Essay 308 - contraception

.Contraceptives are more likely to fail  in obese women and end up in in unintended pregnancies.

Clinical Assessment- History of menstrual cycle regularity,about flow ,heavy,or scant.Medical disorders like diabetes,thyroid,epilepsy,venous thromboembolism.History of drug usage,besides the contraceptive drugs.Details of contraceptives used in the past and current contraceptive method used.Details of what problem she had with contraceptive used.Her obstetric history.History of any childbirth.Sexual history,number of partners,did she use any barrier methods of contraception.Social history.Her occupation,support networks,alcoholism,any illegal drug use.Examination,pulse,bp,general exam for thyroid enlargement.Abdomin exam for abdomino pelvic mass.Speculum exam any  vaginal discharge,this is an oppurtunity for culture swab.per vaginal exam for any any abdomoinopelvic mass,any tenderness.

b)options for hormonal contraception.Progesterone only methods include ,progesterone only pills,depot medroxy progesterone acetate(DMPA)Depo sub q provera 104.Levonorgestrel IUS,Implanol.

Progesterone only method is a good method for obese women.Since they do not contain estrogens which increases the risk of VTE.Disadvantage is the increase in weight gain with DMPA.,and menstrual irregularities,makes women discontiue it.

The contraceptive implant(Implanol)This etonogesterel releasing implant  is safe in obese women.But no studies to prove its bioavailability in obese women,whether its efficiency is decreased.

Levonorgesterel intra uterine system,is safe to use in obese women.This provides a low risk,long term,reversible contraceptive,without the increased risk of vascular events associated with estrogens,and weight gain of DMPA.

Emergency contraception-Levonorgestrel(planB)But no studies to prove that pharmacokinetics of levonorgesterel are altered in obese women.

c)intra uterine contraception  -very useful in this woman.This provides long term,reversible contraception with few side effects.The cu T 380A and levenorgesterel IUS,have no increase risk of vascular events of estrogen.or weight gain of DMPA.But difficulty in placing IUD in large women.Cervix not visualised easily hence removal and insertion of IuD difficult.This is an ideal method for obese women,as no risk, to increase comorbidities of obesity.

Clinical assessment would include taking her menstrual history whether regular,irregular and associated with any problems like excessive bleeding and pain. Obstetrical history of number of children,route of delivery, her future fertility plans .Previous contraception she has used any problem encountered while using them .Medical history of diabetes,hypertension, epilepsy.Personal or family history of Venous thromboembolism or breast cancer.History of smokingand cervical smear history.Examination would include measuring her blood pressure.

Hormonal options include combined oral contraception though not associated with weight gain, might not be suitable as associated with higher failure rates(especially the low dose contraceptive pills), increased risk of VTE and not advisable for   those above a BMI of 30 kg/m2.Combined hormonal patches and vaginal rings may be better suited as associated with  lesser risk of VTE but may be associated with higher failure rate. Progesterone only contraception are not associated with risk for VTE. They include progesterone only pills which  are  not associated with any weight gain but their efficacy has not been studied in women with morbid obesity. Progesterone only implants may have a higher rate of failure in these women and therefore avoided, progesterone only injectables are associated with increase in weight and adversely  affect bone mineral density  therefore may not be suitable They are also associated with delay in return of fertility once stopped. Mirena or levonorgesterol containing Intrauterine contraceptive device are not associated with weight gain and do not have systemic side effects of progesterone therefore can safely advised, however, have problems of oligoammenorhoea ,irregular bleeding,ammenorhoea (after one year of use),ovarian cysts and acne.

Intrauterine contraceptive device is not associated with weight gain or risk of VTE therefore can be safely used provided the woman does have have menorrhagia or dysmenorrhoea ,however,insertion of intrauterine contraceptive device may be difficult and may require long instruments.

History should be taken the type of contraception she was using, compliance to the method is checked. Her menstrual history is taken in detail.

 Her history of use of enzyme inducing drugs like phenytoin , phenobarbitone, carbamazepine anticonvulsant , rifampicin, refabutin, antifungal agent like gresieofulvin which decreases the efficacy of combined and pregestogen only contraception is noted.

Social history of smoking is asked. History of medical disorder diabetes, hypertension, and migraine noted.

Personal and family history of thromboembolism, thrombophilia, breast cancer is evaluated.

Her plans for future pregnancy evaluated. Her sexual history and risk assessment for sexually transmitted infection(STI) done by asking sensitively number of sexual partner, use of barrier contraception, history of STI in partner or partners, history vaginal discharge.

