Contraception Flashcards
Barrier methods of contraception
Barrier methods are still widely used as methods of contraception. Unlike other types of contraception condoms also provide some protection against sexually transmitted infections (STIs). The two most common types of barrier methods used in the UK are:
condoms
diaphragms and cervical caps
Efficacy (defined as percentage of women experiencing an unintended pregnancy within the first
year of use)
male condoms: perfect use - 98%, typical use - 80%
female condoms: perfect use - 95%, typical use - 80%
diaphragms and cervical caps: if used with spermicide then 92-96%
Usage
oil based lubricants should not be used with latex condoms
polyurethane condoms should be used in patients allergic to latex
COCP advantages/disadvantages
Advantages of combined oral contraceptive pill
highly effective (failure rate < 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
reduced risk of colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be seen
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane review did not support a causal relationship.
Combined oral contraceptive pill counselling
Women who are considering taking the combined oral contraceptive pill (COC) should be counselled in a number of areas:
Potential harms and benefits, including
the COC is > 99% effective if taken correctly
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
Advice on taking the pill, including
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
should be taken at the same time every day
the COCP is conventionally taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation. However, there was a major change following the 2019 guidelines. ‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break
advice that intercourse during the pill-free period is only safe if the next pack is started on time
Discussion on situations where efficacy may be reduced*
if vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
if taking liver enzyme-inducing drugs
Other information
discussion on STIs
*Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra-precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
The only absolute contra-indication in the range of answers is migraine with aura.
The Faculty of Sexual and Reproductive Healthcare (FSRH) categorise risk factors on a scale of 1 to 4 as follows:
1 - no restrictions on the use of contraceptive method
2 - advantages of contraceptive method generally outweigh the theoretical and proven risks
3 - theoretical and proven risks generally outweigh the advantages of the contraceptive method, can still be given based on expert clinical judgement
4 - condition that poses unacceptable risk if the contraceptive method is used
The options for this question have the following categories assigned to them:
Migraine with aura (4)
First degree relative with venous thromboembolism aged 25 (3)
Smoker (10/day) over the age of 35 (3)
BMI of 30 kg/m2 (2)
Blood pressure of 150/90 mmHg (3)
Absolute contra-indications for the combined oral contraceptive pill (category 4) include:
Migraine with aura
Breastfeeding <6 weeks post-partum
Age 35 or over smoking 15 or more cigarettes/day
Systolic 160mmHg or diastolic 95mmHg
Vascular disease
History of VTE
Current VTE (on anticoagulants)
Major surgery with prolonged immobilisation
Known thrombogenic mutations
Current and history of ischaemic heart disease
Stroke (including TIA)
Complicated valvular and congenital heart disease
Current breast cancer
Nephropathy/retinopathy/neuropathy
Other vascular disease
Severe (decompensated) cirrhosis
Hepatocellular adenoma
Hepatoma
Raynaud’s disease with lupus anticoagulant
Positive antiphospholipid antibodies
Combined contraceptive patch
The Evra patch is the only combined contraceptive patch licensed for use in the UK. The patch cycle lasts 4 weeks. For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
For delays in changing the patch, different rules apply depending what week of the patch cycle the woman is in.
If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
If the patch removal is delayed at the end of week 3:
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
For further information please see the NICE Clinical Knowledge Summary on combined hormonal methods of contraception: http://cks.nice.org.uk/contraception-combined-hormonal-methods#top
Combined oral contraceptive pill contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Contraception a very basic introduction
The development of effective methods of contraception over the past 50 years has been one of the most significant developments in medicine.
Methods of contraception
Barrier methods
condoms
Daily methods
combined oral contraceptive pill
progesterone only pill
Long-acting methods of reversible contraception (LARCs)
implantable contraceptives
injectable contraceptives
intrauterine system (IUS): progesterone releasing coil
intrauterine device (IUD): copper coil
Contraceptive
Method of action
Notes
Condoms
Physical barrier
Relatively low success rate, particularly when used by young people
Help protects against STIs
Combined oral contraceptive pill
Inhibits ovulation
Increases risk of venous thromboembolism
Increases risk of breast and cervical cancer
Progestogen-only pill (excluding desogestrel*)
Thickens cervical mucus
Irregular bleeding a common side-effect
Injectable contraceptive (medroxyprogesterone acetate)
Primary: Inhibits ovulation
Also: thickens cervical mucus
Lasts 12 weeks
Implantable contraceptive (etonogestrel)
Primary: Inhibits ovulation
Also: thickens cervical mucus
Irregular bleeding a common side-effect
Last 3 years
Intrauterine contraceptive device
Decreases sperm motility and survival
Intrauterine system (levonorgestrel)
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
Irregular bleeding a common side-effect
*desogestrel is a type of progestogen-only pill which also inhibits ovulation
Contraception for women aged > 40 years
Whilst fertility has usually significantly declined by the age of 40 years women still require effective contraception until the menopause. The Faculty of Sexual and Reproductive Healthcare (FSRH) have produced specific guidance looking at this age group - ‘Contraception for Women Aged Over 40 Years’ - a link is provided below.
Specific methods
No method of contraception is contraindicated by age alone. All methods are UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The guidance issued by the FSRH contained a number of points which should be considered about each method:
Combined oral contraceptive pill (COCP)
COCP use in the perimenopausal period may help to maintain bone mineral density
COCP use may help reduce menopausal symptoms
a pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years
Depo-Provera
women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
Stopping contraception
The FSRH have produced a useful table detailing how the different methods may be stopped. Please follow the link for the full table.
