L15B - Comprehensive Contraception Study Notes

Understanding Contraception Suitability (UKMEC)

Category 3: A condition where theoretical or proven risks generally outweigh the advantages of using a particular contraceptive method.
Category 4: A condition representing an unacceptable health risk for using the method. Example: Patient has a history of venous thromboembolism (VTE).
Online Tool: An online calculator is available (link provided in slides) to assess the risk-benefit profile of hormonal contraceptives based on UKMEC categories. It requires a comprehensive patient history.

Types of Hormonal Contraceptive Pills

Combined Oral Contraceptives (COCs): Contain a combination of estrogen and progestogen.
Progestogen-Only Pills (POPs): Contain only progestogen. "Progestogen" is a broader term encompassing natural progesterone and various synthetic progesterones.

Comparison of COCs and POPs

Effectiveness: Both are highly effective when taken perfectly. POPs have lower effectiveness with missed or late doses.
Dosing:
- COCs: Typically $21$ days of active pills followed by $7$ days of inactive pills.
- POPs: Taken daily without a hormone-free interval.
Cycle Control:
- COCs: Allow for predictable withdrawal bleeding and can be tailored to skip periods.
- POPs: Risk of irregular bleeding. Drospirenone is the most effective progestogen for cycle control.
Suitability:
- COCs: Not recommended for women with estrogen contraindications, such as a history of VTE, migraine with aura, or smoking over $35$ years of age.
- POPs: Safe for women who cannot take estrogen, and suitable for postpartum use and during breastfeeding.
Non-Contraceptive Benefits:
- COCs: Offer more benefits, including improvement of acne, dysmenorrhea, endometriosis, premenstrual syndrome (PMS), and reduced risk of ovarian, endometrial, and bowel cancers.
- POPs: May reduce dysmenorrhea or endometriosis pain, but are generally less effective for non-contraceptive benefits compared to COCs.
Risks:
- COCs: Higher risk of VTE, stroke, and myocardial infarction. May increase blood pressure and slightly increase the risk of breast and cervical cancer.
- POPs: Lower cardiovascular risk. Main issues are irregular bleeding and the need for strict adherence due to critical timing.

Initiating Hormonal Contraceptives

Combined Oral Contraceptives (COCs):
- Menstrual Cycle Start: Immediate protection if started between day $1$ and day $5$ of the menstrual cycle. If started after day $5$ , the patient needs to take the medication for $7$ consecutive days for protection to be established (use backup contraception). For example, if starting on day $4$ , immediate protection. If starting on day $6$ , needs $7$ days of continuous use before protection is ensured.
- Postpartum: Immediate protection if started less than $21$ days postpartum. If more than $21$ days postpartum, immediate protection if started by day $21$ , otherwise requires $7$ days of use for protection.
- After Abortion/Miscarriage: Immediate protection if initiated within $5$ days.
Progestogen-Only Pills (POPs):
- Menstrual Cycle Start: Immediate protection if started between day $1$ and day $5$ of the menstrual cycle. If started after day $5$ :
  - Levonorgestrel and Noretisterone-containing POPs: Effective after $48$ hours.
  - Drospirenone-containing POPs: Effective after $7$ days.
- Postpartum: Immediate protection if started less than $21$ days postpartum. If more than $21$ days postpartum, follow specific rules for the progestogen type (e.g., $3$ to $7$ days of continuous use).
- After Abortion/Miscarriage: Immediate protection if initiated within $5$ days.
Switching from Other Contraceptives:
- From another COC or Vaginal Ring: Immediate protection if pills are started within $24$ hours after the hormone-free interval. If switching to POPs, immediate if more than $7$ days of active COC/ring use. Otherwise, $7$ days of backup contraception are needed.
- From Implant, Injection, or Copper IUD: Immediate protection if started between day $1$ and day $5$ of the menstrual cycle.
- From another Progestogen-Only Method:
  - To COCs: Immediate protection if switching directly.
  - To POPs: Immediate if switching from levonorgestrel/noretisterone used for more than $3$ days, or from drospirenone used for more than $7$ days. The specific progestogen type determines the time to protection.

