Update
in
CONTRACEPTION
April 2012
ICGP Meeting
IMI, Sandyford
Dr Deirdre Lundy
CURRENT IRISH OPTIONS
HORMONAL
• Combined Oestrogen + Progestagen via Pills, Patch, & Intra-Vaginal
Ring
•
Progestagen-Only via Pills, Intra-Muscular Injection*, Sub-Dermal
Implant “Implanon”* & Intra-Uterine System “Mirena”* and
Emergency/Post-Coital Contraception or “Morning After Pill”
NON-HORMONAL
•
Condoms
•
Diaphragms
•
Copper Intra-Uterine Devices*
•
Sterilization
•
Natural Methods
* denotes LARC
CONTRACEPTIVE METHOD
IMPLANON
TYPICAL USE PI
.05
PERFECT USE PI
.05
.15
.1
MIRENA IUS
.2
.2
DEPO PROVERA
3
.3
NUVARING
8
.3
EVRA PATCH
8
.3
COCP
8
.3
CERAZETTE POP
8
.3
FEMALE STERILISATION
.5
.5
IUCD
.8
.6
NORIDAY POP
15
3
MALE CONDOM
15
2
DIAPHRAGM
16
6
VAGINAL SPONGE
16-32
9-20
FEMALE CONDOM
21
5
NATURAL METHODS
25
3-5
WITHDRAWAL
27
4
SPERMICIDES
29
18
MALE STERILISATION
Efficacy Graph
20
Perfect use
Typical use
15
LARC
Long acting
Reversible
contraceptives
percent
10
5
ilis
at
ion
nt
ste
r
pla
Im
IU
S
IU
D
De
po
CO
C
PO
P
nd
co
dia
ph
ra
g
ca
p
m
om
0
Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 17. NY: Ardent Media, 1998;800-801
METHOD
Consult
Fee
Condoms
€0
Product Duration
€0.50
Single use
€0.50-€180
+
(bulk)
Copper T
Annual
Cost
€80-100
€20
12 Years
€ 10
€ 450
€ 60
€80- €100
€80- €100
€60 x 2
€0
€ 40+
€120
€120
€3- € 22
Indefinitely
€60 x 4
€60 x 2
€60 x 2
€15
€16
€20
€20- € 40
€20- € 50
€40
€65
€ 180-€
360
€300
€320
€360
380
Sterilisation
Diaphragm
Mirena
Implanon
OCP
Depo
Nuvaring
Evra patch
2 yrs/ device
5 Years
3 Years
6 months
3 months
6 months
6 months
“THE PILL”
PROGESTIN
2ND GENERATION
Norethisterone acetate (NET)
AVAILABLE BRANDS & DOSAGE
GMS
COST
BREVINOR (30mcg EE+ 150mcg NET)
€ 0.67
MICROLITE (20mcg EE + 100mcg LNG)
LEONORE (20mcg EE + 100mcg LNG)
OVRANETTE (30mcg EE + 150mcg LNG)
LOGYNON (30/40mcg EE + 50/75/125mcg LNG)
€ 3.75
€ 3.00
€ 0.71
€ 3.71
MERCILON (20mcg EE+ 150mcg DSG)
MARVIOL (30mcg EE + 150mcg DSG)
€ 3.30
€ 2.75
Gestodene (GEST)
MINULET (30mcg EE + 75mcg GEST)
ESTELLE (30mcg EE + 75mcg GEST)
€ 6.54
€ 2.14
Norgestimate (NGST)
CILEST (35mcg EE +250mcg NGST)
€ 2.17
YASMIN (30mcg EE + 3mg DRSP)
YASMINELLE (20mcg EE + 3mg DRSP)
YAZ (20mcg EE + 3mg DRSP)
€ 5.63
€ 6.50
€ 7.96
QLAIRA (3/2/1 mg Estradiol Valerate+ 2/3mg DNG)
ZOELY (1.5mg Estradiol + 1.5mg NMG)
€ 8.49
€ 7.96
DIANETTE ( 35mcg EE + 2mg CPA)
€ 5.58
Levonorgestrel (LNG)
3rd GENERATION
Desogestrel (DSG)
4th GENERATION
Drospirenone (DRSP)
Dienogest (DNG)
Nomegestrol (NMG)
ANTI- ANDROGEN
Cyproterone acetate (CPA)
‘MINOR’ COC SIDE EFFECTS
•
•
•
•
•
Nausea
Bloating
Breast Tenderness
Acne
Disruptive Vaginal or ‘Breakthrough’ Bleeding
(BTB)
• Libido changes
• Migraine
• Weight Gain??
