Contraception Advice | Sexually Transmitted Infections by 132Healthwise

An overview ofAn overview of
contraceptioncontraception
Ms C Domoney MRCOG
Contraception Advice – Read More

Ideal contraceptionIdeal contraception
• 100% reversible
• 100% effective
• 100% free side effects
• 100% protective from STDS
• Sadly it doesn’t exist !!

Types of contraceptionTypes of contraception
• Natural family planning
• Persona
• Spermicides
• Condoms
• Diaphragms/caps
• IUCD
• IUS
• Post coital contraception
• Combined oral contraceptive
pill
• Combined contraceptive ring
• Combined contraceptive patch
• Progesterone oral pill
– Mini pill
– Anovulatory Cerazette
• Depot injection
• Implant
• Sterilisation
– Female
– Male

Pearl indexPearl index
PI = total accidental pregnancies x1200 / total months of exposure
Method Pearl index
Male sterilisation 0.02
Implanon 0-0.1
Depo provera 0.1
Female sterilisation 0.13
COC 0.2
POP (mini pill) 1.2
Diaphragm 2
Condom 3.6
No method < 35 80-90

COCsCOCs
• 20-50 micrograms oestrogen
• 0.5-1mg norethisterone (2nd
generation)
• 0.15-0.25 mg Levonorgestrel (2nd
generation)
• 0.15mg Desogestrel (3rd
generation)
• 0.075mg Gestodene (3rd
generation)
• 0.25 Norgestimate (3rd
generation but less VTE data)

COCs – which one?COCs – which one?
General principlesGeneral principles
• Use lowest dose that gives cycle controlUse lowest dose that gives cycle control
and adequate contraceptionand adequate contraception
• Low dose (20mcg) ideal for obese/older
women
• Standard strength (30-35mcg) for younger
women (more fertile)
• Higher dose (50mcg) women taking
enzyme inducing drugs

COCs – which one ?COCs – which one ?
• Biphasic / triphasic preparations may give better cycle
control
• 3rd
generation progestogen ?
Better for acne/headache/depression/wt gain/BTB/breast
symptoms/lipid profile/smoke/BP
• 3rd
generation 30/100,000 VTE
2nd
generation 15/100,000 VTE
• Give 1st
time user with no obvious advantage a 2nd
generation as first line
• But consider 3rd
generation pill for those with arterial
disease risk

COCs – how they workCOCs – how they work
• Inhibit LH surge
• Inhibit ovulation (-ve feedback)
• Reduces endometrial receptivity
• Reduces mucus sperm penetration

COCs - risksCOCs - risks
• Thromboembolic disease
• MI (smokers / over 40 years / high BP)
• Wt gain
• BTB
• Breast cancer

COCs - contraindicationsCOCs - contraindications
• IHD/valve cardiac disease/ TIA / focal
migraine
• Acute liver disease / tumour / porphyria
• SLE
• Trophoblastic disease / breast cancer
• Breast feeding

Relative C.I. To OCPRelative C.I. To OCP
• Young stable IDDM
• Smoking 5-40 cigs / day
• BP 160/95
• Age > 35
• 50% above ideal body weight
• Sickle / Chronic renal disease

Diseases not affected by COCDiseases not affected by COC
• Asthma/sarcoidosis
• MS / Myasthenia gravis / Raynauds / RA
• Spherocytosis / Thalassaemia major
• Thyrotoxicosis
• WPW
• Renal dialysis

COCs benefitsCOCs benefits
• Reversible
• Reduce dysmenorrheoa, PID, menorrhagia, (PMS)
• Reduce ectopic pregnancy rate, ovarian cysts
• Reduce incidence ovarian / endometrial Ca

Instructions for COC users
• If diarrhorrea or vomiting or broad spectrum antibiotics (ie interription
of enterohepatic circulation of EE and gut flora) then must use barrier
precautions for 4 days after
• Enzyme inducing drugs will require higher dose of EE or change of
contraception
– Anticonvulsants (not Na valproate)
– Rifampicin
– Griseofulvin
• Can ‘tricycle’ pill ie up to 4 packs
• Before surgery, consider risk of no contraception -?
thrombophrophylaxis better

Missed pill?Missed pill?
• COC - < 12hrs – next pill asap
• COC - > 12hrs - next pill asap, barrier methods for
7 days
– (if within 7 days of finishing packet – start next packet)
• POP - > 3hrs late - barrier methods for 4 days
• NB ED preps may need 14 days if at beginning of pack)

POP – how it worksPOP – how it works
• Cervical mucus hostility
• Reduced endometrial receptivity
• 40-50% don’t ovulate
– (NB Cerazette anovulatory)

POPPOP
Advantages DisadvantagesAdvantages Disadvantages
• Use in older women
– lower failure rate
• Use in VTE risk
• Use in migraine
• Use in DM
• Use in hypertension
• No effect on lactation
• Less effective
contraception
• Erratic bleeding
– 40%
– 20% amenorrhoea
• Acne
• Breast discomfort
• Need good compliance

Desogestrel (Cerazette)
• Higher dose progestogen only pill
• As efficacious as COC
• Suitable for those with CI to COC
• Less spotting
• Can be used in lactating women
• Inhibits ovulation

Evra: COC patch
• Efficacious
• Good compliance esp in teenagers
• Once weekly patch change
• Ethinyl estradiol and norgestimate

Depot injectionDepot injection
• Inhibits LH, FSH, oestradiol
• Unreceptive endometrium
• Cervical mucus hostile
• Anovulation
• Depot medroxyprogesterone acetate:150mg
– 12 weeks cover
• (Norethisterat
– 200mg NET 8/52)
• Amenorrheoa in 1/3 within 1 year

Depot injectionDepot injection
• Advantage - Useful for poor compliers
• C.I. – IHD/MI/CVA/liver disease
• Disadvantages
– menstrual irregularity
– wt gain
– 8 month fertility reduction
– mood symptoms
– Prolonged use may reduce bone density
– Acne

ImplantsImplants
• Norplant (6 levonorgestrel rods)–
withdrawn Sept 1999, some patients may
have still inserted until 2004
• Difficulty removing the rods !

