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Hi, this is Tom and welcome to the Zero to GP podcast.
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In this episode, we're going to be going through progestogen only contraception, all the key stuff you need to know for your GP exams.
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And as always, the format of these episodes is I'm going to present you with cases and ask you questions.
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I want you to come up with your answer in the pause.
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Ideally say it out loud or write it down so you really know whether you know that information or not.
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And then I'll go through an explanation.
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So let's jump straight in.
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The first case is a 34-year-old woman, and she comes into a GP because she wants contraception.
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She's otherwise well, but she does have a family history of a deep vein thrombosis which affected her mother.
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The first question is, what would be the UK MEC, which is the UK medical eligibility criteria for contraception, for the combined oral contraceptive pill?
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The UK MEC for the combined pill, if there's a first degree relative with a history of venous thromboembolism, like we have in this case, is three.
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So the risks would outweigh the benefits in this patient for the combined pill, so it wouldn't be recommended.
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My next question is: what would be the UK MEC for the progestogen-only pill?
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The UK MEC for the progestogen-only pill with a family history of deep vein thrombosis is one.
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So the progestogen-only pill is not known to increase the risk of venous thromboembolism, so DBTs and PEs.
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However, the combined pill does increase the risk.
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So in this case, the progestogen-only pill would be fine, but the combined pill would be too risky.
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So it should be more suitable for progestogen-only contraception.
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My next question is what are the progestogen-only contraceptive options?
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There are four types of contraception that contain only progestogens.
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They are the pill, for example, desigesteril, the injection, which you have every twelve to thirteen weeks, which contains just progestogen, the implant, which gets inserted, it's like a little matchstick inserted in the upper arm typically, and that releases progestogen.
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And finally the levonogesteral intrauterine device.
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So this is a coil, for example, the marina coil, and that releases progestogens just locally inside the uterus.
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My next question is what is the mechanism of action of progestogen-only contraceptives?
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How do they work to prevent pregnancy?
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So they have three main mechanisms of action.
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The first is that they inhibit ovulation.
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Not all of them inhibit ovulation.
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For example, the progestogen-only pill doesn't typically inhibit ovulation, although with desigesterol, a lot of women do stop ovulating.
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But that's not the main mechanism for the progestogen-only pill.
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And with the intrauterine system, so the marina coil or other progestogen-only coils, they don't always inhibit ovulation.
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They do in a small number of women, but that's not their main mechanism of action.
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But for the implant and injection, they do inhibit ovulation.
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The second mechanism of action is that the progestogens thicken the cervical mucus.
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So there's a mucous plug in the cervix that prevents sperm from getting past the cervix into the uterus and then the fallopian tubes where they cause um where they cause conception.
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So if the sperm can't get through the cervix, pregnancy can't occur.
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And then the third mechanism of action is that they thin the endometrium, which makes it less um accepting of implantation and less likely to develop into a pregnancy.
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Okay, on to so we've got this 34-year-old woman, and she wants to start the progestogen-only pill.
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My question for you is when do you start the progestrogen-only pill?
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When should this woman take away the pill box and start taking it?
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So she can actually start it any time of her menstrual cycle.
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But there's some key things.
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If she starts on day one to five of the menstrual cycle, day one being the day that she starts bleeding, if it's day one to five, she's immediately protected from pregnancy.
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So that's a great time to start it because she doesn't need to think about anything else.
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However, if she starts after day five, firstly, she needs to be sure she's not already pregnant.
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So she hasn't had any unprotected sexual intercourse since her last period.
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That's one way.
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Uh, but there are other ways to tell that she's not pregnant.
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For example, she's had a pregnant, let's say she's not uh having periods, she's had a pregnancy test at least 21 days since her last unprotected sexual intercourse.
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However, we're overcomplicating things, we'll get onto that.
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But if she's after day five, she'll need extra protection for the first 48 hours of taking the pill.
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So with a progesterogen-only pill, it takes 48 hours for that cervical mucus to thicken enough that she's protected from pregnancy.
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So if she starts in the day one to five, she's immediately protected.
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After day five, she needs to use extra protection, for example, condoms, or avoid sexual intercourse for at least 48 hours of taking the pill.
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Hope that makes sense.
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Okay, on to the next question, which is what follow-up would you arrange in general practice as a GP after initiating the progestogen only pill for the first time?
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The guidelines recommend following up at 10 to 12 weeks.
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And this is to check everything's going okay with the pill, no adverse effects, managing to take it uh on time and all that kind of stuff.
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Okay, on to the next case, which is a 28-year-old woman and she's two weeks postpartum.
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She gave birth two weeks ago.
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She wants contraception.
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First question is can you start the progestrogen only pill at this point?
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So she's two weeks postpartum.
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You can start the progestogen-only pill at any time after a woman gives birth.
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She's immediately protected from pregnancy if she starts the progestogen-only pill within 21 days of giving birth.
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So they say you can't get pregnant 21 days after giving birth, you won't ovulate.
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So if you start the progestogen-only pill during that time, uh she's immediately protected.
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This is in contrast to the combined pill, which you can't start until three or six weeks after giving birth, depending on whether you're breastfeeding or not, because of the risk of venous thromboembolism.