Side-Effects:
•
•
•
•
•
•
•
•
•
•
•
•
•
Nausea
Bloating
BTB
↑Weight
↓Libido
↑Vaginal discharge
↓Vaginal discharge
Dizziness
Hirsuitism
↓Mood
Acne
Breast discomfort
Migraine
Causes:
•
•
•
•
•
•
•
•
•
•
•
•
•
E only
E only
E &/or P
E &/or P
E &/or P
E only
P only
E only
P only
P only
P only
E &/or P
E &/or P
Discussion…
A monophasic COC containing 30 μg EE with
norethisterone or levonorgestrel is a suitable first
pill.
There is no current evidence to justify claimed
benefits for newer more expensive pills
especially for starters.
They are also more oestrogenic and have higher
VTE risk.
•
•
No scientific evidence for causal relationship
between OC use and weight gain.
SIDE EFFECT
POSSIBLE CAUSE(S)
POSSIBLE SOLUTIONS
SUGGESTED BRANDS
NAUSEA
Too much Oestrogen
Reduce Oestrogen strength
Take after food/ in evenings
Consider non oral / Non Oestrogen
Options
Leonore,Microlite, Mercilon,Yaz, Yasminelle
Zoely
Nuvaring, POP, LARC, etc.
BREAK THROUGH BLEEDING
Too little Oestrogen
Increase Oestrogen strength
Estelle, Minulet, Cilest, Brevinor, Ovranette, Logynon
Insufficient Oestrogen absorbtion
Too much Progestagenic potency
Too much Androgenic potency
Undiagnosed STI
Try transdermal or Intravaginal route Evra, Nuvaring
Try less progestagenic brands
Yasmin, Qlaira
Try less androgenic brands
Mercilon, Marviol
Outrule Chlamydia,et al
BLOATING / BREAST TENDERNESS Too much Oestrogen
Reduce Oestrogen strength
Leonore,Microlite, Mercilon,Yaz, Yasminelle
Too much progestagenic potency
Consider intravaginal route
Try less progestagenic brands
Nuvaring
Yasmin, Yasminelle,Yaz, Qlaira
IRRITABILITY/DEPRESSION/
LOSS OF LIBIDO
Too much progestagenic potency
Try less progestagenic brands
Yasmin, Yasminelle,Yaz, Qlaira
Try increasing Oestrogen dose
Cilest, Brevinor, Ovranette
HEADACHES
Too much Oestrogen
Reduce Oestrogen strength
Leonore,Microlite, Mercilon,Yaz, Yasminelle
Consider intravaginal route
Nuvaring, Zoely
HEADACHES during Pill Free Interval
Too much of hormone drop
Reduce Oestrogen strength
Shorten or omit PFI
Leonore,Microlite, Mercilon,Yaz, Yasminelle
Yaz,Qlaira, tri-cycle packets
ACNE
Too little Oestrogen
Increase Oestrogen strength
Estelle, Minulet, Cilest, Brevinor, Ovranette, Logynon
Insufficient Oestrogen absorption
Too much androgenic potency
Too much progestagenic potency
Consider transdermal route
Try less androgenioc brands
Try less progestagenic brands
Evra
Mercilon, Marviol
Yasmin, Yasminelle,Yaz, Qlaira, Dianette
WEIGHT GAIN
Too much Oestroegn
Too much progestagenic potency
Reduce Oestrogen strength
Try less progestagenic brands
Leonore,Microlite, Mercilon,Yaz, Yasminelle
Yasmin, Yasminelle,Yaz, Qlaira
THRUSH
Too much Oestrogen
Reduce Oestrogen strength
Try non Oestrogen products
Leonore,Microlite, Mercilon,Yaz, Yasminelle
MAJOR COCP SIDE EFFECTS
• Because Oestrogen affects coagulability
Thrombo-Embolic phenomenon are possible
therefore……………
Thrombosis & COCP
• Risk is always higher on COCP (approx 4 fold on
average) but far lower than during Pregnancy
• Incidence peaks within first 3 months of use ( so be
careful to whom you prescribe) and usually presents
as DVT
