Cash! - Dr Jane Dickson 5.3 MB

Dr Jane Dickson

Contents• Local picture• Small update• New guidelines – interactions, quick-start,missed pill• Chlamydia• HIV testing

Abortion rates in LondonBexleyBromleyGreenwich

Teenage pregnancy rates in LondonBexleyBromleyGreenwich

Levonelle• Main mechanism of action is to delay ovulation- can’t do this if LH surge has begun• 1.5mg up to 72 hours post UPSI orcontraceptive failure• Efficacy shown to 96 hours (96-120 hoursunknown)• Can be used > once per cycle (or even ifanother UPSI outside treatment window)

Taylor• 14 years old• SI for first time at a party four days ago• LMP 13 days ago• Regular 28 day cycle• Brought in by cousin requesting EmergencyContraception• Declines IUD

Introducing ellaOne ®• ellaOne ® is an orally-active,synthetic, selective, progesteronereceptor modulator which bindswith high-affinity to the humanprogesterone receptor 1• ellaOne ® is indicated for use‘within 120 hours (five days) ofunprotected sexual intercourse(UPSI) or contraceptive failure’ 1• ellaOne ® ’s primary mode of actionis to inhibit or delay ovulation 1SP*RM

LARC• All women presenting for contraceptionshould be advised about the availability ofLARC• All LARC more cost effective than COC atone year• IUD/IUS/Implanon more cost effective at oneyear than depot• Increasing LARC will reduce numbers ofunintended pregnancy

LARC Suitability• Nullips• Breastfeeding• Post TOP• BMI>30• HIV• Diabetes• Migraine• Contraindication to estrogen

Have things changed?2000/01 2008/09Pill 25 25Condom 21 25IUD 5 6Injection/Implant 3 4IUS 1 2Female Sterilisation 11 6Male Sterilisation 11 11

QOF• Four points – Contraception register• Three points – All those on patch/COCcounselled about LARC• Three points – All those given emergencycontraception counselled about LARC• Local and national enhanced services

How to increase LARC uptake• Information• Access• Opportunity• Counselling• Management of side effects• Adequate training• Adequate funding

BarriersRequest for contraceptionSomething toremember?Something toforget?Oral (patch/ring)Intrauterine method acceptable?NoPlanningpregnancy?NoCome every 12weeks – likelyamenorrhoeaYesYesImplantNoYesHeavier(regular)periods?Lighterperiods?(three years)Depot (two yearsand review)IUD(10 years)IUS(five years)

Lucy• 15 years old• Implanon in situ four months• Has bled irregularly since insertion• Wants device removed

Bleeding problems with implant• Rule out other causes of bleeding• If no contraindication to estrogen try COC, egMarvelon®• If contraindication try Cerazette®• Other things that can be tried include NSAIDsand one week of doxycycline

UK MEC

Obesity and CHC• BMI > 30 UK MEC 2• BMI > 35 UK MEC 3• BMI > 40 Gone

Headache• If migraine with aura >five years ago – COCnow a 3• Migraine with aura – allother methods 1 or 2(COC still a 4)

Smoking• < 35 yrs UK MEC 2• > 35 and 15/day UK MEC4• > 35 and < 15/day orstopped 35 and stopped > oneyear ago UK MEC 2

IUDs• Contraindicated introphoblastic disease• Only a 3 with fibroids/uterine anomalies if thecavity is distorted• Current PID/ CT only a 4for insertion of device(safe to keep in if developPID)

Caroline• 17 years• Learning Disability• Heavy menstrual bleeding• Mother is a very senior nurse• Microgynon® made her sick• Loestrin® bled all the time• Had opted for IUS but became afraid andchanged her mind

Step up ProgestogenStep down Estrogen

Qlaira®• Only COC licensed for heavy menstrualbleeding• 88% reduction in median menstrual bloodloss• Reductions in blood loss are significant, rapidand sustained (Fraser IS et al. Poster atCOGI 2010)

Missed Pill rulesIf have missed one pill, take next missed pilleven if it means taking two in one dayIf have missed more than one pill :1.Take last pill missed now2.Take the rest of the pack3.Condoms for seven days4.May need EC5.If last week of pack miss PFI

Tailored/extended Pill taking• Continuous use of COC with breaksindividually tailored for each woman• Take pill until there is a bleed and then havea PFI (unlicensed)• Suitable for women who have problems inPFI• Women tend to develop a regular pattern• Requires time, effort and motivation!

BANG!

Marilyn• Age 35• Has developed post herpetic neuralgia and isprescribed carbamazepine for four weeks• Takes COC and doesn’t want to switch themethod• What should she be advised?

