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Contraception Update
Dr Clio TimaeusClinical Lead/Associate Specialist for
Bromley Healthcare Contraception and Reproductive Health Service
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Overview
• Quick starting contraception
• Nuvaring
• Qlaira
• CHC and antibiotics
• Ella-one
• Faculty qualifications amnesty
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Nuvaring• Flexible transparent ring
(54mm diameter; 4mm thick)• Inserted vaginally• Combined hormonal contraception• 15 µg/day ethinyl estradiol (EE)
120 µg/day etonogestrel (ENG)• One ring every 4-week cycle
(3 weeks ring in; 1 week ring free)
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Useful for• Once monthly dosing – not LARC, but
related advantages compared to daily and weekly methods (good for women who want to remain in control of method)
• Women who cant settle on a progestogen- only LARC method (usually due to bleeding problems) and choose not to have an IUCD
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Useful for
• Problems with taking pills/COC:
- forgets
- changes in time zone
- difficulty swallowing pills
- nausea on taking pills
- absorption problems
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Advantages• Monthly dosing• Good cycle control• Rapid return of ovulation
(median time 19 days)• Easy to use• High user satisfaction once tried• Low EE dose (15 µg/day)• Avoids oral administration
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User satisfaction study
• 1492 women tried Nuvaring for 13 cycles:
- at baseline 66% said COC preferred method compared to Nuvaring
- after 3 Nuvaring cycles 81% said Nuvaring their preferred method
• 9/10 women would recommend Nuvaring to a friend
Novak A et al. Contraception 2003; 67: 187-194
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Can use with:
• Tampons
• Vaginal thrush treatments
• Spermicides
• Diarrhoea and vomiting
• Antibiotics
(but still need extra precautions with liver-inducing enzymes)
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Disadvantages
• Cost, 3-ring pack costs £27.00 (BNF)
• Before dispensing, needs to be stored in a fridge at 2-8 ºC; once dispensed needs to be used within 4 months (so only dispense 1 pack of 3 rings at a time)
• Still have to remember to remove and insert each month: www.nuvaring.co.uk for text or e-mail reminders
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In practice
• Easy to insert – no special technique or position; effective as long as in contact with vaginal mucosa; just ‘shove it in like a tampon’
• Remove by hooking finger round it • Rarely expelled spontaneously (about 0.5% of
cycles) – if comes out ok if re-inserted within 3h• Clients and their partners, both seem to be
either unaware of or not bothered by it
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In practice
The Nuvaring is meant to be removed after 3 weeks and a new one inserted after a 7-day ring-free interval, however:
- known to be effective for upto 4 weeks if a delay in removing it (un-licensed)
- as with COC must not have more than a 7-day hormone-free interval
- no reason cant ‘run rings on’ (un-licensed)
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Starting schedules• Commence on day one of menstrual cycle or
use condoms for at least 7 days• Can commence at the end of the 7-day PFI if
changing from the COC without extra precautions
• Need extra precautions for at least 7 days if changing from the POP or starting the same day an implant or IUS is removed or contraceptive injection runs out
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Qlaira
• A COC available since 2009
• A phasic pill – consisting of a 28-day cycle with a quadriphasic dosage regimen and a 2-day placebo phase
• The resulting reducing estrogen and increasing progestogen doses are designed to optimise cycle control
• First COC to contain estradiol valerate, which is metabolised to estradiol (that also exists naturally in women)
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Phasic nature of QlairaNumber of pills
Colour Estradiol valerate (mg)
Dienogest (mg)
2 dark yellow 3 0
5 medium red 2 2
17 light yellow 2 3
2 dark red 1 0
2 white 0 0
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Disadvantages• Complex regimen
• Different (complicated) missed pill rules
Therefore need to be a good pill taker and
prepared to follow the regimen
• Cost (£25.18 for a 3-cycle pack – BNF)
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Advantages
• Has recently been licensed for heavy menstrual bleeding in women desiring contraception
• Dienogest is a highly selective progestogen that produces good suppression of endometrial proliferation
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Data from Bayer HealthCare• In 421 women with DUB, including HMB (269
Qlaira; 152 placebo)• 88% reduction in median menstrual loss vs.
