Family Planning and Pelvic Infection

Family planning and pelvic infection Notes
COMBINED CONTRACEPTIVE
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Combined hormonal contraceptives (CHCs)
Contain estrogen and progestogen and there are currently three methods available in the UK:
Combined oral contraceptive pill (COC)

Combined transdermal patch (CTP)
Combined vaginal ring (CVR).
Currently available CHCs contain synthetic estrogen ethinylestradiol or mestranol, except for the
COC Qlaira, which contains estradiol valerate.
Progestogen
2nd generation
Norethisterone 1mg
Levonorgestrel 150mcg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Spironolactone derivative
Drospirenone 3mg
Failure rate (Pearl index - failure rate per 100 woman year) = 0.1 if correctly taken.
Mode of action
Primarily by inhibiting ovulation via action on the hypothalamo-pituitary-ovarian axis to

reduce LH & FSH levels
Alterations to cervical mucus and the endometrium may also contribute to the efficacy of
CHC
Standard regimen
Combined oral contraception (COC)
Majority of COCs in the UK are monophasic (fixed dose) pills containing between 20
and 35 g of EE in combination with a progestogen. Variable dose (phasic) COCs also
available.
The majority of COCs contain 21 active pills; the first seven pills inhibit ovulation and
the remaining 14 pills maintain anovulation.
Traditionally women have then either had seven pill-free days or taken seven placebo
tablets before starting the next packet of pills. During this time most women will have a
withdrawal bleed due to endometrial shedding.
Combined transdermal patch (CTP)
Measures 20 cm2 and releases an average of 33.9 g EE and 203 g norelgestromin per
24 hours.
One patch is applied and worn for 1 week to suppress ovulation. Thereafter the patch is
replaced on a weekly basis for two further weeks.
The fourth week is patch-free to allow a withdrawal bleed. A new patch is then applied
after seven patch-free days.
Combined vaginal ring (CVR)
Releases EE and etonogestrel at daily rates of 15 g and 120 g, respectively.

A ring is inserted into the vagina and left in continuously for 21 days. After a ring-free
interval of 7 days to induce a withdrawal bleed, a new ring should be inserted.
Tailored regimens
The traditional cyclical pill regimens were designed to mimick naturally occurring
menstrual cycles.
There are COCs that are licensed to be used continuously or with pill-free intervals less
than 7 days. In the UK the only currently available regimen is the COC containing
estradiol valerate with dienogest (Qlaira), which consists of 26 active pills and two
placebo tablets.
Continuous dosing or extended regimens were similar in terms of contraceptive efficacy,
safety profiles and compliance, and that where satisfaction was assessed, women reported
high satisfaction with extended regimens.
The potential advantages of such regimens are that they enable women to eliminate or
reduce the frequency of their withdrawal bleed and any related symptoms.
Women using everyday COCs would need to be advised to omit the placebo pills in a
packet or to switch to a monophasic 21-day COC.
Efficacy
A Cochrane review comparing the combined patch, ring and pill has concluded that these
methods have similar efficacy
With perfect use the failure rate is 0.3% and with typical use (actual use including
inconsistent or incorrect use) is 9%
A Cochrane review has concluded that the current evidence examining the effects of
body mass index (BMI) on COC effectiveness is limited and that COC appears to be
effective in all women when the recommended regimen is followed.
The Summary of Product Characteristics (SPC) specifies that contraceptive efficacy may
be decreased in women weighing 90 kg, therefore additional precautions or an
alternative method should be advised.
Cycle control
Unscheduled bleeding is less common with CHC than with progestogen-only methods
CTP and COC provide similar cycle control
CVR provides similar or improved cycle control compared with COCs
Cycle control may be better with COCs containing 3035 g EE compared with those
containing 20 g EE.
Side effects
CTP users experience more breast discomfort, dysmenorrhoea, nausea and vomiting
CVR users report less nausea, acne, irritability and depression than pill users, but studies
suggest they experience more vaginal irritation and discharge
Adherence
Figures from the USA suggest that approximately 68% of women will have discontinued
contraception by the end of 12 months, although oral contraceptives were the least likely
method of contraception to be discontinued for method-specific reasons (32%)
Discontinuation is likely to be followed by resumption of another method rather than
complete abandonment of contraception
In relation to CHC, rates are generally similar for COC and CVR users, whereas in
clinical trials CTP users have reported better compliance than COC users
Assessment
History
Medical conditions (past and present); family history of medical conditions (past and
present); and drug history (prescription, non-prescription and herbal remedies)
Specific attention to enquiring about migraine and cardiovascular risk factors (smoking,
obesity, hypertension, thrombophilia, previous venous thromboembolism (VTE) and
hyperlipidaemia).
Examination
BP, weight and BMI should be documented for all women before a first prescription of
CHC.
Routine screening for thrombophilias not appropriate because of the rarity of the conditions and
the high costs of screening
UKMEC should be referred to when assessing a persons eligibility for combined hormonal
contraception
Unless specifically stated, UKMEC does not take account of multiple conditions. Therefore
assessing a persons eligibility in the presence of multiple medical and social factors will require
clinical judgement and balancing of risks and benefits.
Criteria for excluding pregnancy
One or more of the following should be met
Has not had intercourse since last normal menses

Has been correctly and consistently using a reliable method of contraception
Is within the first 7 days of the onset of a normal menstrual period
Is within 4 weeks postpartum for non-lactating women
Is within the first 7 days post-abortion or miscarriage
Is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
A pregnancy test, if available, adds weight to the exclusion of pregnancy but only if 3 weeks
since the last episode of UPSI
Also consider if a woman is at risk of becoming pregnant as a result of UPSI within the last 7
days and undertake pregnancy testing where appropriate (3 weeks since last UPSI)
Starting CHC
Conception is most likely to occur following unprotected sexual intercourse on the day of
ovulation or in the preceding 24 hours.
Timing of the fertile period is highly variable
The probability of pregnancy from a single act of intercourse in the first 3 days of the
cycle appears to be negligible
COCs containing EE can be started up to and including Day 5 of the cycle without the
need for additional contraceptive protection
Beyond Day 5 a woman may start COC at any other time if it is reasonably certain she is
not pregnant
When starting COCs after Day 5 women should use additional precautions such as
condoms or avoid sex for the next 7 days
Estradiol valerate/dienogest-containing pill (Qlaira) should be started on Day 1, with
additional precautions used for 9 days if starting any time after this.
For the CTP and CVR there is little direct evidence on the safety of starting after Day 1.
In a randomised study comparing ovarian suppression between the CVR started on Day 5
and COC started on Day 1 a difference was found in the maximum follicular diameters in
the first treatment cycle, with those starting the ring having larger follicular diameters
than those starting the COC. However, ovulation was adequately suppressed with no
ovulations occurring in either group
In a small, open-label, randomised study ovarian suppression has been demonstrated with
3 days of ring use
No evidence is available for the CTP and therefore the advice is extrapolated from COC
evidence
Women who are amenorrhoeic
Start at any time if it is reasonably certain she is not pregnant. Use additional
contraception for 7 days, 9 days for estradiol valerate/dienogest pill
Postpartum (not breastfeeding)
Start on Day 21 postpartum if no additional risk factors for VTE

After Day 21 postpartum, if menstrual cycles have returned, start CHC as for other
women having menstrual cycles
After Day 21 postpartum if menstrual cycles have not returned start as amenorrhoeic
women
Post first- or second-trimester abortion
Up to and including Day 5b post abortion (Day 1 for estradiol valerate/dienogest pill)
At any other time if it is reasonably certain she is not pregnant plus additional
contraception for 7 days, 9 days for estradiol valerate/ dienogest pill
Switching
From one CHC to another CHC
Start on day after last active COC, CTP, CVR. If a 7-day interval is taken the need for
additional precautions and EC should be assessed on an individual basis, taking account
of correct use before the hormone-free period
Traditional POPs and LNG-IUS to CHC
Can be started immediately if the previous method was used consistently and correctly
Additional contraception for 7 days, 9 days estradiol valerate/ dienogest pill
The primary mode of action is not inhibition of ovulation and therefore additional
precautions are required in case ovulation occurs before contraceptive efficacy of CHC
has been established. The cervical mucus effect may be maintained but there is no
evidence to prove adequate contraceptive protection
Progestogen-only anovulatory methods (implant, injectable and desogestrel-only pill) to CHC
Can be started any time up to when the repeat injection is due or implant is due for
removal or next day after pill
The primary mode of action of these methods is inhibition of ovulation. CHC suppresses
ovulation by the time the inhibitory effect of the previous method is lost
IUD to CHC
Up to Day 5 of menstrual cycle. IUD can be removed at that time (Day 1 only estradiol
valerate/dienogest pill)
At any other time during the menstrual cycle or if amenorrhoeic. Additional
contraception required for 7 days, 9 days for estradiol valerate/ dienogest pill.
Additional precautions are required unless CHC was started 7 days prior to IUD removal
(9 days estradiol valerate/dienogest pill)
Women with short cycles
Fewer than 5% of women aged 1544 years and fewer than 2% of women aged 2039
years have menstrual cycles less than 20 days
<1% of women aged 1442 years have cycle lengths less than 15 days
If there is concern about very short or variable cycles, women can be given the option to
use condoms when starting after Day 1
Missed COC pills (except estradiol valerate/dienogest pill)
A missed pill is a pill that is completely omitted (i.e. more than 24 hours have passed
since the pill was due; 48 hours since last pill taken)
When pills are missed, the inhibitory effects on the ovaries may be reduced sufficiently
for ovulation to occur and women may therefore be at risk of pregnancy
If ONE pill has been missed (4872 hours since last pill in current packet or 2448 hours
late starting first pill in new packet)
The missed pill should be taken as soon as it is remembered
The remaining pills should be continued at the usual time
Emergency contraception (EC) is not usually required but may need to be considered if
pills have been missed earlier in the packet or in the last week of the previous packet
If TWO OR MORE pills have been missed (>72 hours since last pill in current packet or
>48 hours late starting first pill in new packet)
The most recent missed pill should be taken as soon as possible.
The remaining pills should be continued at the usual time.
Condoms should be used or sex avoided until seven consecutive active pills have been
taken. This advice may be overcautious in the second and third weeks, but the advice is a
backup in the event that further pills are missed
If pills are missed in the first week (Pills 17), EC should be considered if unprotected
sex occurred in the pill-free interval or in the first week of pill-taking.
If pills are missed in the second week (Pills 814)
No indication for EC if the pills in the preceding 7 days have been taken consistently and
correctly (assuming the pills thereafter are taken correctly and additional contraceptive
precautions are used).
If pills are missed in the third week (Pills 1521)
OMIT THE PILL-FREE INTERVAL by finishing the pills in the current pack (or
discarding any placebo tablets) and starting a new pack the next day
Unscheduled removal of the patch
If a patch has been partially or fully detached for less than 24 hours contraceptive
efficacy is maintained and no additional precautions are required
If the patch has been worn for 7 days a patch can remain off for up to 48 hours before
contraceptive efficacy is reduced. After 48 hours of being detached additional
contraception would be required
Extended use of the patch
Pharmacokinetic data suggest that there is sufficient release of norelgestromin and EE to

maintain serum levels within the reference range for up to 10 days
A patch can be worn for up to 9 days without contraceptive efficacy being affected. After
9 days additional precautions are required and EC may need to be considered
Extended patch-free interval
The patch-free interval can be extended up to 48 hours (9-day patch-free interval) with no
effect on contraceptive efficacy, providing the patch was worn consistently and correctly
prior to the patch-free interval
Extension of the ring-free interval
If the ring-free interval is extended by 48 hours or more additional contraception is

required. EC may be required if sexual intercourse has occurred in the ring-free interval
or Week 1. Such use is off licence
Unscheduled removal of the ring
In Week 1
The advice in relation to extended ring-free interval applies
In Weeks 2 and 3
Providing the CVR has been used consistently and correctly for the previous 7 days, it
can be left out of the vagina for up to 48 hours without affecting efficacy (outside the
terms of the product licence). After 48 hours, additional contraception is required until 7
days of consistent use
In Week 3 a woman may opt to start a new cycle by inserting a new ring immediately and
missing her ring-free week or providing the CVR has been in for 7 days previously she
can have her withdrawal bleed and insert a new ring no later than 7 days from the time
the CVR was expelled / removed
Extended use of the ring
Ring can be worn for up to 4 weeks without efficacy being affected and ring-free interval
can still be taken. Additional contraception needed after 4 weeks. Additional precautions
not required until the end of the 5th week providing the ring is inserted immediately and
no ring-free period is taken
Drug Interactions
Antibiotics (non enzyme-inducing)
Additional precautions not required when using antibiotics (non enzyme-inducing)

