Presentation: What`s new in contraception and teen troubles

What’s new in
contraception and teen
troubles
Dr Jane Dickson, Consultant in Sexual Health
and Reproductive Healthcare
@thesexdoctorUK
@thegynaedoctor
Wednesday 6 May 2015
Myth Busting
• February 2014 “Deadly risk of pill used by 1m women:
Every GP in Britain told to warn about threat from popular
contraceptive” www.dailymail.co.uk
• FSRH Statement on Venous Thromboembolism (VTE) and
the hormonal contraception November 2014
• CEU Statement - Combined Oral Contraception and Risk
of Stroke November 2014
VTE Risk
Post Partum
Pregnant
300-400
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Drospirenone (Yasmin),
Desogestrel, Gestodene, Cocyprindiol (3rd and 4th gen)
9-12
Norelgestromin,Etonogestrel
(Evra and Nuva ring)
6-12
Levonogestrel, Norethisterone,
Norgestimate (1st and 2nd gen)
Non-Users
5-7
2 per 10,000 women years
Tailored/ Extended Pill taking
• Continuous use of COC with breaks individually tailored
for each woman
• Take pill until there is a bleed and then have a PFI
(un-licensed)
• Suitable for women who have problems in PFI
• Women tend to develop a regular pattern
• Requires time, effort and motivation!
Tailored pill taking
Regimes include :
• Extended with 4/2 day break or bi or tri-cycle
• Continuous with 4 day break following 3 consecutive
days of bleeding
The reasons for using these regimes include:
• Women prefer fewer bleeding days (save money!)
• Better compliance and less failure
• Treatment of endometriosis, dysmenorrhoea and
menstrual disorders including migraine and PMS/PMDD
• Benefits supported by Cochrane
review
• 12 RCT comparing conventional
with extended and continuous
regimes
• Failure rate and safety profile the
same
• Fewer menstrual symptoms with
extended or continuous regimes
• Bleeding patterns improved with
extended or continuous regimes
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New POP Guidelines
• Generic desogestrel pills available
• 97% anovulation
• 12 hour window period
• DSG containing pills may offer more benefits to management of
dysmenorrhoea
• Femulen® discontinued
• Recommended that POP commenced on Day 1 post MTOP
8
New Injection Guidance
• Recommended women stop using at 50 years
• Could use beyond if informed of the potential risks to 55 years
• Recommended interval between injections now 13 weeks (up to
• 7 days late without need for extra protection)
• A causal relationship between injection and HIV
transmission/acquisition has not been established but cannot be
•
•
completely excluded. Women at high risk of HIV should be
advised to use condoms.
9
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• Bio equivalent to Depo Provera
• Delivered via a unique Unijet™single dose prefilled injector
• 13 weeks +/- 7 days
• Shake first
• Obese/bleeding disorders
• BMD, amenorrhoea, weight gain and return to fertility
same as with conventional i.m. DMPA
• Potential for self administration
• Slightly more expensive
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Conception
• Chances of conception up to 30% from single episode
of intercourse around the time of ovulation
• Much lower 2-4% at other times of cycle
• Chances of conception influence how we advise and
treat women after unprotected sexual intercourse
• Young women much more fertile than older ones
Cautions/contraindications
• Hypersensitivity/pregnancy
• Severe asthma with glucocorticoids
• Hepatic dysfunction
• Hereditary problems of galactose intolerance, Lapp
lactase deficiency, glucose-galactose malabsorption
• Not with enzyme inducers/drugs which increase gastric
pH
Use of EC > once per cycle
• LNG can be used more than once in cycle and can be
used even if there have been earlier episodes of UPSI
outside the treatment window
• If LNG taken within previous 12 hour further dose of EC
not necessary
• SPC says UPA shouldn’t be given more than once per
cycle but now enough evidence is safe to do so
Caya
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Contoured silicone diaphragm
• Fits 80% women (conventional diaphragm size 60-85mm)
•
Estimated pregnancy rate at 12 months 17.8% with
typical use
•
Need to use Caya gel® (£15)
•
£30-40 online
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Jaydess
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Dimensions
Insertion
tube
diameter
Duration of
use
Dose
Indications
Jaydess®
Mirena®
3.8mm
4.4mm
3 years
5 years
13.5 mg
Contraception only
52 mg
Contraception
Idiopathic menorrhagia
Endometrial protection in HRT
Jaydess® - T frame
• Horizontal flexible arms
–
Allows the device to flex as the uterine cavity expands and contracts
• T-frame contains barium sulphate
–
Enables it to be visualised on
X-ray examination
• Silver ring
–
Allows it to be distinguished from other
uterine devices
• Monofilament threads
– Allows the removal of Jaydess® from the uterine cavity
– Locating the threads provides reassurance that Jaydess® is still in place
Jaydess® Summary of Product Characteristics, Bayer plc
Jaydess® - silver ring
• The T-frames of Jaydess® and Mirena® are
both visible on ultrasound1,2
• Jaydess® has a silver ring just below the
transverse arms that allows it to be
distinguished in utero1
• Jaydess® is contraindicated in
women with known
hypersensitivity to silver1
1.