ImplantsImplants
• ImplanonImplanon (etonogestrel) – 1 rod 68mg
• Use up to 3 years
• Post partum 21-28 days post delivery
• 1st
trimester abortion – immediately
• Side effects similar to depo provera
• Avoids first pass effect of oral route

• Inert / copper types (progestogen containing =IUS)
- Copper increases efficacy Cu 200-375 mm2
• Nova T – 5 years
• If over 40, can stay in till after menopause
• Insert days (no later than day 19, preferably around day 5)
• CI – PID / Cu allergy / abnormal bleeding/ risk of
bacteraemia/ congenital uterine anomaly
IUCDS(1)
IUCDS – Read More

IUCDs (2)IUCDs (2)
• Disadvantages
– menorrhagia / dysmenorrheoa / perforation (1/1000) / expulsion
(50% within first 3 months)
  rate of infection after insertion only unless multiple partners
– May cause discharge 2ry to chronic foreign body endometritis
  chance of a pregnancy being ectopic (but not increase in
ectopic rate)
– If intrauterine pregnancy,  risk of miscarriage, preterm labour,
chorioamnionitis
• remove if can in 1st
trimester
IUCDS – Read More

IUCDs (3)
• If remove ensure LSI > 1 WEEK AGO !
• Insert at TOP or 6-8 weeks post delivery
– but higher perforation and expulsion rate
• Post coital insertion up to 5 days of first episode of unprotected SI
• Missing strings
– USS and advice barrier contraception
• Gynefix – frameless device
– Less menorrhagia and dysmen
IUCDS – Read More

IUS - MirenaIUS - Mirena
• 5 years
• Licensed for Tx of menorrhagia
(dysmenorrhoea/PMS/fibroids/etc)
• Can’t use for emergency contraception
• Irregular bleeding 3-6/12 (some longer)
• Progestogenic side effects
• Efficacy = lap sterilisation
– Cervical mucus
– Endometrial atrophy
IUS 0 Mirena

Safe sex
• Remember barrier methods

CondomsCondoms
• Barrier to infection: SAFE SEX message
• Can burst (baby oil / vaseline)
• Ideally with spermicide
(cream/gel/supp/tabs/foam/C-film)
• Female condoms
Read More - Condoms

DiaphragmsDiaphragms
• From posterior fornix-behind pubis
• Dome downwards / teach insertion /
introducer
• Leave for at least 6 hrs post coitus
• Spermicide both sides
• Review 1 week, 3/12, 1 year
• Change size postpartum and weight
changes?
• Efficacy up to 2/100WY
Diaphragms – Read More

Cervical capsCervical caps
• Suction over the cervix
• Spermicide
• Teach fitting technique
• Can leave 24hrs insitu post coitus
• Dumas – fits fornix – allows cervix to be
felt
• Vimule – thimble shaped prolongation of
cervical cap (for longer cervix)

Sponges and spermicides
• Nonoxynol-9 most common spermicide
– May cause allergic symptoms
– Not to be recommended alone
• Sponges
– relatively ineffective
– Not very reliable
– May be used by older women
– Not available on prescription

Natural methodsNatural methods
• Calendar- ovulate 12-16 days before next
period
• BBT-Temp before waking 0.2° rise from
basal (after day 4 though)- intercourse
allowed 3 days after rise until period
• Mucus chart- SI alt days from day 1
abstain when wet/stretchy for 4 days
• Combination of above methods

Persona (ovulation predictor)Persona (ovulation predictor)
• Estrone –3– glucuronide and LH in urine
• Use if 23-35 day cycle
• CI – menopausal /breastfeeding /tetracyclines / ?herbal
therapy /PCO /HRT /PCC
• Test urine days 1-16 1st
cycle then days 1-8 for next 2 cycles
• Green light conception unlikely, red light – conception more
likely

SterilisationSterilisation
• Open / at LSCS /minilaparotomy/laparascopic
• Lap sterilisation – counselling
– Failure rate 1 in 200 -500 (higher after LSCS)
– Irreversible
– Alternatives
– Risks of op and GA
– Ensure not pregnant and used contraception up to op if in luteal phase
• Vasectomy
– Smaller risks
– Under LA
– Failure rate 1 in 1000
Sterilization – Read More

Emergency contraceptionEmergency contraception
• Levonelle 2:
– 750mcg levonorgestrel (1tab)
repeat 12 hrs
• (Yuzpe:100mcg E2, 500mcg LNG
no longer used)
• New regimen: 2 tablets stat
• Failure rate = 3.2%
• Over the counter for over 16s (
50% A&E)
• Advance prescribing
• IUD (not Mirena IUS) up to
5 days postcoital (or day
19)
Birth Control – Read More

Contraception Advice | Sexually Transmitted Infections by 132Healthwise

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