Only proviso would be that if the antibiotics caused vomiting or diarrhoea then the usual
additional precautions relating to these conditions should be observed
Enzyme-inducing drugs
Increase the metabolism of estrogens and progestogens and may reduce the
contraceptive efficacy of CHC
Women using enzyme-inducing drugs should ideally switch to a method that is
unaffected (IUD or the progestogen-only injectable)
If enzyme-inducing drugs are used short term, additional precautions may be used (COC
used must contain at least 30 g EE, the patch or ring) during and for 28 days after
stopping the enzyme-inducing drug
With the exception of the very potent enzyme inducers rifampicin and rifabutin, women
who are taking an enzyme-inducing drug and who do not wish to change from COC or
use additional precautions may increase the dose of COC to at least 50 g EE (maximum
70 g EE) and use an extended or tricycling regimen with a pill-free interval of 4 days
Women using rifampacin or rifabutin should use condoms in the short term or switch to a
method unaffected by enzyme-inducing drugs
Lamotrigine
Serum levels of lamotrigine are reduced by CHC

Increased side effects have been reported on cessation of CHC
A case series reported increased frequency of seizures in four women with reduced
lamotrigine levels following the initiation of COC
Increase in lamotrigine levels during the pill-free weekand following cessation of oral
contraceptives
When lamotrigine is combined with sodium valproate, no reduced effect occurs
Due to the risk of drug interactions, the use of lamotrigine (except in combination with
sodium valproate) with CHC is a UKMEC 3
Other drugs
Ulipristal acetate (UPA) blocks the action of progesterone and could reduce the efficacy
of progestogen-containing contraceptives
Additional precautions are advised for 14 days after using UPA and CHC concomitantly
(16 days estradiol valerate/dienogest pill)
Although mifepristone is similarly a progesterone receptor modulator, the SPC for
mifepristone does not currently indicate a possible interaction.
Some drugs such as anti-obesity drugs may have the potential to reduce the efficacy of
contraceptives indirectly by causing severe diarrhoea or vomiting
The general advice for women using oral contraceptives who have persistent vomiting or
severe diarrhoea for more than 24 hours is to follow the instructions for missed pills
Health risks
VTE
Risk of VTE in women of reproductive age not using oral contraceptives is about 45/10
000 woman-years
The reasons for the apparent increase in the background prevalence of VTE over time
include
1. a true increase in incidence (perhaps due to changing demographic trends such as obesity
rates)
2. increased clinician awareness and better diagnostic precision, or a combination of these
factors.
The risk of VTE amongst COC users is approximately twice that of non-users [910/10
000 woman-years
The risk is greatest in the first few months of starting, after which the risk falls although
is still higher than among non-users until COC is stopped
The risk returns to that of non-users within weeks of discontinuation
An increased risk in VTE has been observed in women restarting the pill after breaks of 4
weeks or more, but providing there is less than a 4-week break, switching COC
preparations does not appear to be associated with an initial excess risk compared to
long-term use
Risks of VTE associated with pregnancy = 29/10 000 woman-years and the immediate
postpartum period 300400/10 000 woman-years
VTE and individual products
Observational studies have reported that COCs containing desogestrel, gestodene and
cyproterone are associated with a higher risk of VTE than those containing levonorgestrel
(LNG), norethisterone and norgestimate
There is conflicting evidence in relation to COCs containing drospirenone (DSP)
The MHRA states that the risk of VTE associated with DSP-containing COCs is higher
than with LNG-containing COCs and may be similar to the risk associated with
desogestrel- or gestodene-containing COCs
The MHRA indicates that LNG-containing pills may be the safest pill choice for
women starting or switching contraception
Given none of the newer generation pills have been shown to be associated with a lower
risk of VTE, women should probably be offered an older, low-dose formulation in the
first instance
Women should be informed that while some progestogens may be associated with a
higher risk of VTE than others, the risk of VTE in women who use CHC is very small
and smaller than that associated with pregnancy
Breast cancer
Increased risk of breast cancer whilst using COC [RR 1.24; 1.151.33], which is
approximately an increase of 24% above the background risk
Any excess risk of breast cancer associated with COC increases quickly after starting,
does not increase with duration of use, and disappears within 10 years of stopping COC
use
Women can be informed that use has not been associated with a long-term effect, with
studies finding no statistically significant difference in risk between ever-users and never-
users
Use of COCs have not been found to be associated with increased mortality from breast
cancer
Breast cancer and family history
Family history of breast cancer associated with an increased risk of breast cancer
Risk of breast cancer amongst women with a family history is not increased further by
using COCs
A family history of breast cancer therefore does not restrict use of CHC (UKMEC 1)

Breast cancer and genetic mutations
Evidence is conflicting on whether women who are carriers of BRCA1 or BRCA2

mutations are at further increased risk of breast cancer with COC use
Having a genetic mutation associated with breast cancer is UKMEC 3
Current breast cancer
UKMEC 4
Cervical cancer
The risk of cervical cancer appears to increase with duration of COC use
However, long-term users can be reassured that the benefits of use generally outweigh the
risks
After COC use ends the risk of invasive cancer declines, returning to that of never-users
10 or more years after stopping
Women should be informed about the link between HPV and cervical cancer, and that
risk can be reduced through condom use, stopping smoking, regular cervical screening
and, where appropriate, vaccination against HPV
Non-contraceptive health benefits
Mortality
Ever-use of oral contraceptives was associated with a 12% reduction in all-cause

mortality and no overall increased risk of cancer
Ovarian and endometrial cancer
The risk of developing or dying from ovarian and endometrial cancer is reduced with use
of COC
With every 5 years of use there is approximately a 20% reduction in the risk of ovarian
cancer. A womans risk after 15 years of use was around half of those who had never
used COC
Risk reductions of at least 50% have also been noted for endometrial cancer
The protective effect increases with increasing duration of use and whilst it decreases
over time after stopping, it has been shown to last up to several decades after use
Amongst BRCA mutation carriers, COC use has been shown to provide a protective
effect against ovarian cancer
Data also suggest a reduction in the incidence of ovarian cysts and benign ovarian
tumours
Acne
A Cochrane review found that the four COCs studied within included trials were
effective in reducing inflammatory and non-inflammatory facial acne lesions
Co-cyprindiol (COCs containing EE and cyproterone acetate), which is licensed for the
treatment of acne that has not responded to oral antibiotics, can be used for contraception
but should not be used solely for contraceptive purposes
Because co-cyprindiol is associated with a higher VTE risk, it should ideally be
withdrawn 34 months after the condition has resolved
Colorectal cancer
COC associated with a decreased risk

The protective effect appears to be associated with current or recent use and there is
currently no evidence of a relationship with duration of use
Dysmenorrhoea and heavy menstrual bleeding
Data from observational studies suggest that women report improvement with use of
different combined methods, although dysmenorrhoea has been more commonly reported
in patch users than COC users
Low-dose COC could possibly be used to treat pain associated with endometriosis
NICE indicates that COC can be used for the treatment of heavy menstrual bleeding
Side effects
Unscheduled bleeding
Up to 20% of COC users have irregular bleeding

Bleeding usually settles with time and women should continue their combined hormonal
methods for 3 months before considering changing
Consider likely causes such as missed pills, STIs, pregnancy and malabsorption
Mood changes
CHC may be associated with mood changes but there is no evidence that it causes
depression
Weight gain
Current evidence does not support a causal association between CHC and weight gain
Follow-up Arrangements
After 3 months allow BP to be rechecked, and assessment of any problems

Women may be offered up to a 12 months supply of COC or CTP at the follow-up
appointment
A yearly routine follow-up visit, plus advice to return at any time if there are problems, is
recommended
Follow-ups should involve checking BP, BMI and enquiring about any health changes.
After dispensing, rings should be stored at room temperature and used within 4 months.
Therefore no more than three rings can be provided
Duration of use
CHC can be used up until the age of 50 years

No limit is given as to the number of years a woman can use a combined hormonal
method
CHC, Travelling & High Altitude
Long duration travel is a moderate risk factor for VTE

Maintaining mobility in all travellers is a reasonable precaution for flights over 3 hours
CHC users who are taking flights over 3 hours should be advised to reduce periods of
immobility
Women travelling through different time zones should be reminded of the importance of
taking their pill approximately 24 hours after their most recent pill
A pill is missed when it has been more than 48 hours since the last pill was taken. Two
pills have been missed when it has been more than 72 hours since the last pill was taken.
Due to theoretical concerns about estrogen-induced thrombosis during long stays at high
altitude women should consider avoiding the COC if they are to spend more than a week
above 4500 m.
UK Medical eligibility criteria
Personal
Menarche to < 40 years = UKMEC 1

40-50 years = UKMEC 2
Post-partum and breastfeeding up to 6 weeks = UKMEC 4
6 weeks to < 6 months breastfeeding = UKMEC 2; 6 months or over = UKMEC 1
Post-partum and not breastfeeding up to 3 weeks with one other risk factor for VTE =
UKMEC 4. Without VTE risk factors = UKMEC 3. From 3-6 weeks with one risk factor
for VTE = UKMEC 3 and without risk factors = UKMEC 2. At or after 6 weeks =
UKMEC 1
VTE risk factors include immobility, transfusion at delivery, BMI 30 kg/m2, postpartum
haemorrhage, immediately post-caesarean delivery, pre-eclampsia or smoking
Miscarriage / TOP
Post first / second trimester TOP / miscarriage / ectopic pregnancy / septic miscarriage =
UKMEC 1
Smoking
Aged < 35 years = UKMEC 2

Aged 35 years or older and < 15 cigarettes per day = UKMEC 3
Aged 35 years or older and 15 or more cigarettes pre day = UKMEC 4
Stopped smoking < 1 year = UKMEC 3
Stopped smoking 1 year or more = UKMEC 2
BMI (including history of bariatric surgery)
Less than 30 = UKMEC 1

30-34 = UKMEC 2
35 or more = UKMEC 3
Organ transplant
Uncomplicated = UKMEC 2
Complicated: graft failure (acute or chronic), rejection, cardiac allograft vasculopathy =
UKMEC 3
Cardiovascular disease
Multiple risk factors for CVD (such as smoking, diabetes, hypertension, obesity and
dyslipidaemias) = UKMEC 3
Adequately controlled hypertension = UKMEC 3
BP 160/110 mmHg or more = UKMEC 4
Vascular disease including ischaemic heart disease and stroke (including TIAs) =
UKMEC 4
History of hypertension in pregnancy = UKMEC 2. COC users with a history of high BP
in pregnancy have an increased risk of MI and VTE, compared with COC users who do
not have a history of high BP during pregnancy
Known dyslipidaemias = UKMEC 2
VTE
History of VTE = UKMEC 4

First degree relative with VTE aged < 45 years = UKMEC 3
First degree relative with VTE aged 45 years or over = UKMEC 2
Varicose veins = UKMEC 1
Superficial vein thrombosis = UKMEC 2
Known thrombophilia = UKMEC 4. Factor V Leiden, prothrombin mutation, protein S,
protein C and antithrombin deficiencies
Surgery
Major surgery with prolonged immobilization = UKMEC 4.

Discontinue 4 weeks before major elective surgery (>30 mins duration) and all surgery
on the legs or surgery which involves prolonged immobilisation of a lower limb
Restart at least 2 weeks after full mobilization
POC may be offered as an alternative
When discontinuation of CHC is not possible, LMWH and TED stockings recommended
These recommendations do not apply to minor surgery with short duration of anaesthesia
(e.g. laparoscopic sterilisation or tooth extraction)
Major surgery without prolonged immobilization = UKMEC 2
Minor surgery = UKMEC 1
Prolonged immobilization not related to surgery = UKMEC 3
Valvular & congenital heart disease
Uncomplicated = UKMEC 2. Uncomplicated cases could be considered to be where:

there is (i) no requirement for cardiac medication, (ii) the woman is asymptomatic and
(iii) a cardiology review is required annually or less.
Complicated = UKMEC 4
Cardiomyopathy with normal cardiac function = UKMEC 2, abnormal cardiac function =
UKMEC 4
Atrial fibrillation = UKMEC 4
Headache
Non-migrainous initiation = UKMEC 1, continuation = UKMEC 2

Migraine without aura initiation = UKMEC 2, continuation = UKMEC 3
Migraine with aura = UKMEC 4
History of migraine with aura (5 years or more) = UKMEC 3
Benign intra-cranial hypertension = UKMEC 2
Epilepsy
Epilepsy on anti-epileptic drugs = UKMEC 1

Certain anti-epileptic drugs can affect the bioavailability of hormonal contraception. In
addition, hormonal contraception may affect the levels of certain anti- epileptic drugs
with potential adverse effects
Molar pregnancy
Molar pregnancy / gestational trophoblastic neoplasia = UKMEC 1

Following molar pregnancy evacuation, COC use does not increase the risk of gestational
trophoblastic neoplasia, and some COC users experience a more rapid regression in hCG
levels compared with non-users. Use of COC during chemotherapy does not significantly
affect the regression or treatment of gestational trophoblastic neoplasia compared with
women who use a non-hormonal contraception method or DMPA.
Depression= UKMEC 1
COC use does not increase depressive symptoms in women with depression compared to
baseline or to non-users with depression
Breast
Undiagnosed breast symptoms / mass: Initiation = UKMEC 3, continuation = UKMEC 2.