an exception is the thrombosis associated with
Cyproterone acetate preparation ( Dianette) which
has a higher TE risk(4x that of other pills, tends to be
upper limb & can occur years into use
QUICK GUIDE- OBESITY
MAJOR SIDE EFFECTS
• BMI 30-34
Both POP & all LARC OK
E2 OK if otherwise healthy
• BMI 35-39
Both POP & all LARC OK
E2 Cat 3
• BMI >39
Both POP & all LARC OK
E2 Cat 4
EFFICACY
• > 70 kg
Avoid Noriday
• >90 kg
Avoid Evra
• >100 kg
Change Implanon
early
The Pill & Cancer
RCGP’s Contraception Study (began in 1960’s and was evaluated
again at the million woman/year point. Compared ‘ever’ vs. ‘never’ pill
users from 35-64 yoa) reported in the BMJ in Sept 2007.
It found:
• Significant decreases in rates of Ovarian, Endometrial, Uterine Body &
Colorectal Cancers
• Slight (statist. insignif.) increases in:
* Lung
* Cervical (VERY SMALL INCREASE FROM 38PER 100,00 TO
40/100,000 AFTER 5 YEARS- REVERTS BACK AFTER 10 YRS
POST USE)
* CNS & Pituitary Cancers
• No increases in Breast CA rates
Ever users had an overall reduction in cancers
of 12% when taken as a whole !
Antibiotic Interaction Concerns
• In 2011 FSRH & RCOG in UK:
“additional contraceptive precautions are
not required during or after courses of
antibiotics that do not induce liver
enzymes”
Tuberculosis meds Rifampicin & Rifabutin
are excluded form the guidance
MISSED PILLS
PHARMACOKINETICS OF
COC
Pill 7
↓
Pill 21
↓
Pill 7
↓
7 DB &Withdrawal bleed
Pill 1
↓
“OVULATION ZONE” !!!!
Pill 1
←
NEWER PILLS
NEWER Combined PILLs: ‘YAZ’
• Different pill taking regimen
• 24 consecutive days on/ 4 days off- bleed typically
arrives as she Restarts the next packet
Uses 4 placebos instead
of asking patient to
remember which day to
restart
“Beyaz” coming soon ?
Qlaira (“Natazia” in USA
FDA passed May 2010)
• First COC to use ‘Oestradiol Valerate’ (E2V)
instead of Ethinyl Oestradiol (EE)
• E2V combined with a well- known European
progestagen ( Dienogest or ‘DNG’) in an
“oestrogen step-down and progestagen stepup” regimen.
• Pearl Index same as EE pills (<1)
• Has minimal effect on haemostatic parameters
and may have a favourable effect on lipid
profiles
“ZOELY” avail since March 1
st
2012
• 1.5 mg Estradiol +
• 2.5mg
Nomegestrol
• Monophasic 24/4
• Good tolerability
Pearl Index same as EE pills (<1).. NMG has 46 hr duration of
protection
Has minimal effect on haemostatic parameters and may have a
favourable effect on lipid profiles
Alternative ROUTES for Combined
Oestrogen & Progestagen
Contraception
• Transdermal Patch
• Intravaginal Ring
TRANSDERMAL
“Evra” PATCH
• EE ( 20 microg) plus Norelgestromin (150
microg)- similar to progestagen in Cilest)
• > € 16 per month
• Higher E2 exposure (greater
bioavailability +continuous release) assoc
with 25% more breast tenderness
• Not affected by vomiting, diarrhoea or
antibiotics (but as there is no data we still
advise precautions)
• Still unreliable if Obese (reduced efficacy in
patients > 90kg)
or on LEI Rx
INTRAVAGINAL
“Nuvaring”
– Contains 2.7mg EE
Releasing 15µg/24 hrs) plus
– 11.7mg Etonoergestrel
releasing 120mcg per day
• € 15-21 per month
• VERY popular among French women!!