Her blood pressure checked.

  B Hormonal contraception

Combined oral contraceptive acts by preventing ovulation so are associated with regularization of menses. They decrease in blood loss by 50% if experiencing heavy menses, relieves dysmenorrhea. It is category 3 uk medical eligibility criteria, associated with increased of risk thromboembolism, stroke. The alternative path of use of combined hormonal preparations as patch, vaginal ring shows decreased efficacy with increasing body weight, and have same mechanism of action and contraindication as to oral preparations. Pearl index is 0.3-4 per 100 women years.

Progestogen only hormonal contraception can be used by women in whom estrogen is contraindicated. The newer preparation like Cerazatte contains desogesteral , acts by preventing ovulation, can used in women more than 70 kg. it leads to amenorrhea in 20%, regular menses in 40% and irregular in 40% which  is most common reason to discontinue. They can be used in women with thromboembolism, with migraine with or without aura.

Progestegen only implant nexplanon , contain etonrgesteral 68mg, used for three years. Need health professional trained in insertion and removal . it leads to irregular bleeding . 40% discontinue due to erratic bleeding while 10% discontinue due to other side effects such as acne, bloating, breast tenderness.

Injectable progestogen preparation like depot medroxy preogesterone 150 mg can be given every 12 weekly acts by preventing ovulation. It lead to weight gain of 2-3 kg over a period of 6 month and decrease in bone mineral density.  According to faculty of sexual health and reproduction its use should be restricted for 2 years, need further evaluation of bone mineral density if women wish to continue. It lead to delay in return of fertility which can be detrimental to women who wish to conceive soon after discontinuation of contraception. Can be used  in those on enzyme inducing drugs , do not need to increase the frequency. It is highly efficacious with failure rate of 4 pregnancies per 1000 women in 2 years.

Both progestogen implant and injection are long acting reversible contraceptive which need their use less than once per month and they are cost effective.

C

Intrauterine device containing copper 380mm2 gives contraceptive effect for 5-10 years. It prevents implantation and has toxic effect on gametes. Gynefix is frameless device used for 3 years associated with high expulsion rate.

Intrauterine system , Mirena can used for 5 years contains levonorgesteral 52 mg. it acts by preventing implantation and effect on cervical mucus, associated with irregular bleeding for first 3-6 month, but decreases  blood loss by more than 90% at the end of year. It is cost effective if continued for more than a year. It have noncontraceptive benefit as decrease in dysmenorrhea, treatment of heavy menstrual bleeding. It is associated with minimal progestogenic side effect as acne, bloating but associated with immediate return of fertility after discontinuation.

Both these methods are associated with risk of perforation which is 1 in 1000, six fold increase risk of infection in first 3 weeks as 1 in 100. There is risk of expulsion and cervical trauma which can be minimized by insertion by expert professional. There is small risk of ectopic pregnancy which is less than the noncontraceptive user , but if women is pregnant the risk is 1 in 20. They need long acting contraceptives and are cost effective.

Women should undergo screening for chlamydia prior to insertion, or should receive empirical treatment if result is unavailable at the start of method. If found positive referral to genito urinary medicine, partner notification and treatment is essential.

Both these methods can be safely used in her case. She is provided with adequate information supported by information leaflet. She is provided with appropriate web addresses and allowed to make informed decision.

(1)

I would ask about her menstrual history, including regularity, dysmenorrhea, menorrhagia, and last menstrual period. I would also ask about sexual history, including number of partners (to assess risk of STD), and previous contraceptive usage with regard to side effects, compliance and failure. Obstetric history, any complication during previous terminations (sepsis) and fertility intension should be enquired. For medical history, venous thromboembolism (VTE), thrombophilia, severe liver disease, hypertension and diabetes with chronic complications should be asked about. Family history of VTE is also an important risk factor affecting decision about contraception, mainly COCP. Smoking status should be clarified. Blood pressure should be taken during physical examination. Pelvic examination should be to palpate the uterus and assess the size which could be technically difficult in view of her BMI.

(2)

Combined oral contraceptive pills, would not be suitable for her in view of her obesity (UKMEC3).

Progesterone only pills are effective, with a failure rate of 0.3 - 4% and not affected by BMI. To be reliable, it is advised to be taken same time every day (Cerazette allows a time window of 12 hours), thus compliance could be a potential issue. Common side effects include menstrual disturbances (irregular menses or amenorrhea) and progesterone effects like headache, mood swing, and abdominal bloating. 