Benign breast condition / family Hx of breast cancer = UKMEC 1
Carrier of gene mutation associated with breast cancer = UKMEC 3. The very limited
evidence in this area suggests that the risk of breast cancer among women with either a
family history of breast cancer or with known inherited breast cancer gene mutations is
probably not modified by the use of COC
Current breast cancer = UKMEC 4
Past breast cancer = UKMEC 3
Genital tract malignancy
Endometrial / ovarian cancer = UKMEC 1

CIN, cervical cancer awaiting treatment and radical trachelectomy = UKMEC 2.
Among women with persistent HPV infection, long-term COC use (5 years) may
increase the risk of carcinoma in situ and invasive carcinoma
HIV
HIV disease = UKMEC 1 regardless of CD4 count. Certain anti-retroviral drugs have the
potential to affect the bioavailability of steroid hormones in hormonal contraception
Diabetes
Diabetes mellitus = UKMEC 2. Among women with insulin or non- insulin-dependent

diabetes, COC use has limited effect on daily insulin requirements and no effect on long-
term diabetes control (e.g. HbA1c levels) or progression to retinopathy.
Nephropathy, retinopathy, neuropathy and other vascular disease = UKMEC 3
Liver / bowel disease
Symptomatic or medically treated gall bladder disease = UKMEC 3

Asymptomatic disease / cholecystectomy = UKMEC 2
Acute viral hepatitis / flare: initiation = UKMEC 3, continuation = UKMEC 2
Obstetric cholestasis = UKMEC 2
COCP-related cholestasis = UKMEC 3
Chronic hepatitis, chronic carrier or mild compensated cirrhosis = UKMEC 1
Decompensated cirrhosis = UKMEC 4
Focal nodular hyperplasia = UKMEC 2
Hepatocellular adenoma / carcinoma = UKMEC 4
Inflammatory bowel disease = UKMEC 2
Anaemias & auto-immune diseases
Sickle cell disease = UKMEC 2

SLE with anti-phospholipid antibodies = UKMEC 4
SLE without anti-phospholipid antibodies = UKMEC 2
Anti-phospholipid antibodies = UKMEC 4

PROGESTOGEN-ONLY CONTRACEPTIVE
Add your own notes

PROGESTOGEN ONLY PILLS (POP)
Types
POPs commonly available in the UK are as follows:
Brand name Progestogen and dose

- Cerazette 75g desogestrel
- Femulen 500 g etynodiol diacetate
- Noriday 350 g norethisterone
- Micronor 350 g norethisterone
- Norgeston 30 g Levonorgestrel
Mechanisms of action
Primary effect - thickening of cervical mucous and reducing sperm penetrability

Primary effect of cerazette - by suppressing ovulation (97% of cycles on desogestrel are
anovulatory)
Other POPs suppress ovulation to a variable extent (60% of cycles on levonogestrel only pill
are anovulatory.)
Reduces endometrial receptiveness
Reduces fallopian tube motility
Efficacy
Daily pill taking around same time of day (within 3 hrs) or (within 12 hrs for cerazette)
Failure rate for traditional POPs vary from 0.3 to 0.8 / 100 women years
Cerazette pearl index 0.41 / 100 woman years
Efficacy increases with age particularly after 40 yrs
No evidence to suggest reduced efficacy in women > 70 kg therefore licensed use of 1 pill / day
is recommended
No evidence that one POP is more effective than another
Advantages
Contraceptive benefits
Effective - see notes on efficacy above

Reversible
No delay in return of fertility
Everyday regime may help compliance with some patients
Non contraceptive benefits (including Cerazette)
Endometriosis may improve symptoms

Primary dysmenorrhoea inhibits ovulation therefore can relieve primary dysmenorrhoea
Premenstrual tension - inhibits ovulation therefore cyclical changes
Can be used when oestrogens pose a significant health risk e.g. smokers over 35 yrs, diabetics
with vascular complications,
Side effects / disadvantages
General progestogenic side effects:

Bloating
Amenorrhoea
Breast tenderness
Acne
Decreased libido
Mood swings can occur but no evidence it causes depressions
Vaginal dryness
Weight gain though weight gain has been documented, there is NO evidence of a causal
association between POP use and weight gain (FSRH Nov 2008 guidance)
Increased risk of ectopic if becomes pregnant whilst on the pill
Needs to be taken around same time every day (3 hr window of safety or 12 hrs for cerazette)
Managing complications irregular bleeding
Exclude
1. Sexually transmitted infections
2. Cervical causes of bleeding e.g. cervicitis, polyps
3. Pregnancy complications e.g. ectopic
Consider increasing dose of progestogen though there is no evidence, it may work for some
individuals
Consider changing to a COCP if no contraindications
Progestogen-only Pills: UKMEC 3 Risks outweigh benefits
Cardiovascular
Current / history of ischaemic heart disease (Continuation). UKMEC 2 for initiation

Stroke (Continuation). UKMEC 2 for initiation
Malignancy
Past history of breast cancer with no evidence of recurrence for 5 years (current breast
cancer = UKMEC 4)
GI Disorders
Severe decompensated cirrhosis, hepatocellular adenoma and hepatoma
Rheumatological
SLE with positive or unknown anti-phospholipid antibodies (SLE on its own or on
immuno-suppressive therapy or severe thrombocytopaenia = UKMEC 2)
PROGESTOGEN ONLY INJECTABLES
Types
Depo-medroxyprogesterone acetate 150mg (depo-provera, given every 12 weeks).

Norethisterone oenanthate 200mg (noristerat, given every 8 weeks)
Mechanism of action
Main effect is by inhibiting ovulation. In addition, thickening of cervical mucous prevents sperm
penetration and changes to the endometrium make it an unfavourable environment for
implantation.
Pearl index
0.25-0.5 / 100 women years (depo-provera)
0.4-2.0 / 100 women years (noristerat)
Depo-provera is most commonly used progestogen injectable in the UK
Advantages
Effective method of contraception

Lower risk of ectopic compared to POP
Lower risk of PID, endometrial cancer
Disadvantages / side effects
a) Menstrual irregularities common. Amenorrhoea becomes more likely with repeated doses.
(35% after 1st dose, 70% by 1 year). About 50% of users will discontinue after 1 year because of
irregular bleeding patterns. (FFHRC 2008)
b) Delay in return of fertility can be delayed for up to 1 2 years after last injection.
c) Weight gain associated with weight gain of up to 3 kg at 2 years. Those with higher BMI >
30 are more likely to gain more weight.
d) Heavier bleeding has been associated with use in women who are less than 6 weeks
postpartum though it is not contraindicated.
e) Depo-provera & osteoporosis there is evidence that depot causes a reduction in bone mineral
density. Reduction appears to be partly reversible after discontinuation and resumption of
ovarian activity. There is no evidence on long term fracture risk. In adolescents, depo-provera
should only be used after other methods have been considered and found to be unsuitable or
unacceptable.
In women with risk factors for osteoporosis, other methods should be considered prior to depo-
provera.
In all women, careful re-evaluation of risks and benefits of treatment should be undertaken in
those who wish to continue longer than 2 years.
Progestogen-only Injectables: UKMEC 3 Risks outweigh benefits
Cardiovascular
Multiple risk factors for cardiovascular disease (such as age, smoking, diabetes,
hypertension, obesity)
Vascular disease
Current / history of ischaemic heart disease
Stroke
Malignancy
Unexplained vaginal bleeding before investigation

cancer = UKMEC 4)
Endocrine
Diabetes mellitus with nephropathy, neuropathy or retinopathy
GI Disorders
Rheumatological
SLE with positive or unknown anti-phospholipid antibodies or severe thrombocytopaenia

(im injection). (SLE on its own or on immuno-suppressive therapy = UKMEC 2)
PROGESTOGEN ONLY SUB-DERMAL IMPLANTS
Types
Implanon (68mg etonorgestrel. Active metabolite of desogestrel)

Licensed for use for 3 years
Pregnancy rate: less than 1 in 1,000 over 3 years

Mechanism of action
Primary effect is by inhibiting ovulation.

In addition, implants thicken cervical mucous preventing sperm penetration and alter the
endometrium which makes it an unfavourable environment for implantation.
Advantages
a) Effective method of contraception

b) Long acting reversible contraception
c) Reduces overall risk of ectopic compared to non contraceptive users
d) Rapid return of fertility 90% of women ovulate within 30 days.
e) Can be used in women with BMI > 30 without reduction in efficacy.
f) No evidence of clinically significant effect on bone mineral density with implanon use.
Disadvantages
a) Irregular bleeding patterns 20% will become amenorrhoic, 50% will have irregular bleeding
patterns. Most common reason for discontinuation is irregular bleeding.
Progestogen-only Implants: UKMEC 3 Risks outweigh benefits
Cardiovascular
Current / history of ischaemic heart disease (Continuation). UKMEC 2 for initiation

Stroke (Continuation). UKMEC 2 for initiation
Malignancy
Unexplained vaginal bleeding before investigation

cancer = UKMEC 4)
GI Disorders
Rheumatological
SLE with positive or unknown anti-phospholipid antibodies (SLE on its own or on

immuno-suppressive therapy or severe thrombocytopaenia = UKMEC 2)
IUD & IUS / PERSONA
Add your own notes
INTRA-UTERINE CONTRACEPTION
Act by preventing fertilisation and implantation. The progesterone releasing intra-uterine

system has local progestogenic effects on the endometrium and cervical mucus.
Disadvantages are difficulties with insertion, pain and vaginal bleeding, risk of pelvic infection,
expulsion.
TYPES
Cu T 380 or T Safe 380A
Licensed for 8 years in theUK

First choice IUCD - low failure rate (1.4 - 2.2 / 100 women over 5 years) and low expulsion rate
(~8 / 100 women over 5 years)
Multiload Cu 375
Licensed for 5 years

Twice as likely to result in pregnancy compared to Cu T 380 with similar expulsion rates and
removal rates for abdominal pain and bleeding.
GyneFix
Licensed for 5 years

Frameless device with 6 copper beads wound around a monofillament polypropylene thread
Should only be inserted by those who have received appropriate training
Has similar efficacy to Cu T 380 but with significantly lower expulsion rate (3.0 / 100 women at 3
years) compared to Cu T 380 (7.38 / 100 women at 3 years).
Total use discontinuation rates lower than with Cu T 380
Value in reducing dysmenorrhoea, menstrual loss and potential ease of insertion in nulliparous
women remain to be proven in RCTs
Efficacy of IUCDs is dependent on the surface area of copper and the Nova-T200, and Multiload
Cu 250 (devices containing 200-250 square mm of Cu) are less effective and unsuitable for long-
term use.
The Faculty of Family Planning recommends that IUCDs fitted after the 40th birthday need not
be changed, since fertility declines rapidly at this age and should be removed 1 year after the
menopause
Screening for genital tract infections and prophylactic antibiotics should be considered in all
women who are having an IUD fitted.
THE MIRENA INTRA-UTERINE SYSTEM
Contains 52mg Levonorgestrel released at the rate of 20mcg / day.

