Contraception Guidelines
Initial consultation
Offer overview of different forms of contraception in particular counsel re LARC
Take History including migraine, drug use, Fhx and lifestyle factors including smoking
Record BP
Measure BMI
Combined Hormonal Contraception
Options
· COCP
· Patch
· Nuvaring
First choice Microgynon
A full list of risk classification can be found here
http://www.fsrh.org/pdfs/UKMECSummaryOfChanges2009.pdf
Specific points of note
A personal history of VTE or a known thrombogenic mutation are conditions that
represent an unacceptable health risk if CHC is used.
For women with a family history of VTE, a negative thrombophilia screen does not
necessarily exclude all thrombogenic mutations.
Use of CHC in women aged ≥35 years who smoke is not recommended
The risks of using CHC in women with properly taken blood pressure (BP) which is
consistently elevated generally outweigh the advantages. Bp 160/95 is an unacceptable health risk if
CHC is used.
The risk of using CHC in women with a BMI ≥35kg/m2 usually outweighs the benefits.
Migraine with aura is a condition for which the use of CHC presents an unacceptable
health risk.
Drugs that effect efficacy of cocp
http://www.fsrh.org/pdfs/CEUguidancedruginteractionshormonal.pdf (see appendix 4)
Drug interactions
Ok to continue contraception with antibiotics exception is rifampicin
Can use additional contraception and need to continue for 28 days after stopping enzyme inducer, with exception of rifampicin can take 50 mcg cocp and tricycle with 4 day pill free interval
Women taking lamotrigine (except in combination with sodium valproate) should be
advised that due to the risk of reduced seizure control whilst on CHC, and the potential
for toxicity in the CHC-free week, the risks of using CHC may outweigh the benefits.
Women should be advised that ulipristal acetate (UPA) has the potential to reduce the
efficacy of hormonal contraception. Additional precautions are advised for 14 days
after taking UPA (9 days if using or starting the progestogen-only pill, 16 days for the
estradiol valerate/dienogest pill) (outside product licence).
Missed pills
http://www.fsrh.org/pdfs/CEUStatementMissedPills.pdf
CHC whilst travelling or at high altitude
Women taking CHC should be advised about reducing periods of immobility during
flights over 3 hours.
Women trekking to altitudes of >4500 m for periods of more than 1 week may be
advised to consider switching to an alternative method.
Qlaira
Quadraphasic COC containing estradiol valerate which is converted to estradiol and is supposed to closely follow normal cycle
Manufacturer’s Instructions for Use of Qlaira
Starting regimen
There is no need for additional contraception if Qlaira is started:
· On the first day of menses
· On the day after the last active tablet of a previous combined oral contraception
· On the day a combined patch or combined vaginal ring is removed
· Immediately post termination or miscarriage
· On day 21-28 following delivery or second trimester termination
An individual should be advised to refrain from sexual intercourse or use condoms for 9
days* if Qlaira is started:
· Any day after day 1 of menses (if it is reasonably certain that she is not pregnant)
· Any day when changing from a progestogen-only method
· Any day after the first day post termination or miscarriage
· After day 28 onwards following delivery or second trimester termination
*This differs to other COCs where additional protection is recommended for 7 days
Missed Pills (Principles if missing one pill for more than 12 hours)
Day 1-17 Take missed pill immediately and the next tablet at the usual time (even if means taking two on same day)
Continue with the tablet taking in the normal way
Abstain or use an additional contraceptive method for 9 days
Day 18-24 Discard the rest of the packet
Start taking the Day 1 pill from a new packet immediately and continue taking these pills at the correct time
Abstain or use an additional contraceptive method for 9 days
Day 25-26 Take the missed tablet immediately and the next tablet at the usual time (even if it means taking two tablets on the same day)
Additional contraception is not necessary
Day 27-28 Discard the forgotten table and continue tablet taking in the normal way.
Additional contraception is not necessary. No more than two tablets are to be taken in any one day. If a woman has forgotten to start a new wallet or if she has missed one or more tablets during Day 3-9 of the wallet she may already be pregnant (provided she has had intercourse in the 7 days before the missed pills). The more tablets (of those with two combined active ingredients on day 3- 24) that are missed and the closer they are to the placebo tablet phase, the higher the risk of pregnancy.
Nuvaring
Combined Hormonal Contraception - ethinylestradiol and etonogestrel
Insert 1ring for 3 weeks then remove for 1 week
Well tolerated
99% effective
Not effected by diarrhoea and vomiting
POP
Generally is suitable where COCP contraindicated
http://www.fsrh.org/pdfs/CEUGuidanceProgestogenOnlyPill09.pdf see table 2 for eligibility criteria
Traditional POPs (containing norethisterone, levonorgestrel or etynodiol diacetate) work by altering cervical mucus to prevent sperm penetration and for some women ovulation is also inhibited.
The desogestrel-only pill also alters cervical mucus, however its primary mode of action is inhibition of ovulation.
If used consistently POPs are more than 99% effective at preventing pregnancy. There are no data to suggest that some POPs are better at preventing pregnancy than others.