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Okay, on to the next case is a 46-year-old woman, and she's had no periods for the past four months.
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The next question is how are you going to exclude pregnancy in this patient?
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So she's 46 and no periods for the past four months.
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She may be perimenopausal, which is why there's a large gap between her periods, but she could potentially still get pregnant at this age.
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The key way to exclude pregnancy is that she's had no unprotected sexual intercourse in the past 21 days, and she has a negative urine pregnancy test.
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If you have uh unprotected sex and then you do a pregnancy test within 21 days of that unprotected sex, there could be an early pregnancy that's not yet producing enough HCG to make a pregnancy test positive.
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So it needs to be 21 days after the last unprotected sexual intercourse to exclude a pregnancy.
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Okay, on to the next case.
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The next case is an 18-year-old woman.
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She takes the combined oral contraceptive pill, and now she's switching to desigesteral from the combined pill.
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Maybe she's come in with new headaches or migraines and it's decided on a risk-benefit analysis that is better on the progesterone only pill.
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So she's switching to desigesterol.
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My question is when can she start the desigester pill immediately?
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When would it be fine to switch straight from the combined pill to the desigesteral pill?
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So there's two scenarios where she could switch directly.
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The first is if she's in week two or three of the combined pill, meaning that she had the hormone-free interval, she's had the full first week of the pill pack, the full seven days, and now she's in week two or three.
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At that point, she could stop the pill and the next day start the desigesteral pill and she'll be immediately protected.
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The other scenario is if she's in day one or two of the hormone-free interval.
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So she's finished the pill pack and now she's on day one or two of the hormone-free interval.
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At that point, she could just immediately start taking desigesterol and she'd be protected.
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Let's say a different scenario, she's currently on day three of the hormone-free interval.
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And she tells you she's had no unprotected sexual intercourse since the start of the hormone-free interval.
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In this scenario, how are you going to switch her to the combined pill?
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So the recommendation here, if you can do, is if someone's on day three plus of the hormone-free interval, then they'll need additional protection for the first 48 hours.
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So they can start the desigesterol pill straight away, but they'll need additional protection for the first 48 hours.
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Now the caveat here is that they need to have had no unprotected sexual intercourse since the start of the hormone free interval.
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So let's say she's currently on day three of the hormone free interval, and she had unprotected sexual intercourse yesterday.
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In this scenario, how are you going to switch her to the digesteral pill?
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So in this scenario, she's not necessarily protected from um from pregnancy here because she's had unprotected sex and she's on day three of the hormone-free interval.
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So the way to switch here is to restart the combined contraceptive pill and then take it uh consistently for seven days and then switch to the desigesteral pill.
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So she's past day one and two.
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If she was on day one and two of the hormone for interval, she could switch immediately, start desigesteral, and she's protected.
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But because she's day three or above and she's had unprotected sex, then she needs to restart the combined pill and take that for seven days.
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And this is to suppress ovulation.
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And then after she's been taking it consistently for seven days, then she can switch to desigesterol.
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In some scenarios, it may not be appropriate to restart the combined pill.
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For example, they've developed migraines with aura.
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And that's in this scenario, you um you can quick start desigesterol, but you'd need to consider emergency contraception and a urine pregnancy test at least 21 days after the episode of unprotected sexual intercourse.
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And of course, she would need uh additional protection for 48 hours after starting desigesterol.
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Okay, onto a new scenario.
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We've got a 25-year-old woman and she wants long-acting contraception.
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She doesn't want to be taking the pill every day.
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My question to you is how long acting is each option?
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So you're gonna have to give the long-acting options of reversible uh contraception, and how long those uh are valid for once you once you have them.
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Okay, so there's four long-acting reversible contraception options.
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So let's go through each one of those.
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The first is the injection, for example, Depo Provera.
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And this injection lasts for 13 weeks in terms of protecting against pregnancy.
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So they say you need a new injection every 12 to 13 weeks.
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It is kind of um potentially lasts for 14 weeks, but officially 13 weeks, and they recommend a new injection every 12 to 13 weeks.
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The second is the implant, for example, Nexplanon, which is that little matchstick that goes in the upper arm.
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And this lasts for five years.
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The next one is the levinogesteral intrauterine device, for example, the marina coil.
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And these devices, there's quite a few of them, I believe there's five currently in the UK market, and they last a varying amount of time from three years up until eight years.
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So the marina coil, once it's put in place, it protects against pregnancy for eight years.
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And the final one is the copper coil.
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Depending on the device, this will last from five to ten years.
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So the longest potential one is a copper coil that lasts for ten years.
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The next question is which one of these long-acting contraceptives can cause weight gain?
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The only one officially known to cause weight gain is the injection, for example, Depo Provera.
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My next question is which which of which two of these long-acting reversible contraceptives require caution in a patient who's younger, for example, younger than eighteen.
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So the coils, meaning the levin or gestral, intuitively device or the copper coil, are UKMEC2 in patients under 20.
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And the reason they require caution for coils in patients under 20 is there's a higher risk of expulsion.
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So a higher risk that the coil will pop out and then it won't be effective and won't protect against pregnancy.
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The injection, the DMPA injection, uh is UKMEC2 in patients under 18.
