Contraceptive ProblemsContraceptive Problems

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhDMarch 2014March 2014

Postnatal ConsultationPostnatal Consultation Elizabeth, a 40 year-old multiparous patient, Elizabeth, a 40 year-old multiparous patient,

visits for her 6 week check after the birth of visits for her 6 week check after the birth of her fourth child. The recent pregnancy her fourth child. The recent pregnancy occurred after a condom failure and was occurred after a condom failure and was complicated by third trimester hypertension. complicated by third trimester hypertension. She is keen to discuss her contraceptive She is keen to discuss her contraceptive alternatives.alternatives.

What further information do we What further information do we require?require?

What are the contraceptive options for What are the contraceptive options for Elizabeth?Elizabeth?

40 yo P40 yo P4 4 6w postpartum and some PIH...6w postpartum and some PIH...

Does she want Does she want more childrenmore children

Is she breastfeedingIs she breastfeeding What are her What are her

periods likeperiods like Is she likely to be a Is she likely to be a

“good pill taker”“good pill taker” Any other relevant Any other relevant

family or personal family or personal history?history?

If the family is complete then If the family is complete then vasectomy is the best optionvasectomy is the best option

If the husband is unwilling If the husband is unwilling then tubal ligation is next then tubal ligation is next bestbest

Interim contraception is Interim contraception is required. required.

If she is breastfeeding a POP If she is breastfeeding a POP would sufficewould suffice

If she has unacceptable If she has unacceptable periods then Mirena would be periods then Mirena would be better than male or female better than male or female sterilisationsterilisation

If she is not a good pill taker If she is not a good pill taker then Implanon or IUD betterthen Implanon or IUD better

If we elect COC, POP or IUD If we elect COC, POP or IUD then we need to check then we need to check personal and family personal and family contraindications to eachcontraindications to each

Teenage ConsultationTeenage Consultation Tammy is a 15 year old mildly obese and Tammy is a 15 year old mildly obese and

mentally slow girl brought along by her mentally slow girl brought along by her mother “for the pill”. Her mother tells you mother “for the pill”. Her mother tells you that she herself is on Warfarin because of that she herself is on Warfarin because of a previous DVT associated with a previous DVT associated with homozygous Factor V Leiden.homozygous Factor V Leiden.

What further information do we What further information do we require?require?

What are the contraceptive options What are the contraceptive options for Tammy?for Tammy?

15 yo Low IQ and FH of Factor V Leiden15 yo Low IQ and FH of Factor V Leiden

Is it contraception, Is it contraception, protection from STD or protection from STD or menstrual problems menstrual problems that the mother is that the mother is there forthere for

Some cycle historySome cycle history Some sexual historySome sexual history Is this patient likely to Is this patient likely to

comply with daily comply with daily medication or condomsmedication or condoms

A Factor V Leiden test A Factor V Leiden test is homozygous positiveis homozygous positive

Mirena is a better option Mirena is a better option than Depot Provera or than Depot Provera or Implanon for this patientImplanon for this patient

All provide excellent All provide excellent contraception with no contraception with no thromboembolic risk but thromboembolic risk but PV bleeding can be a PV bleeding can be a problem for the latter twoproblem for the latter two

Depot may cause Depot may cause osteoporosis when used osteoporosis when used long termlong term

Only condoms (male or Only condoms (male or female) will protect from female) will protect from STD’sSTD’s

Hysterectomy is often Hysterectomy is often requested but requested but problematicalproblematical

At the Aboriginal Health ServiceAt the Aboriginal Health Service Raquel is a 32 year old woman undergoing Raquel is a 32 year old woman undergoing

her 3her 3rdrd termination of pregnancy in two termination of pregnancy in two years. She is morbidly obese, prediabetic years. She is morbidly obese, prediabetic and she smokes 20-25/day. She has one and she smokes 20-25/day. She has one child in the care of a former partner’s child in the care of a former partner’s parents. She says that she “bled all the time parents. She says that she “bled all the time after the needle”.after the needle”.

What further information do we What further information do we require?require?

What are the contraceptive options for What are the contraceptive options for Raquel?Raquel?

32 yo G32 yo G44PP11TT33 Obese Pre-diabetic Smoker Obese Pre-diabetic Smoker

Bleeding after DepotBleeding after Depot Partner(s) relationship Partner(s) relationship

and wish for more and wish for more childrenchildren

Something about her Something about her spontaneous cyclesspontaneous cycles

More details about Depot More details about Depot experience. Who, where, experience. Who, where, when and how many?when and how many?

What other methods of What other methods of contraception has she contraception has she used or does she know used or does she know aboutabout

What does she weighWhat does she weigh

All oral contraception is All oral contraception is contraindicatedcontraindicated

Sterilisation may be a Sterilisation may be a good option for this good option for this patient but it may be patient but it may be technically difficult. technically difficult. Essure maybe?Essure maybe?

