate

– Norethisterone enantate

– Levonogestrel

– Desogestrel *

– Norgestimate *

– Gestogene*

• Progesterone derivatives– Medroxyprogesterone

– Chlormadinone acetate

– Cyproterone

– Drospirinone*

So what’s the difference19-Nortestosterone derivatives

• Take on the male characterisitics (Androgenic effects)

– Acne

– Excess hair

– Weight gain (due to increased appetite)

– May reduce libido

– Raise LDL decrease HDL

– Counteract rise in SHBG

– Affect insulin production

Newer progestogens3rd generation• Are more specific less androgenic

• Fewer niggling side effects

• BUT ? Effects on blood clotting

• Desogestrel

• Gestogene

• Norgestimate

So what’s the differenceProgesterone derivatives

• Take on the characteristics of natural progesterone

Oestrogenic side-effects• Breast enlargement

• Breast tenderness

• Bloating

• Weight gain due to water retention

• Nausea

• Non-infective vaginal discharge

• Some headaches

• Chloasma

• Photosensitivity

Progestogenic side-effects• Acne

• Greasy hair

• Hirsuitism

• Weight gain due to increased appetite

• Depression

• Loss of libido

• Vaginal dryness

No method

Couples having intercourse regularly for 1 year without contraception (there are approximately 80 million sperm in 1ml ejaculate):

◼ Young women 80% will get pregnant◼ Women aged 40 40-50% will get

pregnant◼ Women aged 45 10-20% will get

pregnantGuillebaud 1997

Main determinants for contraceptive use by teenagers

◼ Adequate sexual and contraceptive education

◼ High preventative motivation

◼ Self confidence and communication skills

◼ Easy access to acceptable services

Evert Kettings,Netherlands 1998

Over 30s - Challenges for the older woman

◼ Fertility

◼ hormonal instability

◼ rate of termination of pregnancy

◼ miscarriage rate

◼ risk of foetal abnormalities

◼ maternal morbidity

◼ stillbirth

◼ sexual frequency

◼ number of women delaying first pregnancy

◼ number of women with new partners

Day Two

SESSION TWO – 19th May (12th June)

◼ Quick overview of all contraceptive methods

◼ What is UKMeC and its role in delivery?

What are the methods

available today?

◼ Combined oral contraceptive pill (COC)

◼ Combined patch

◼ Combined ring

◼ Progestogen only pill

◼ (2 types) (POP)

◼ IUD

◼ IUS

◼ Injectables

◼ Implant

◼ Barriers: - Caps and condoms and sponge

◼ Natural Methods

◼ Sterilisation - Male and Female

◼ Emergency Contraception -Types

◼ POEC

◼ IUD

◼ Mefipristone

Fertility Awareness

Use in General Practice

◼ To avoid pregnancy

◼ To achieve pregnancy

◼ To monitor cyclical symptoms

◼ For breast feeding mothers

◼ For Peri-menopausal women

Cervical Mucus

Helping patients to choose

◼ What do they know generally about different methods?

◼ Do they have any idea what they want to use?

◼ What is their knowledge of that choice?◼ Is their choice medically suitable?◼ When can they start it?◼ Who is the best person to carry it

forward?

◼ 1.Have your periods started?NO

◼ 2.Are you supplementing regularly or allowing long periods without breastfeeding, YESeither by day or night?

NO◼ 3.Is your baby more than YES

6 months old?NO

There is only a 1 or 2% chance of pregnancy at this time

LAM AlgorithmAsk the mother to ask herself 3 Questions

The mother’s chance of pregnancy is increased. For continued protection advise the mother to begin using a complementary family planning method and continue breast feeding for the child’s health

BarriersCaps/Diaphrams and condoms

Caps and Diaphragms

◼ Protects against some STI’s and PID

◼ can be damaged by oil based lubricants

◼ protection against HIV not shown

◼ Some women get increased UTI’s

◼ Allergy possible

◼ increased protection with spermicides (Germicides)?

Latex Condoms

◼ Mainstay of STI prevention

◼ Problems can be allergy to latex

◼ Complaints of decreased sexual pleasure

◼ also condoms made of polyurethane filmBUT breakage rates 6% compared to 1% with Latex (Cook et al. 2000)

overall failure rate 7% versus 2%

◼ female condom is it the answer?

Spermicides

◼ Active ingredient - Nonoxyl 9

◼ Kills HIV and herpes viruses in vitro

◼ But can cause cellular damage to vaginal epithelium leading to increased transmission rate

◼ Condoms should not be lubricated with N-9 (WHO)

Does your practice regularly

teach condoms use at

consultations?

Lets look at UKMeC

◼ United Kingdom Medical Eligibility

Criteria and its importance

◼ UK Medical Eligibility Criteria

◼ Up to date, evidence based guidelines for the use of all methods of contraception, based on the medical conditions of our patients

◼ UKMEC Definition of category

◼ Category 1 - A condition for which there is no restriction for the use of the method

◼ Category 2 - A condition where the advantages of using the method generally outweigh the theoretical or proven risks

◼ Category 3 - A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable

◼ Category 4 - A condition which represents an unacceptable health risk if the method is used

Examples Condition Cu IUD LNG-IUS IMP DMPA POP CHC

History of VTE

1 2 2 2 2 4

Migraine with aura,

1 2 2 2 2 4

Migraine without aura

1 2 2 2 I C I C

2 31 2

Current PID

I C I C 1 1 1 1

4 2 4 2

Combined Hormonal Contraception

How do they work?

