Webinars

ESC Webinar

30 June 2020

Webinar: Contraception in COVID time

• Challenges in reproductive health & contraception in COVID Time
  Mr. Ali Kubba, MB ChB FRCOG FFSRH / UK
• Innovation: New estrogen free contraceptive choices
  Mrs. Teresa Bombas, MD / PORTUGAL
• This webinar is supported by an unrestricted educational grant from Exeltis Healthcare.

Save the date for our upcoming webinar:
Hormone use and breast cancer, Wednesday, 16 September, 4PM CET.

Questions and answers

• How is your approach to the appointments and guide to doctors with contraception choice for patients in covid times?
  Most care can be arranged virtually, LARC use can be extended, POP for bridging, these are the 3 big principles
• Isn’t there a high risk on uterine perforation by the IUD immediately after birth. How do you tackle this?
  the risk of perfpration is nil if the device is placed at caesarian section, you can tie a surgical ligature to the device to keep in place, insertion is easy after birth but only up to 48 hours, the device can be introduced with a sponge holding forceps while feeling the fundus with the other hand. Perforation risk is not increased. I hope we see you in Ghent in 2021. The ESC website now has a discussion platform called docmatters, you can raise any issue on the website and get colleagues views.
• Do you have a prescribed setup of clinics, including the use of proper protective equipment and other special tools for covid protection?
  Our routine is that the patient is seen without a companion, is given a mask if she does not have one [this is now mandatory by the British government], we check her temperature and ask her to use the sanitiser, when she is in the consulting room we sit at least 1.5 meters apart, we wear a surgical mask, eye shield and scrubs. if we are doing an outpatient procedure such as LLETZ/LEEP we where a single use gown + plastic Apron and a FFP3 mask and goggles. See you in Ghent in 2021.
• Do you think that the people are afraid or not able to reach contraceptive services (no insurance/ distance to centers, no internet etc.) and this may lead to unwanted pregnancies, violence, septic abortions? if you think so, how can we prevent them?
  I agree that there are all the barriers you mention. In our hospital we send information with the appointment and in many cases the nurses or admin team ring the patient and the message is we are seeing you in a green part of the hospital, we will see you quickly with no waiting as long as you arrive on time and we have all the sanitation meaures you require. We also offer patients who do not want a face to face consultation a phone or video consultation and at least 30% of cases can be dealth with this way, please pass our greetings to Turkish colleagues, hope to see you in Ghent in 2021.
• Are they able to fight with fear alone without any support if yes then what strategy they applied.
  I think offering a video or phone consultation help, most people want a plan they can engage with and the plan could be to send medication, organise an appointment in in the future if the condition is not urgent, and arrange to see in a green facility, we would give them a dedicated contact line to follow up the initial contact.
• Would you expand on difficult implant removals and PPE?
  The view is to wear scrubs for all, patient wears a mask and points face away from operator and full PPE and time for cleaning after.
• Are there any plans for the DRSP POP to be marketed in the UK?
  Not a the moment but I [Ali Kubba] am lobbying!
  
• Do you screen your patients when they come to your clinic, such as checking their temperature and their symptoms? Do you need to take a covid test?
  The answer is yes except we do not do COVID tests for outpatient attendances but do them for inpatients and day surgery cases and in the latter they have to self isolate for 7 days.
• Can we insert Larcs in Public Health during pandemia?
  The instructions from our college and faculty in the UK was to protect patients and not see them for routine LARC insertion as they can depend on the their devices beyond the licence and have the option to use the POP as a bridging backup. We are now in the recovery phase in the UK and seeing patients for LARC.
  The answer is YES, you should keep the access to contraception (all methods including LARCs) (on the majority of the countries during the contingency period the access to health services not urgent were canceled but restored now) . Second topic is safe insert Larcs during pandemic: On Covid + (symptomatic and asymptomatic) you should postpone the insertion. Third topic: Do you need to screen for Covid before insert a Larcs. depending on the rules of which country. On my country is not necessary screen for covid before insert a Larcs.
• There should have been some coverage on male sexual health & contraception.
  I will take your suggestion to our planning group and will plan a session in future. Our next Webinar is scheduled 16 September about breast cancer and hormones.
• The system is very similar to what is being done here. We do have to take a covid 19 swab test if they are for surgery so that we know what is the level of risk.
  Agree
• Considering that half life of DSP is 30 hrs, how is it possible that in the 4 days rest period is not a risk of failure?
  A previous study showed that the drospirenone-only pill effectively inhibited ovulation despite the 4-day treatment–free period. Return of ovulation after stopping treatment occurred at the earliest on day 13 after the last active DRSP tablet, indicating very efficient ovarian suppression. The results of this study showed that occasional delays in tablet intake for up to 24 hours will not compromise the contraceptive efficacy of the new drospirenone-only pill, even if they occur around the pill-free period. Because ovarian suppression appeared to be very efficient, it was expected that the same flexibility in tablet intake would be allowed for the drospirenone-only pill as for combined pills, without compromising contraceptive efficacy
• What do you recommend for irregular bleeding effects of pop?
  The exact mechanisms of problematic bleeding associated with hormonal contraception are largely unexplained. The evidence to date implicates superficial blood vessel fragility within the endometrium and local changes in endometrial steroid response, structural integrity, tissue perfusion and local angiogenic factors as contributing factors. There are no established long-term interventions available to manage problematic bleeding. The bleeding in the 3–6 months after starting a POP is quite normal and don´t need any medical intervention. A clinical history should be taken to identify or exclude some of the possible underlying causes (including compliance). All women using hormonal contraception who have problematic bleeding should be assessed to identify the risk of STIs (in special Chlamydia trachomatis) and pregnancy. If the use of estrogen is eligible, you could try one month of COC or Estradiol supplementation (2 weeks) or tranexamic acid. These strategies could may help to reduce bleeding induced by progestogen-only contraceptives in the short term, evidence does not support routine use of such regimens particularly for a long-term effect. No evidence to support the use of two POPs per day to improve bleeding
  