The frame is rendered radio-opaque by impregnation with barium sulphate.
Licensed for contraception for 5 years. Levonorgestrel - induced endometrial changes are
established within three cycles with atrophy of endometrial glands, decidualisation of the
stroma, inactivation of the epithelium, supression of spiral arterioles and an inflammatory
response. The endometrium becomes unresponsive to oestrogen.
After removal, endometrial morphology returns to normal with menstruation within 30 days
NON-CONTRACEPTIVE USES / BENEFITS
1) Management of menorrhagia - Reduction in menstrual blood loss of up to 97% after 12

months of use with an increase in serum ferritin and Hb concentrations. 35% amenorrhoea rate at
1 year
2) Dysmenorrhoea - There is evidence that this may be improved.
3) Progestogenic opposition for oestrogen replacement therapy / oestrogen therapy for PMS
4) Low rate of ectopic pregnancy (0.02/100 woman years compared to 0.25/100 woman years for
the Nova T and 1.2-1.6/100 woman years for sexually active women not using contraception).
5) Protection against PID - thickening of cervical mucus, inactivation of the endometrium and
reduced bleeding.
6) Management of endometrial hyperplasia
7) Some evidence that the incidence of uterine fibroids and their growth is reduced
8) Cost-effectiveness - compare to cost of hysterectomy / medical treatment for menorrhagia.
SIDE-EFFECTS / COMPLICATIONS
1) Difficulties with insertion - especially in nulliparous women, cervical dilatation required

under para-cervical block / NSAID.
2) Irregular bleeding - takes 3 months for endometrial atrophy - good counselling required prior
to insertion
3) Increased incidence of functional ovarian cysts compared to copper IUD users
4) Amenorrhoea - unless appropriately counselled, some women may regard this as abnormal
5) Progestogenic side-effects - oedema / headache / breast tenderness / acne ? subside after a few
months
6) Expulsion - commonly occurs during first month following insertion.
COMPLICATIONS OF IUCD USE
Expulsion
Most occur in the first year, and especially in the first 3 months. Increased risk of expulsion in
women with heavy painful periods, with insertion within 6 weeks post-partum, previous
expulsion and with inexperienced operator.
Perforation
Risk 1.2 / 1000 insertions
Pregnancy
Remove device gently if possible, as soon as pregnancy is diagnosed - reduces the risk of
spontaneous miscarriage by 50%. Exclude ectopic pregnancy (risk 1:25 with IUCD).
Pelvic infection
Six fold increase in risk of developing PID in the first 20 days following insertion compared with
any other time
Thereafter the risk of infection remains constant at 1.4 / 1000 women
Increased menstrual loss
Abdominal pain / dysmenorrhoea

IUCD: UKMEC
Pregnancy
Women who become pregnant whilst using IUCD should be informed of the increased risks of
second-trimester septic miscarriage, preterm delivery and infection if the IUCD is left in situ.
Women who are pregnant with IUCD in situ and wish to continue with the pregnancy should be
informed that, when possible, IUCD removal reduces the risk of an adverse outcome.
However, removal itself carries a small risk of miscarriage
Post-partum
Up to 48 hours post-partum including post- CS = UKMEC 1

48 hours to 4 weeks post-partum = UKMEC 3
Post-placental insertion and insertion between 10 minutes and 48 hours after delivery result in
higher expulsion rates than insertion 46 weeks postpartum or non-postpartum insertion
Insertion at the time of a caesarean section is associated with lower expulsion rate than post-
placental insertion at the time of vaginal delivery
The rate of uterine perforation associated with IUCD use is very low. The most important risk
factors for uterine perforation are insertion during lactation and insertion in the 36 weeks after
giving birth
The majority of studies show no significant differences in breastfeeding outcomes in women
using LNG-IUS with insertion either immediately postpartum or after 4 weeks
Less than 4 weeks post-first / second trimester (up to 24 weeks) abortion = UKMEC 1 and 2
respectively)
Septic abortion or puerperal sepsis = UKMEC 4
Gestational trophoblastic disease with persistently elevated HCG or malignancy (UKMEC 4).
Undetectable HCG = UKMEC 1. Falling HCG = UKMEC 3
Malignancy
Unexplained vaginal bleeding before evaluation (UKMEC 4 for initiation)

Cervical cancer awaiting treatment (UKMEC 4 for initiation; UKMEC 2 for continuation)
Radical trachelectomy = UKMEC 3
Endometrial cancer: UKMEC 4 for initiation and UKMEC 2 for continuation. Ovarian cancer =
UKMEC 1
Current breast cancer = UKMEC 1 for Cu IUCD and UKMEC 4 for levonorgestrel IUS
Past breast cancer = UKMEC 1 for Cu IUCD and UKMEC 3 for levonorgestrel IUS
Uterine abnormalities
Uterine fibroids distorting cavity = UKMEC 3. Cavity not distorted = UKMEC 1

Uterine anomaly distorting cavity = UKMEC 3
STI & PID
Current PID (UKMEC 4 for initiation and UKMEC 2 for continuation)

Chlamydia infection (symptomatic or asymptomatic), current purulent cervicitis or gonorrhoea
(UKMEC 4 for initiation and UKMEC 2 for continuation). Treat the STI using appropriate
antibiotics. There is usually no need for removal of the IUD if the woman wishes to continue use.
Increased risk of STI including HIV = UKMEC 2
HIV with CD4 count > or = 200 / ml = UKMEC 2
HIV with CD4 count < 200 / ml = UKMEC 3 for initiation and UKMEC 2 for continuation
Pelvic TB = UKMEC 4 for initiation and UKMEC 3 for continuation
Liver disease
Severe decompensated cirrhosis, hepatocellular adenoma or carcinoma = UKMEC 3 for

levonorgestrel IUS and UKMEC 1 for Cu IUCD
Anaemias = UKMEC 2 for Cu IUCD and UKMEC 1 for levonorgestrel IUS
Organ transplantation complicated by graft failure or rejection: Initiation = UKMEC 3,

continuation = UKMEC 2
Cardiovascular disease
Multiple risk factors for cardiovascular disease and vascular disease: Cu IUCD = UKMEC 1,
Levonorgestrel IUS = UKMEC 2
Current history of ischaemic heart disease and stroke including TIAs: Cu IUCD = UKMEC 1,
Levonorgestrel IUS = UKMEC 2 for initiation and UKMEC 3 for continuation
Known dyslipidaemias: Cu IUCD = UKMEC 1, Levonorgestrel IUS = UKMEC 2
History of VTE, current VTE on anti-coagulants or known thrombophilia: Cu IUCD = UKMEC 1,
Levonorgestrel IUS = UKMEC 2
Uncomplicated valvular / congenital heart disease = UKMEC 1
Complicated valvular / congenital heart disease = UKMEC 2. Prophylaxis against bacterial
endocarditis is no longer indicated for women with artificial heart valves or previous
endocarditis when inserting or removing IUCD
Impaired cardiac function = UKMEC 2. IUCD insertion may induce cardiac arrhythmias in women
with cardiomyopathy. The IUC should be fitted in a hospital setting as a vasovagal reaction
presents a particularly high risk of cardiac events
PERSONA
Natural family planning - measures levels of LH and oestron-3-glucuronide in early morning

urine.
Needs to be programmed for three months (test urine for 16 days in the first month and 8 days
in subsequent months) before device can be relied upon.
Not suitable for the following groups of women:
1. Cycle length <23 days or > 35 days

2. PCOS
3. Breastfeeding
4. Menopausal symptoms
5. Women taking hormonal medication
Needs to be re-programmed after post-coital contraception
Failure rate ~ 6/100 woman years with perfect use. Much higher for typical user.
POST-COITAL CONTRACEPTION
Add your own notes

POST-COITAL CONTRACEPTION
Suitable agents:
Oestrogen
Oestrogen + progesterone
Progesterone only
Mifepristone
IUCD
Oestrogen-only regimes associated with lower pregnancy rate compared to Oestrogen +

Progesterone regime (Yuzpe, 100mcg ethinyl-oestradiol + 500mcg levonorgestrel 12 hours apart
given within 72h of unprotected intercourse) but are associated with greater side-effects -
nausea / vomiting.
Ho and Kwan regimen - 750mcg levonorgestrel 12h apart X 2 doses more effective than the
Yuzpe regimen in preventing pregnancy (RR: 0.51; 95% CI: 0.31 to 0.83; Failure rate 1.1% 95% CI
0.6 - 2.0 Vs 3.2% 95% CI 2.2-4.5 ) and has significantly fewer side-effects - nausea / vomiting /
breast tenderness. Ho and Kwan regimen is method of choice.
Single dose (1.5 mg) administration seems to have similar effectiveness as the standard 12 hours
apart split-dose (0.75 mg twice) of levonorgestrel (RR: 0.77, 95% CI: 0.45 to 1.30).
Levonorgestrel has similar effectiveness to mid-dose (RR: 1.64; 95% CI: 0.82 to 3.25) or low-dose
(RR: 1.38; 95% CI: 0.93 to 2.05) mifepristone.
Single dose of mifepristone 600mg within 72h of unprotected sexual intercourse - highly
effective and no pregnancies have been reported in randomised trials. Low-dose (=< 10 mg)
mifepristone is similarly effective as mid doses (25-50 mg). Delay in the onset of subsequent
menses is the main unwanted effect of mifepristone and seems to be dose-related. Mifepristone
is associated with fewer side-effects and a delay in menstruation.
Copper IUCD effective post-coital contraceptive - may be used up to 5 days after unprotected
intercourse or after the most probable day of ovulation - failure rate < 0.1%, main primary
complications: uterine cramps / bleeding; risk of infection therefore avoid in women with recent
/ recurrent PID / multiple sexual partners.
The effects of hormonal methods are reduced by enzyme inducing drugs - and dose should be
increased by 50%. For the levonorgestrel-only method, the first dose should be 1.5mg followed
by a second dose of 750mcg. Antibiotics that are not enzyme inducers do not affect efficacy.
Hepatic enzyme inducers & levonorgestrel (MHRA Update 2016)
Women seeking emergency contraception who have used cytochrome P450 enzyme inducers
within the last 4 weeks, should:
Preferably use a non-hormonal emergency contraceptiveie, a copper IUCD
If this is not an option, double the usual dose of levonorgestrel from 1.5 milligrams to 3
milligrams
Provide advice on highly effective ongoing contraception that is not affected by hepatic enzyme-
inducing drugs
Advise them to have a pregnancy test to exclude pregnancy after use of levonorgestrel-
containing emergency contraception
Advise them to seek prompt medical advice if they do become pregnant
Effect of hepatic enzyme inducers on levonorgestrel metabolism
Concomitant use of liver enzyme inducers increases levonorgestrel metabolism

Concomitant administration of the antiretroviral efavirenz reduces plasma levels of
levonorgestrel by about 50%
Elevated levels of cytochrome P450 enzymes can persist for up to 4 weeks after cessation of the
enzyme-inducing medicine
The decrease in plasma levonorgestrel may reduce contraceptive efficacy of levonorgestrel-
containing emergency contraceptives
Enzyme inducers that reduce plasma levonorgestrel levels include
1. epilepsy (eg, barbiturates, primidone, phenytoin, carbamazepine)

2. tuberculosis (eg, rifampicin, rifabutin)
3. HIV (eg, ritonavir, efavirenz)
4. fungal infections (eg, griseofulvin)
5. Herbal remedies that contain St Johns wort (Hypericum perforatum) also reduce levonorgestrel
levels.
Comments
Posted by Saud-ur R.
EC Tue Aug 16, 2011 01:13
pm
Dear dr paul
Posted by celine S.
what about other new emergency contracetive. Sat Jan 25, 2014 01:24
am
ULIPRISTAL ACETATE

MIFEPRISTONE and ULIPRISTAL
Add your own notes

MIFEPRISTONE (RU486)
Derivative of norethindrone (19-norsteroid) - similar chemical structure to progesterone /

glucocorticoids.
Progesterone / glucocorticoid antagonist.
Like progesterone, binds to the progesterone receptor causing dimerisation of the receptor and
binding to progesterone response elements of progesterone responsive genes. Unlike
progesterone, however, transcription is inhibited.
METABOLISM
Administered orally, 70% absorbed, hepatic first pass metabolism reduces its bio-availability to
40%.
Half life 20-25h.
Bound in serum to alpha-1-acid glycoprotein and serum orosomucoid but does not bind to
cortisol binding globulin or sex steroid binding globulin.
Maximum serum concentrations 1 hour after oral dose.
Metabolised mainly by the liver and excreted via the GI tract - < 10% excreted in urine.
ACTIONS
1) Suppression of ovulation
Continuous daily doses of 2,5 or 10mg suppress ovulation - risk of unopposed oestrogenic
stimulation of the endometrium.
2) Glucocorticoid axis
Glucocorticoid antagonist
Inhibit negative feed-back of cortisol on ACTH secretion resulting in a significant increase in
ACTH and cortisol after single 100mg dose.
Raised cortisol levels may persist for up to 10 days.
No objective clinical manifestation of glucocorticoid deficiency has been reported in healthy
individuals after single dose treatment.
3) Endometrium
Direct effect on endometrium to induce menstrual bleeding if administered in mid - late luteal
phase. Histological changes include inhibition of endometrial glandular secretory activity,
accelerated degenerative changes, increased stromal mitotic activity.
4) Pregnant uterus
Acts on the high concentration of progesterone receptors in decidua resulting in withdrawal of

progesterone support, disruption of placental function and uterine bleeding.
Detachment of chorionic tissue results in a fall in HCG levels, degeneration of the corpus luteum
and further withdrawal of hormonal support to the endometrium.
On its own, mifepristone results in complete medical abortion in 60-80% of subjects - this is
improved by the administration of prostaglandins 36-48h later.
Pre-treatment with mifepristone reduces the interval between prostaglandin administration and
expulsion.
Mifepristone increases uterine concentrations of prostaglandins (probably by inhibiting
prostaglandin metabolism) and also increases the sensitivity of the myometrium to
prostaglandins.
5) Cervix
Results in cervical ripening (priming)
6) Post-coital contraception
Compared to the Yuzpe method (two doses of 100mcg ethinyl-oestradiol + 500mcg

levonorgestrel 12h apart), 600mg mifepristone administered within 72h of unprotected
intercourse has similar efficacy but is better tolerated (lower incidence of nausea, vomiting,
breast symptoms) and has a higher incidence of delayed menses.
TERMINATION OF PREGNANCY WITH MIFEPRISTONE
Licensed for use in early medical termination of pregnancy up to 63 days from last menstrual
period with administration of prostaglandins (oral / vaginal) 36-48h after mifepristone.
Effective dose 200, 400 or 600mg with no dose-dependent difference in efficacy.
Success rate 94 - 96% with continuation of pregnancy in ~0.3%.
With respect to prostaglandins, gemeprost is more expensive and must be refrigerated.
Misoprostol - cheaper and stored at room temperature. Oral misoprostol associated with GI
side-effects (nausea, vomiting, diarrhoea, abdominal cramps), greater induction - abortion time
and higher failure rate than vaginal misoprostol.
Mifepristone is also licensed for use in second trimester (13-20 weeks) termination of pregnancy
SIDE-EFFECTS (mifepristone)
Vaginal bleeding, Malaise, Headache, Nausea, Vomiting, Rash
CONTRA-INDICATIONS
Suspected ectopic pregnancy