• Highest user satisfaction stats of all
hormonal contraception
- has very low discontinuation rates
compared to other routes
“Nuvaring”
• Lower E2 exposure (50% that of 30
microg pill)
• Good Bleed pattern - 40% less BTB
than Yasmin
Not affected by vomiting , diarrhoea or
antibiotics
But we only have data confirming that for amoxicillin &
doxycycline
• Still unreliable if on LEI Rx
No reports of reduced efficacy in Obesity
Starting day 1-safe immed, day 2-5, wait 7 days;
shouldn’t be flushed, should be stored in fridge but
can be at room temp for up to 4 months
PROGESTAGEN ONLY CONTRACEPTIVES
Different varieties of Progestagens can be delivered in one
of these Routes:
•
•
•
•
Oral
Intra-Muscular
Subcutaneous
Intra-Uterine
“THE MINI-PILL”
•
•
•
•
New POP for Irish women
Launched in Ireland –finally!- September 2009
Has been widely prescribed in the UK since 2002
Has become Number 1 prescribed POP & No 2 oral
contraceptive overall in the UK’s GMS even though
alternatives are cheaper! Why?
Cerazette
•
•
•
•
•
75 µg DESOGESTREL
Taken daily – 365 days- NO BREAKS
36 hour Duration of action
OVULATION inhibition in 97%
Pearl Index of .4 (same as ‘Microlut’ but much
better than ‘Noriday’)
• Will not guarantee regular monthly bleeding
• € 6 GMS so should be about €12-15 private
“Noriday”
• May impair ovulation
• Variable efficacy
• Must be taken within
3 hrs of usual time
• Bleeding disruption
not unusual
vs
“Cerazette”
• Always impairs
ovulation
• High efficacy (= to
COC)
• Can be taken up to 12
hrs late (= to COC)
• Bleeding disruption rare
Advantages of Cerazette
• Headache, breast pain, nausea and bloating are
known side effects of oral contraceptives, and these
are generally related to the estrogen dose of the
pill.
• Not affected by antibiotics
• OK to use with Hx of previous ectopic pregnancy
• May alleviate Menorrhagia, Dysmenorrhoea, PMS
• Thrombo embolic events less likely as E2-free so
OK to prescribe for:
Smokers
Obese (anyone over 70 kg requesting POP should
be offered Cerazette in preference acc to JG)
Problems with Cerazette
• Irregular Bleeding is common
• By 11 months 50% users will have
INFREQUENT bleeds or AMENORRHOEA
but there is a high drop out rate before
patients get to 11 months
• Acne, Breast Tenderness, Mood
changes, Headaches, Weight increase
are more rare & usually self-limiting
• Compliance issues
• Influenced by Liver Enzyme Inducers
..can Rx 2 tabs /day off licence
POST COITAL or
EMERGENCY
CONTRACEPTION
VARIETIES
of PCC
• HORMONAL
COC, POP, Mifepristone, Ulipristal
• INTRA UTERINE COPPER COIL
“THE MORNING AFTER PILL”
ECP History
• PROGESTAGEN ONLY preparations studied and compared to Yuzpe
in late 1990’s
• 2001 Yuzpe phased out & Levonorgestrel progestagen phased in
• 2004 Levonorgestrel licensed in Ireland for PCC
• 2006 became OTC (or “Behind the Counter”)
in USA , UK, et.al. NOT IN Ireland
• 2009 ‘ellaOne’ licensed in Europe
• 2011 Levonorgestrel licensed OTC in Ireland
• 2012 ellaOne available throughout ROI
LEVONORGESTREL
• “LEVONELLE” & “NORLEVO”
• 1500 micrograms Levonorgestrel
progestagen stat
• Single dose
• Within 72 hrs
(Replacing the original Yuzpe COC
method)
EFFICACY
• If taken within 24 hrs prevents up to 95% of
pregnancies expected to occur if no EC had been
used
• If taken after 24 but before 48 hours prevents up
to 85%
• If taken 48 to 72 hrs after UPSI prevents up to
58%
• If taken 120 hrs after UPSI no firm data but still
thought to be somewhat effective.. WHO suggest
levonorgestrel offers prevention of a high
proportion of pregnancies even up to 5 days after
coitus. Named patient use.
