Contraception
Contraception can involve physical methods, directly impeding the sperm from reaching the egg and hormonal methods of contraception.
Contraception is not required in the first 21 days after childbirth.
Barrier Methods
Male Condoms
This is a Latex/polyurethane/synthetic rubber sheath placed over the erect penis.
Advantages
Provides protection against STIs
Disadvantages
Relatively low success rate with typical use
Female Condom
This is a Polyurethane sheath that lines the vagina and covers the area just outside
Advantages
Provides protection against STIs
Disadvantages
Relatively low success rate with typical use
Diaphragm/Cap
This is a flexible latex/silicone device placed in the vagina to cover the cervix and is used with spermicide
Patients must be fitted to ensure the right size cap/diaphragm is used
After giving birth, women should wait 6 weeks before using diaphragm again as uterus size changes
Advantages
Can be put in any time before sex
Disadvantages
Relatively low success rate with typical use (71-88%) and does not protect against STIs.
Combined Hormonal Contraception
This type of contraception contains both oestrogen and progesterone.
They prevent pregnancy by preventing ovulation (due to oestrogen) and also thickening the cervical mucus and thinning the uterine lining (due to progesterone)
General Advantages
More effective than barrier methods and does not interrupt sexual intercourse
May reduce risk of endometrial cancer, ovarian and colorectal cancer
Reduced risk of ovarian cysts and benign tumours
Less menstrual bleeding and reduced acne
General Disadvantages
Not protect against STIs, and affected by drugs which alter liver function
Higher risk of cardiovascular disease, DVT and cervical + breast cancer
Can cause breast pain, irregular bleeding, mood change and abdominal pain
Contraindications
This can be remembered by the mnemonic: Some Important Votes Can’t Be Done By Mail:
Smoking – >35yrs and smoking >15 cigarettes/day
Immobilisation – Major surgery with prolonged immobilisation
VTE – History of thromboembolism or thrombogenic mutation
CVS disease – History of stroke or IHD or Uncontrolled hypertension
Breast cancer – Current active breast cancer
Diabetes – Severe diabetes (with DM diagnosed >20yrs ago
Breastfeeding – Breastfeeding <6 weeks post-partum (can only be used after 6 weeks)
Migraine with aura
Combined oral contraceptive pill (COCP)
Ethinylestradiol + Progestogen
This pill is usually taken once a day for 3 weeks followed by a pill free interval of 1 week
The women are not protected during the pill-free week
Instructions whe prescribing
When giving the pill to patients, it is important to highlight the following bits of information;
Initiation
If started within first 5d of menstrual cycle –> no additional contraception needed
If started at other point in menstrual cycle –> barrier contraception or abstain for 7d
The pill should be taken regularly at the same time of the day to be effective
Missed pills
If missed 1 pill, advise to take the missed pill even if it means taking two pills in day
If missed 2 days, take the most recent missed pill and not the one before
Must also use contraception for 7 days to be completely protected
If missed pill is in week 3, omit the pill free interval and take 2 courses back-to-back
Vomiting/Diarrhoea
If vomiting occurs within 3 hours of taking pill, then take another pill
If vomiting persists >24hours, count each day as a missed pill
Combined transdermal patch
Ethinylestradiol (oestrogen) + Norelgestromin (progesterone)
This is a short acting contraceptive which lasts for 1 week
Women have to apply the patch on the same day every week for 3 weeks and then patch free 1 week
It is applied to upper outer arm, buttock, lower abdomen and use a different site each time
It can become detached from the skin, cause skin irritation and may be a delay in return to fertility.
Combined contraceptive vaginal ring
Ethinylestradiol (oestrogen) + Etonogesterel (progestogen)
This is a flexible transparent ring which are self-inserted into vagina
One ring should be used for 3 weeks and then have a ring free interval for 1 week
The ring can be expelled whilst removing a tampon or during sexual intercourse so advise about this
It is more convenient than the pill and is not affected by diarrhoea and vomiting
However, it can cause a delay in return to normal fertility and become broken causing irritation.
Progesterone only Contraception
These only contain a progestogen which works by slowing an egg’s progress through the fallopian tubes, thickening cervical mucus and thinning the endometrium. Some can also suppress ovulation in women.
General Advantages
More effective than barrier methods and can be used when COCP is not suitable
May reduce risk of endometrial cancer and can be used whilst breastfeeding
General Disadvantages
Not protect against STIs, Increased risk of ovarian cysts and ectopic pregnancy
Breast tenderness
Periods can become heavier and painful for a few months
Progesterone-only pill (POP)
Levonorgestrel (Norgeston) + Norethisterone + Desogesterel
The POP is taken for 28 days consecutively with no pill-free interval
Instructions whe prescribing
When giving the pill to patients, it is important to highlight the following bits of information;
Initiation
If started within first 5d of menstrual cycle – no additional contraception needed
If started at other point in menstrual cycle – barrier contraception or abstain for 2 days
The pill should be taken regularly at the same time of the day to be effective
Missed pills
If missed 1 pill, advise to take the missed pill even if it means taking two pills in day
Use barrier protection or abstain from intercourse from 48 hours
Vomiting/Diarrhoea
If vomiting occurs within 3 hours of taking pill, then take another pill
If vomiting persists >24hours, count each day as a missed pill
Progesterone-only injection
Medroxyprogesterone acetate + Norethisterone (Depo-Provera)
This is a long acting contraceptive which is taken every 8-13 weeks
The problem is that it is non-rapidly reversible after stopping (can take up to 1yr to return to fertility)
Also leads to weight gain, lower bone density and injection site reactions.