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And the reason for this is that it has the potential to reduce bone mineral density in patients under 18 where their skeleton is still growing and hardening.
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Um, if you give them the injection, there's a risk that it will thin the bones, and um the sort of anti-estrogen effect will mean that the bones are not as strong.
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My next question is when are you going to start these long-acting progestogen-only contraceptives?
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So here we're talking about long-acting progestion-only contraceptives, meaning the implant, the injection, or the myrena coil, the hormone coil.
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If you give them uh or insert them on day one to five of the menstrual cycle, then uh they're immediately protected.
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If it's after day five, they need to use additional protection for the first seven days.
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So unlike the progestogen-only pill, which requires additional contraception for two days, the long-acting ones require additional protection for seven days.
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Okay, onto a new case.
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A 23-year-old woman who started the progestogen-only pill 10 weeks ago.
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And she's come in because she has unscheduled bleeding.
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She says, I'm I'm having bleeding like a period, but it's kind of erratic and I can't predict it, and it's not so not so good.
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My first question is which key tests are you gonna consider in this patient?
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So two key tests.
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The first is a sexually transmitted infection test, so you can do a urine sample or swab, particularly testing for chlamydia, but you can test for others like Connery as well.
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And the second one is a pregnancy test to exclude pregnancy.
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My next question is are you gonna perform a speculum or pelvic exam in this 23-year-old who started the POP 10 weeks ago and is having unscheduled bleeding?
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Now this depends if uh the bleeding is quite obviously or very likely due to the pill and is kind of typical unscheduled bleeding associated with progestogen only contraceptives.
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You don't need to or you you aren't recommended to perform a speculum or pelvic exam until the bleeding has persisted for more than three months.
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It's not necessary to perform the examination.
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However, you would consider performing an examination if the woman has not had cervical screening, because you want to have a look at the cervix and make sure there's no cervical pathology, for example, cervical cancer.
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Um, if the woman requests an examination, then you would um you know perform that for her.
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Or if there's other symptoms that will make you suspicious about other pathology, for example, pain or postcoital bleeding.
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In these scenarios, it's worth performing examination.
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But if it's typical progestrogen-only contraception-induced uh irregular, unscheduled bleeding, they don't need to necessarily need an examination until the bleeding's persisted more than three months.
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You can assume it's because of the contraception.
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Okay, on to the next case.
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You've got a 19 year old woman.
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She's had the implant, the progesterone only implant, for six months.
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And she's been having unscheduled bleeding during that time.
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You've examined her and performed some testing, for example, estimating.
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Testing and these are all normal.
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So you're not concerned about any kind of pathology other than it's the implant causing this bleeding.
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What options do you have to manage this bleeding?
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She doesn't want to have the implant taken out if she can avoid it, so what can you do instead to manage the bleeding?
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There's two options here.
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The first is you could give her methanamic acid, which is an NSAID that helps reduce the bleeding and shorten the bleeding time, which she could take when the bleeding occurs for up to five days.
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So she starts having an unscheduled bleed, takes methanamic acid, and it will shorten the bleed.
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The second option is to give her the combined oral contraceptive pill on top of her implant, and you can use that for up to three months to kind of get control of the bleeding and then hope that the bleeding then stays settled after that's stopped.
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Okay, and on to the final case, which is a 21-year-old woman.
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She takes the progestogen-only pill and she comes in because she's missed a pill.
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My question to you is when is the progestogen-only pill classed as a missed pill?
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At what point would you say she's missed the pill?
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This depends on the type of pill that she's taking.
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For the traditional progesterogen-only pill, for example, levanogesterol pill, uh it's after three hours.
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So if she's three hours or more late of taking the pill, she's missed that pill.
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For the desigesteral progesterone-only pill, it's more than 12 hours after the scheduled pill time.
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And for the Drosperinone progesterone-only pill, it's more than 24 hours after the missed pill.
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My next question is what's the missed pill advice you're gonna give this patient taking the progesterone-only pill?
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So she needs to take the missed pill as soon as she remembers, and then continue with the other pills in the pack at the normal time.
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So this might mean taking two pills in the same day.
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She'd also need extra protection, so avoiding intercourse or uh take using condoms, additional protection for 48 hours until she's been taking the pill regularly again.
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So the 48 hours until she's established back on the pill.
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And if she's had unprotected sexual intercourse, you need to consider emergency contraception.
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So if she's had unprotected sex since the missed pill, uh she could be um the the cervical mucus could have thinned enough that it's allowed the sperm through, and she could uh be susceptible to pregnancy.
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So emergency contraception should be considered.
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Final case or final question is a 21-year-old woman and she comes in with a positive pregnancy test, and she's been taking the progestogen only pill.
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Maybe she's missed a few and she's not been taking it perfectly, she's become pregnant, and she says she wishes to continue with the pregnancy.
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What advice would you give this patient?
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So she's a pregnant woman who's been taking the progesterone-only pill.
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She should stop the progestogen-ony pill.
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And um it's worth noting to her that the progester-ony pill is not known to be harmful to pregnancies.
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So women who got pregnant while taking the progestogen-only pill, it's not known to harm the pregnancy or cause any issues with the baby.