Chronic adrenel insufficiency
Long-term corticosteroid therapy
Haemorrhagic disorders
Anti-coagulant therapy
Smokers over the age of 35 (avoid smoking / alcohol 2 days before and on the day of
prostaglandin administration)
Hepatic / renal impairement
Avoid aspirin / NSAIDS for at least 8-12 days after mifepristone.
Ulipristal acetate (30 mg)
Synthetic steroid derived from 19-norprogesterone

Selective progesterone receptor modulator (second generation SPRM; mifepristone is first
generation) with antagonistic and partial agonistic effects
Licensed for emergencycontraception up to 120 hours (5 days) after unprotected sexual
intercourse or contraceptive failure.
Weaker antiglucocorticoid activity than mifepristone as a result of differences in their active
metabolites.
Mechanism of Action
Inhibition or delay of ovulation. A single mid-follicular dose has been shown to suppress growth
of lead follicles.
Administration just before, or in some cases just after, the luteinising hormone surge can inhibit
follicular rupture.
Endometrial changes may also play a role. Early luteal administration results in delayed
endometrial maturation and alterations in progesterone-dependent markers of implantation.
A mid-luteal dose has been shown to induce early endometrial bleeding in a dose-dependent
manner.
Alterations to the endometrium may inhibit implantation by rendering the uterus less receptive
to the trophoblast.
Regimen
One tablet should be taken orally as soon as possible, but no later than 120 hours after
unprotected intercourse or contraceptive failure with or without food. If vomiting occurs within
3 hours, another table should be taken.
Not recommended to be used more than once per cycle as the safety and efficacy of repeated
exposure has not been assessed.
If hormonal contraception is continued after administering ulipristal, barrier contraception
should be used until the next period or withdrawal bleed.
Efficacy
Efficacy has been demonstrated up to 120 hours after unprotected intercourse

As effective as levonorgestrel for emergency contraception.
In a Phase II randomised double-blinded non-inferiority trial of women within 72 hours of
unprotected intercourse, pregnancies occurred in 7/775 ulipristal users [0.9%, 95% confidence
interval (CI) 0.21.6] and 13/774 levonorgestrel users (1.7%, 95% CI 0.82.6).
85% of anticipated pregnancies in the ulipristal group had been avoided and 69% in the
levonorgestrel group.
An unpublished meta-analysis of the two comparative studies suggests ulipristal is superior to
levonorgestrel when administered both within 120 and 24 hours of unprotected sexual
intercourse.
There is evidence that regardless of the type of emergency contraceptive drug used, the risk of
pregnancy is significantly increased with increasing body mass index (BMI) (8% per point
increase in BMI).
However, ulipristal acetate appears to be more efficacious compared to levonorgestrel in
women who are categorised as overweight or obese (grade 1) (OR 3.1, 95% CI 0.110.74)
Safety
Side effect profile similar to progestogen-only emergency contraception

No serious reactions reported
Interactions
Metabolised via cytochrome P450, in particular CYP3A4.
Liver enzyme inducers
CYP3A4 inducers (e.g. rifampicin, phenytoin, carbamazepine, ritonavir, St Johns wort) may
reduce plasma concentrations of ulipristal and may reduce efficacy.
Liver enzyme inhibitors
The effect of CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, clarithromycin) may increase
exposure to ulipristal, but the significance is uncertain.
Drugs that increase gastric pH
Use of ulipristal with antacids, proton pump inhibitors and H2 receptor antagonists, or any other
drugs that increase gastric pH, may reduce absorption of ulipristal and decrease efficacy.
Other contraceptives
Ulipristal binds to progesterone receptors and so may reduce the efficacy of progestogen-
containing contraceptives
Contraindications
Pregnancy or suspected pregnancy

Severe hepatic impairment
Severe asthma insufficiently controlled by oral glucocorticoids
Breastfeeding women are advised not to breastfeed for 36 hours after treatment.
Side-effects
Abdominal pain
Menstrual disorders (irregular vaginal bleeding, premenstrual syndrome, uterine cramps). The
post-treatment cycle length is on average 2.9 days longer than the expected length. 7% of
women reported a shortened cycle, and 19.2% reported an increase in cycle length of more than
7 days.
No associated adverse outcomes in the small numbers of inadvertent pregnancies that have
occurred to date.

PELVIC INFLAMMATORY DISEASE
Add your own notes
PELVIC INFLAMMATORY DISEASE
Definition
Inflammation caused by infection of the upper genital tract - endometrium (endometritis),

fallopian tubes (salpingitis), ovary (oophritis), uterine serosa and broad ligament (parametritis)
and the pelvic peritoneum. PID is most commonly used to describe infection of the fallopian
tubes (salpingitis) as this is the most common and most significant presentation.
Chronic PID is now rarely used as the chronic sequelae of acute PID (adhesions / hydrosalpinx)
are bacteriologically sterile. Only infections with rare organisms such as TB and actinomycosis
cause chronic PID.
85% are spontaneous infections in sexually active women caused by ascending microbes from
vaginal and cervical flora
15% follow invasive procedures which disrupt cervical mucus barrier - termination of
pregnancy, insertion of IUD, endometrial biopsy / curretage, hysteroscopy
<1% of infections result from trans-peritoneal spread from perforated appendix / intra-
abdominal abscess
MICROBIOLOGY
Poly-microbial infection.
<50% correlation between microbes isolated from the endo-cervix and those isolated from tubal
cultures at laparoscopy - endo-cervical cultures only provide a crude indication of the possible
cause of PID
Chlamydia Trachomatis
Commonest sexually transmitted infection in the UK
Intra-cellular gram negative bacteria, can only be grown in cell culture systems
Various serovars: L1, L2 L3 - Lymphogranuloma venereum; A,B,C - Trachoma; B-K - genital

infection / neonatal conjunctivitis / pneumonia
Infectious particle is known as an elementary body - attaches to susceptible host cells and is
taken up by phagocytosis. Intracellular form is known as a reticulate body - non-infectious and
does not survive outside the cell. Replicates by binary fission to produce intracellular inclusions
Involved in ~40% of hospitalised patients with PID
10-30% of women with PID who lack culture evidence of chlamydia infection have evidence of
acute chlamydial infection on serial antibody testing
20-40% of sexually active women have antibodies to chlamydia trachomatis
DNA based testing (PCR) of early morning urine specimen more sensitive than ELISA (detects
chlamydia antigens) based tests
Produces a milder form of salpingitis with insidious onset
May remain in the fallopian tubes for several months in untreated patients (N. Gonorrhoea
persists for a few days only)
Chlamydia salpingitis is confined to the tubal mucosa only
Neisseria Gonorrhoea
Gram negative intracellular diplococci
Causes intense inflammatory reaction in the fallopian tubes with tubal occlusion from necrotic
debris and pus
Isolated on its own (20-30%) or in association with anaerobes (5-30%) or chlamydia (~25%) of
women with PID
Non-gonococcal, non-chlamydial PID
Caused by anaerobes (Bacteriodes / Peptostreptococcus), G. Vaginalis, Coliforms, haemolytic

and non-haemolytic streptococci and mycoplasma
Bacterial vaginosis
G. Vaginalis and Mobiluncus spp - associated with PID and post-partum endometritis
Actinomyces Israelii
Associated with use of IUDs.
Gram positive branching filamentous bacilli which form pseudo-mycelium
Strictly anaerobic and without acid-fast staining
Characterised by the presence of sulphur granules in pus, sinus formation and lack of lymphatic
involvement
Sensitive to penicillin / tetracyclines
RISK FACTORS
Age - incidence decreases with advancing age - 75% occur in women < 25 years old. A
diagnosis of PID in a post-menopausal woman should prompt a search for genital tract
malignancy / diabetes mellitus / concurrent GI disease
Early age at first sexual intercourse
Multiple sexual partners
Marital status
Contraception - if risk of PID in sexually active women not using contraception = 1.0, risk in
COCP users = 0.3 and risk in users of barrier contraception = 0.4. IUCD use - greatest risk of
PID is in the first three weeks after insertion. Thereafter, increased risk related to life-style. PID
rare following tubal ligation
Previous PID - 25% of women with PID will develop another episode - direct cultures indicate
that these are new infections - life-style / untreated partner - >80% of partners are untreated;
~50% of males with sexually transmitted infections are asymptomatic
Frequent vaginal douching associated with a 3-4 fold increase in risk of PID
Instrumentation of the upper genital tract - risk ~1:200 after first trimester surgical termination
of pregnancy
Smoking - associated with increased risk
Changes in virulence of organisms increasing the risk of ascending infection

DIAGNOSIS
Based on clinical criteria, however, there is a wide range of non-specific symptoms - bilateral
lower abdominal pain increased on movement (commonest presentation), deep dyspareunia,
dysmenorrhoea, inter-menstrual bleeding, menorrhagia, abnormal vaginal discharge, frequency
and dysuria; nausea, vomiting, malaise, fever.
Atypical / silent PID - relatively asymptomatic upper genital tract infection, associated with
chlamydia. Repeated infections lead to tubal infertility and ectopic pregnancy. Now thought that
silent PID out-numbers clinically apparent cases by 3:1
On examination - pyrexia, tachycardia, lower abdominal tenderness, guarding and rebound

tenderness; cervical excitation, bilateral adnexal tenderness and presence of adnexal mass
Clinical diagnosis has a high false positive and false negative rate. However, because of long-
term sequelae, diagnosis should be made and treatment instituted with minimum suspicion
Criteria for clinical diagnosis:
1) Abdominal tenderness +/- rebound tenderness +

2) Cervical excitation +
3) Adnexal tenderness + one or more of the following:
a) Temperature >38C (present in 1/3rd of women with PID)

b) Gram stain of endocervix positive for gram negative intracellular diplococci
c) Leukocytosis >10,000/ml (present in <50% of women with PID)
d) Pelvic abscess / inflammatory complex on pelvic examination / ultrasound scan
e) Purulent material in peritoneal cavity
5-10% of women with PID develop symptoms of perihepatitis (Fitz-Hugh-Curtis syndrome) -

RUQ pain, pleuritic pain, RUQ tenderness. Liver enzymes may be elevated. Associated with
gonococcal and chlamydia infection. Classical violin string adhesions to the parietal
peritoneum underneath the diaphragm at laparoscopy
ESR and CRP not always raised and are non-specific. CA-125 raised in PID
Ultrasonography is of limited value in mild to moderate PID - helpful in documenting adnexal

mass or in women who are too tender to allow effective clinical assessment - should not
routinely be ordered in women with acute disease
Laparoscopy is gold standard for diagnosis. However, 15-30% of suspected cases may have no
laparoscopic evidence of acute infection despite organisms being isolated from the fallopian
tubes
Mild PID: Erythema and oedema of tubes, no spontaneous purulent exudate, tubes freely mobile.
Moderate PID: More marked erythema and oedema, purulent material evident, tubes may not be
freely mobile and fimbrial stoma may not be patent.
Severe PID: Pyosalpinx / inflammatory complex / abscess
*Only 17% of laparoscopically diagnosed cases of PID have the classic triad of fever, raised
ESR and adnexal tenderness or mass*
DIFFERENTIAL DIAGNOSIS
20-25% of women with clinically diagnosed PID have no identifiable pelvic / abdominal
disease at laparoscopy
Acute appendicitis
Adnexal torsion
Ectopic pregnancy
Bleeding corpus luteum
Endometriosis
Urinary tract infection
TREATMENT
CDC criteria for in-patient treatment RCOG criteria in bold

