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Contraception Update

Contraception Update . Dr Tracey Dibble Associate Specialist at Sheffield Contraception & Sexual Health Service March 2012 Sponsored by HRA Pharma.

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Contraception Update

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  1. Contraception Update Dr Tracey Dibble Associate Specialist at Sheffield Contraception & Sexual Health Service March 2012 Sponsored by HRA Pharma

  2. “Family planning could provide more benefits to more people at less cost than any other single technology now available to the human race” James Grant, Unicef Annual Report 1992

  3. Aims • UK Picture • Human Fertility • History Lesson • Current UK Use • Contraceptive Methods • LARC • User Dependent • EC • New Developments

  4. Why is this important in the UK? • High teenage pregnancy rates in Sheffield & UK (compared to Europe) • Increasing abortion rate • Increasing repeat abortions

  5. Teenage Pregnancy 2010 Figures • E & W rate is 35.5 / 1000 • Lowest since 1969 • ↓ 9.5% since 2009 • Sheffield rate is 41.4 /1000

  6. Teenage Pregnancy Rates 1998 - 2010

  7. Abortion 2010 Figures E & W • Total numbers189,574 (↑0.3% 2009) • Rate 17.5 / 1000 women • Rate 16.5 / 1000 under 18s Sheffield • Total numbers 1683 • Rate 13.2 / 1000 all women • Rate 18 / 1000 under 18s

  8. How fertile are human beings ? • No breeding season • For women maximum desire corresponds to most fertile phase • 350 million sperm / ejaculate • Sperm survive average 3-4 days (“super sperm” 6-7 days) • Ovum needs to be fertilised within 12hrs • Most fertile days are 2-3 days prior to ovulation

  9. The menstrual cycle

  10. Brief History Lesson

  11. Development of Condoms • 1000BC - Egyptians used linen sheath condoms for prevention of infection • 1500s - linen sheaths used in European Syphilis epidemic – usefulness against pregnancy also discovered • 1700s – animal intestine condoms available but expensive • 1880’s – vulcanisation of rubber & mass production of rubber condoms, Goodyear & Hancock

  12. Decline of Birth Rate in Victorian England – McLaren 1978

  13. Consequence of birth control?-McLaren 1978

  14. What methods were available? • Coitus interruptus “until at least WWII the most popular form of contraception in England”-McLaren 1978 • Temporary abstinence • Condoms • Abortion – although illegal it was common

  15. Development of the pill • Early 20th Century Feminists & Birth Control movement – Stopes, Sanger & McCormick • Mexico 1950s – Marker & Djerassi • 1960 1st pill marketed

  16. Contraception in UK 2008/09, ONS

  17. LARC Methods From NHS Community Contraception Clinics

  18. Characteristics of a good contraceptive • Effective • Forgettable • Convenient • Reversible • Safe • Cheap • Few side effects

  19. Effectiveness Spermicides Female condom Diaphragm w/spermicides Male condom Oral contraceptives DMPA IUD (TCu-380A) Rate during perfect use Female sterilization Rate during typical use Implants 0 10 20 25 30 5 15 Percentage of women pregnant in first year of use Source: CCP and WHO, 2007.

  20. Cost

  21. Forgettable ! User Dependent Methods • Condoms • Pills • Unfortunately are very forgettable!! • Success depends upon excellent compliance

  22. Forgettable User Independent Methods • LARC methods • Sterilisation • Cannot be forgotten therefore woman can relax - she is not going to get pregnant

  23. Consequences of forgetting Audit of contraception use in 200 vulnerable women at Sheffield TOP clinic, 2008 Contraception being used before pregnancy • None 39% • Condoms 35% • Pill methods 27% • No LARC failures

  24. What is LARC? • Long Acting Reversible Contraceptives are methods of contraception which are administered less than once / month

  25. Depo Provera Pros • Effective • High dose progestogen im injection • Inhibits ovulation • Every 12 weeks • Doesn’t interfere with sex • More under patient control • Often causes amenorrhoea

  26. Depo Provera Cons • Can be forgotten • Osteopenia / osteoporosis • Irregular / heavy bleeding • Weight gain • Low mood • Delay in fertility return – average 1yr

  27. Nexplanon • Replaced Implanon in Oct 2010 • Small rod in upper arm - inhibits ovulation Pros • Very effective (0 – 0.07% ) • Lasts 3 yrs • Forgettable • Doesn’t interfere with sex • Very safe • Cost effective

  28. Nexplanon Cons • Needs to be fitted & removed by Dr or nurse • Some people don’t like idea of foreign body in arm • Irregular or heavy bleeding • Amenorrhoea • Weight gain??