Progesterone-only implants
Etonogesterel (Nexplanon)
This is a long acting contraceptive which is inserted into the upper arm and provides protection for 3 years
The good thing is that normal fertility returns as soon as the implant is removed
It is also not associated with many serious specific side effects
However, the efficacy can be reduced by liver modifying drugs (as it has to undergo first-pass metabolism.
Intrauterine devices
These are small devices which sit inside the uterus and are referred to as “the coil”.
They are usually long lasting and release chemicals to give a high protection rate.
Intrauterine Device (IUD)
IUDs are a small T-shaped devices with strings of copper which last <10 years
It primarily prevents fertilisation by toxic effects on the ovum and sperm
May also thicken cervical mucus and cause inflammatory reactions in the endometrium (which may prevent implantation)
When using the coil, it is effective immediately after insertion
Advantages
Very effective (>99%), Long-term (10 years), normal fertility returns as soon as removed
Reduced risk of endometrial and cervical cancer and no hormonal side effects
Disadvantages
Not protect against STIs, risk of pelvic inflammatory disease and ectopic pregnancy
Discomfort and bleeding + period can become heavier and painful for a few months
Intrauterine system (IUS) – Mirena, Kyleena Coils
A long acting reversible contraceptive which contain varying amounts of the progestogen levonorgestrel
They are small, T-shaped plastic devices which are inserted into the uterus
This is released where it prevents endometrial proliferation and thickens cervical mucus
The IUS is effective 7 days after insertion and women should also check for threads like the IUD
Advantages
Very effective (>99%), Long-term (10 years), normal fertility returns as soon removed
Can be used when the COCP is contraindicated and during breastfeeding
Periods become lighters (or stop) and may reduce pain with dysmenorrhoea
Disadvantages
Does not protect against STIs, risk of pelvic inflammatory disease and ectopic pregnancy
Increased risk of functional ovarian cysts
Acne, breast tenderness, headaches, irregular bleeding for 3-6 months post-insertion
Risk of uterine perforation – severe pelvic pain, sudden changes in periods, dyspareunia
Irreversible Approaches
These are surgical approaches which are irreversible. They have close to 100% pregnancy prevention rate.
Vasectomy
Involves a surgical procedure to permanently occlude the vas deferens, thus ensuring sperm cannot enter the ejaculate.
This is done using an incision on the scrotum.
To check the efficacy of the procedure, post-vasectomy semen analysis needed to confirm azoospermia
This is done 12 weeks post-procedure, and other methods of contraception must be used in the meantime
Advantages
Very effective, does not interrupt sexual intercourse and permanent
Disadvantages
Does not protect against STIs, not easily reversed
Chronic post-vasectomy pain (CPVP)
Tubal Occlusion
Involves a surgical procedure to occlude or interrupt the fallopian tubes to prevent fertilisation
Pregnancy must be excluded before the procedure
Post-procedure, other methods of contraception must be used until tests confirm tubal occlusion
Advantages
Very effective, does not interrupt sexual intercourse and permanent
Disadvantages
Does not protect against STIs
Increased risk of ectopics if procedure fails.
Emergency contraception
There are 3 methods of emergency contraception currently available in the UK.
Levonorgestrel
This is a progestogen taken as a single tablet, which has an unknown mechanism of action
It is given within 72hrs of unprotected sex, but it is ineffective after ovulation has occurred
Side effects
Nausea and vomiting
Diarrhoea
Dizziness
Breast tenderness
Menstrual irregularities (delay, irregular bleeding, spotting)
Ulipristal acetate (EllaOne)
This is a selective progesterone receptor modulator taken as a single tablet
If given before ovulation, it suppresses follicle development
If given after the LH surge has started, it can delay follicular rupture
It is given within 120hrs of unprotected sex, but it is ineffective after ovulation has occurred.
Side effects
Nausea, vomiting
Diarrhoea
Dizziness
Dysmenorrhea
Pelvic pain
Copper IUD
This is a copper releasing intrauterine device which is inserted within 120hrs of unprotected sex or, if >120hrs since unprotected sex, within 5d of earliest expected date of ovulation
If given pre-fertilisation, copper is toxic to sperm and ovum so prevents fertilisation
If given post-fertilisation, it prevents implantation
Side effects
Discomfort
Increased risk of PID and ectopic pregnancy
Disclaimer
The intended purpose of this website is to be used as a resource for revision for exams. It should not be used as a guideline or reference for clinical practice/decision making or by patients looking for medical information or advice. In2Med takes no responsibility for any loss or damaged resulting from the use of information from this website.