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She'd also need other pregnancy advice, for example, make sure she's taking folic acid, vitamin D, books in with the midwife, and so on.
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So, thanks for listening to this episode on the progestogen-only contraception.
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Hopefully, it was helpful.
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A few resources for you if you're preparing for GP exams.
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The first is the AKT revision book.
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This book covers all the key topics you need for your GP exams.
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There's also the zero to GP.com website where I go through uh or where you'll you can find questions, flashcards, a fact trainer tool, and notes for your GP exams.
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And I've got an upcoming revision course in September in London where we go through the whole GP curriculum for the AKT exam.
00:27:26.319 --> 00:27:28.000
So check out those resources.
00:27:28.240 --> 00:27:35.200
Subscribe if you're not already subscribed to the podcast or the YouTube channel, and I'll see you in the next episode.
00:00:00.160 --> 00:00:03.520
Hi, this is Tom and welcome to the Zero to GP podcast.
00:00:03.759 --> 00:00:12.160
In this episode, we're going to be going through progestogen only contraception, all the key stuff you need to know for your GP exams.
00:00:12.880 --> 00:00:19.519
And as always, the format of these episodes is I'm going to present you with cases and ask you questions.
00:00:19.760 --> 00:00:22.640
I want you to come up with your answer in the pause.
00:00:22.879 --> 00:00:28.719
Ideally say it out loud or write it down so you really know whether you know that information or not.
00:00:28.960 --> 00:00:31.280
And then I'll go through an explanation.
00:00:31.519 --> 00:00:33.679
So let's jump straight in.
00:00:34.240 --> 00:00:40.159
The first case is a 34-year-old woman, and she comes into a GP because she wants contraception.
00:00:40.320 --> 00:00:48.240
She's otherwise well, but she does have a family history of a deep vein thrombosis which affected her mother.
00:00:48.960 --> 00:01:00.640
The first question is, what would be the UK MEC, which is the UK medical eligibility criteria for contraception, for the combined oral contraceptive pill?
00:01:09.040 --> 00:01:18.640
The UK MEC for the combined pill, if there's a first degree relative with a history of venous thromboembolism, like we have in this case, is three.
00:01:19.200 --> 00:01:26.799
So the risks would outweigh the benefits in this patient for the combined pill, so it wouldn't be recommended.
00:01:27.200 --> 00:01:33.120
My next question is: what would be the UK MEC for the progestogen-only pill?
00:01:42.400 --> 00:01:48.480
The UK MEC for the progestogen-only pill with a family history of deep vein thrombosis is one.
00:01:48.879 --> 00:01:56.239
So the progestogen-only pill is not known to increase the risk of venous thromboembolism, so DBTs and PEs.
00:01:56.640 --> 00:01:59.920
However, the combined pill does increase the risk.
00:02:00.159 --> 00:02:05.599
So in this case, the progestogen-only pill would be fine, but the combined pill would be too risky.
00:02:05.680 --> 00:02:09.199
So it should be more suitable for progestogen-only contraception.
00:02:10.080 --> 00:02:16.400
My next question is what are the progestogen-only contraceptive options?
00:02:31.759 --> 00:02:37.360
There are four types of contraception that contain only progestogens.
00:02:37.599 --> 00:02:56.879
They are the pill, for example, desigesteril, the injection, which you have every twelve to thirteen weeks, which contains just progestogen, the implant, which gets inserted, it's like a little matchstick inserted in the upper arm typically, and that releases progestogen.
00:02:57.520 --> 00:03:01.599
And finally the levonogesteral intrauterine device.
00:03:01.759 --> 00:03:10.000
So this is a coil, for example, the marina coil, and that releases progestogens just locally inside the uterus.
00:03:11.199 --> 00:03:18.000
My next question is what is the mechanism of action of progestogen-only contraceptives?
00:03:18.319 --> 00:03:20.960
How do they work to prevent pregnancy?
00:03:35.759 --> 00:03:39.120
So they have three main mechanisms of action.
00:03:39.360 --> 00:03:42.960
The first is that they inhibit ovulation.
00:03:43.360 --> 00:03:46.000
Not all of them inhibit ovulation.
00:03:46.400 --> 00:03:56.719
For example, the progestogen-only pill doesn't typically inhibit ovulation, although with desigesterol, a lot of women do stop ovulating.
00:03:57.039 --> 00:04:00.719
But that's not the main mechanism for the progestogen-only pill.
00:04:00.879 --> 00:04:09.120
And with the intrauterine system, so the marina coil or other progestogen-only coils, they don't always inhibit ovulation.
00:04:09.280 --> 00:04:14.400
They do in a small number of women, but that's not their main mechanism of action.
00:04:14.719 --> 00:04:19.360
But for the implant and injection, they do inhibit ovulation.
00:04:20.000 --> 00:04:26.240
The second mechanism of action is that the progestogens thicken the cervical mucus.
00:04:26.399 --> 00:04:39.519
So there's a mucous plug in the cervix that prevents sperm from getting past the cervix into the uterus and then the fallopian tubes where they cause um where they cause conception.
00:04:39.920 --> 00:04:44.319
So if the sperm can't get through the cervix, pregnancy can't occur.