◼ Prevents ovulation

◼ Thickens cervical mucus

◼ Reduces receptivity of endometrium to blastocyst

COC’s -Types of

◼ 1. Amount of Oestrogen.◼ Ethynlestradiol 20mcg - 35mcg;50mcg

◼ Estradiol 1500mcg and (1000 to 3000)

◼ 2. Type of progestogen. levonorgestrel, northisterone; desogestrel, gestodene &norgestimate.

◼ 3. Phasic (includes newer coc)

◼ 4.Every-day

Which is pill of choice?

Which pills do your practice provide

What is on your formulary

First line is for most but not everyone

Try an audit of the practice prescribing and with 1st, 2nd and 3rd

most common used (pop and coc)

UKMEC rules

◼ Can start up to and including Day 5 –no extra precautions

◼ A woman can switch brands (different progestogens) immediately without need for extra precautions

◼ Up to 12 months supply can be given at first and subsequent visits

Other combined methods

◼ The patch – Evra

◼ Changed weekly

◼ The Vaginal Ring – Nuvaring

◼ Self inserted and used for 3w

Lots more next week

◼ Maybe coffee here?

Progestogen only Contraception

Progestogen only contraception

◼ Progestogen only pills(pops)

◼ Injectables

◼ Implant

◼ Intrauterine System (IUS)

◼ Emergency Contraception (POEC)

Mode of action

◼ mucus

◼ ovaries

◼ endometrium

Old style pops

◼ Norgeston

◼ Micronor

◼ Noriday

Main side effects

◼ Are on menstrual pattern1. 40% Cycles show no change, apparent

normal ovulation2. 21% irregular cycles3. 23% functional ovarian cysts can be

formed4. 16% complete amennorrhoea or very

intermittent light bleeding – No ovulationGuillebaud p283 from Swedish Study(1980)

Desogestrel

The oestrogen free pill that consistently inhibits ovulation

◼ 12 hour window

◼ Excellent reliability

◼ First oestrogen-free pill with consistent ovulation inhibition

◼ Trend towards more amenorrhoea and less bleeding with time

◼ High acceptability

◼ Negligible effect on metabolic parameters

◼ No effect on lactation and growth of newborns

Contraceptive Effect

◼ Ovulation inhibition in 97% cycles

◼ Thickening of cervical mucus

InjectablesDepo Provera or Noristerat

or Sayana Press

Types

◼ Depo Provera (DMPA) 150mg in 1 ml every 12 weeks

◼ Noristerat (NET EN) 200mg every 8 weeks

◼ Sayana Press (DMPA) 104mg in 0.65ml

Effectiveness

◼ 0-1/100 woman years

◼ 99-100%

Advantages - Contraceptive

◼ High Effectiveness

◼ Highly convenient

◼ fully reversible

Advantages - Non -Contraceptive◼ Less heavy bleeding

◼ Less anaemia

◼ Less dysmenorrhoea

◼ Less symptoms of pre-menstrual tension

◼ No ovulation pain

◼ Less PID◼ Less extra uterine

pregnancies◼ ?less functional cysts◼ reduction in the growth of

fibroids◼ less endometriosis◼ beneficial social effects◼ Overdose extremely

unlikely◼ protection against

endometrial cancer

How to give

◼ Start on day 1 – 5 of cycle

◼ Give every 12 weeks: Up to 14 weeks.

◼ 6 weeks PN

◼ Immediate post top

◼ ?At any other time

◼ What to do if late?

DOH Guidelines

◼ Potential risks associated with long term use

◼ Particular under 18 and over 40

◼ Proper assessment of other risk factors

Depo-provera and bone

◼ There is evidence to suggest:-◼ Loss of BMD with 2 years of use

◼ In adult women BMD starts recovering as soon as stopped. Some data say this rate depends on duration of use

◼ In adolescents may be more significant effect

◼ It is not clear whether use of Depo increases risk of osteoporosis in later life

Subdermal Implant

Efficacy

◼ Duration of use 3 years

◼ 0% failure rate in trails

◼ If enzyme inducer treatment consider additional precautions

◼ Some pregnancies in this country with Implanon (Why!!)

Considerations

◼ Special insertion training vital

◼ Irregular bleeding – Counselling

◼ Body weight

◼ Enzyme inducers

Intrauterine Device

◼ How does it work• Blocks implantation? or prevents fertilisation

• Inflammatory cells in genital tract impede sperm transport and may damage sperm and ova

• Increased rate of ovum transport

Intrauterine devices

Efficacy

◼ T-Safe Cu 380 - At 10 years cumulative failure 1.4/100 women(99%)

◼ Can be left in until Menopause if fitted after age of 40

IUS or Levonorgestrel IUD

Mirena/Kyleena/Jaydess

Levocert

Advantages of Mirena

It is unsurpassed efficacy, around 0.2 per 100 woman-years

Return of fertility is rapid

Highly convenient, few adverse side-effects and beneficial effects on the menstrual cycle

Dysmenorrhoea can be improved

Progestogenic protection of the uterus with HRT

Reduce PID

Emergency Contraception

◼ 3 types :-

❑ IUD

❑ Levonelle

❑ Mifipristone (Ella-One or generic)

What Methods Should be Offered to

Women Requesting EC?

◼ Faculty clearly state that all women should be offered an IUD as

it is the most effective method

◼ BUT

◼ How do we manage that in practice? Find out what happens in your

practice and we will discuss in detail in Session 5

SterilisationMale and Female

What work for next 2 sessions

◼ Check what template is used in practice and have

it with you for session 3

◼ Print off any bits I have sent you and have with

you for next 2 sessions

Useful websites

◼ www.fsrh.org.uk

◼ www.fpa.org.uk

◼ www.who.int/reproductive-health

◼ www.nice.org.uk

◼ www.bnf.org

◼ www.bashh.org

◼ www.ippf

See you next week

Keep safe Keep well