Mirena would be a good Mirena would be a good option but she would option but she would need to be warned about need to be warned about the “settling in” bleeding the “settling in” bleeding that occursthat occurs

If Implanon or a POP is If Implanon or a POP is elected she may require elected she may require two!two!

At the Family Planning ClinicAt the Family Planning Clinic

Victoria is a 29-year old business executive Victoria is a 29-year old business executive who has always experienced severe who has always experienced severe dysmenorrhoea with her periods. Her mother dysmenorrhoea with her periods. Her mother died from breast cancer. She has never been died from breast cancer. She has never been pregnant.pregnant.

What further information do we require?What further information do we require?

What are the contraceptive options for What are the contraceptive options for Victoria?Victoria?

29 yo Nullipara Severe Dysmenorrhoea 29 yo Nullipara Severe Dysmenorrhoea Mother breast CaMother breast Ca

Mother’s age when Mother’s age when she developed breast she developed breast CaCa

Any other relatives Any other relatives with breast, ovarian or with breast, ovarian or bowel cancerbowel cancer

Any FH endometriosisAny FH endometriosis Any other Any other

contraindication to contraindication to COCCOC

Is she a good pill-takerIs she a good pill-taker

The COC increases a The COC increases a woman’s lifetime risk of woman’s lifetime risk of 1.24-fold but the absolute 1.24-fold but the absolute risk is lowrisk is low

If there are multiple others If there are multiple others in the family with Ca of in the family with Ca of breast, ovary, bowel then breast, ovary, bowel then this patient may require this patient may require testing for BRAC genestesting for BRAC genes

COC is a reasonable COC is a reasonable option and has a good option and has a good chance of reducing chance of reducing dysmenorrhoea and dysmenorrhoea and maybe endometriosismaybe endometriosis

Mirena would be the next Mirena would be the next best option if compliance best option if compliance a problema problem

Victoria 2Victoria 2

Victoria is prescribed Levlen 30 ED Victoria is prescribed Levlen 30 ED but is experiencing break through but is experiencing break through bleeding when she returns after 6 bleeding when she returns after 6 weeks. She says that she also feels weeks. She says that she also feels “pre menstrual” all the time and has “pre menstrual” all the time and has lost interest in sex.lost interest in sex.

What would you recommend?What would you recommend?

29 yo Nullipara develops BTB on Levlen & 29 yo Nullipara develops BTB on Levlen & reduced libidoreduced libido

Breakthrough bleeding is too little oestrogenBreakthrough bleeding is too little oestrogen It’s too early to change the formulation. BTB is It’s too early to change the formulation. BTB is

common for 2 – 3 cycles but may then disappear. common for 2 – 3 cycles but may then disappear. Check compliance. Check compliance. If the problem persists then switch up to 50 ug EEIf the problem persists then switch up to 50 ug EE

Low libido arises from the progestinLow libido arises from the progestin It may be too early to switch formulation for her It may be too early to switch formulation for her

other side effects as well.other side effects as well. These problems may respond to a switch to a 3These problems may respond to a switch to a 3rdrd

or 4or 4thth generation progestin e.g. Marvelon or generation progestin e.g. Marvelon or YasminYasmin

Working at the After Hours Medical Working at the After Hours Medical CentreCentre

Samantha is a 22 year old single receptionist Samantha is a 22 year old single receptionist who has had one previous baby. She comes who has had one previous baby. She comes after a 7-day cruise holiday and reports that, after a 7-day cruise holiday and reports that, “on the first night of the cruise the condom “on the first night of the cruise the condom broke” during intercourse with a new partner.broke” during intercourse with a new partner.

What further information do we require?What further information do we require?

What are the contraceptive options for What are the contraceptive options for Samantha?Samantha?

22 yo P22 yo P11 7 days post-coital emergency 7 days post-coital emergency

Was she using any Was she using any other method of other method of contraceptioncontraception

Date of LNMP and Date of LNMP and usual cycle lengthusual cycle length

Is there a need for Is there a need for ongoing contraceptionongoing contraception

Any contraindications Any contraindications to copper IUCD use?to copper IUCD use?