Managing Missed Hormonal Contraceptive Pills

Combined Oral Contraceptives (COCs):
- Missed by < $24$ hours: Take the missed pill immediately (resulting in two pills in one day). Protection is maintained, no additional measures are needed.
- Missed by > $24$ hours:
  - Take the most recent missed pill immediately. Discard any other missed pills.
  - Use condoms for the next $7$ days, and continue active pills as usual.
  - If within $7$ days of the next hormone-free break, skip the inactive pills and continue active pills without a break.
  - Emergency Contraception (EC) Consideration: If fewer than $7$ active pills have been taken since the last hormone-free break AND unprotected sexual intercourse occurred in the preceding $5$ days, EC should be considered in addition to continuing the usual pill.
Progestogen-Only Pills (POPs):
- Missed by > $3$ hours:
  - If one pill missed: Take it as soon as remembered.
  - If more than one pill missed: Take the most recent missed pill as soon as remembered, discard others.
  - Take the next pill at the usual time (may mean two pills in one day).
  - Continue daily as usual.
  - Use condoms until three consecutive pills have been taken.
  - Emergency Contraception (EC) Consideration: If unprotected sexual intercourse occurred since the first pill was missed until three consecutive pills have been taken, EC should be considered.

Vaginal Ring (NuvaRing)

Advantages:
- Monthly use (inserted for $3$ weeks, removed for $1$ week), beneficial for adherence issues.
- Steady hormone release provides stable cycle control.
- Regulates periods, reduces dysmenorrhea, acne, and endometriosis symptoms, similar to COCs.
- Discrete, rarely felt during intercourse.
- Immediate return to fertility after removal.
Disadvantages:
- Requires remembering monthly insertion and removal.
- Can cause discharge, irritation, or discomfort.
- Not suitable for women with estrogen contraindications (contains ethinyl estradiol).
- Carries similar cardiovascular risks as COCs.
- Must be kept refrigerated before dispensing and expires four months after supply.

DMPA (Depot Medroxyprogesterone Acetate) Injection

Advantages:
- Injections are required only every $12$ weeks (every $3$ months), eliminating the need for daily pill taking.
- Highly effective and user-independent once administered.
- Discreet and convenient.
- Suitable for women with estrogen contraindications (e.g., smokers over $35$ , migraine with aura, history of VTE).
Disadvantages:
- Requires a healthcare visit every $12$ weeks for the injection.
- Cannot be stopped immediately if side effects occur.
- Often causes irregular bleeding initially, which may become abnormal later.
- Delayed return to fertility.
- May cause side effects such as weight gain and decreased libido.

Long-Acting Reversible Contraceptives (LARCs)

Types:
- Intrauterine Devices (IUDs):
  - Hormonal (levonorgestrel-releasing): E.g., Mirena, Kylena. Last approximately $5$ to $10$ years depending on type.
  - Non-hormonal: Copper IUDs. Last approximately $5$ to $10$ years.
- Progestogen Implants: Etonogestrel implant. Lasts for $3$ years.
Effectiveness and Advantages:
- Most effective contraception methods, often considered a first-line option for all ages.
- Minimal user involvement, high satisfaction, and highest continuation rates among contraceptives.
- "Set and forget" approach, no need to remember daily pills or monthly ring changes.
- Can lead to decreased or absent menstruation.
- Can be used while breastfeeding.
Long-Acting Contraceptives in Australia: Levonorgestrel IUD, Copper IUD, Etonogestrel implants. Copper IUDs are not covered by the Pharmaceutical Benefits Scheme (PBS), which can be a financial drawback.
Risks with IUDs:
- Infection: Risk of $1$ in $300$ patients, highest within the first $3$ weeks (routine antibiotics are not recommended due to low risk).
- Perforation: Risk of $2.3$ in $1000$ patients. Higher risk in breastfeeding women, those with previous C-sections, or less than $6$ months postpartum.
- Expulsion: Risk of approximately 5 ext{%}, may go unnoticed. Women are advised to check for strings monthly.
Additional Contraception for IUD Insertion:
- Needed for $7$ days after the first IUD insertion if it occurs after day $5$ of the menstrual cycle and no hormonal contraception was used previously.
- Required for $7$ days when switching from COCs, vaginal rings, or POPs.