Nulliparity
Pregnancy
Tubo-ovarian complex or abscess
All adolescents
Uncertain diagnosis - need to exclude surgical emergency
Peritonitis in upper quadrant
Presence of IUCD
History of operative / diagnostic procedure
Inadequate response / intolerance to out-patient therapy
Women with HIV were initially thought to get more severe PID but recent studies suggest
that the differences are minor and the response to standard antibiotic therapy is adequate.
In-patient treatment is only required in those with clinically severe disease.
ANTIBIOTICS (CDC recommendations, adopted by RCOG)

Out-patient treatment:
Cefoxitin 2g im + probenecid 1g orally (single dose) or other parenteral third generation

cephalosporin + doxycycline 100mg orally twice daily for 14 days. OR
Ofloxacin 400mg orally twice daily for 14 days + clindamycin 450mg orally four times a day for
14 days or metronidazole 400mg twice daily for 14 days
Reassess patient after 48-72h therapy to evaluate response
In-patient treatment:
Cefoxitin 2g iv 6 hourly (or other cephalosporin such as cefotaxime / ceftriaxone) + doxycycline

100mg twice daily orally or iv, continue for 48h after clinical improvement. Continue
doxycycline 100mg twice daily after discharge for a total of 14 days. OR
Clindamycin 900mg iv 8 hourly + gentamicin (loading dose 2mg/kg + maintenance dose

1.5mg/kg ) 8 hourly - continue for 48h after clinical improvement. After discharge - doxycycline
100mg twice daily for 14 days or clindamycin 450mg orally 5 times a day for 10-14 days.
Intravenous doxycycline can be started if unable to tolerate oral therapy
Importance of contact-tracing and treatment of sexual partner

Check gentamicin levels
Clindamycin effective against 90% of chlamydia strains
Operative treatment for pelvic abscess may be required - drainage by laparoscopy / laparotomy
or ultrasound guided aspiration / drainage
Ofloxacine should be avoided in young women in whom bone development is still
occurring. Doxycycline can safely be used in children over the age of 12 years
IUCD may be left in situ in a woman with mild PID but should be removed in cases of
severe disease
LONG TERM SEQUELAE
Recurrent acute PID - occurs in 25% of women with PID, treatment of male partner /
appropriate contraception important
Ectopic pregnancy - ~50% occur in fallopian tubes previously damaged by salpingitis
Chronic pelvic pain - subsequently occurs in ~20% of women with PID (5% general
population)
Deep dyspareunia
Infertility - 10% risk of tubal infertility after one episode, 20% and 40% risk after two and three
or more episodes respectively.
RCOG RECOMMENDATIONS FOR PREVENTION OF PID
Antibiotic prophylaxis in women undergoing induced abortion - cover chlamydia and

organisms associated with bacterial vaginosis. Metronidazole 1g pr at time of TOP +
doxycycline 100mg po twice daily for 7 days post-TOP. Alternatively, screen for chlamydia /
gonorrhoea / BV and treat positive cases.
Prophylactic antibiotics / screening in non-pregnant women under the age of 35 years

undergoing uterine instrumentation / IUCD insertion.
PCR based screening for chlamydia on first void urine specimens more sensitiveand specific
than ELISA based techniques
Sexual partners should be treated empirically with contact-tracing + screening whenever

possible
Granuloma inguinale
Chronic bacterial infection

Characterized by intracellular inclusions in macrophages referred to as Donovan bodies
Usually affects the skin and mucous membranes in the genital region, where it results in nodular
lesions that evolve into ulcers
Caused by gram-negative pleomorphic bacillus as Klebsiella granulomatis
Sexually transmitted but repeated exposure is necessary for clinical
Also transmissible by fecal route or by passage through an infected birth canal
Rare in temperate climates, but it is common in the tropics and subtropics. Endemic in Western
New Guinea, the Caribbean, Southern India, South Africa, Southeast Asia, Australia, and Brazil
First-line drug treatment is azithromycin
Alternative regimens include doxycycline, ciprofloxacin, erythromycin base, and trimethoprim-
sulfamethoxazole
All antibiotics should be given for at least a 3-week or until re-epithelialization of the ulcer
occurs and all signs of the disease have resolved

SEXUAL ASSAULT
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MANAGEMENT OF SEXUAL ASSAULT
The following should be considered:
Assessment and treatment of any life-threatening injuries
Accurate documentation and forensic examination
Risk of pregnancy
Risk of sexually transmitted infections
Psychological morbidity
Medico-legal implications
ASSESSMENT
Assessment and treatment of life-threatening injuries should take priority
The woman should be asked if she wishes to report the matter to the police. It should be
recognised that an allegation may be reported at any time after the event and that a forensic
examination may be useful up to 7 days after the assault
Even if the allegation is not reported to the police, history and examination should be detailed
baring in mind that a complaint may subsequently be made
The approach should be sensitive and flexible by a senior doctor and a female doctor should be
offered wherever possible
History
LMP and contraceptive history
Timing of assault, prior and subsequent consenting sexual intercourse, use of condoms
Orifices involved in the assault
Examination
This should ideally take place at the time of forensic examination to avoid multiple
examinations and should not be undertaken before a forensic examination
Document injuries - diagrams may be useful. Avoid interpreting your findings (scratch marks,
bites)
Look for petechial haemorrhages on the palate if history of forced oral penetration. Anal
examination +/- proctoscopy if anal penetration.
Photography not useful outside a full forensic examination and may cause distress
Investigations
Full STI screen
Number and timing of tests depends on time interval since assault
Recognise that there is a high rate of default with subsequent appointments
Urethral, rectal, cervical and pharyngeal swabs for gonorrhoea
Chlamydia swabs from sites of penetration or attempted penetration
Vaginal swabs for BV, Trichomonas, candida
Blood for syphilis serology, save serum for Hep B & C, HIV
Offer HIV testing - may depend on risk profile of assailant
Screening should be repeated at 2 weeks and 3 months after the assault. If seen over three
months after the assault, one screen is adequate
Treatment
Psychological support / counselling. Provide information on victim / survivors support groups.

Psychological sequelae may manifest several months after the incident
Treat any physical injuries appropriately
Treat any established infections
Prophylactic antibiotics may not be helpful but should be considered if default is likely, woman
is unable to tolerate repeat screening / examination and when an IUCD is required for emergency
contraception
Recommended antibiotic regimes include:
1) Ciprofloxacin + Doxycycline
2) Ciprofloxacin + Azithromycin
3) Amoxycillin and probenecid + Erythromycin
Consider Hep B vaccination - may be useful up to three weeks after the assault.
Consider HIV prophylaxis - no accepted recommendation available for use after sexual
exposure. Risk of exposure is dependent on profile of assailant, including prevalence of HIV in
the area where the assault took place and the nature of the assault - forced anal penetration higher
risk than vaginal penetration. Counsel regarding unproven efficacy and likely side-effects of
post-exposure prophylaxis
Provide appropriate post-coital contraception
Forensic assessment and medico-legal implications
Forensic examination may be useful up to 7 days after the assault and must be prior to medical
examination
This should only be performed by a trained police surgeon using specialised equipment and
sealed specimen bags
If the woman does not wish to report the incident to the police, clinical examination should be
undertaken and documented bearing in mind that the assault may subsequently be reported and a
medical report may be requested
A chain of evidence is required for forensic specimens to be admissible as evidence in court -

this is difficult to implement in a hospital laboratory situation - samples should be marked as
having medico-legal implications. The chain of evidence requires that every individual who
handled the specimen at any stage is clearly identifiable and their role documented.
Signed consent should be obtained from the woman before information contained in her
medical records is disclosed to the police.

CONTRACEPTION & FUTURE FERTILITY
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EFFECTS OF CONTRACEPTION ON FUTURE FERTILITY
Combined oral contraceptive pill
Prompt return to ovulation with 70% of women ovulating in the first cycle and 98% by the third
cycle
Reduced risk of PID due to progestogen
Reduced risk of ectopic pregnancy
Higher Hb and ferritin levels may be associated with improved reproductive outcomes
No effect on early pregnancy loss, sex ratio or congenital anomalies if inadvertently taken in
early pregnancy
1% of women would remain amenorrhoeic 6 months after stopping the pill ? similar to rate of
secondary amenorrhoea in general population. Women who lose weight on the pill are at
increased risk. If persists for over 6 months, investigation warranted to exclude PCOS,
hyperprolactinaemia, premature ovarian failure
Progesterone-only methods
Prompt return to normal fertility with POP and implants
POP - less protection from ectopic pregnancy than the combined pill and may be associated with
a slight increase in risk
Implanon - return to normal ovulation within 6 weeks
Depo-progestogens: No permanent impact on fertility
Ovulation returns on average 4-5 months following last injection with a median conception time
of 5-7 months
Women should be warned that conception may be delayed for up to 2 years after the last
injection and alternative methods should be used in women who may wish to get pregnant sooner
Thought to be due to delayed metabolism of the drug from micro-crystalline deposits in muscle
tissue
IUCD
Risk of PID confined to the first 3 weeks following insertion and thereafter related to life-style
Levonorgestrel releasing IUS associated with lower risk of ectopic pregnancy compared to
copper IUCD
Barrier methods
Associated with lower risk of PID
No evidence that spermicides are associated with an increased risk of congenital anomalies

STERILISATION
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STERILISATION
Information for patients
Include both verbal and written information

Involve both partners together, where acceptable and appropriate. Both vasectomy and
tubal occlusion should be discussed
Highlight the irreversibility/permanence of sterilisation and that sterilisation reversal is
not routinely available through the NHS
Include information on failure rate
Include risks and complications. Vasectomy is safer, quicker to perform and is associated
with less morbidity than female sterilisation by laparotomy or laparoscopy
Discuss myths and misconceptions
Include information on other methods of contraception, including long-acting reversible
contraception (LARC)
Assess for known predictors of regret and highlight the possibility of regret. Additional
care must be taken when counselling individuals under the age of 30 years or individuals
without children who request sterilisation
Explain that sterilisation does not confer protection against sexually transmitted
infections
Highlight need to use contraception until sterilisation has been carried out and the
potential need to continue use beyond the procedure
Enable individuals to make an informed decision
Ensure adequate documentation
Allow a suitable interval prior to the procedure. If tubal occlusion is performed at the
same time as a caesarean section, counselling and agreement should be given at least 2
weeks in advance of the procedure
Hysteroscopic sterilization
Associated with less serious morbidity than laparoscopic tubal occlusion

Does not involve the use of general anaesthesia and can be performed as an outpatient
procedure
Completely irreversible
Hysteroscopic access or micro-insert placement may be unsuccessful
Contraception must be continued for at least 3 months until tubal occlusion is confirmed
Vasectomy
Interruption of the vas deferens to provide permanent contraception