00:04:44.560 --> 00:04:57.600
And then the third mechanism of action is that they thin the endometrium, which makes it less um accepting of implantation and less likely to develop into a pregnancy.
00:04:58.879 --> 00:05:05.680
Okay, on to so we've got this 34-year-old woman, and she wants to start the progestogen-only pill.
00:05:06.000 --> 00:05:10.319
My question for you is when do you start the progestrogen-only pill?
00:05:10.399 --> 00:05:14.480
When should this woman take away the pill box and start taking it?
00:05:24.720 --> 00:05:29.120
So she can actually start it any time of her menstrual cycle.
00:05:29.360 --> 00:05:30.720
But there's some key things.
00:05:30.879 --> 00:05:41.199
If she starts on day one to five of the menstrual cycle, day one being the day that she starts bleeding, if it's day one to five, she's immediately protected from pregnancy.
00:05:41.360 --> 00:05:45.120
So that's a great time to start it because she doesn't need to think about anything else.
00:05:45.360 --> 00:05:52.160
However, if she starts after day five, firstly, she needs to be sure she's not already pregnant.
00:05:52.319 --> 00:05:58.560
So she hasn't had any unprotected sexual intercourse since her last period.
00:05:58.879 --> 00:06:00.079
That's one way.
00:06:00.240 --> 00:06:03.120
Uh, but there are other ways to tell that she's not pregnant.
00:06:03.279 --> 00:06:14.560
For example, she's had a pregnant, let's say she's not uh having periods, she's had a pregnancy test at least 21 days since her last unprotected sexual intercourse.
00:06:14.720 --> 00:06:17.519
However, we're overcomplicating things, we'll get onto that.
00:06:17.759 --> 00:06:25.680
But if she's after day five, she'll need extra protection for the first 48 hours of taking the pill.
00:06:26.319 --> 00:06:37.279
So with a progesterogen-only pill, it takes 48 hours for that cervical mucus to thicken enough that she's protected from pregnancy.
00:06:37.519 --> 00:06:41.279
So if she starts in the day one to five, she's immediately protected.
00:06:41.519 --> 00:06:52.879
After day five, she needs to use extra protection, for example, condoms, or avoid sexual intercourse for at least 48 hours of taking the pill.
00:06:53.120 --> 00:06:54.480
Hope that makes sense.
00:06:54.720 --> 00:07:05.519
Okay, on to the next question, which is what follow-up would you arrange in general practice as a GP after initiating the progestogen only pill for the first time?
00:07:11.199 --> 00:07:14.879
The guidelines recommend following up at 10 to 12 weeks.
00:07:14.959 --> 00:07:22.800
And this is to check everything's going okay with the pill, no adverse effects, managing to take it uh on time and all that kind of stuff.
00:07:23.279 --> 00:07:30.000
Okay, on to the next case, which is a 28-year-old woman and she's two weeks postpartum.
00:07:30.079 --> 00:07:32.319
She gave birth two weeks ago.
00:07:32.560 --> 00:07:33.920
She wants contraception.
00:07:34.560 --> 00:07:40.959
First question is can you start the progestrogen only pill at this point?
00:07:48.560 --> 00:07:50.560
So she's two weeks postpartum.
00:07:50.639 --> 00:07:55.920
You can start the progestogen-only pill at any time after a woman gives birth.
00:07:56.160 --> 00:08:04.639
She's immediately protected from pregnancy if she starts the progestogen-only pill within 21 days of giving birth.
00:08:04.879 --> 00:08:09.920
So they say you can't get pregnant 21 days after giving birth, you won't ovulate.
00:08:10.000 --> 00:08:15.360
So if you start the progestogen-only pill during that time, uh she's immediately protected.
00:08:15.600 --> 00:08:28.399
This is in contrast to the combined pill, which you can't start until three or six weeks after giving birth, depending on whether you're breastfeeding or not, because of the risk of venous thromboembolism.
00:08:30.000 --> 00:08:39.039
Okay, on to the next case is a 46-year-old woman, and she's had no periods for the past four months.
00:08:40.320 --> 00:08:45.759
The next question is how are you going to exclude pregnancy in this patient?
00:08:56.720 --> 00:09:00.000
So she's 46 and no periods for the past four months.
00:09:00.240 --> 00:09:09.120
She may be perimenopausal, which is why there's a large gap between her periods, but she could potentially still get pregnant at this age.
00:09:09.360 --> 00:09:21.600
The key way to exclude pregnancy is that she's had no unprotected sexual intercourse in the past 21 days, and she has a negative urine pregnancy test.
00:09:22.000 --> 00:09:39.600
If you have uh unprotected sex and then you do a pregnancy test within 21 days of that unprotected sex, there could be an early pregnancy that's not yet producing enough HCG to make a pregnancy test positive.
00:09:39.759 --> 00:09:46.960
So it needs to be 21 days after the last unprotected sexual intercourse to exclude a pregnancy.
00:09:48.159 --> 00:09:50.320
Okay, on to the next case.
00:09:50.879 --> 00:09:53.519
The next case is an 18-year-old woman.
00:09:53.759 --> 00:10:01.679
She takes the combined oral contraceptive pill, and now she's switching to desigesteral from the combined pill.