baseline at 7 cycles, compared to 24% on placebo
• Other studies show a 96% reduction for women with an IUS at one year and
• 35-43% for women using other COC (un-licensed use)
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Potential users• women who have HMB and choose not to
have an IUS or who it has proved difficult to fit one in and want to avoid surgery
• women who have had problem bleeding (BTB and/or heavy menses) on various COC, as well as with any progestogen-only methods they have tried
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Antibiotics and CHC
• Still need to use an alternative method unaffected by enzyme-inducing drugs (at the very least good condom use) if using the enzyme-inducing rifamycins (such as rifabutin and rifampicin)
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Antibiotics and CHC
- No longer advised to use extra precautions (e.g. condoms) when using CHC with antibiotics that are not enzyme-inducers, even if broad spectrum
- Only proviso if antibiotics or illness cause significant vomiting and/or diarrhoea
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Antibiotics and CHC
- World Health Organisation Medical Eligibility Criteria for Contraceptive Use (WHOMEC, 2009/10)
- US Medical Eligibility Criteria for Contraceptive Use (USMEC, 2010)
- FSRH Clinical Effectiveness Unit (CEU) - (UK Medical Eligibility Criteria for
Contraceptive Use, UKMEC 2009)
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Antibiotics and CHC
• WHOMEC states that there is intermediate level evidence that the contraceptive effectiveness of COCs is not affected by co-administration of most broad-spectrum antibiotics and advises no restriction on use (WHOMEC Category 1) of CHC with antibiotics
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Antibiotics and CHC
• FSRH CEU Clinical Guidance – Drug Interactions with Hormonal Contraception (January 2011)
• On web-site: www.fsrh.org.uk
- as are UKMEC guidelines 2009
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ellaOne
• New (2009) oral post coital/emergency contraceptive
• 30mg ulipristal acetate (one tablet to be taken as soon as possible after UPSI)
• Prescription only (i.e. no direct provision available by pharmacists)
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• Levonelle is a progestogen (1500 µg levenorgestrel)
• ellaOne is a selective progesterone modulator, i.e. acts on the progesterone receptor (tissue-selective) but is not a progestogen
Both primarily work by inhibiting/delaying ovulation, but may also effect endometrium – inhibiting implantation if fertilisation has occured
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• Levonelle licensed for use up to 72 hours post UPSI, but in practice used up to 120 hours (supported by FSRH)
• ellaOne licensed for use up to 120 hours post UPSI
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• ellaOne appears to be marginally more effective than Levonelle, this superior efficacy increasing the longer the time since UPSI
• Would need to treat about 120 women with ellaOne rather than Levonelle to prevent one pregnancy
• If the client wants the most effective method available to prevent pregnancy, she should have a copper IUD fitted (which can be removed at the next menses or kept as a long term method)
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ellaOne concerns
• Effects of ellaOne on any subsequent pregnancy or current pregnancy unknown
• May reduce the efficacy of any ongoing hormonal contraception use or any hormonal contraception started immediate;y after its use
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Costs from current BNF
• Levonelle 1500 - £5.20
• Levonelle OneStep - £13.83
• ellOne - £16.95
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• Bromley Contraception &RH service don’t provide ellaOne
• We issue Levonelle 1500 up to 120 hours post UPSI (and will also consider more than once in a cycle and more than 120 hours post UPSI if before the earliest expected date of ovulation – Dr only)
• Always offer emergency Cu-IUD fit as an alternative if fit parameters – not necessarily at same visit (when give Levonelle as well)
• Dedicated LARC clinics on Tuesday a.m. and Thursday p.m. and can also usually fit on a Monday and Thursday evening
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Faculty of Sexual and Reproductive Healthcare qualification amnesty
• Until 31st July 2011• For people who have already held the qualification in the
past and continue to utilise the relevant skills, but for whatever reason have not re-certified, or experienced IUCD/implant fitters and removers
• Diploma (DFSRH) – necessary for LoC• LoC SDI (sub-dermal implants)• LoC IUT (intrauterine techniques)
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Diploma (DFSRH)• Experienced practitioner currently providing
contraceptive and sexual healthcare• Previously held DFSRH/DFFP or JCC• Completed 15 hours of relevant CPD in last 5
years (meetings/reading/discussions/audit/etc)• Above to include completion of module 8
(Contraceptive Methods) of the e-SRH programme on www.e-lfh.org.uk website (1-2 hours of updating)
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LoC IUT (intra-uterine techniques)
• Experienced IUCD fitters, who have not re-certified or never obtained qualification
• Have the Diploma (DFSRH)
• Self-certify to fitting at least 12 devices per year and to be auditing results
• Have 2 fittings observed by a Faculty Registerd Trainer or a GP trainer who holds LoC IUT
• Have completed module 18 (IUTs) of e-SRH on e-learning for healthcare website
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LoC SDI (sub-dermal implants)• Experienced in SDIs, but
- not re-certified or
- originally trained in a non-Faculty LoC programme as did not have DFSRH
• Need DFSRH now to take advantage of amnesty• Provide details of original training and if >5 years ago
complete module 17 (SDIs) of e-lfh• Received Nexplanon training/updating• Self-certify doing at least 6 procedures a year (at least
one a removal and one an insertion)
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e-learning for Healthcare (e-lfh)• Free to everyone working in NHS• Can access with GMC number – need to register• http://www.e-lfh.org.uk/projects/e-srh/index.html• http://registration.elfh.org.uk/UserRegistration/R
egistrationForm.aspx?pid=18• Access the e-SRH package (sexual and
reproductive health); different to SRH overview in GP training package
• www.fsrh.org
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