EFFICACY
ETHICACL CONCERNS
is ECP an ABORTOFACIENT?
This question was at the heart of the 3 year delay in granting Levonorgestrel its OTC license
by the food and drug but they finally made it so in 2006
RELIGIOUS OBJECTIONS by Patients
•
The United States Conference of Catholic Bishops authorizes doctors to offer a rape
survivor a drug that blocks ovulation or fertilization if there is no evidence that conception
has occurred already. As there is no direct evidence that ECP blocks implantation most
Catholic hospitals in the US use ECP liberally.
•
Anglican church offers no specific prohibition but expressed reservations about the move
to make ECP available without prescription.
•
Muslims have no official policy on contraception. The Qur’an allows any form of
contraception prior to “ensoulment” (except Vasectomy!!) but doesn’t specify when this
occurs. Most schools argue this event occurs long after implantation so very few Muslim
women are likely to have religious concerns about using ECP.
•
In Judaism as in Islam there is no blanket guideline. Halacha (Jewish law) binds a married
man to have children but states that he can delay these children after consultation with the
rabbi. It does not specify which methods of delaying children a man can employ & neglects
to offer any restrictions at all to a woman.
•
Hinduism offers no objections.
Recently available…
Alternative HORMONAL POST COITAL
CONTRACPTIVE called
ellaOne
ULIPRISTAL
• “ellaOne”
• Selective Progesterone Receptor Modulator
(SPRM)
• 30mg single dose
• more expensive (? € 25)
• Made by HRA Pharma who also produce
‘Norlevo’
Modes of action compared
• LEVONORGESTREL
• ULIPRISTAL
• Not fully understood
• May inhibit ovulation
• ?? Inhibit implantation
•
•
•
•
↓Follicle growth
↓LH surge blocking
Follicle Rupture
Delays Endometrial
maturation
• Induces early Endom
Bleeding
POST COITAL IU COPPER COIL
• Less commonly employed but extremely
effective and reliable method of post coital
contraception
• Commonly offered in UK FP clinics
• Must be very familiar & comfortable with
Coil insertion
• CAN NOT USE MIRENA (must have Cu)
MODE OF ACTION
• Inhibit fertilization
• ?? Effect on cervical mucus
• Strong Anti-implantation effect
…..and so can be offered up to 5 days after UPSI or
up to 5 days after predicted date of Ovulation
where there has been multiple “exposures” (acc to
UK FP clinics)
Flexi T
ONLY HAS 300 mm² of COPPER
CONTRAINDICATIONS
• Same general rules for coil insertion
• Out rule current pregnancy with urine PT in all
patients
• Consider caution with
• Young age
• Nulliparity … use smallest device available e.g. Flexi –
T… remove with next Menstrual Bleed
• Previous ectopic
• STI exposure especially asymptomatic, prevalent
diseases like CHLAMYDIA
9%
8%
7%
6%
5%
No treatment
Levonelle
Copper IUD
4%
3%
2%
1%
0%
1 4 7 10 13 16 19 22 25 28 31 34 37 40
Probability of Pregnancy by Cycle Day
Source: Wilcox et al. 2001
INTRAMUSCULAR INJECTABLE
PROGESTAGEN
“DEPO-PROVERA”
• 150mg/ 1ml IM INJECTION of MEDROXY
PROGESTERONE ACETATE
Regarding Depo Provera; would
you…
A Order a bone density scan for patients on
DMPA for >5 years
