Contraception

There are many different forms of contraception. These can involve physical methods, directly impeding the sperm from reaching the egg and hormonal methods of contraception.
– Contraception is not required in the first 21d after childbirth.

a) 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%)
– Does not protect against STIs

b) 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

There is a list of contraindications due to the high risk of cardiovascular disease and cancer. 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 ➔ Migraine with aura

Women on combined contraceptives need to be followed up at 3 months and annually after to measure:
– BP and BMI
– Ask about side effects
– Ask about migraines
– Ask about new contraindicating factors

  •  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

When giving the pill to patients, it is important to highlight the following bits of information;

i) 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

ii) 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

iii) Vomiting/Diarrhoea
– If vomiting occurs within 3hours 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 – 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

 

c) 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 + period 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

When giving the pill to patients, it is important to highlight the following bits of information;

i) InitiationIf started within first 5d of menstrual cycle = no additional contraception needed
– If POP started at other point in menstrual cycle = barrier contraception or abstain for first 2d – The pill should be taken regularly at the same time of the day to be effective

ii) Missed pills
– If missed pill, advise to take the missed pill even if it means taking two pills in one day
– Use barrier protection or abstain from intercourse for 48hours

iii) Vomiting/Diarrhoea
– If vomiting occurs within 3hours 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)

d) 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

N.B. Women who have been fitted with an IUS should check for the IUS threads regularly and then seek medical attention if they cannot locate the threads. If they cannot feel threads:
– 1
st exclude pregnancy
– 2
nd perform speculum exam ➔ if still not location, refer for ultrasound, then pelvic X-ray
– If not located, suggests expelled from uterus or embedded in the uterine wall

  • Intrauterine system (IUS)

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

e.g. Mirena coil – 5years                                                      – Kyleena – 5 years

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
– 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

e) 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, irreversible + increased risk of ectopics if procedure fails

f) 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, vomiting, diarrhoea, dizziness and 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 and 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 
➔ prevents implantation


Side effects
– Discomfort, increased risk of PID and ectopic pregnancy

Diagram from the CDC1 / Adapted from World Health Organization (WHO) Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health/Centre for Communication Programs (CCP). Knowledge for health project. Family planning: a global handbook for providers (2011 update). Baltimore, MD; Geneva, Switzerland: CCP and WHO; 2011; and Trussell J. Contraceptive failure in the United States. Contraception 2011; 83:397–404.
https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/family-planning-methods-2014.pdf

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