Injectable progesterones e.g. Depo-provera carries the benefits of high efficacy (failure rate < 1 per 100 woman-years) and less frequent dosing (every 3 months) which would help to improve compliance. Side effects include irregular menstruation, weight gain, and delayed return of ovulation after discontinuation (as long as up to 6-12 months). There is also concern of reduced bone density after prolonged usage (> 2years) especially in young girls.

Implant (i.e. Implanon) is a highly effective long acting reversible contraceptive (3 years) with a failure rate less than 0.1 per 100 woman-years. Return of ovulation after removal is rapid. Common side effect is also menstrual irregularity.

(3)

IUD is an effective long-term reversible contraceptive (Cu T380 valid for 8 years) with a failure rate of 0.6 - 0.8 per 100 woman-years. Infection (Chlamydia) should be screened before insertion. It is not suitable for those with uterine abnormalities or fibroids distorting uterine cavity. Complications include expulsion (usually in the first 3 months), perforation during insertion and heavier and more painful menses in which case LNG-IUS (Mirena) would be a better option but may cause irregular bleeding. Insertion of IUD could be potentially difficult due to habitus. General anaesthesia may be considered for better assessment of uterus position and size and visualisation of cervix. And longer instruments (speculum and forceps) may be required.

a) Take a menstrual history asking about the cycle, flow and regularity of periods and associated dysmenorrhea. Ask about previous contraception methods and reasons behind failed contraception, identifying issues with compliance or access to contraception. Take a history of previous terminations of pregnancy and complications if any. Assess risk factors for sexually transmitted diseases. Take a medical history for migraines, cardiac and autoimmune dieases, personal or family history of venous thromboembolism (VTE) or breast and gynaecological cancers, as these will guide contraceptive choice. Take a social history for smoking and alcohol use. Take a full drug history for other medications she might be on. On examination check blood pressure. Abdominal and vaginal examination should be carried out if indicated by abnormal menstrual pattern. However these may be difficult in an obese patient. An ultrasound scan of the pelvis may be needed if indicated by history. Screening for chlamydia and other sexually transmitted diseases may be offered if risk factors are present. 

b) Estrogen-containing methods such as the combined oral contraceptive pill, patches and vaginal rings are highly effective methods and also confer non-contraceptive benefits of reducing menstrual blood flow and dysmenorrhoea. These are however not advisable in this woman whose BMI is 42. (UKMEC 3 in BMI >35). COCP require a woman to take a pill every day, which may be difficult to adhere to if compliance is an issue. Progestogen-only methods may be used as they are not associated with an increased risk of VTE. The progestogen-only pill is an effective method of contraception with a failure rate of less than 1 in 100. It is removed from the act of coitus but needs to be taken at around the same time every day. The window for a missed pill is 3 hours with traditional POPs and 12hrs with Cerazette. This may be a problem if compliance is an issue. POPs are also associated with irregular bleeding and progestogenic side effects such as bloating and weight gain. Progestogen-only injections such as IM depot medroxyprogesterone acetate can be given in 12 weekly intervals and are a reliable long-acting contraceptive method. Failure rate is 0.4 in 100. It results in amenorrhoea in 70% of women in the first year of use. However, it is associated with bone loss with prolonged use and use in a young woman should be reviewed every 2 years. Its use is also associated with weight gain which may be unacceptable in a morbidly obese woman. There is also a delay in the return of fertility. Progestogen-only implants such as Nexplanon are also long-acting reliable contraception with a failure rate of 0.1 in 100. It confers contraception for 3 years. It is also related with irregular bleeding and weight gain. The levonorgestrel intrauterine system (IUS) confers long-acting reliable contraception for 5 years and reduces systemic side effects of progestogens such as weight gain and bloating. It can give rise to irregular bleeding in the first 6 months of use but results in amenorrhoea in 65% of women after 1 year of use.

c) The copper containing intrauterine device (Cu IUD) can be used for up to 10 years depending on the type of device used. The IUS can be used up to 5 years. These are both reliable long acting contraceptive methods, which minimize the systemic side effects of hormones. The Cu IUD may result in heavier and more painful periods while the IUS confers added benefits of decreased menstrual flow and dysmenorrhoea. There is a small risk of uterine perforation and expulsion. This patient should be screened for sexually transmitted diseases including chlamydia prior to insertion, especially if risk factors such as a recent change of partner are present. Antibiotic prophylaxis may be required for insertion. Insertion may be technically difficult in view of habitus and additional instruments and staff may be required to help with insertion. 