• Since the half live is 30-36 hours and intake usually 24 hours, is there any data about accumulation e.g. in fat tissue?
  This is measured. You reach steady state of the concentraction after a few days in pharmacocinetic studies
• Would you expand on difficult implant removals and PPE?
  The view is to wear scrubs for all, patient wears a mask and points face away from operator and full PPE and time for cleaning after.
• What are side effects of POP?
  There is a little concern about side effects: cycle control and acne are the major concerns, but the results with drospirenne pill compared with desogestrel were better.
• It has been known that progesterone plays a role that increases a woman’s risk for breast CA, do we have a data on Drospirenone POP on Breast Ca?
  No. we don´t have specific studies from Slinda and the risk of breast cancer. What we know from the studies with hormonal contraception and the risk of beast cancer is that the absolute risk is very low, and the relative risk is slightly increase comparing the hormonal users and not users. The studies that show an increase risk of Breast cancer with Progestin only contraception must be read with precaution. the eligibility criteria for the use of contraceptives of WHO continues to classify the use of HCs in this population at risk as category 1, because the evidence does not suggest an increased risk of breast cancer among women with either family history of breast cancer or bearer of increased susceptibility genes for this, are modified by the use of COC.
• How we can remove their fear of Corona?
  Great question with a difficult answer. In my personal opinion, Improve the knowledge about the real risk of the disease, having the pandemic situation under control and improving the conditions of Health system to offer better answers for the population and better protection systems for health professionals
• If she forgetfulness of 1 tablet in the first week, she´ll need to take emergency contraception
  If tablets were missed in the first week after initiation of Slinda® and intercourse took place in the week before the tablets were missed, the possibility of a pregnancy should be considered and the use of EC should be proposed. If tablets were missed in the third week of pill taking, the risk of reduced reliability is imminent because of the forthcoming 4-day hormone-free interval. However, by adjusting the tablet-intake schedule, reduced contraceptive protection can still be prevented. The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take the active tablets at her usual time. The user is advised not to take the placebo pills and continue straight on to the next active blister pack. If tablets were missed in the third week of pill taking, the risk of reduced reliability is imminent because of the forthcoming 4-day hormone-free interval. However, by adjusting the tablet-intake schedule, reduced contraceptive protection can still be prevented. The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take the active tablets at her usual time. The user is advised not to take the placebo pills and continue straight on to the next active blister pack. Resume: This data suggests that the guidance to women regarding a missed dose of Slinda ® can be the same as for newest COCs.
• Can you describe the “ultimate” contraception? Does this new drospirenon contraception meet your criteria?
  There will never be an ultimate contraceptive but many products aim to be close, DRSP estrogen free pill has ultimate contraception features to many women, it is safe medically, as effective as COCPs, has a good progestin, gives the woman the advantages of suppressing ovulation while maintaining oestradiol levels.
  
• how to make sure contraceptic will be safe for woman and reduce covid?
  Your question included to different topics: This new contraceptive with dropirenone according with the studies and data published is very safe. No TEV have been registered. No impact on bone, no impact on weight, no impact on breastfeeding, better cycle control (when compared with desogestrel pill).
  The contraception (all forms of contraception) use will not have an impact on Covid infection but the pandemic infection of Covid could have an impact on access to contraception and safe abortion. We must be sure that the access to sexual and reproductive health (an essential service according with WHO) is guaranteed during the pandemic time.
• is the drosperidon only also safe in adolescents?
  There is a study done by Dan Apter during 13 cycles in 103 adolescent women (12–17 years old) and the results were very promising with improving of dysmenorrhea, declining of use of pain killers and good cycle control. The acceptability was good to excellent in 82% of the adolescents.
  
• The literature on POP’s claims that ovulation occurs in 40-50% of cases. Do we have any data on drisperonone?
  COC and POP have the same efficacy.Traditional POPs inhibit ovulation in only 60-70% of users, so the efficacy of these POPs is dependent on the other mechanisms of action, i.e. the effects on cervical mucus penetrability, endometrial receptivity and ciliary activity in the fallopian tubes. The Pearl Index from the Drospirenone is comparable to the other oral contraceptives.
• When can we start DOP postpartum?
  Yes, we can start a Progestin only contraception including a Drospirenone pill immediately after delivery since that are no increase risk of TEV in use of hormonal contraception free of EE.
• Is drospirenon only pill safe in patients with severe hypertension?
  Yes. The women with severe hypertension are not eligible for CHC but are eligible for Progestin only contraception including drospirenone only pill. There are two studies regarding the use of drospirenone only pill in women with mild showing that the use of drospirenone only pill reduces BP in women with mild hypertension (Archer DF, Ahrendt HJ, Drouin D. Drospirenone-only oral contraceptive: results from a multicenter noncomparative trial of efficacy, safety and tolerability. Contraception. 2015;92: 439–444; Palacios S, Colli E, Regidor PA. Multicenter, phase III trials on the contraceptive efficacy, tolerability and safety of a new drospirenone- only pill. Acta Obstet Gynecol Scand. 2019;98: 1549–1557.
• What about influence on libido with Slinda compared to other POP?
  There are no specific studies of Slinda on Libido.