Italian pharmacy online: cialis senza ricetta medica in farmacia.
Microsoft word - final versioncontraception guideline jan 2012 practical aspects.doc
Contraception and Sexual Health – practical aspects
(N.B. The school doctor is referred to throughout as ‘he’. ‘He or she’, ‘himself or herself’ should of course be
understood as appropriate.) Background
This guideline should be read in conjunction with the companion guideline, “Contraception
and Sexual Health – legal and ethical aspects”. Contraceptive choices
1. When a young person requests contraception, all options should be discussed, particularly
highlighting the benefits of long acting reversible contraception
(LARC). Age should not
be considered a barrier to any method, including intrauterine methods.
2. The young person should be advised to return within 3 months of starting hormonal
contraception to discuss any concerns, and encouraged to return at any time with any
3. They should be made aware of the different types of emergency contraception
, and how
to access them.
4. Sexually transmitted infections
(STIs) should be discussed, along with the correct and
consistent use of condoms to reduce transmission risk. STI screening
should be carried
out 2 and 12 weeks after an episode of unprotected sexual intercourse
5. Typical failure rates
for the combined oral contraceptive
(COC) are 8%,
and for the male condom 15%,
in the first year of use. LARC
methods are less user-dependant, have
very much lower failure rates
, are more cost-effective if used for a year or more, and are
to be encouraged.
6. The UK Medical Eligibility Criteria (UKMEC)
for contraceptive use gives clear guidance
on which contraceptive methods can safely be used in individuals with medical conditions
or a high BMI.
7. The Faculty of Sexual and Reproductive Healthcare (FSRH)
provides very clear guidelines
on the use of all contraceptive methods, including detail on how / when to start,
missed pills and guidance on bleeding problems. The FSRH website
(www.fsrh.org/pages/clinical_guidance.asp) - is freely available to all and is to be highly
recommended. Pills and other combined methods (patch, vaginal ring)
8. Combined oral contraceptive pill (COC)
• this remains the most popular method in teenagers.
• if taken correctly, efficacy is high
. It also protects against pelvic infection and often
• all types carry a similar but very small risk of venous thromboembolism
which is higher in smokers or those with high BMI (avoid if BMI over 30).
• it is contraindicated when there is a history of migraine with aura
• a low dose levonorgestrel or norethisterone product should be the usual first choice.
• a continuous preparation (eg Microgynon ED) may help with compliance.
• desogestrel, gestodene or drospirenone- containing pills may help acne; drospirenone is
• once pill use is established, and in the absence of other problems, annual monitoring
• the ‘Quick Start’
method is now encouraged –
provided there is no possibility of
pregnancy - where the pill can be started at any time in the cycle; condoms need to be used for the first 7 days.
• although off licence, the FSRH now supports extended use in pill taking
pills may be taken continuously, a withdrawal bleed being introduced usually every 10-12 weeks.
• it is no longer considered necessary to advise additional contraception if taking
antibiotics, unless these are enzyme inducers or are causing vomiting or diarrhoea.
• guidance for missed pills
and unscheduled bleeding on the COC and POP is available
9. Progestogen-only pill (POP)
• suitable when oestrogens are contraindicated (e.g. migraine with aura, high risk of
• desogestrel (Cerazette)
is the most effective and therefore first choice in this age
10. Transdermal Patch (EVRA
• a useful alternative in those who forget pills; it is changed weekly for 3 weeks out of 4.
• it is more expensive and is disliked by some because it is visible.
11. Combined Vaginal Ring
• a ring inserted into the vagina and left in continuously for 21 days, followed by a 7 day
Long acting reversible contraception (LARC)
12. All these methods should be discussed with young people; increasing the uptake of
LARC will reduce unwanted pregnancies
13. Implants (Etonogestrel – Nexplanon)
• long acting (3 years), extremely efficacious (pregnancy rate <0.1%) and easily
• problems with irregular (light) bleeding may deter teenagers though amenorrhoea
14. Injections (Depot medroxyprogesterone acetate - Depo-Provera)
• the Medicines and Healthcare Products Regulatory Agency (MHRA) advice (2004,
endorsed by FSRH) is that, because of uncertain effects on bone density, this should be
used as first line contraception in adolescents only
if other methods are unacceptable or
• in practice, it is often a preferred option in teenagers and is freely used by family
planning professionals where there are no significant risk factors for osteoporosis (consider diet, smoking, lack of exercise).