Emergency Contraception (EC)

Three Methods:
1. Copper IUD:
  - Timing: Can be inserted within $5$ days after unprotected sex OR within $5$ days after the earliest predicted ovulation.
  - Effectiveness: Most effective EC method.
  - Suitability: Suitable for patients with obesity and those taking liver enzyme-inducing drugs.
  - Cost: Not covered by PBS.
  - Benefit: Provides ongoing contraception if retained after emergency use.
2. Levonorgestrel (LNG) Pill:
  - Timing: Should be taken as soon as possible, effective up to $96$ hours. TGA states it's more effective within $72$ hours.
  - Effectiveness: Prevents approximately 85 ext{%} of expected pregnancies. Less effective than UPA and copper IUD.
  - Suitability: Not suitable for patients with obesity (may require double dose, not TGA approved).
  - Interactions: Can interact with enzyme-inducing drugs (copper IUD is a better option in such cases).
  - Restarting Hormonal Contraception: Can be restarted immediately after taking LNG.
3. Ulipristal Acetate (UPA) Pill:
  - Timing: Effective up to $120$ hours.
  - Effectiveness: More effective than LNG, but less effective than copper IUD.
  - Suitability: Not suitable for obesity. Risk of interaction with enzyme-inducing drugs and corticosteroids.
  - Restarting Hormonal Contraception: Must wait at least $5$ days after UPA before restarting any regular hormonal contraception.
General EC Considerations:
- EC methods are not needed if within $25$ days postpartum or $5$ days after an abortion.
- Pills (LNG, UPA) only: May cause nausea and vomiting. If vomiting occurs within $3$ hours of taking the pill, the dose needs to be repeated (antiemetics can be considered).
- Pregnancy Test: Advised three weeks after the last unprotected sexual intercourse, even if EC was used.
- Importance of History: Essential to take a proper patient history and fulfill legal/professional obligations when providing EC, especially regarding the exact day of the menstrual cycle and timing of sexual intercourse.

Providing Emergency Contraception (PSA Guidelines)

Required Steps:
1. Gather Patient Information: Includes medical and menstrual history, age, weight, current pregnancy or breastfeeding status.
2. Assess the Patient: Consider the need for referral to a doctor, eligibility for advanced provision, and the most appropriate treatment choice. Evaluate risks related to age (under $18$ ), pregnancy/breastfeeding, and possibility of sexual assault (requiring referral and support).
3. Counseling: Provide clear instructions on how to use the EC, discuss potential adverse effects, ask about any ongoing contraceptive methods, advise on pregnancy testing (three weeks after unprotected sex), discuss sexually transmitted infections (STIs), and provide written information.
Refer Urgently (Cannot Supply Oral EC):
- The patient lacks a mature understanding of the proposed treatment.
- Oral EC cannot be supplied within the required time frame after unprotected intercourse (e.g., beyond $72$ hours for LNG or $120$ hours for UPA).
- The patient has severe asthma treated with oral glucocorticoids (contraindication for UPA).
Supply Oral EC and Refer (Supply with Caution/Additional Action):
- BMI is more than $30$ or weight is more than $85$ kg.
- The patient is taking any enzyme inducers within the previous four weeks.
- The patient has a malabsorption disorder.
- There is an insufficient time interval between UPA use and subsequent progesterone use.
- UPA is required more than once in the same menstrual cycle.
- Patient is a suspected victim of sexual assault (refer for appropriate support services).
- Note: Referral for ongoing contraception, pregnancy testing, and sexual health checks is also appropriate.
Pharmacy Form: A specific form must be completed by the patient in the pharmacy before providing EC, covering all necessary information for decision-making.
Practice Points After Providing Oral EC:
- Timing: Administer as soon as possible as efficacy decreases with time.
- Vomiting: If vomiting occurs within $3$ hours, repeat the dose (consider an antiemetic).
- Drug Interactions: Assess for potential drug-drug interactions with other medications.
- Breastfeeding: LNG is safe. For UPA, express and discard milk for $24$ hours to reduce infant exposure.
- Repeat Use: There is no limit to the number of times LNG can be used or the interval between doses in the same menstrual cycle. For UPA, there is a theoretical concern of hepatotoxicity with frequent, short-term use.
- Follow-Up: Advise a pregnancy test if the next period is more than $7$ days late, bleeding is unusually light, or repeat EC was used in the same cycle.

Clarification on Nausea/Vomiting: Only hormonal EC pills (LNG, UPA) carry a risk of nausea and vomiting. Copper IUD (non-hormonal) has a very low risk of these side effects.