Method
Women < 50 years
Women >= 50 years
Non-hormonal (e.g. IUD, condoms, natural family planning)
Stop contraception after 2 years of amenorrhoea
Stop contraception after 1 year of amenorrhoea
COCP
Can be continued to 50 years
Switch to non-hormonal or progestogen-only method
Depo-Provera
Can be continued to 50 years
Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method and follow advice below
Implant, POP, IUS
Can be continued beyond 50 years
Continue
If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
Hormone Replacement Therapy and Contraception
As we know hormone replacement therapy (HRT) cannot be relied upon for contraception so a separate method of contraception is needed. The FSRH advises that the POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium). In contract the IUS is licensed to provide the progestogen component of HRT.
Contraception mode of action
The table below is based on documents produced by the Faculty for Sexual and Reproductive Health (FSRH).
Standard contraceptives:
Contraceptive
Mode of action
Combined oral contraceptive pill
Inhibits ovulation
Progestogen-only pill (excluding desogestrel)
Thickens cervical mucus
Desogestrel-only pill
Primary: Inhibits ovulation
Also: thickens cervical mucus
Injectable contraceptive (medroxyprogesterone acetate)
Primary: Inhibits ovulation
Also: thickens cervical mucus
Implantable contraceptive (etonogestrel)
Primary: Inhibits ovulation
Also: thickens cervical mucus
Intrauterine contraceptive device
Decreases sperm motility and survival
Intrauterine system (levonorgestrel)
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
Methods of emergency contraception:
Contraceptive
Mode of action
Levonorgestrel
Inhibits ovulation
Ulipristal
Inhibits ovulation
Intrauterine contraceptive device
Primary: Toxic to sperm and ovum
Also: Inhibits implantation
Contraceptive Choices for Young People
The Faculty of Sexual and Reproductive Health (FRSH) produced guidelines in 2010 concerning the provision of contraception to young people. Much of the following is based on those guidelines. Please see the link for more details.
Legal and ethical issues
the age of consent for sexual activity in the UK is 16 years. Practitioners may however provide advice and contraception if they feel that the young person is ‘competent’. This is usually assessed using the Fraser guidelines (see below)
children under the age of 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures
The Fraser Guidelines state that all the following requirements should be fulfilled:
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Sexual Transmitted Infections (STIs)
young people should be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)
Choice of contraceptive
clearly long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication
however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice
the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people
Emergency contraception
There are two methods currently available in the UK:
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.
Levonorgestrel
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
Ulipristal
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
Epilepsy contraception
There are a number of factors to consider for women with epilepsy:
the effect of the contraceptive on the effectiveness of the anti-epileptic medication
the effect of the anti-epileptic on the effectiveness of the contraceptive
the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant
Given the points above, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommend the consistent use of condoms, in addition to other forms of contraception.
For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
For lamotrigine:
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
If a COCP is chosen then it should contain a minimum of 30 µg of ethinylestradiol.
All woman who are taking an enzyme-inducing drug (EID) (carbamazepine is an example of an EID) should be advised to use a reliable contraceptive that is unaffected by EIDs.
Examples of contraceptives that are unaffected by EIDs are:
Copper intrauterine device
Progesterone injection (Depo-provera)
Mirena intrauterine system
The copper intra-uterine device is usually the preferred option, as it is a non-hormonal method.
In the above scenario, the patient is obese with a BMI of 39 kg/m². Therefore, the contraceptive injection (Depo-Provera) would not be the most suitable option. This is because it is associated with weight gain (2-3kg over 1 year).
In patients on EIDs who wish to take the COCP (providing there are no contraindications) it is important to inform them that the effectiveness is decreased and there is an increased risk of pregnancy.
It is recommended that the dose of oestrogen is increased to 50mcg with no pill-free interval, or reduced to 4 days from 7 days (to reduce the chance of ovulation). In addition, barrier methods would also be advised. This applies when the patient is on an EID and for 4 weeks after stopping.
In patients on EIDs who wish to take the POP or progesterone implant, then additional barrier contraception would be required while using EIDs and for 4 weeks after stopping.
Note - rifampicin and rifabutin are potent EIDs and require longer periods of using barrier contraception after stopping (8 weeks).
If emergency contraception is required, the copper intra-uterine device is again the best option. If levonorgestrel (Levonelle) is used, then double the standard dose is recommended. Ulipristal acetate (ellaOne) is not recommended.
FSRH guidelines.
Injectable contraceptives
Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions**
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
Adverse effects
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
*Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks
**the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
New IUS systems
The Jaydess IUS is licensed for 3 years. It has a smaller frame, narrower inserter tube and less levonorgestrel (LNG) than the Mirena coil (13.5 mg compared to 52 mg). This results in lower serum levels of LNG.
The Kyleena IUS has 19.5mg LNG and is also smaller than the Mirena but is licensed for 5 years.. It also results in lower serum levels of LNG. The rate of amenorrhoea is less with Kyleena compared to Mirena.
Combined oral contraceptive pill special situations
Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra- precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Switching combined oral contraceptive pills
the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The Clinical Effectiveness Unit of the FSRH have stated in the Combined Oral Contraception guidelines that the pill free interval does not need to be omitted (please see link). The BNF however advises missing the pill free interval if the progesterone changes. Given the uncertainty it is best to follow the BNF
Post-partum contraception
After giving birth women require contraception after day 21.
Progestogen only pill (POP)
the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant
Combined oral contraceptive pill (COC)
absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
the COC may reduce breast milk production in lactating mothers
may be started from day 21 - this will provide immediate contraception
after day 21 additional contraception should be used for the first 7 days
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
Lactational amenorrhoea method (LAM)
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight and small for gestational age babies.
*this changed from UKMEC 3 in 2016