Short term enzyme inducers• Continue COC• Can tricycle and reduce PFI to 4/7• Use additional precautions whilst taking theenzyme inducer and for four weeksafterwards

Long term Enzyme inducers• If long term use of enzyme inducers isneeded and the woman wishes to continueher COC, then she should be given 50mcgEE (minimum)• Use a tricycling or extended regime with fourdays PFI• If women on enzyme inducers get BTB, thismay indicate low EE levels• Dose of EE can be increased to a maximumof 70mcg

Not ‘reasonably certain’• Can quick-start if woman likely to be atcontinued risk of pregnancy and womanexpresses wish to start contraceptionimmediately• Acceptable for CHC (not Dianette), POP,Implant• Not acceptable for IUD unless criteria foremergency IUD are met• Injection only if potential risks explained

‘Bridging’• Quick starting a method immediately afteremergency contraception with the view ofswitching to a different method whenpregnancy has been excluded• 2-3x increased risk of pregnancy in womenwho go on to have other UPSI in the samecycle that EC has been given compared tothose who abstain

Additional Precautions• After POEC – seven days for CHC, Implant,Injection (nine days for Qlaira )• After UPA EC – 14 days for CHC, Implant,Injection (16 days for Qlaira )

Contraception for women over theage of 40• Risks of pregnancy – death, Downs,miscarriage, diabetes, placenta praevia,abruption, preterm delivery, LBW andperinatal mortality• STIs• Menopause

Can stop contraception• Two years after menopause if age < 50 orone year after menopause age > 50• At age 55• Stop CHC and injectable age 50 and switchto a different method

Use of IUD/IUS in older women• IUD – If >40 years can keep until nolonger need contraception• IUS- If >45 years and amenorrhoeic cankeep until no longer need contraception (ifbleeding can be kept for seven years)

Aim of CSP• Early detection of chlamydia• Treatment of asymptomatic infection• Reduction in sequelae and onwardtransmission of chlamydia• Screen annually or when change partner

Beware missed diagnosis

Testing is easy

Estim ated num ber of persons living with HIV25,00020,00015,00010,0005,000022,9507,8506,3002,650Diagnosed13,2503,650Undiagnosed3,750 2,850 4,600 2,850Total 73,300(68,800 – 78,500)1,200450 550 150MSMHeterosexualmen born inAfricaHeterosexualwomen born inAfricaHeterosexualmen bornelsewhereincluding UKHeterosexualwomen bornelsewhereincluding UKIDU menIDU women

Routine HIV testing• Part of normal diagnostic process• Increased uptake• Reduces stigma• Avoids death and serious illness (earlier Dx)• Reduces onward transmission

Who should have a ‘routine’ test?• All attending specific services, eg sexualhealth, antenatal, TOP, drug services,TB/Hepatitis B/C• Where HIV enters differential diagnosis• Groups at higher risk - MSM, African• Where diagnosed population prevalence > 2in 1000 – GP registration/hospitaladmission/blood test

BexleyGreenwichBromley

–BeninBotswanaBurkina FasoBurundiCameroonCentral African RepublicChadCongoCôte d'IvoireDR CongoDjiboutiEquatorial GuineaEthiopiaGhanaGuineaKenyaLesothoLiberiaMalawiMaliNiger1.2 (2006)25.0 (2008)25.2 (2004)1.8 (2003)3.0 (2007)3.6 (2002)5.5 (2004)6.2 (2006)3.3 (2005)3.2 (2009)4.7 (2005)1.3 (2007)2.9 (2002)3.2 (2004)1.4 (2005)2.2 (2003)1.5 (2005)7.8 (2008)6.7 (2003)23.4 (2004)1.6 (2007)12.7 (2004)1.3 (2006)1.8 (2001)0.7 (2006)0.9 (2002)NigeriaRwandaSenegalSierra LeoneSouth AfricaSwazilandUgandaUR TanzaniaZambiaZimbabweCambodiaIndiaPapua province (Indonesia)Hai Phong province (Vietnam)Dominican RepublicHaiti3.6 (2007)3.0 (2005)0.7 (2005)1.5 (2008)1.5 (2005)16.9 (2008)16.2 (2005)15.6 (2002)25.9 (2006–07)6.4 (2004–05)5.7 (2007)7.0 (2004)14.3 (2007)15.6 (2001–02)18.1 (2005–06)0.6 (2005)0.3 (2005–06)2.4 (2006)0.5 (2005)0.8 (2007)1.0 (2002)2.2 (2005–06)

BarriersPatients• Fear of disease• Confidentiality• Insurance• Immigration issues• Stigma• Fear of prosecutionClinicians• Embarrassment• Lack of time• Perceived lack ofskills• Patient won’t cope• Patient doesn’tconsider risk

Alice• 37 year old South African• No SI seven years• Moved to UK four years previously• Recurrent herpes and candida

Dr Jane DicksonMarket Street Health CentreSE18 6QRJane.dickson@nhs.net07960 963 926020 8855 3777

Upcoming GP Masterclass dates foryour diaryTuesday 24 April 2012Theme: mental health – cognitive behavioural therapy(to be confirmed)Wednesday 4 July 2012Theme: cardiology (to be confirmed)Wednesday 3 October 2012Theme: to be advised