00:10:01.840 --> 00:10:10.639
Maybe she's come in with new headaches or migraines and it's decided on a risk-benefit analysis that is better on the progesterone only pill.
00:10:10.879 --> 00:10:13.039
So she's switching to desigesterol.
00:10:13.279 --> 00:10:19.279
My question is when can she start the desigester pill immediately?
00:10:19.519 --> 00:10:24.399
When would it be fine to switch straight from the combined pill to the desigesteral pill?
00:10:37.519 --> 00:10:40.639
So there's two scenarios where she could switch directly.
00:10:40.799 --> 00:10:56.639
The first is if she's in week two or three of the combined pill, meaning that she had the hormone-free interval, she's had the full first week of the pill pack, the full seven days, and now she's in week two or three.
00:10:57.279 --> 00:11:03.519
At that point, she could stop the pill and the next day start the desigesteral pill and she'll be immediately protected.
00:11:03.759 --> 00:11:09.200
The other scenario is if she's in day one or two of the hormone-free interval.
00:11:09.279 --> 00:11:14.720
So she's finished the pill pack and now she's on day one or two of the hormone-free interval.
00:11:14.879 --> 00:11:20.080
At that point, she could just immediately start taking desigesterol and she'd be protected.
00:11:21.120 --> 00:11:26.960
Let's say a different scenario, she's currently on day three of the hormone-free interval.
00:11:27.200 --> 00:11:34.159
And she tells you she's had no unprotected sexual intercourse since the start of the hormone-free interval.
00:11:34.720 --> 00:11:39.039
In this scenario, how are you going to switch her to the combined pill?
00:11:49.120 --> 00:12:03.279
So the recommendation here, if you can do, is if someone's on day three plus of the hormone-free interval, then they'll need additional protection for the first 48 hours.
00:12:03.440 --> 00:12:10.159
So they can start the desigesterol pill straight away, but they'll need additional protection for the first 48 hours.
00:12:10.399 --> 00:12:18.720
Now the caveat here is that they need to have had no unprotected sexual intercourse since the start of the hormone free interval.
00:12:19.759 --> 00:12:27.519
So let's say she's currently on day three of the hormone free interval, and she had unprotected sexual intercourse yesterday.
00:12:27.840 --> 00:12:32.639
In this scenario, how are you going to switch her to the digesteral pill?
00:12:45.039 --> 00:12:56.399
So in this scenario, she's not necessarily protected from um from pregnancy here because she's had unprotected sex and she's on day three of the hormone-free interval.
00:12:56.559 --> 00:13:12.399
So the way to switch here is to restart the combined contraceptive pill and then take it uh consistently for seven days and then switch to the desigesteral pill.
00:13:13.039 --> 00:13:15.279
So she's past day one and two.
00:13:15.519 --> 00:13:22.639
If she was on day one and two of the hormone for interval, she could switch immediately, start desigesteral, and she's protected.
00:13:22.799 --> 00:13:32.240
But because she's day three or above and she's had unprotected sex, then she needs to restart the combined pill and take that for seven days.
00:13:32.399 --> 00:13:34.639
And this is to suppress ovulation.
00:13:34.799 --> 00:13:41.120
And then after she's been taking it consistently for seven days, then she can switch to desigesterol.
00:13:41.600 --> 00:13:45.840
In some scenarios, it may not be appropriate to restart the combined pill.
00:13:46.000 --> 00:13:48.559
For example, they've developed migraines with aura.
00:13:49.039 --> 00:14:05.600
And that's in this scenario, you um you can quick start desigesterol, but you'd need to consider emergency contraception and a urine pregnancy test at least 21 days after the episode of unprotected sexual intercourse.
00:14:05.840 --> 00:14:12.159
And of course, she would need uh additional protection for 48 hours after starting desigesterol.
00:14:13.200 --> 00:14:14.879
Okay, onto a new scenario.
00:14:15.039 --> 00:14:20.720
We've got a 25-year-old woman and she wants long-acting contraception.
00:14:20.960 --> 00:14:23.519
She doesn't want to be taking the pill every day.
00:14:23.840 --> 00:14:27.679
My question to you is how long acting is each option?
00:14:27.840 --> 00:14:38.159
So you're gonna have to give the long-acting options of reversible uh contraception, and how long those uh are valid for once you once you have them.
00:14:55.360 --> 00:15:00.559
Okay, so there's four long-acting reversible contraception options.
00:15:00.720 --> 00:15:02.639
So let's go through each one of those.
00:15:02.879 --> 00:15:07.519
The first is the injection, for example, Depo Provera.
00:15:08.000 --> 00:15:13.200
And this injection lasts for 13 weeks in terms of protecting against pregnancy.
00:15:13.360 --> 00:15:17.679
So they say you need a new injection every 12 to 13 weeks.
00:15:18.080 --> 00:15:28.240
It is kind of um potentially lasts for 14 weeks, but officially 13 weeks, and they recommend a new injection every 12 to 13 weeks.
00:15:28.559 --> 00:15:35.759
The second is the implant, for example, Nexplanon, which is that little matchstick that goes in the upper arm.
00:15:35.919 --> 00:15:38.399
And this lasts for five years.
00:15:38.639 --> 00:15:44.480
The next one is the levinogesteral intrauterine device, for example, the marina coil.