Her knowledge of Her knowledge of STDsSTDs

Was the condom the sole Was the condom the sole means of contraception or means of contraception or was it for STD protectionwas it for STD protection

If she was definitely post If she was definitely post ovulatory then the risk of ovulatory then the risk of conception is lowconception is low

This is too late for Pills (5 This is too late for Pills (5 days) but an IUD is still an days) but an IUD is still an option (7 days)option (7 days)

IUD will provide ongoing IUD will provide ongoing contraceptioncontraception

Copper-containing IUD is Copper-containing IUD is recommended and not recommended and not MirenaMirena

Testing for STD is Testing for STD is probably requiredprobably required

In the Antenatal ClinicIn the Antenatal Clinic Bronwyn is a 38 year old about to undergo Bronwyn is a 38 year old about to undergo

her third and elective Caesarean section in her third and elective Caesarean section in an unplanned pregnancy that occurred an unplanned pregnancy that occurred whilst she was “taking the Pill”. She has a whilst she was “taking the Pill”. She has a known uterine fibroid and was treated for known uterine fibroid and was treated for CIN3 5 years ago. In the past she has had CIN3 5 years ago. In the past she has had “very heavy and irregular periods”.“very heavy and irregular periods”.

What further information do we What further information do we require?require?

What are the contraceptive options for What are the contraceptive options for Bronwyn?Bronwyn?

38 yo P2 for CS. Failed COC. Fibroid. CIN3 5 yrs ago. Menorrhagia38 yo P2 for CS. Failed COC. Fibroid. CIN3 5 yrs ago. Menorrhagia

Any more pregnancies Any more pregnancies wantedwanted

Is her CIN curedIs her CIN cured Location of the fibroidLocation of the fibroid

Tubal ligation at the time Tubal ligation at the time of her CS is simple but will of her CS is simple but will not control her not control her menorrhagia and has a menorrhagia and has a 1% risk of failure1% risk of failure

If the HPV test for high risk If the HPV test for high risk subtypes is negative then subtypes is negative then the CIN is inconsequentialthe CIN is inconsequential

Besides, hysterectomy or Besides, hysterectomy or even myomectomy at the even myomectomy at the time of CS is not a good time of CS is not a good ideaidea

Mirena may be a better Mirena may be a better option unless the fibroid is option unless the fibroid is submucosalsubmucosal

Or even tubal ligation plus Or even tubal ligation plus a trial of the Mirenaa trial of the Mirena

A GP ConsultationA GP Consultation Robin and Mia come to talk to you about a Robin and Mia come to talk to you about a

vasectomy. Mia is 34 and Robin is 28. They vasectomy. Mia is 34 and Robin is 28. They have been married for 5 years and do not have been married for 5 years and do not want any children. Three years before she want any children. Three years before she met Robin Mia had a son, currently 8 years of met Robin Mia had a son, currently 8 years of age and a handful because of ADD. Mia has a age and a handful because of ADD. Mia has a Implanon but is experiencing frequent vaginal Implanon but is experiencing frequent vaginal bleeding.bleeding.

What further information do we require?What further information do we require?

What are the contraceptive options for What are the contraceptive options for Robin and Mia?Robin and Mia?

F34 & M28. One child with ADD. Implanon but bleedingF34 & M28. One child with ADD. Implanon but bleeding

What if something What if something were to happen to the were to happen to the child or the child or the relationshiprelationship

Are there any Are there any contraindications to contraindications to COC useCOC use

Or contraindications to Or contraindications to IUCD useIUCD use

Vasectomy is not a good Vasectomy is not a good option because this male option because this male is likely to regret it if is likely to regret it if there is a relationship there is a relationship failurefailure

If Mia is unwilling or If Mia is unwilling or unrelaible or unsuitable unrelaible or unsuitable for long term COC use for long term COC use thenthen

Mirena orMirena or Tubal ligation are better Tubal ligation are better

optionsoptions

A Question of Drug InteractionA Question of Drug Interaction Cindy is an 18 year old who takes Logynon Cindy is an 18 year old who takes Logynon

for contraception. She has moderately for contraception. She has moderately severe pustular acne and a dermatologist severe pustular acne and a dermatologist has recommended that she goes on has recommended that she goes on Vibramycin 100 mg daily for 6-12 months. Vibramycin 100 mg daily for 6-12 months. The dermatologist has recommended that The dermatologist has recommended that she consults you about her current COC she consults you about her current COC formulation.formulation.

Why is the dermatologist concerned?Why is the dermatologist concerned?

What would you recommend?What would you recommend?

18 yo on Logynon (20 ug EE) about top start Doxycline long term18 yo on Logynon (20 ug EE) about top start Doxycline long term

There is a small risk There is a small risk that the antibiotic may that the antibiotic may alter bowel flora and alter bowel flora and the enterohepatic the enterohepatic recirculation of recirculation of oestrogen required for oestrogen required for ovulation suppressionovulation suppression

May be heralded by May be heralded by break through break through bleedingbleeding

Step up the dose of EE to Step up the dose of EE to 30 or 50 ug30 or 50 ug

Consider lengthening Consider lengthening cycles to 3 months andcycles to 3 months and

Shortening the placebo Shortening the placebo period to 4 or 5 daysperiod to 4 or 5 days

Or just add a POP and Or just add a POP and take pills morning and take pills morning and nightnight

Any Questions or Any Questions or Comments?Comments?

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