No-scalpel or minimally invasive vasectomy (MIV) involves a puncture wound in the
scrotal skin to access and occlude the vas. The skin opening is 10 mm, the dissection
area surrounding the vas deferens is minimised and skin sutures are not required
MIV may include the use of a scalpel, to expose the vas
MIV techniques reduce the level of bleeding and intraoperative pain when compared to
other methods of exposing the vas deferens
Vasectomy should be performed under local anaesthesia wherever possible. Local
anaesthetic should be administered via infiltration of the subcuticular tissue and by direct
injection to the vas deferens using a fine-gauge needle to reduce pain
Consideration may be given to warming local anaesthetic to approximately 37C before
infiltration to reduce pain associated with injection
Cauterisation followed by division of the vas deferens, with or without excision, is
associated with the lowest likelihood of early failure when compared to other occlusion
techniques
Division of the vas on its own is not an acceptable technique because of the associated
failure rate. It should be accompanied by diathermy or ligation and fascial interposition
Clips are not recommended for occluding the vas deferens as their use is associated with
a potentially high failure rate when compared to other occlusion methods
If a vas deferens cannot be located, unilateral vasectomy can be carried out following
appropriate counselling, and the man advised to comply with additional contraception
until sterility is confirmed. These men should be informed of the probability of ipsilateral
renal agenesis and may be referred for renal ultrasound
Where apparent bilateral absence of the vas deferens is encountered, men should be
referred to a urology specialist
If a double or duplicate vas deferens is encountered or suspected, a Doppler ultrasound
should be used to determine whether it is a true double vas or an ectopic ureter
Health professionals can consider playing music in the clinical room if the patient wishes,
as listening to music has been shown to reduce patient anxiety
The routine use of prophylactic antibiotics is not recommended
Routine irrigation of the vas deferens does not reduce time to achieve azoospermia and is
not recommended
Routine histological examination of the excised portions of vas deferens is no longer
recommended
Post-vasectomy semen analysis (PVSA) should be carried out to identify early failure.
Additional contraception should be used until azoospermia is confirmed or special
clearance given
12 weeks post-vasectomy is the optimal timing to schedule the first PVSA
Postal semen samples can be used for PVSA; however, such samples will not be suitable
for the assessment of sperm motility
A routine second PVSA is not required if azoospermia is found in the first sample
In a small proportion of men non-motile sperm will persist following vasectomy. In such
cases special clearance can be given to cease using additional contraception when less
than 100 000 non-motile sperm/ml are observed in a fresh semen sample post-vasectomy
If motile sperm are observed in a fresh sample 7 months post-procedure, the vasectomy
should be considered a failure
If more than 100 000 non-motile sperm/ml are observed in a fresh sample 7 months after
vasectomy, clinical judgement and/or local protocols may be used to determine whether
or not the procedure should be deemed a failure
Individuals should be informed that vasectomy has an associated failure rate and that
pregnancy can occur several years after vasectomy. The contraceptive failure rate is
about 1 in 2000 (0.05%) after clearance has been given
Post-vasectomy information
Contact their health care provider if they have any concerns following the procedure
Contact for urgent review if they have persistent bleeding, pain, possible infection, or
rapidly enlarging one-sided scrotal swelling
Use NSAIDs for pain/discomfort
Rest and refrain from strenuous activity
Abstain from sexual activity for 2 - 7 days post-procedure
Wear tight underpants/athletic support for the first few days following the procedure,
including at night for the initial 48 hours or longer according to symptoms
Provide instructions regarding semen analysis
Discuss need to use additional contraception until sterility is confirmed
Long-term complications
Postoperative testicular, scrotal, penile or lower abdominal pain that is rarely severe and
chronic in some men
NSAIDs and treatment to alleviate neuropathic pain are common first-line treatment
options for chronic post-vasectomy pain (CPVP) and are preferable to surgery which
involves the reversal of vasectomy. Surgery can be effective but permanent relief is not
achieved in every case
There is no evidence of an increase in testicular cancers or cardiovascular disease
FEMALE STERILISATION
Counselling
Provide information on advantages and disadvantages and failure rates of other methods
of long-term reversible contraception - cumulative pregnancy rate after 12 years with
CuT380A is 1.9% and after 5 years with LNG-IUS is 1.1%. Intra-uterine pregnancy rates
after reversal of sterilisation are 31 - 92% with an ectopic pregnancy rate of 0 - 7%
Sterilisation is intended to be permanent. However, provide information on success rate
of reversal and that reversal and treatments like IVF or ICSI may not be available on the
NHS
Women should be informed that vasectomy carries lower failure rate (1:2000) than tubal
ligation (1:200 life-time, 2-3 :1000 after 10 years) and carries fewer risks.
If tubal ligation fails, there is a risk of ectopic pregnancy - women should seek medical
advice if they think they may be pregnant or have abnormal abdominal pain or vaginal
bleeding. Risk of ectopic pregnancy 4-76% depending on method of sterilisation. Risk of
ectopic pregnancy is however lower in sterilised than non-sterilised fertile women
Discuss method of access for tubal ligation - laparoscopy or mini-laparotomy - and the
method to be used if the intended method fails. Outline reasons for preferring a particular
approach. Discuss risks associated with laparoscopy, possibility of requiring laparotomy
particularly if previous abdominal surgery or overweight. Risk of laparotomy is 1.4 - 3.1 /
1000 with a risk of death of 1:12,000
Tubal ligation is not associated with increased risk of heavy menstrual bleeding. There is
an association with increased hysterectomy rates. Limited data on younger women.
Advise women to use effective contraception until the date of the procedure and continue
until their next period
Post-partum or post-TOP tubal ligation is associated with increased regret rate and
possibly increased failure rate.
Pre-op assessment
Detailed history and clinical examination - ensure that the patient does not have
concurrent conditions which may require additional or alternative procedures or
precautions. Gynaecological history of menorrhagia or significant pelvic pathology may
make options like LNG-IUS or hysterectomy more appropriate
Ensure that the woman has used effective contraception up until the date of the
procedure. Otherwise defer procedure until the follicular phase and advise the woman to
use effective contraception until her next period
Perform pregnancy test to exclude pre-existing pregnancy. Negative test does not exclude
luteal phase pregnancy.
Procedure
General anaesthesia usually used. Local anaesthesia is an alternative

Perform as a day case if possible
Culdoscopy should not be used - associated with unacceptably high incidence of
technical difficulty and major complications
Laparoscopy is quicker and carries lower (minor) morbidity rate compared to mini-
laparotomy with no significant difference in major morbidity rate
Only perform laparoscopic tubal ligation at sites with facilities to perform laparotomy
safely
Pomeroy technique - use absorbable suture to tie the base of a loop of tube near the mid-
portion and cutting off the top of the loop. Destroys 3-4cm of tube, making reversal more
difficult
Modified Pomeroy procedure (separating a small segment of tube from the mesosalpinx,
tying each end of the segment and removing the portion between the sutures) rather than
Filshie clip may be preferable for post-partum sterilisation performed at C/S or by mini-
laparotomy - lower failure rates
Filshie clips or rings are method of choice for laparoscopic procedure. Routine use of
more than one Filshie clip is not recommended
Filshie clips should be applied at right angles to the isthmic portion of the tube, 1-2cm
from the cornu, making sure the whole width of the tube is encased in the clip. This
should be confirmed by the surgeon at the end of the procedure and documented
Hulka clips associated with higher rate of failure than Filshie clips
Diathermy should not be used as primary method - less reversible and carries increased
risk of ectopic pregnancy
Topical application of local anaesthesia to the fallopian tubes whenever mechanical
occlusive devices are being applied significantly reduces post-op pain scores and post-op
requirement of opiates. Intra-peritoneal instillation of local anaesthetic after the
procedure may also be effective
Women should be informed of the method of access and tubal ligation actually used and
any complications after the procedure. If technical difficulties were encountered such that
the tubal occlusion is in doubt, effective contraception should be continued and an HSG
arranged
Tubal occlusion should be performed at an appropriate interval after pregnancy wherever
possible. Should tubal occlusion be requested either postpartum or post-abortion, women
should be made aware of the increased rate of regret and the possible increased failure
rate
Pre-procedure contraception
Tubal occlusion can be performed at any time during the menstrual cycle, providing that
the woman has a negative pregnancy test and is not at risk of luteal-phase pregnancy [no
unprotected sexual intercourse (UPSI) in the past 3 weeks]. If this is not the case, the
procedure should be deferred and contraception used until at least 3 weeks from the last
instance of UPSI
If the progestogen-only injectable or implant is being used, laparoscopic tubal occlusion
can be carried out at any time during the period of licensed use without the need for
additional contraception
The progestogen-only implant can be removed at the time of the procedure or any time
following laparoscopic tubal occlusion
During tubal occlusion, curettage should not be performed for the purpose of preventing
luteal-phase pregnancy
Women using CHC, the progestogen-only pill or non-hormonal contraception should be
advised to continue their contraceptive method for at least 7 days after laparoscopic
sterilization
If laparoscopic sterilisation is scheduled for the hormone-free interval or Day 1 of a cycle
of CHC, the hormone-free interval should be omitted or CHC should be restarted, and
CHC should be continued for at least 7 days after sterilization
If a Cu-IUD or LNG-IUS is in situ prior to sterilisation, this should be retained and
removed at least 1 week after laparoscopic tubal occlusion
Hysteroscopic sterilisation may be safely and effectively undertaken when intrauterine
contraception is already in situ (outside the terms of the manufacturers instructions for
use). Women should be advised to use additional contraception or abstain from
intercourse for 7 days before the procedure in case the intrauterine device needs to be
removed to gain access to the fallopian tubes
Hysteroscopic sterilization
Tubal cannulation and placement of intra-fallopian implants is usually performed with

the patient under local anaesthesia and/or intravenous sedation.
A hysteroscope is inserted through the vagina and cervix.
A flexible microinsert is passed through the hysteroscope using a guidewire and placed
into each of the fallopian tubes.
The microinserts induce scar tissue formation, which occludes the fallopian tubes and
prevents conception.
An additional contraception should be used until imaging has confirmed satisfactory
placement of the microinserts. Imaging may be by X-ray or ultrasound scanning initially,
followed by hysterosalpingogram (HSG) in selected patients; or by HSG as a routine test
to ensure that the fallopian tubes have been occluded.
Women who do not attend for confirmatory testing should be informed that they need to
continue using additional contraception until tubal occlusion is confirmed
A number of different devices may be used for this procedure; these may include the use
of adjunctive radiofrequency ablation.
Efficacy
Successful bilateral placement of microinserts reported in 86-99% of cases

Tubal occlusion confirmed by HSG, or the position of the microinserts confirmed by X-
ray or ultrasound, 3 months after the procedure in 91-97% of women who had successful
bilateral placement of microinserts and completed 3 months of follow-up.
Available evidence suggests that tubal occlusion by intra-fallopian micro-insert has a
failure rate of about 1 in 500 at 5 years of follow-up; this includes caseswhere luteal-
phase pregnancy or non-adherence with post-procedural instructions wasdocumented
Safety
In a case series of 645 women, 1 of the 6 reported pregnancies was ectopic

Unsatisfactory microinsert placement (including microinsert expulsion and migration to
the abdominal cavity) reported in 1-4% of cases
Perforations of the uterine wall or tubal lumen caused by improper microinsert placement
reported in 1-2.6% of cases.
79% of women who had a successful procedures and completed a questionnaire at 3
months reported postoperative pain, with 8% describing it as severe.
Vaginal spotting and postoperative bleeding were reported by 68% and 28% of women
respectively on the day of the procedure (resolved within a mean of 3 days).
Postoperative bleeding that persisted for 7 days was reported by 19% of women
There have been case reports of women who required subsequent procedures 6 days to 3
years after hysteroscopic sterilisation to remove the microinserts due to pain.
Other potential adverse events include infection, device migration or expulsion,
vasovagal reaction and pelvic pain.
Comments
Posted by Jamie T.
New sept 2014 guidenace Mon Dec 8, 2014
02:21 pm
As above but some more evidence for ESSURE, vasectomy etc - hope this is useful
Posted by Jamie T.
Address for guidance Mon Dec 8, 2014
02:21 pm
http://www.fsrh.org/pdfs/MaleFemaleSterilisation.pdf

Contraception: Starting, Stopping & Changing
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STARTING, CHANGING AND STOPPING, MISSED PILLS
When to start COCP

Ideally within first 5 days of menstrual cycle. No need for additional contraception
Need additional contraception for 7 days if started at other times. Exclude pregnancy
Start on day 21 postpartum if NOT breastfeeding
Start after 6 months if fully breastfeeding
Start within 5 days if post abortion without need for additional contraception. Otherwise, use
barrier methods or abstinence for 7 days.
When to start POP
Start on day 1 of the cycle and take 1 pill everyday.
Can be started up to and including day 5 of menstrual cycle without need for additional
contraception. If started after day 5 and woman is not pregnant, needs additional contraception
for 48 hours.
Can be started up to and including day 21 post partum without need for additional
contraceptive cover
Can be started within 5 days of termination of pregnancy or miscarriage (< 24wks gestation)
Can be continued up to age 55 yrs if no contraindications
When to start progestogen only implants & injectables
Ideally in the 1st 5 days of cycle. No additional contraception needed.
Can be inserted at any other time provided woman is not pregnant. Use barrier methods or
abstinence for 7 days.
Can be started up to and including day 21 post partum without need for additional
contraceptive cover. If started after day 21, use barrier methods or abstinence for 7 days.
Can be started within 5 days of termination of pregnancy or miscarriage (< 24wks gestation)
without need for additional contraception. If after 5 days, advise barrier methods or abstinence
for 7 days.
When to start Levonorgestrel Intrauterine system (Mirena)

