POP

Question 1

What types of POP are available? (4)

Answer 1

1. Desogestrel (DSG) 75mcg
2. Levonorgestrel (LNG) 30mcg
3. Norethisterone (NET) 250mg

Coming soon: 4. Drospirenone (DRSP) 4mcg

Question 2

How is the POP taken?

Answer 2

Continuously at 24h intervals without HFI
Apart from the new pill drospirenone which has 4 HFI days. Some will have a bleed.

Question 3

How do the POPs prevent pregnancy?

Answer 3

Desogestrel and drospirenone (the D’s) inhibit ovulation.

Levonorgestrel & norethisterone (the “traditional” POPs) do not reliably inhibit ovulation, they rely for contraceptive effectiveness on their effect on cervical mucus, endometrium and tubal motility.

Question 4

Age limitations POP

Answer 4

All POPs can be used between menarche and age 55 in medically eligible individuals

Question 5

What UKMEC is it for POPs for those individuals with a history of ectopic pregnancy and ovarian cysts?

Answer 5

1

Question 6

List the UKMEC 3’s for the POPs

Answer 6

UKMEC 3

1. Current and history of ischaemic heart disease (UKMEC 2 for initiation, UKMEC 3 for continuation) [UKMEC 4 in CHC]
2. History of stroke (UKMEC 2 for initiation, UKMEC 3 for continuation) [UKMEC 4 in CHC]
3. Past breast cancer [UKMEC 3 in CHC]
4. Severe (decompensated) cirrhosis (associated e.g. with ascites, jaundice, encephalopathy or GI haemorrhage) [UKMEC 4 in CHC]
5. Hepatocellular adenoma or carcinoma [UKMEC 4 in CHC]

Question 7

List the UKMEC 4’s for the POPs

Answer 7

1. Current breast cancer

NB. For individuals with a history of breast cancer, any decision to initiate hormonal contraception may be best made in consultation with their oncology team.

Question 8

How does the new POP drospirenone work? What is the risk of this.

Answer 8

It is a potent progestogen with a similar pharmacological profile to progesterone. A spironolactone derivative [aldosterone antagonist], it has anti-mineralocorticoid and mild anti-androgenic activity. Drospirenone is an aldosterone antagonist thus there is a risk of hyperkalaemia in susceptible individuals.

Question 9

Who should drospirenone not be used by?

Answer 9

Patients:
- with severe renal insufficiency or acute renal failure
- with known hyperkalaemia or untreated hypoaldosteronism (e.g. Addison’s)
- using K sparing diuretics, aldosterone antagonists or K supplements

Question 10

Who should drospirenone be used with caution by?

Answer 10

Patients:
- with mild/ moderate renal insufficiency
- with treated hypoaldosteronism (e.g. treated Addison’s)
- using ACEi’s and ARBs

Question 11

What investigations might be considered before starting drospirenone and in who?

Answer 11

U+Es & BP
In those who have risk factors for CKD e.g. HTN, CVD, DM, particularly if over 50

Question 12

How effective is the POP?

Answer 12

• Contraceptive effectiveness of the POP relies on correct use
• If used perfectly, POPs may be more than 99% effective
• Estimated typical failure rate is about 9%

Question 13

What potential drug interactions are there?

Answer 13

• POP effectiveness reduced during use of the enzyme-inducer and for 28 days after stopping the enzyme-inducer. Offer alternatives: DMPA, the Cu-IUD or the LNG-IUS are suitable options if the individual is medically eligible.
• POP could reduce effectiveness of UPA for EC. The ability of UPA-EC to delay ovulation could be reduced if a POP is started within 5 days of taking the UPA. The ability of UPA-EC to delay ovulation could theoretically be reduced if a POP has been taken in the preceding 7 days. Advise use condoms for 5d after UPA + 2 days while POP takes effect (7d for drospirenone)

Question 14

Weight / BMI with POP

Answer 14

Contraceptive effectiveness not affected by body weight or BMI

Question 15

What could effect the absorption of POP

Answer 15

Vomitting
Severe diarrhoea
Bariatric surgery

Question 16

Bleeding patterns to warn people of with:
Traditional POPs

Answer 16

Bleeding pattern is unpredictable
As a guide, over a 3 month period ending at about 12 months of use:

• <1 in 10 (2%) amenorrhoeic
• 1 in 10 = infrequent bleeding (1-2 bleeding/spotting episodes)
• 8 in 10 = normal frequency bleeding (3-5 episodes)
• 1 in 10 = frequent bleeding (6 or more episodes)
• <1 in 10 = prolonged bleeding for >14d

[<1, 1, 8, 1, <1)

Question 17

Bleeding patterns to warn people of with:
Desogestrel

Answer 17

Bleeding pattern is unpredictable
As a guide, over a 3 month period ending at about 12 months of use:

• 2-3 in 10 = amenorrhoeic
• 3 in 10 = infrequent bleeding (1-2 episodes)
• 4 in 10 = normal frequency bleeding (3-5)
• < 1 in 10 = frequent bleeding (6 or more)
• 1 in 10 = prolonged bleeding >14d

[3, 3, 4, <1, 1]

NB this is similar in the new Drospirenone pill

Question 18

What should be done in first consultation?

Answer 18

1. Check medically eligible [PMH / Meds Hx / check specific UKMEC 3/4s]
2. Check no interacting meds
3. Check no allergies to pop content - note some DSG preps contain soya and may case cross reaction to individuals allergic to peanuts
4. Check any existing risk of pregnancy, requirement for EC / additional precautions / f/u testing
5. Give individual info on:
   a) contraceptive effectiveness (perfect 99% and typical 91%)
   b) how to take pills
   c) any requirement for initial contraception
   d) management of late/ missed pills
   e) interaction with medicines / herbal remedies
   f) potential bleeding patterns
   g) alternative contraceptions incl LARC
   h) STI risk assessment / screen
   i) cervical screening status
6. Send them link to online resouce eg sexwise

Question 19

How much can you prescribe at once

Answer 19

12 months
Advice to seek advice if any change to med history
some may require r/v before 12months eg those on new DRSP pop with rfs for hyperK

NB specific approved brands of desogestrel POP can now be bought by the user from a pharmacist

Question 20

When can you start a POP?