00:15:44.639 --> 00:15:55.759
And these devices, there's quite a few of them, I believe there's five currently in the UK market, and they last a varying amount of time from three years up until eight years.
00:15:55.919 --> 00:16:02.080
So the marina coil, once it's put in place, it protects against pregnancy for eight years.
00:16:02.320 --> 00:16:04.879
And the final one is the copper coil.
00:16:05.039 --> 00:16:09.519
Depending on the device, this will last from five to ten years.
00:16:09.679 --> 00:16:15.200
So the longest potential one is a copper coil that lasts for ten years.
00:16:15.919 --> 00:16:23.440
The next question is which one of these long-acting contraceptives can cause weight gain?
00:16:31.919 --> 00:16:38.159
The only one officially known to cause weight gain is the injection, for example, Depo Provera.
00:16:38.879 --> 00:16:51.039
My next question is which which of which two of these long-acting reversible contraceptives require caution in a patient who's younger, for example, younger than eighteen.
00:17:06.480 --> 00:17:16.720
So the coils, meaning the levin or gestral, intuitively device or the copper coil, are UKMEC2 in patients under 20.
00:17:16.880 --> 00:17:23.680
And the reason they require caution for coils in patients under 20 is there's a higher risk of expulsion.
00:17:23.759 --> 00:17:30.480
So a higher risk that the coil will pop out and then it won't be effective and won't protect against pregnancy.
00:17:31.279 --> 00:17:38.720
The injection, the DMPA injection, uh is UKMEC2 in patients under 18.
00:17:38.960 --> 00:17:50.480
And the reason for this is that it has the potential to reduce bone mineral density in patients under 18 where their skeleton is still growing and hardening.
00:17:50.559 --> 00:18:01.279
Um, if you give them the injection, there's a risk that it will thin the bones, and um the sort of anti-estrogen effect will mean that the bones are not as strong.
00:18:03.920 --> 00:18:12.480
My next question is when are you going to start these long-acting progestogen-only contraceptives?
00:18:25.519 --> 00:18:35.920
So here we're talking about long-acting progestion-only contraceptives, meaning the implant, the injection, or the myrena coil, the hormone coil.
00:18:36.160 --> 00:18:44.559
If you give them uh or insert them on day one to five of the menstrual cycle, then uh they're immediately protected.
00:18:44.720 --> 00:18:50.559
If it's after day five, they need to use additional protection for the first seven days.
00:18:50.720 --> 00:19:01.440
So unlike the progestogen-only pill, which requires additional contraception for two days, the long-acting ones require additional protection for seven days.
00:19:02.640 --> 00:19:04.480
Okay, onto a new case.
00:19:04.720 --> 00:19:10.720
A 23-year-old woman who started the progestogen-only pill 10 weeks ago.
00:19:10.960 --> 00:19:14.880
And she's come in because she has unscheduled bleeding.
00:19:15.039 --> 00:19:23.279
She says, I'm I'm having bleeding like a period, but it's kind of erratic and I can't predict it, and it's not so not so good.
00:19:24.160 --> 00:19:29.200
My first question is which key tests are you gonna consider in this patient?
00:19:40.000 --> 00:19:41.440
So two key tests.
00:19:41.599 --> 00:19:52.160
The first is a sexually transmitted infection test, so you can do a urine sample or swab, particularly testing for chlamydia, but you can test for others like Connery as well.
00:19:52.400 --> 00:19:57.759
And the second one is a pregnancy test to exclude pregnancy.
00:19:59.759 --> 00:20:11.279
My next question is are you gonna perform a speculum or pelvic exam in this 23-year-old who started the POP 10 weeks ago and is having unscheduled bleeding?
00:20:24.799 --> 00:20:36.480
Now this depends if uh the bleeding is quite obviously or very likely due to the pill and is kind of typical unscheduled bleeding associated with progestogen only contraceptives.
00:20:36.720 --> 00:20:45.920
You don't need to or you you aren't recommended to perform a speculum or pelvic exam until the bleeding has persisted for more than three months.
00:20:46.079 --> 00:20:49.039
It's not necessary to perform the examination.
00:20:49.680 --> 00:21:02.480
However, you would consider performing an examination if the woman has not had cervical screening, because you want to have a look at the cervix and make sure there's no cervical pathology, for example, cervical cancer.
00:21:03.200 --> 00:21:10.640
Um, if the woman requests an examination, then you would um you know perform that for her.
00:21:10.880 --> 00:21:20.480
Or if there's other symptoms that will make you suspicious about other pathology, for example, pain or postcoital bleeding.
00:21:20.799 --> 00:21:24.559
In these scenarios, it's worth performing examination.
00:21:24.720 --> 00:21:37.599
But if it's typical progestrogen-only contraception-induced uh irregular, unscheduled bleeding, they don't need to necessarily need an examination until the bleeding's persisted more than three months.
00:21:37.839 --> 00:21:40.960
You can assume it's because of the contraception.
00:21:42.000 --> 00:21:43.440
Okay, on to the next case.
00:21:43.519 --> 00:21:45.279
You've got a 19 year old woman.