2.
Jaydess® Summary of Product Characteristics, Bayer plc
Mirena® Summary of Product Characteristics, Bayer plc
Levosert
• Same dose of levonorgestrel as Mirena
• Currently licensed 3 years
• Like a Nova T insertor
• 2 handed technique
• Inserter tip is soft and has flexible design
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Perforation
• 81 perforations were reported out of >61,000 insertions
(1.3 per 1000 insertions) EURAS Study
• Largely associated with a benign clinical course
• Breast feeding at the time of insertion was associated with
a 6 x increased risk of perforation
• There was no difference between copper IUDs and LNGIUS in terms of perforation rate
Origami Condom (male/female
and anal) engineered for the 21st
century, non-rolled to “provide
pleasure from within”
•
•
•
Remote control
contraceptive chip
Releases levonogestrel
Effective for 16 years and
can be wirelessly turned
off
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•
•
•
RISUG (reversible
inhibition of sperm under
guidance) or Valsalgel;
new male contraception
being developed
Polymer gel injected into
the vas deferens and
coats the walls rendering
sperm inactive when they
come into contact with it
Reversible
NATSAL-3
Statistics
• 16,500 children each year
• Some professionals may dismiss
• 5-16% YP (650,000-1 million) experience abuse
• 1:3 don’t tell
• 16% increase between 2009 and 2010
• One quarter – on-line grooming
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What is CSE?
• Child sexual exploitation (CSE) is a form of sexual abuse
that involves the manipulation and/or coercion of
young people under the age of 18 into sexual activity
• Young person receives something as result if
performing sexual activities
• Technology may be involved
• Child often has limited choice due to vulnerability
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• Can be used for any young
person <18 or where you may
have concerns for capacity
• The proforma will help to identify
both verbal and non-verbal
indicators
• Be “chilled” and ask in “calm
way”
• “Don’t act like a doctor - you
need to listen and not jump to
conclusions”
Domestic Violence
• The Family Rights Group reported an
800% increase in domestic violence
cases - being a witness to or victim of
abuse in the home is a key indicator for
CSE
• Natsal 3 found that 1:10 women and
1:71 men had experienced nonvolitional sex
• Good practice to ask about a patient’s
experience of domestic violence and
offer counselling/referral where
needed
Female Genital Mutilation
Partial or total removal of the external female genitalia
or alteration of genitalia for non medical reasons
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FGM
• It is mandatory for health
professionals to record the presence
of FGM in a patient's healthcare
record whenever it has been
identified
• It has been mandatory since
September 2014 for Acute Trusts to
inform the DoH the numbers of FGM
cases reported each month
• From April 2015 mandatory data
collection will extend to mental health
trusts and GPs
• Natsal 3 showed that we start
having sex younger and settling
down later
• There is a longer need for
contraception and prevention of
unplanned pregnancy
• More sexual partners
• Accessing sexual health services
more readily
http://natsal.ac.uk/media/823260/nats
al_findings_final.pdf
• Conception rate for women over 40 has more than
doubled since 1990 from 6.6 to 14 per 1000 women
(ONS)
• FPA survey among 40-54 year olds:
• 34% said they had had unprotected sex in the last two
years when not planning a pregnancy; of these 94% did
not use emergency contraception
• 62% knew “very little” about emergency contraception or
where to access it
• 44% thought you needed a prescription for EC
• 54% thought it caused abortion
Relative changes in age-specific conception rates, 1990-2013
England and Wales (www.ons.gov.uk)
• Under 18 conception rate is falling (ONS 2014)
•
But poor understanding of contraception and emergency
contraception methods remain
•
•
Of the 2131 women surveyed by the FPA only 38% felt
that they had a “good understanding” about LARC
methods
Only 1 in 6 women (16%) thought that their health
professional provided enough information
Porn and young people
• Survey of more than 2,500
young people carried out by
the National Union of
Students found
• 1/3 teenagers are turning to
porn to fill the gaps left by
their sex-education lessons,
• almost 2/3 of young people
have used pornography to
find out more about sex
• 2/5 say that it has helped
them to understand sex
•
Pornography has been linked to
unrealistic attitudes about sex,
beliefs that women are sex objects,
uncertainty about sexuality
•
Access and exposure to
pornography are linked to children
and young people’s engagement in
“risky behaviours” including
“Sexting”
•
But causal relationships between
pornography and associated
expectation, attitudes and
behaviours are still unclear
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Molly
• 16y referred c/o prolonged heavy bleeding
• Cycle 7/14 with 3 heavy days
• Menarche age 11
• Tranexamic acid not helpful
• Sexually active using condoms
• Non smoker BMI 31 kg /m2
• Hb 140
• Scan – thickened endometrium 14.2 mm
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Treatment (NICE Guideline 44)
Therapy (Improvement)
IUS ( provided >12m use
expected)(79-97%)@12m
Tranexamic acid(34-59%),
NSAIDS (20-49%)or COC(43%)
NET 5mg tds D5-26 cycle or
injected long acting
progestogens(37-87%)
Katie
•
•
•
•
•
•
•
•
•
•
18y Prolonged heavy bleeding
Menarche age 11
BMI 36 kg/m2
Had COC for 6 months – made her depressed
Had POP for 1 year – made her depressed
Sexually active but wont consider LARC
Scan shows endometrium 12mm irregular with cystic spaces
Had oligo-amenorrhoea before started COC
Has facial hairs which plucks weekly – are very distressing
Cried throughout consultation
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Rotterdam Criteria
• 2 out of 3
• Polycystic ovaries (↑ ovarian volume > 10cm2 or 12 +
peripheral follicles)
• Oligo or anovulation
• Hyperandrogenism
• No longer do LH/FSH and androgens not necessary
(unless suspect tumour)
Associations
• Acne
• Hirsuitism
• Infertility
• Obesity
• Impaired glucose tolerance / DM
• Metabolic syndrome
• Endometrial hyperplasia/ cancer
Management
• Exercise and weight reduction
• Need a bleed every 3-4 months
• COC / cyclical progesterone / IUS
• Choice of management depends on which other
symptoms are present
• Metformin/ Fertility Rx
• Treatment specific for endometrium if any abnormality
Joanna
• 14 years old
• Severe cerebral palsy and epilepsy
• In a wheelchair
• Periods are very distressing and problematic
• BMI 16.5 kg/m2
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What are the problems ?