(a) Aim is to identify medical eligibility and safety for various contraceptive methods. Take a detailed history for previous or current contraceptive use, any failure of contraception that resulted in the unplanned pregnancies, any other obstetric history. Detailed menstrual history including last menstrual period, cycle length and regularity and flow. Latest cervical screen should be enquired. Sexual history should be taken. Any concurrent medical problems especially hyperlipidemia, hypertension, diabetes mellitus, vascular disease, cerebrovascular or cardiovascular disease. Any personal or family history of venous thromboembolism and thrombophilia is relevant. History of cancer, especially breast, endometrial, ovarian, cervical. Smoking use, and history of sexually transmitted infections (STI) is important. Do a urine pregnancy test. Offer STI screen if deemed high risk. Examination should include blood pressure, speculum and cervical screen if necessary, vaginal examination for any pelvic masses and size of uterus. 

(b) Hormonal methods can be combined or progestogen only. Combined hormonal methods such as the combined oral contraceptive pill, patch, or ring offer good cycle control but are contraindicated in obese patients like her (UKMEC 3) where risk of use of method outweigh the benefits, due to the increased risk of venous thromboembolism in these patients. Progesterone-only methods are preferable and safer, with no association to venous thromboembolism. The progesterone only pill (POP) has poorer efficacy compared to the implant or injectables, with a failure rate with typical use of around 8%. There is also poor cycle control, and required strict taking regular time daily. Missed pill intervals for desogestrel only and traditional POP are 12 hours and 3 hours late respectively. Irregular bleeding occurs in 40% of patients. Long acting reversible contraceptives can decrease unplanned pregnancy rates. Injectable progesterone such as depomedroxyprogesterone acetate and NET-EN are licensed for 12 weeks and 8 weeks respectively, good for patients with poor compliance for pill. Associated with weight gain of 2-3kg. Efficacy better than POP at less than 4 in 1000. Amenorrhoea is common, up to 55%. Irregular bleeding is common reason for discontinuation. Can worsen acne, and associated with decrease in bone mineral density (but no evidence of long term bone loss on stopping). Implants have the best efficacy of hormonal methods, failure rate less than 1 in 1000. Use is licensed for 3 years, no issue of missed pills or delayed injections. Risks include pain during insertion and removal of about 1%. Need of local anaesthesia with insertion in a clinical setting, but no regular followup needed till change of implant. Also associated with bleeding issues with 20% amenorrhoeic in 1 year, and 50% with irregular bleeding. May worsen acne. Intrauterine system LNG-IUS licensed for 5 years, most cost effective (even compared to the implant if use is 3-5 years). Higher amenorrhoea rates. Choice if menorrhagia is a problem. Risk of expulsion 1 in 20, failure rate less than 1 in 1000, better than POP but not as effective as implant or injectable. Risk of ectopic pregnancy if pregnant is 1 in 20. 

(c) Intrauterine contraception can be copper intrauterine device (Cu-IUD), or with levonorgestrel intrauterine system (LNG-IUS). Cu-IUD may cause heavier menstrual bleeding, but keeps regular cycles in women, whereas LNG-IUS irregular bleeding common in first 6 months, with amenorrhoea common. May be difficult to insert due to habitus, difficulty in vaginal examination. Prior to insertion need to test for STI and treat. Need to feel thread regularly and return in 3-6 weeks post insertion for review. Associated with risk of pelvic infection in first 3 weeks after insertion. Cu-IUD agood for patient as non-hormonal, no venous thromboembolism risk, UKMEC 1 in obese patients. 