  29. IUDs Pros • Effective • Forgettable • Doesn’t interfere with sex • Long lasting up to 10yrs • Good safety record • No hormones

  30. IUDs Cons • Needs fitting / removal by Dr or nurse • Some patients do not like idea of IUD inside them • Heavy bleeding • Risk of perforation/ expulsion/ infection • Not always tolerated esp by nullips

  31. Mirena IUS Pros • Very effective • Forgettable • Doesn’t interfere with sex • Long lasting –5yrs • Treatment of menorrhagia • Used as part of HRT

  32. Mirena IUS Cons • Needs fitting / removal by Dr or nurse • Some patients do not like idea of IUD inside them • Irregular bleeding / spotting • Risk of perforation/ expulsion/ infection • Not always tolerated esp by nullips

  33. Sterilisation Female Sterilisation Vasectomy Irreversible Under LA Dissect Vas deferens & remove a small piece Failure rate 1 in 2000 Not immediately effective • Irreversible • Under GA • Filshie Clips on Fallopian tubes • Failure rate 1 in 200 • Immediately effective

  34. User Dependent Methods • Oral Contraceptives • COC • POP & Cerazette • Barrier Methods • Condoms • Diaphragms • Natural Family Planning

  35. Combined Oral Contraceptive Pill • Combines Oestrogen & Progestogen • Very effective 0.2 – 3% • Good menstrual cycle control • Not related to sexual intercourse • Helps heavy / painful periods

  36. COC Cons • Complicated pill rules • Difficult to remember • Minor side effects – nausea, breast tenderness • Increased venous thrombosis, heart disease, stroke but only if have pre-existing risk factors (e.g. obesity , smoking) • Small increased risk of breast cancer

  37. How safe is the pill? Comparative Risks /100,000 women (Yr 2000) • Taking pill = 1 death • Home accidents = 3 deaths • Having a baby, UK = 6 deaths • Road accidents = 8 deaths • Smoking at age 35yr = 167 deaths, next yr • Having a baby, Rural Africa = 600-1000 deaths

  38. Evra • COC in patch form • Efficacy 0.99-1.24% failure rate • 20 cm patch • 4.6% patch detachment • Worn for 3 weeks with 1 week break • Each patch lasts 7 days • If forget to change patch - ok up to 2 days late • Expensive £7.74 / month ( Compared to COC £0.50 / month

  39. Progestogen Only Pill Pros • Very safe • Less effective (0.3 – 4%) • Relies on thickening cervical mucus • Inhibits ovulation in some women • OK if oestrogen is contraindicated • OK if breastfeeding

  40. POP Cons • Difficult to remember • Only 3 hour window • Higher failure rate • Poor cycle control – irregular bleeding

  41. Cerazette • New POP • Higher dose • Inhibits ovulation in 97% of cycles • Still very safe • More effective (0.7 – 1.1%) • 12hr window • Poor cycle control for some women – irregular bleeding

  42. Condoms • Still best protection against STIs • Good for additional protection alongside another contraceptive • User failure rates are high • Non latex versions available

  43. Diaphragms • Not very effective • Perfect Use 6% • Typical Use 16% • Useful to space children • Use in 40s • Irritation from spermicide

  44. Emergency Contraception Copper IUD • Most effective • Can be fitted up to 5 days after sex Levonelle • High dose progestogen • Can be used up to 3 days after sex • Available OTC • Delays ovulation • Safe

  45. ellaOne • Licensed in Autumn 2009 • Progestogen blocker • Inhibits ovulation • More effective than Levonelle • Works up to 5 days after sex • Must not be used more than once in cycle or if any earlier risk of pregnancy • May effect ongoing contraception • Expensive £ 16.95

  46. New Developments New Methods • Nuvaring • Qlaira New Ways of Using Old Methods • Tricycling COC & reducing PFI

  47. Nuvaring • Vaginal ring containing hormones • Wear for 3 weeks, 1 week off – withdrawal bleed • Stops ovulation • <1% failure rate • Well tolerated • Can be worn during sex • Periods lighter, regular, shorter • Expensive

  48. Tailored Pill Regimes • Pill Free Interval is cause of high failure rate of COC • Now out dated • Who needs a period? Options • Reduce PFI to 4 days • Reduce frequency of PFI – only every 3 months

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