B Check serum oestradiol level if
amenorrhoeic on DMPA for 5 years
C Stop DMPA at 40 years of age
D Not prescribe it for teenagers
My choice…
• None of the above
Discussion…
• No conclusive causal association between DMPA
and osteoporotic fractures or hypo oestrogenaemia
• Assess osteoporosis risk weighing up all factors
(FH, smoking, diet as child, exercise, drugs, etc)
• Use symptoms as guide to occasional low oestrogen
levels – Blood E2 levels have no correlation to bone
density
• Reconsider all choices for women at regular
intervals regardless of method used
• Amenorrhoea reduces anaemia and possibly
endometriosis
• Dexa scan is not useful for fracture risk
BONE MINERAL DENSITY
• REDUCED DURING USAGE ESP IN
AMENORRHOEIC PATIENTS
• QUICKLY RETURNS AFTER
DISCONTINUATION
• RE-EVALUATED IN 2004 RESULTING IN
NEW GUIDELINES FROM UK DEPT OF
HEALTH
GUIDELINES
FFPRHC
• ALTERNATIVE CONTRACEPTION SHOULD ALWAYS
BE OFFERED AND DISCUSSED WITH WOMEN
REQUESTING DEPO ESPECIALLY UNDER 18YO AND
OVER 45YO
• WOMEN WITH OTHER RISK FACTORS FOR
OSTEOPOROSIS SHOULD BE ADVISED AGAINST
ADDING IN DEPO
• CURRENT DEPO USERS SHOULD HAVE THEIR
OPTIONS REVIEWED EVERY 2 YEARS
• MARGARET PYKE CENTRE PUTS A CEILING OF 5
YEARS CUMULATIVE ON THE METHOD.
SUBCUTANOEOUS
PROGESTAGEN
IMPLANT
“IMPLANON NXT”
IMPLANON NXT
• ETONOGESTREL-RELEASING
SUBCUTANEOUS IMPLANT
• 3 YEARS
• €120 + insertion fee
• TRAINING NEEDED FOR INSERTION
AND REMOVAL
Mode of Action
• Primarily blocks Ovulation (but allows
other Ovarian function e.g. E2 production)
so no concerns over BMD
• Alters Cervical mucus
• Inhibits normal Endometrial development
SIDE EFFECTS
• Disruptive Vaginal Bleeding
(Initial removal rates seemed very high but 2009 is the 6 yr anniversary in Ireland
and MANY patients are returning for their 3rd device!)
Management: out rule disease (e.g. Chlamydia), reassure and then consider trial of
a suitable 20-30 mg COC for around 3 cycles. Marviol with the same progestagen
as Implanon usually controls the bleeding while the tablets are being taken, with
predictable withdrawal bleeds between packs. Thereafter the woman may (or may
not!) obtain an acceptable bleeding pattern !
Alternatively Provera 5mg daily OR Cerazette useful in patients with EE
contraindications OR Doxycycline 100mg BD x 5 days (MATRIX
METALLOPROTEINASES)
• Progestagen – related symptoms e.g..
Bloating, Acne, Moodiness
often resolve if patient perseveres for at least 3 months
• Infection of insertion site
• Migration of Device inside arm
Contraceptive
method
Bleeding pattern
in first 3 months
Bleeding pattern
in the longer term
Depo Provera
Bleeding disturbances
(spotting, light, heavy or
prolonged bleeding) are
common BUT up to 35%
are amenorrhoeic at 3/12
Up to 70% are amenorrhoeic
>1 year
Implanon
Bleeding disturbances in
first 3-6/12 are common.
After 6 months use, 30% have
infrequent bleeding; 10-20%
have prolonged bleeding.
NICE LARC Guideline suggests:
20% amenorrhoeic; 50% have
infrequent, frequent or
prolonged bleeding, which
may not settle with time
Mirena
Irregular, light or heavy
bleeding is common in
first 6 months
65% are amenorrhoeic or have
light bleeding at 1year.