• the high incidence of amenorrhoea
may be welcomed; prior warning about increased
appetite reduces the risk of weight gain.
• injections are repeated at 12 weekly intervals; advice for delayed injections available at
15. Intra-uterine Devices (IUDs - copper)
• good, long acting method.
• although not commonly popular in this age group it should be offered and discussed.
is not a contraindication
, though fitting, rarely, may be more difficult.
• it is important to exclude infection
by taking swabs, including Chlamydia, prior to
• gold standards are Cu TT380 Slimline
and T-Safe 380A Quickload
, licensed for 10
16. Intra-Uterine System (IUS – Mirena)
• a good choice in teenagers (though see IUDs above) since there is no added infection
• greater efficacy and lighter (but unpredictable) bleeding.
promote ‘double Dutch’
approach – the use of condoms in addition to
other contraception - to reduce infection risk.
• high failure rate
if used alone – but a lot better than nothing!
• consider ease of availability in schools – see below.
in their use should form part of SRE.
18. Condom availability in schools
• it is now considered good practice for condoms to be made available to pupils in
schools. This understandably remains a sensitive subject and one which will require discussion with the school.
• although sexual activity on school premises may be officially prohibited, the behaviour
of teenagers off (or on) the premises needs to be recognised in order to minimise the risk of adverse consequences to their health.
19. The copper IUCD
• by far the most effective form
of emergency contraception in preventing pregnancy.
• ideally should be offered to every young person
attending for emergency
contraception, even if presenting within 72 hours.
• if it cannot be inserted immediately, one of the oral methods should be given in the
• it can be inserted at any time up 5 days
after the first UPSI, or 5 days after the earliest
likely ovulation date (day 19 in a 28 day cycle), and provides ongoing contraception after the event.
20. Levonorgestrel emergency contraception (Levonelle)
• is effective up to 72 hours
after UPSI, but is more effective the sooner it is taken
• no absolute contraindications and can be used more than once in a cycle.
• may be given ‘off licence’ between 73 and 120 hours after UPSI.
• effectiveness poor after 96 hours.
21. Ulipristal acetate
• a new emergency contraceptive licensed for use up to 120 hours
• NB a copper IUD is significantly more effective if the patient presents after 72 hours.
22. ‘Quick start’ contraception
can be started immediately after either of the above, provided
condoms are used for 7 days (14 days with EllaOne) and a pregnancy test is done in > 3
23. Education and the easy availability of emergency contraception
is paramount and forms
an important part of sex and relationship education.
24. It may be useful for the doctor to agree a policy with the school about this.
25. The use of patient group directions
(PGDs) enables Levonelle to be given by the school
Sexually Transmitted Infections (STIs)
26. These are all increasing in incidence.
27. Pupils should be made fully aware of infection risks
both throughout their SRE and
during every consultation concerning contraception.
28. The use of the ‘double Dutch’ method - a condom as well as other contraception – should
29. It is good practice to take a sexual history
to assess the risk of STI when discussing
contraception, especially if emergency contraception has been requested.
30. The commonest STIs are Chlamydia
, non-specific urethritis (
NSU) and wart virus
31. Chlamydia infection is present in >10% of asymptomatic 16 - 24 year olds
32. Consider testing for Chlamydia 14 days after an episode of UPSI, followed by a full sexual
health screen at 12 weeks. Chlamydia screening.
33. In conjunction with national policy, Chlamydia screening should be offered to all sexually active under 25 year olds
34. The local screening policy includes pupils at independent schools.
35. The school doctor should be aware of the policy in the school and should ensure screening is
available to all. Self testing kits could be available from the medical centre and the pupils
informed of the website for obtaining self testing kits. (http://freetest.me.uk )
Human Papilloma Virus (HPV) vaccination.
36. A national programme of routine immunisation
of 12-13 year old girls has been in place
since 2008. This should substantially reduce the incidence of cervical cancer
attributable to HPV infection.