• Can’t swallow
• Not mobile
• Low BMI
• Frequent seizures
• Learning difficulties – consent issues
• Interacting medication
• Options – combined patch, implant, depot, IUS
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Chanice
• 17 years old
• Severe dysmenorrhoea
• K 4/28
• Dyschezia during menstruation
• Not sexually active
• No pain at other times
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Differential diagnosis of pelvic pain
Gynaecological
• Dysmenorrhoea
• Endometriosis
• PID
• Ovarian Cyst
• Anatomical anomaly
• Ectopic pregnancy
• Vaginal pain
Non-gynaecological
• IBS
• Bowel pathology
• Urological
• Psychological
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Endometriosis
• Presence of endometrial like tissue outside the uterus
which induces chronic inflammatory reaction
• 2-10% women of reproductive age
• 50% of those with infertility
• 50-70% of adolescents with dysmenorrhoea not
responding to CHC/NSAIDS have endometriosis –
symptoms may be acyclic
• Average 5.2 y to Dx after menarche ( Liang 1995)
Consider the diagnosis of endometriosis :
• In the presence of gynaecological symptoms such as
dysmenorrhoea, non-cyclical pelvic pain, deep
dyspareunia, infertility and fatigue in the presence of
any of these
• In women of reproductive age with non-gynaecological
cyclical symptoms e.g. dyschezia, dysuria, haematuria,
rectal bleeding and shoulder pain
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Is empirical treatment of pain acceptable ?
• Rule out other causes of pelvic pain
• Counsel thoroughly and treat with analgesia and CHC
or progesterone Rx –IUS, depot and implant may all be
helpful
• Laparoscopy if want definitive diagnosis, infertility,
advanced disease
Aysha
• 9 years old
• Middle Eastern
• Referred because she has developed body odour
• Has already got pubic and axillary hair
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Normal puberty
• Breast development
• Growth spurt
• Pubic hair
• Menarche
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Precocious Puberty
• Secondary sexual characteristics before age 8 in girls
and 9 in boys
• Menarche before age 9
• May be set lower
• As young as 6 in African Americans
• Associated with psychological problems and ultimate
short stature
• Initially tall, rapid growth spurt, sex steroids
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Causes
• Centrally mediated e.g. idiopathic, tumours
• Abnormal Gn pattern e.g. thelarche, hypothyroidism
• GIPP – McCune Albright Syndrome
• Virilisation e.g. Adrenarche, CAH, Cushings
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Adrenarche / Pubarche
• May be GN secretion age 5-8
• Prob benign variant
• Height, sweat, pubic hair
• More common Mediterranean, African, Indian
• May just be more sensitive to androgens
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Investigations
• Hx and Ex
• LH/FSH
• Poss GnRH
• Estradiol/androgens
• TFT
• Bone age
• May need scans e.g. head
Management
• GnRH analogues
• Cyproterone
• Aromatase inhibitors
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Emma
• 15 years old
• Referred because she hadn’t yet had a period
• Breasts are normal
• No pubic hair
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Delayed puberty
• Secondary sexual characteristics after 13 for girl or 14
for boy
• Menarche after 15 years
• May also be when puberty ‘arrests’
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Causes
Central
Peripheral
• Intact HP axis e.g. chronic • DSD e.g. AIS
disease
• PCOS
• Impaired HP axis e.g.
• Turners syndrome
tumours, Kallman
syndrome, congenital
anomalies, XRT
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Investigations
• Initial Hx and Ex guides
• Left wrist Xray for bone age
• Full hormonal profile
• May need Chromosomes
• May need GnRH stimulation test / MRI
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Thank you
jane.dickson@oxleas.nhs.uk
@TheSexDoctorUK
@thegynaedoctor