a)Take a menstrual history including last menstrual period to rule out pregnancy, and any heavy menstrual bleed or irregular menses, which may be amenable to treatment by combined hormonal contraceptives. Take a full obstetric history, including previous deliveries, previous termination and any complications, and reasons for termination. Take a full contraceptive history including types of contraception used, and likely reason for failure, for example missed pills. Take a sexual history, including number of sexual partners, to assess risk of sexually transmitted diseases (STDs). Take a history for previous pelvic infections or STDs, and any barrier contraception used. Take a social history, including marriage status, family support and financial support. Take a history for contraindications for hormonal contraception, for example hypertension, stroke, migraine with aura, smoking, liver disease, personal or family history of venous thromboembolism (VTE). Take blood pressure reading with suitable sized cuff. Do a vaginal examination for size of uterus if considering intrauterine contraception.                                 b) Combined hormonal contraception is contraindicated in this lady, due to risk of VTE. It may be useful in a woman with BMI < 35, as it provides cycle control, effective contraception, and reduces the risk of ovarian and endometrial cancer with long term use (> 1 year). Progesterone only pills are suitable as they do not increase the risk of VTE significantly. They provide effective contraception. There are issues with compliance, leading to decreased efficacy with typical use and missed pills, side effects such as weight gain, water retention, mood changes and increased appetite. Depo-provera is an effective long-acting reversible contraception (LARC). However there are progestogenic side effects, anmely weight gain, water retention, increased appetite and mood changes. There are concerns with loss of bone mineral density with long term use (>2 years). Progesterone implants are effective LARCs. However side effects include irregular uterine bleeding, which does not resolve with time, water retention, mood changes and increased appetite. Levonorgestrel intrauterine contraception is an effective LARC. Side effects include irregular uterine bleeding for the first 6 months, expulsion, migration and increased risk of pelvic infection.                                    c) Intrauterine contraception (IUCD) is a LARFC which has low failure rate. However, they precipitate or exacerbate pelvic infection at the time of insertion, and this patient is at high risk of STD. Empirical antibiotics against chlamydia should be prescribed or a chlamydia screen arranged and insertion delayed until results are back. It also has a higher ectopic pregnancy rate if the patient does get pregnant, even though absolute rates of pregnancy are low, and this needs to be considered as the patient is also at high risk of ectopic pregnancy.

A 24 year old woman has been referred to the gynaecology clinic because of problems with contraception. She has 3 unplanned pregnancies resulting in early medical termination. Her BMI is 42 kg/m2. (a) Discuss your clinical assessment [6 marks]. (b) Critically evaluate the options for hormonal contraception [10 marks]. (c) Discuss the use of intra-uterine contraception in this woman [4 marks].

I would like to enquire regarding  current contraceptive method that she is using. If it is oral contraceptive pill I would ask the dose and and her compliance in taking the pills. I would ask about her previous obstetric history, and her future fertility wishes . I would enquire about  her menstrual history, the LMP, regularity of cycles & associated problems like pain and heavy bleeding during periods . I would like to know about her past medical history which may affect the method of contraception like migraine, jaundice & hypertension . personal or family history of thrombophilia should be enquired about. I would also ask about the medications she is currently on as drug interaction can be a potential cause of contraceptive failure.  Information on sexual  history , if there was any change in last 6 months & any history of STI in the partner should be obtained as this may affect her options for contraceptive method. lifestyle factors like smoking should be asked about. Her previous  records on STI screening for HbsAg, HIV, Syphillis, Chlamydia should be looked into. I would check her  BP using appropriate size cuff .

The hormonal options include  combined oral  contraceptive pills, progesterone only methods like pills ,injectables and implants  and IUCD.The benefits and risks of each must be informed to the women during counseling .While Combined hormonal contraceptive methods will provide effective contraception  it is associated with increased risk of venous thromboembolism  and hence  are  not a safe alternative for this women . Progesterone containing contraceptives provide excellent contraception  with failure rate of less than .4/100 woman years .Progesterone only pills  have a disadvantage of having to take the pills at the  almost the  same time everyday or with a  maximum of  3 hours gap beyond which failure rates increase . Injectable progesterone like Depot medroxyprogesterone acetate and norethisterone enanthate, have low failure rate        of .4/100 wy .  DMPA is given intramuscularly  once in 12 wks and is associated with weight gain which can be unto 2-3 kg in 1 year , unscheduled bleeding  ,a reversible  bone loss & delay in return of fertility  unto 1 year after stopping . Levonorgestrel containing IUCD have additional advantage of reduced menstrual blood loss but 50 % of women discontinue due to the erratic bleeding patterns .   The women  should a be informed that these methods do not protect against sexually transmitted infections.

Intrauterine device for contraception is associated with  low failure rate ( CUT 20/1000 and LNG IUS  10/1000 wy) .They  have the advantage of  being reversible with long duration of action . Compliance is not an issue with these methods. Risk of endometrial hyperplasia and endometrial cancer is reduced with use of levonorgestrel containing IUCD, which is a significant advantage in obese women. copper containing IUCD may cause  heavier  bleeding  and dysmenorrhea during cycles.IUCD do not protect against STI and screening should be undertaken prior to insertion . Insertion can be done immediately after termination of pregnancy . There is a very small risk of 1/1000 for perforation of uterus during insertion .Followup after the next cycle should be arranged to rule out expulsion.