Can be inserted anytime within the 1st 5 days of menstrual cycle without need for additional
contraceptive cover.
Can be started at any other time provided the woman is not pregnant. Use condoms or
abstinence for 7 days.
Postpartum insert from 4 weeks postpartum
Post abortion / miscarriage insert within 48 hrs or delay until 4 weeks post abortion.
When to start Copper intrauterine contraception
Can be inserted at any time provided the woman is not pregnant. A Cu-IUD is effective
immediately.
Postpartum insert from 4 weeks postpartum
Post abortion / miscarriage insert within 48 hrs or delay until 4 weeks post abortion.
Managing Missed pills
When faced with a women presenting with having missed her pills, it is important to know when
to provide emergency contraception if there is a risk of pregnancy.
COCP
If 1 or 2 missed pills (30 g) or 1 missed pill (20 g): take pill as soon as possible. NO need for
emergency contraception
If 3 or more missed pill (30g) or 2 or more missed pills (20g): take pill as soon as possible
continue taking pill as usual and avoid sex or use condoms for 7 days
If missed pills are in 1st week of pack (day 0-7): Emergency contraception if unprotected
intercourse in pill free interval or 1st 7 days of pack
If pills missed in 2nd week of pack (day 8-14): NO need for emergency contraception if she has
taken at least 7 consecutive days of the pill.
If missed pills in the 3rd week (day 15-21): Omit pill free interval of current park and continue
straight to new pack
POP
Traditional POPs
More than 3hrs late OR more than 27 hrs from last pill: Take pill as soon as remembered and
take next pill atthe usual time. Use additional contraceptive cover e.g. condoms or abstinence for
at least 2 days. If woman vomits within 2 hrs of taking pill, another pill should be taken.
Cerazette
More than 12 hrs late OR more than 36 hrs from last pill: Take pill as soon as remembered and
take next pill as per the usual time. Use additional contraceptive cover e.g. condoms or
abstinence for at least 2 days. If woman vomits within 2 hrs of taking pill, another pill should be
taken.
Comments
Posted by R V.
start of LNG-IUS Wed Jan 26, 2011
12:39 am
Faculty of sexual
Posted by R V.
LNG-IUS Wed Jan 26, 2011
12:43 am
faculty of sexual and repro health care guidelines (sept.2010) - LNG-IUS can be inserted from
day 1 - 8 of the cycle without any need for additional contraception
Posted by R V.
LNG-IUS Wed Jan 26, 2011
12:44 am
Sorry it is day 1-7
Vaginal Discharge
Add your own notes
VAGINAL DISCHARGE IN WOMEN OF REPRODUCTIVE AGE
Causes of vaginal discharge in women of reproductive age
Physiological
Infective (non-sexually transmitted)
Bacterial vaginosis
Candida
Infective (sexually transmitted)

Trichomonas vaginalis
Chlamydia trachomatis
Neisseria gonorrhoeae
Non-infective
Foreign bodies (e.g. tampons, condoms)
Cervical polyps and ectopy
Genital tract malignancy
Fistulae
Allergic reactions
MANAGEMENT
History
Note the womans main concerns and reasons for presenting now
Characteristics of the discharge (what has changed, odour, onset, duration, colour, consistency)
Associated symptoms (itch, superficial dyspareunia, dysuria)
Symptoms indicative of upper reproductive tract infection (abdominal pain, STIs, deep
dyspareunia, abnormal bleeding, dysuria, pyrexia)
Sexual history for risk of STIs (higher if aged <25 years; new partner or more than one partner in
the last year)
Contraceptive use, pregnancy, postpartum, post-termination of pregnancy / miscarriage
Concurrent medications (e.g. antibiotics, corticosteroids)
Previous treatments used (prescription and over-the-counter)
Medical conditions (e.g. diabetes, immunocompromised state)

Consider non-infective causes of discharge (e.g. foreign body, cervical ectopy or polyps, genital
tract malignancy)
Examination
Abdominal examination identify mass / tenderness
Speculum examination erythema of the vulva, nature and odour of the discharge, presence of
vaginal and cervical lesions. Microbiology swabs if appropriate
Vaginal examination foreign body, uterine tenderness, adnexal tenderness
Low risk of STI and no symptoms indicative of upper reproductive tract infection:
Empirical treatment based on clinical and sexual history
1) Non-offensive white discharge with an itch : Candida antifungal
2) Offensive discharge without itch: Bacterial vaginosis metronidazole

Indications for investigations
Recurrent infection
High risk of STI
Upper reproductive tract symptoms
Woman requesting investigation
Pregnant, postpartum, post-abortion
Recurrent infection
Failed treatment
Medical conditions
Investigations
Vaginal pH
High vaginal swab - if the HVS is not transported immediately to the laboratory, it should be
stored at 4C for no longer than 48 hours.
Endocervical swabs for Neisseria gonorrhoeae
Test for Chlamydia trachomatis
Features of low genital tract infections
Bacterial vaginosis
Thin discharge. Offensive or fishy odour
No itch
Discharge coating vagina and vestibule
No vulval inflammation,
Vaginal pH 4.5
High vaginal swab (from lateral vaginal walls diagnosis made using Amsels criteria (3/4
present): White discharge, pH>4.5, Fishy odour (with addition of 10% KOH to discharge), Clue
cells (vaginal epithelial cells surrounded by bacteria)
Candida
Thick white discharge
Non-offensive
Vulval itch or soreness
Superficial dyspareunia
External dysuria
Normal findings or Vulval erythema, oedema, fissuring, satellite lesions

Vaginal pH <4.5
Treatment options
Bacterial vaginosis
Oral regimens (7080% cure): Recommended: Metronidazole: 400500 mg twice daily for 57
days or single 2 g dose
Alternatives
Vaginal regimens (7080% cure)
Metronidazole gel (0.75%): 5 g applicator nightly for 5 days
Clindamycin cream (2%): 5 g applicator nightly for 7 days
Oral clindamycin: 300 mg twice daily for 7 days
Tinidazole 2 g oral single dose
Recurrent infection
Suppressive therapy
Oral metronidazole: 400 mg twice daily for 3 days at the beginning and end of menstruation
Intravaginal metronidazole (0.75%): 5 g applicator twice weekly for 46 months after an initial
10-day course (outside product licence)
Avoid douching, and shampoo, gels and antiseptics in the bath
Routine screening and treatment of male sexual partners not recommended
Candida
Vaginal regimens (8095% cure): Recommended: Clotrimazole pessary: single 500 mg dose, 200
mg nightly for 3 days or 100 mg nightly for 6 days
Econazole pessary: one 150 mg pessary or 150 mg nightly for 3 days
Feticonazole pessary: single 600 mg pessary at night or 200 mg pessary nightly for 3 days
Miconazole intravaginal cream (2%): 5 g applicator nightly for 1014 days or twice daily for 7
days. Can apply to anogenital area
Oral regimens
Fluconazole capsule: 150 mg single dose; Itraconazole capsule: 200 mg twice daily for 1 day
Vaginal regimens (7090% cure)
Nystatin vaginal cream (100 000 units): 4 g for 14 nights or nystatin pessary (100 000 units): 12
for 14 nights
Recurrent infection (four or more episodes in 12 months)
Induction regimen (as above for initial treatment)
Maintenance regimen
Oral fluconazole: 100 mg as a single dose weekly for 6 months
Clotrimazole pessary: a single 500 mg pessary weekly for 6 months
Oral itraconazole: 400 mg (two divided doses in 1 day) monthly for 6 months
Avoid local irritants, perfumed products, tight-fitting synthetic clothing
Routine screening and treatment of male sexual partners not recommended
Treatment in pregnancy
Treatment with topical azoles as above but longer duration of treatment (7 days) may be
required. Avoid oral regimens due to potential teratogenicity
Trichomoniasis
Oral regimens (95% cure): Metronidazole: 400500 mg twice daily for 57 days or single 2 g
dose
Recurrent infection / treatment failure
Exclude vomiting with metronidazole and repeat standard regimen as above
Check risk of re-infection, partner notification and treatment, and compliance
If drug resistance is suspected seek specialist advice

Spontaneous cure rate of 2025%
Partner notification and treatment is recommended. Screen for other STIs
Comments
Posted by Giannis D.
Brand names antifungals Sat Sep 1, 2012 09:21
am
econazole: Pevaryl
feticonazole: Lomexin
miconazole: Daktarin
fluoconazole: Fungustatin
itraconazole: Sporanox

Hormonal contraception: Drug Interactions
Add your own notes

DRUG INTERACTIONS
COCP drug interactions
Anti-retroviral drugs
Can increase or decrease the bioavailability of steroid hormones. Metabolism of
oestrogens increased by Ritonavir and Nevirapine while Atazanavir increases plasma
oestradiol concentrations
Women on anti-retroviral drugs should be advised to use condoms
The dose of ethinyl-oestradiol should be 30-50 mcg
Neucloside reverse transcriptase inhibitors (Zidovudine, Lamivudine): UKMEC 1
Non-neucloside reverse transcriptase inhibitors (Efavirenz, Nevirapine, Etravirine):
UKMEC 2
Ritonavir-boosted protease inhibitors (Atazanavir, Indinavir): UKMEC 3.
Anti-Convulsants
Hepatic enzyme inducers including Carbamazepine, Phenytoin, Barbiturates, Primidone,

Topiramate, Oxcarbazepine: UKMEC 3
Recommend consistent use of condoms plus additional contraception
Use COCP with at least 30 mcg ethinly-oestradiol
Lamotrigine: UKMEC 3
Combinations of Lamotrigine + non-enzyme inducing anti-epileptics such as Valproate
do not interact with COCP
Anti-microbial agents
Broad spectrum antibiotics, anti-fungal and anti-parasitic agents: UKMEC 1

Hepatic enzyme-inducing antibiotics: Rifampicin or rifabutin. UKMEC 3
Progestogen-only pills
Women on anti-retroviral drugs should be advised to use condoms

UKMEC 2
Anti-Convulsants
Hepatic enzyme inducers including Carbamazepine, Phenytoin, Barbiturates, Primidone,

Topiramate, Oxcarbazepine: UKMEC 3
Lamotrigine does not interact with progestogen-only contraceptives
Broad spectrum antibiotics, anti-fungal and anti-parasitic agents: UKMEC 1

Progestogen-only Injectables
UKMEC 1 for depo-medroxyprogesterone acetate

UKMEC 2 for depo-norethisterone oenanthate
Anti-Convulsants
Hepatic enzyme-inducing anti-convulsants: UKMEC 1 for depo-medroxyprogesterone

acetate; UKMEC 2 for depo-norethisterone oenanthate
Broad spectrum antibiotics: UKMEC 1

Hepatic enzyme-inducing antibiotics: Rifampicin or rifabutin. UKMEC 1 for depo-
medroxyprogesterone acetate; UKMEC 2 for depo-norethisterone oenanthate
Progestogen-only Implants

UKMEC 2
Anti-Convulsants
Hepatic enzyme-inducing anti-convulsants: UKMEC 2

Broad spectrum antibiotics: UKMEC 1

Comments
progesterone implant Posted by walied S.
Tue Apr 30, 2013
08:35 am
NICE guidline in 2005 said that implant should not be used with enzyme inducer

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Combined oral contraceptive pill (COC)

Primarily by inhibiting ovulation via action on the hypothalamo-pituitary-ovarian axis to

Combined oral contraception (COC)

Combined transdermal patch (CTP)

Releases EE and etonogestrel at daily rates of 15 g and 120 g, respectively.

Criteria for excluding pregnancy

One or more of the following should be met

Has not had intercourse since last normal menses

Women who are amenorrhoeic

Postpartum (not breastfeeding)

Start on Day 21 postpartum if no additional risk factors for VTE

Post first- or second-trimester abortion

From one CHC to another CHC

Traditional POPs and LNG-IUS to CHC

Progestogen-only anovulatory methods (implant, injectable and desogestrel-only pill) to CHC

Women with short cycles

Unscheduled removal of the patch

Extended use of the patch

Pharmacokinetic data suggest that there is sufficient release of norelgestromin and EE to

Extended patch-free interval

Extension of the ring-free interval

If the ring-free interval is extended by 48 hours or more additional contraception is

Unscheduled removal of the ring

The advice in relation to extended ring-free interval applies

Extended use of the ring

Antibiotics (non enzyme-inducing)

Additional precautions not required when using antibiotics (non enzyme-inducing)

Serum levels of lamotrigine are reduced by CHC

Breast cancer and family history

Breast cancer and genetic mutations

Evidence is conflicting on whether women who are carriers of BRCA1 or BRCA2

Current breast cancer

Non-contraceptive health benefits

Ever-use of oral contraceptives was associated with a 12% reduction in all-cause

Ovarian and endometrial cancer

COC associated with a decreased risk

Dysmenorrhoea and heavy menstrual bleeding

Up to 20% of COC users have irregular bleeding

After 3 months allow BP to be rechecked, and assessment of any problems

CHC can be used up until the age of 50 years

CHC, Travelling & High Altitude

Long duration travel is a moderate risk factor for VTE

UK Medical eligibility criteria

Menarche to < 40 years = UKMEC 1

Aged < 35 years = UKMEC 2

BMI (including history of bariatric surgery)

Less than 30 = UKMEC 1

History of VTE = UKMEC 4

Major surgery with prolonged immobilization = UKMEC 4.

Valvular & congenital heart disease

Uncomplicated = UKMEC 2. Uncomplicated cases could be considered to be where:

Non-migrainous initiation = UKMEC 1, continuation = UKMEC 2

Epilepsy on anti-epileptic drugs = UKMEC 1

Molar pregnancy / gestational trophoblastic neoplasia = UKMEC 1

Undiagnosed breast symptoms / mass: Initiation = UKMEC 3, continuation = UKMEC 2.

Genital tract malignancy

Endometrial / ovarian cancer = UKMEC 1

Diabetes mellitus = UKMEC 2. Among women with insulin or non- insulin-dependent

Liver / bowel disease

Symptomatic or medically treated gall bladder disease = UKMEC 3

Anaemias & auto-immune diseases