90% reduction of menstrual
blood loss over first 12
months of use
Implanon & Osteoporosis???
No concerns….
the data are reassuring so far, with regard
to etonogestrel’ s effects on both
circulating estradiol levels and bone
density.
In comparative 2 yr. studies both remained
similar to those in copper IUD-users.
INTRA UTERINE
PROGESTAGEN
“MIRENA”
MIRENA INTRA UTERINE
SYSTEM
• LEVONORGESTREL- RELEASING INTRA UTERINE
SYSTEM
• 5 YEARS
• € 120 + insertion fee
• SPECIALIST INSERTION
COMPOSITION
• LEVONORGESTREL- RELEASING
INTRAUTERINE SYSTEM
• 52 milligrams LEVONORGESTREL in a
SILASTIC PLASTIC MEMBRANE wrapped
around a POLYETHYLENE FRAME
• RELEASING 20 micrograms of hormone per 24
hours
• Lasts 5 years
• Not affected by Obesity, LEI
Difficult Insertions & Late Bleeding
Uterine and Cervical PATHOLOGIES
frequently present as:
•
•
•
•
Tight Cervical Ossa
Early Expulsion
Persistent menorrhagia
Later return of menorrhagia
German data published in Contraception 2007
Future Mirena
• 2013? Expect to have the slim line Mirena
• 3 year device
• “Better” for Nullips ?
“Intra Uterine Copper Coils”
• Usually T shaped Polyethylene plastic
frames
• Copper wire “coiled” around the shaft
• Copper bands affixed to horizontal arms
(ideally)
• Cu is a spermicide & causes mild local
inflammation of Endometrium
• Plastic frame acts as a foreign body to
also cause endometrial inflammation
EXAMPLES
EFFICACY IS AFFECTED BY THE SIZE
OF THE DEVICE ITSELF AND THE
PRESENCE OF BANDS OF COPPER
WIRE- NOT JUST COILED COPPER
+
DURATION of EFFICACY
(all brands reliable to
Menopause if inserted in
women > 40 yoa)
&
DIMENSIONS
Cu T 380
12 years
6.5cm
Highest Efficacy of all IUDs (<2 % failures)
TT 380 Slimline
10 years
6.5cm
Retails for €23 from Medisource, Bray
Not Contraindicated in
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Nulliparity
After Caesarean Section (caution though)
Smoking
Obese
Previous Ectopic
Hx of PID ( treated > 3 mos ago)
Breast feeding
Valvular Heart Disease ( but use IV antibiotic
prophylaxis)
Multiplicity of Cardio vascular Risk factors
Hx of VTE
GA + Immobilisation
Hyperlipidaemia
CIN
Current Breast Cancer
Highlight indicates situation where IUD safer than IUS
Recent IUCD news
• Previous Ectopic no longer an absolute
contraindication- package labelling has
been revised
• No longer need prophylactic antibiotics
for women with cardiac valve disease
during insertion (American Heart Assoc
& FFPRHC)
• Sourcing them:
• www.medisource.ie Ph (01) 2866288
• www.wms.co.uk
• www.wellwomancentre.ie
Websites
• www.nmic.ie
(2010 Newsletter on Contraception)
• www.medicalmasterclass.com
(Click on “Handouts”)
• www.ffprhc.org.uk/
Faculty of Sexual & Reproductive Health March 2010 Guidance
“Contraceptive Choices for Young People”
• www.margaretpyke.org
• www.rcog.org.uk
• http://www.cks.nhs.uk
MASTERCLASS in Contraception
11th May 2012
REGISTRATION
Please email [email protected] to register your
interest
FEES
To be announced.
DURATION
1day:
•Morning - Principles of Adult Teaching.
•Afternoon - Update in all areas of contraception.
NB: Established GP trainers will only be required to
attend the afternoon session.
DELIVERY
Small group teaching, interactive quiz, lectures.
ACCREDITATION
Full Day: 2 CME & 5 CAS, Half Day: 1 CME & 3 CAS
CONTACT
[email protected] or tel: 01 6763705
01 6763705
.