00:21:45.440 --> 00:21:50.720
She's had the implant, the progesterone only implant, for six months.
00:21:50.880 --> 00:21:54.960
And she's been having unscheduled bleeding during that time.
00:21:55.279 --> 00:21:59.839
You've examined her and performed some testing, for example, estimating.
00:22:00.559 --> 00:22:02.720
Testing and these are all normal.
00:22:02.880 --> 00:22:09.440
So you're not concerned about any kind of pathology other than it's the implant causing this bleeding.
00:22:10.640 --> 00:22:14.000
What options do you have to manage this bleeding?
00:22:14.319 --> 00:22:20.480
She doesn't want to have the implant taken out if she can avoid it, so what can you do instead to manage the bleeding?
00:22:35.759 --> 00:22:37.519
There's two options here.
00:22:37.839 --> 00:22:51.119
The first is you could give her methanamic acid, which is an NSAID that helps reduce the bleeding and shorten the bleeding time, which she could take when the bleeding occurs for up to five days.
00:22:51.279 --> 00:22:57.200
So she starts having an unscheduled bleed, takes methanamic acid, and it will shorten the bleed.
00:22:57.440 --> 00:23:15.200
The second option is to give her the combined oral contraceptive pill on top of her implant, and you can use that for up to three months to kind of get control of the bleeding and then hope that the bleeding then stays settled after that's stopped.
00:23:16.160 --> 00:23:20.799
Okay, and on to the final case, which is a 21-year-old woman.
00:23:20.960 --> 00:23:27.039
She takes the progestogen-only pill and she comes in because she's missed a pill.
00:23:27.920 --> 00:23:33.599
My question to you is when is the progestogen-only pill classed as a missed pill?
00:23:33.759 --> 00:23:36.640
At what point would you say she's missed the pill?
00:23:47.519 --> 00:23:51.440
This depends on the type of pill that she's taking.
00:23:51.680 --> 00:23:59.839
For the traditional progesterogen-only pill, for example, levanogesterol pill, uh it's after three hours.
00:24:00.000 --> 00:24:06.079
So if she's three hours or more late of taking the pill, she's missed that pill.
00:24:06.799 --> 00:24:13.759
For the desigesteral progesterone-only pill, it's more than 12 hours after the scheduled pill time.
00:24:14.079 --> 00:24:21.759
And for the Drosperinone progesterone-only pill, it's more than 24 hours after the missed pill.
00:24:22.160 --> 00:24:29.440
My next question is what's the missed pill advice you're gonna give this patient taking the progesterone-only pill?
00:24:44.000 --> 00:24:52.559
So she needs to take the missed pill as soon as she remembers, and then continue with the other pills in the pack at the normal time.
00:24:52.799 --> 00:24:56.720
So this might mean taking two pills in the same day.
00:24:57.039 --> 00:25:09.200
She'd also need extra protection, so avoiding intercourse or uh take using condoms, additional protection for 48 hours until she's been taking the pill regularly again.
00:25:09.359 --> 00:25:13.359
So the 48 hours until she's established back on the pill.
00:25:13.680 --> 00:25:18.880
And if she's had unprotected sexual intercourse, you need to consider emergency contraception.
00:25:19.039 --> 00:25:33.200
So if she's had unprotected sex since the missed pill, uh she could be um the the cervical mucus could have thinned enough that it's allowed the sperm through, and she could uh be susceptible to pregnancy.
00:25:33.279 --> 00:25:36.079
So emergency contraception should be considered.
00:25:37.200 --> 00:25:47.920
Final case or final question is a 21-year-old woman and she comes in with a positive pregnancy test, and she's been taking the progestogen only pill.
00:25:48.079 --> 00:25:57.440
Maybe she's missed a few and she's not been taking it perfectly, she's become pregnant, and she says she wishes to continue with the pregnancy.
00:25:58.079 --> 00:26:00.720
What advice would you give this patient?
00:26:11.519 --> 00:26:15.920
So she's a pregnant woman who's been taking the progesterone-only pill.
00:26:16.079 --> 00:26:19.200
She should stop the progestogen-ony pill.
00:26:19.599 --> 00:26:28.400
And um it's worth noting to her that the progester-ony pill is not known to be harmful to pregnancies.
00:26:28.640 --> 00:26:35.920
So women who got pregnant while taking the progestogen-only pill, it's not known to harm the pregnancy or cause any issues with the baby.
00:26:36.160 --> 00:26:44.319
She'd also need other pregnancy advice, for example, make sure she's taking folic acid, vitamin D, books in with the midwife, and so on.
00:26:44.559 --> 00:26:49.680
So, thanks for listening to this episode on the progestogen-only contraception.
00:26:49.839 --> 00:26:51.279
Hopefully, it was helpful.
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A few resources for you if you're preparing for GP exams.
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The first is the AKT revision book.
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This book covers all the key topics you need for your GP exams.
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There's also the zero to GP.com website where I go through uh or where you'll you can find questions, flashcards, a fact trainer tool, and notes for your GP exams.
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And I've got an upcoming revision course in September in London where we go through the whole GP curriculum for the AKT exam.
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So check out those resources.
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Subscribe if you're not already subscribed to the podcast or the YouTube channel, and I'll see you in the next episode.