37. The school doctor should ensure that arrangements are in place for giving the vaccine, and
that parental consent is obtained in the usual way for those under 16. (Girls over 16 are
deemed capable of consent, though it would be normal to inform the girl’s parents of the
vaccination). A sample consent form is available on the DoH website. References:
[N.B. some of the references, resources and website information below are more applicable to
the companion Guideline “Contraception and Sexual Health – legal and ethical aspects” but
the author has deliberately retained all this information together in both Guidelines
• Statement on Contraception and Teenage Pregnancy
: London: Department of
Health, 2009. DH Gateway ref 10098. www.dh.gov.uk/en/publications.statistics.
• Sex and relationships education in schools
: Ofsted (2007)
• Best practice guidance for doctors and other health care professionals on the
provision of advice and treatment to young people under 16 on contraception,
sexual and reproductive health
: DoH (July 2004).
• National Strategy for Sexual Health and HIV
: DoH (2001)
• Faculty of Sexual and Reproductive Healthcare
(www.fsrh.org) : -
New Product Review:
• Evra Transdermal Patch (2003) • NuvaRing (2009)
• Emergency Contraception Guidance (August 2011)
• Combined oral Contraception – first prescription of COC (January 2007)
• Progestogen-only pills (June 2009)
• Quick starting contraception (Sept 2010)
• Missed pill recommendations (May 2011)
• Drug Interactions with hormonal contraception (Jan 2011)
• Management of unscheduled bleeding in women using hormonal
• Progestogen-only injectable contraception (June 2009)
• UK Selected Practice Recommendations for Contraceptive Use
• UK Medical Eligibility Criteria
• Long-acting reversible contraception (NICE Clinical guideline 30) (
• Non-oral contraceptive options: their efficacy and suitability
: Prescriber (May 2008)
• Confidentiality and people under 16 - Guidance issued jointly by the BMA, GMSC,
HEA, Brook Advisory Centres, FPA and RCGP.
BMA Publications www.bma.org.uk
• The National Chlamydia Screening Group: Results from first full year of screening.
exually Transmitted Infections (2004): 80: 335-341.
• Human Papillomavirus Vaccination in the UK
: DoH Guidance from Chief Medical
Officer. 2 July 2008 and 22 July 2008. BMJ (2008): 337.
Resources and useful websites:
• www.fsrh,org/pages/clinical_guidance.asp. Clinical Effectiveness Unit’s (CEU) guidance
• UK Medical Eligibility Criteria (UKMEC) 2009. Available on above website. • www.rcog.org.uk Evidence-based college guidelines on all forms of contraception and
• www.nice.org.uk Useful for LARC guideline • www.fpa.org.uk Patient information and leaflets • www.ippf.org Online version of Directory of Hormonal Contraception • www.bashh.org National Guidelines for management of all STIs and a list of GUM
• www.dh.gov.uk Portal to Department of Health web resources • www.immunisation.nhs.uk NHS immunisation website
BMJ learning modules:
useful modules available at www.learning.bmj.com include :
• Sexual health: managing patients under 18 • Sexual health: contraception and unplanned pregnancy in young women.
Useful websites for Teenagers and Young People
www.fpa.org.uk (Family Planning Association )
www.likeitis.org (Marie Stopes International, aimed at 11-15 year olds)
http://freetest.me.uk/ (Links to sites for free Chlamydia screening)
www.healthy-respect.com (Scottish website for young people and parents )
www.there4me.org.uk (Online counsellors)
www.youthhealthtalk.org.uk Websites for parents
U.S. Department of Justice United States Attorney Northern District of Illinois ─────────────────────────────────────────────────────────── Zachary T. Fardon Everett McKinley Dirksen Federal Courthouse TEXAS HONEY BROKER SENTENCED TO THREE YEARS IN PRISON FOR AVO
Alcohol & Drug Questionnaire CLIENT : NAME ____________________________________ / M F / DOB __________ AGE ______ / HT ______ WT _____ / STATE ______ AMT. REQUESTED $ _______________ / MAX. ANNUAL PREMIUM $ ___________________ / TYPE OF INS. UL TERM YRS. LVL _______ TOBACCO USE NO YES, TYPE ______________________ / REPLACEMENT YES NO / CURRENT A