Answer 20

Day 1-5 of period without need for extra precautions

[DRSP POP can only be started on day 1 without need for extra precautions]

Quick start - any time if 1. PT negative or certain no UPSI 2. Use condoms for 2 days [7d for DRSP] 3. F/U PT at 21d if appropriate

Question 21

Missed pill windows

Answer 21

Traditional POPs - 3 hours
Desogestrel - 12 hours
DRSP - 24 hours

Question 22

What follow up arrangements needed?

Answer 22

• Annual review
• Can usually be done without an in person r/v
• At follow up recheck:
  Medical eligibility
  Drug history
  Method adherence and method satisfaction
  Alternative options - LARC if appropriate

Question 23

What happens with fertility when stop POP?

Answer 23

• immediate return to underlying fertility
• need alternative contraception immediately if dont want to get pregnant
• options for ongoing contraception

Question 24

When is a traditional POP considered missed

Answer 24

3 hours

Question 25

When is a traditional DSG considered missed

Answer 25

12h

Question 26

When is a traditional DRSP considered missed

Answer 26

24h

Question 27

After childbirth, how many days do you have before having to think about pregnancy risk (regardless of LAM)

Answer 27

21 days - so if wanting to start POP before day 21 dont need to do a PT or consider EC

Question 28

After day 21 following childbirth it is unlikely cycles will be back to normal. If the mother is not doing LAM, what considerations are needed after day 21 when starting POP?

Answer 28

If >d21 and last UPSI was >21 days ago - do a PT, dont need to consider EC, can start POP if PT negative. No need to repeat. IF >d21 and UPSI <21d ago do a PT and consider EC. If negative then start POP but advise to repeat PT at 21d after UPSI

Question 29

How long can you consider LAM as an effective method of contraception (i.e. no additional needed when starting POP)?

Answer 29

6 months

Question 30

How long can a PT stay positive for after miscarriage, ectopic or abortion

Answer 30

6 weeks. If positive and concerns consider EC and f/u PT

Question 31

I want to switch from a correctly taken CHC to POP. What scenarios do I have to wait in, or have to use additional protection in, and what should I do?

Answer 31

Essentially it is the risky times of the CHC taking, and then considering when last UPSI was. If starting at risky time you will either need condoms or to wait depending on upsi. ADDITIONAL PROTECTION: 1. Day 3-7 HFI and last UPSI before HFI - can start pop now but condoms 2 days 2. Week 1 after HFI, last UPSI before HFI - can start pop but condoms 2 days WAIT: 1. If it is day 3-7 of HFI and you have had sex since start of HFI you should restart CHC until 7 pills have been taken after HFI and then switch (with no additional precautions) 2. Week 1 after HFI, last UPSI since start of HFI - 7 pills then switch (no additional precautions)

Question 32

What happens if want to switch to POP from CHC or another POP, but been taking CHC/ other POP incorrectly?

Answer 32

Consider whether last UPSI was less or more than 21d ago. If more than 21d then do PT and start. If less than, do PT and start if neg but repeat at 21d.

Question 33

Switching from implant to POP Considerations re: length of implant in and action depending

Answer 33

If implant in for less than 3y, can switch without additional protection for 2d If implant in for 3-4 years, consider when last UPSI was (21d) and do +/- repeat PT / start if initial negative and use condoms for 2d. If implant older than 4 years then consider EC if UPSI <21d ago and same as 3-4y otherwise.

Question 34

Switching from DMPA to POP Considerations

Answer 34

DMPA works for 14 weeks. If its less than 14 since last injection, start POP and no need for extra protection. If its longer than 14w, then work out if more or less than 21d since last UPSI, do PT, consider EC etc. Start POP if PT negative +/- repeat. Use condoms for 2d.

Question 35

Switching from mirena to POP Considerations re: length of mirena in and action depending

Answer 35

If mirena in date, consider when last UPSI - if <7d ago then start POP but keep mirena in for 7d If mirena been in 5-7y, then there's no need to consider EC even if had recent UPSI but do a PT regardless of last UPSI, do consider repeating at 21d. Start POP if negative and use additional protection for 2days. If last sex was >7d ago can remove mirena but if <7d then need to also keep that in for 7d. If it has been in for >7y then same as above but also consider EC if UPSI <21d ago.

Question 36

Starting POP after EC - what is the sitch with levonorgesterel oral EC

Answer 36

Start POP immediately, additional condoms for 2d, repeat PT 21d after UPSI

Question 37

Starting POP after EC - what is the sitch with ulipristal acetate oral EC

Answer 37

Start POP 5d later, condoms 7d, repeat PT 21d after UPSI

Question 38

Starting POP after EC - what is the sitch with Cu-IUD

Answer 38

Need to keep Cu-IUD in until PT done at 21 days

Question 39

What do I do if I have missed a POP (traditional or DSG)

Answer 39

traditional is missed at 3h, DSG is at 12h - take missed pill ASAP - take next pill at usual time, even if 2 pills in one day - use condoms for 48h - consider EC if any UPSI from time pill was missed until correct pill taking had resumed for 48 hours - i.e. missed pill Monday 9am, then took Monday 10pm, and should wait until Wednesday 10pm before UPSI but had sex in there somewhere. - Consider PT at 21d