Ideally women should be advised to take one POP at the same time every day and without a pill-free
interval.
_There is no evidence that the efficacy of POPs (traditional or desogestrel-only) is reduced in women weighing >70 kg and therefore the licensed use of one pill per day is recommended.
Women can be advised that if a traditional POP is more than 3 hours late or a desogestrel-only pill is more than 12 hours late they should:
· take the late or missed pill now
· continue pill taking as usual (this may mean taking two pills at the same time)
· use condoms or abstain from sex for 48 hours after the pill is taken.
· _ If a woman vomits within 2 hours of pill taking another pill should be taken as soon as possible.
Enzyme inducers
· Women using liver enzyme-inducing medications should be advised to use condoms in addition to POPs and for at least 4 weeks after the liver enzyme-inducer is stopped.
· Women using liver enzyme-inducing medications long term should be advised that the efficacy of POPs is reduced and an alternative contraceptive method should be considered.
There is no delay in the return of fertility following discontinuation of a POP and therefore if pregnancy is not desired another effective method of contraception may be required.
Changes in bleeding patterns with POP use are common:
· 2 in 10 women have no bleeding,
· 4 in 10 women have a regular bleeding pattern
· 4 in 10 women have irregular bleeding.
Women can be advised that there is no evidence of a causal association between POP use and weight change, depression, headache, cardiovascular disease (myocardial infarction, venous thromboembolism and stroke) or breast cancer.
WHEN TO START
No additional contraceptive protection is required if POPs are started:
§ up to and including Day 5 of the menstrual cycle
§ up to and including Day 21 postpartum
§ up to 5 days following abortion or miscarriage (<24 weeks’ gestation).
§ If a POP is started outside these times condoms or abstinence is advised for 48 hours.
Table 3 Recommendations for timing of initiation of progestogen-only pills
Circumstance / Recommendations for timing of initiation / Additionalcontraception advised
General initiation / Progestogen-only pills (POPs) can be started up to and including Day 5 after
the start of the menstrual cycle.
POPs can also be started at any other time if the clinician is reasonably certain
that the woman is not pregnant and there has been no risk of conception.
If the woman is amenorrhoeic, the clinician must be reasonably certain that the
woman is not pregnant and there is no risk of conception. / NO
YES, for 48 hours
YES, for 48 hours
Postpartum / POPs initiated up to Day 21 postpartum.
POPs initiated after Day 21 postpartum. / NO
YES, for 48 hours
Following miscarriage or abortion / POPs initiated on the day of surgical abortion or second part of medical
abortion or immediately following miscarriage.
POPs initiated >5 days after surgical abortion or second part of medical
abortion or miscarriage / NO
YES, for 48 hours
Switching from another method of
contraception
Combined hormonal contraception
(CHC)
Progestogen-only pill (POP)
Progestogen-only implant
Progestogen-only injectable
Levonorgestrel-releasing intrauterine
system (LNG-IUS) or copper-bearing intrauterine device (IUD)
Barrier method (male condom,
female condom, cap or diaphragm) / Can be initiated immediately if CHC has been used consistently and correctly
or if the clinician is reasonably certain that the woman is not pregnant and that
there has been no risk of conception.
Can be initiated immediately if POP has been used consistently and correctly
or if the clinician is reasonably certain that the woman is not pregnant and that
there has been no risk of conception.
Can be initiated immediately if the implant has been used consistently and
correctly or if the clinician is reasonably certain that the woman is not pregnant
and that there has been no risk of conception.
If the woman’s previous method was an injectable she should start POPs when
the repeat injection would have been given or before.
POP initiation at time of IUD removal (avoid intercourse or use condoms in
addition for 7 days before the removal of an IUD).
POP initiation at least 2 days before the removal of an IUD.
POP initiation at time of LNG-IUS removal.
Can be initiated immediately if barrier method has been used consistently and
correctly or if the clinician is reasonably certain that the woman is not pregnant
and that there is no risk of conception. / NO
NO
NO
NO
YES, for 48 hours
NO
NO
YES, for 48 hours
unless POP initiated on
Days 1–5 of menstrual
cycle
Ok to prescribe upto 12/12 at first consultation
Women may be advised that a progestogen-only pill can be continued until the age of 55 years when natural loss of fertility can be assumed.
Alternatively they can continue using a POP and have FSH concentrations checked on two occasions 1–2 months apart. If both FSH measurements are >30 IU/l this is suggestive of ovarian failure and they may continue with a progestogen-only pill or barrier contraception for one further year (or 2 years if aged <50 years).
Women who have a change in bleeding pattern when using a progestogen-only pill need to be
assessed and the risk of STIs, pregnancy or gynaecological pathology considered.
There is no evidence that changing the type and dose of progestogen will improve bleeding but
this may help some individuals. If, after exclusion of other causes, bleeding patterns are still
unacceptable then an alternative contraceptive method may need to be considered.
LARCS
o Injection
o Every 12 weeks
o Deep IM injection
Mode of action and efficacy
· The progestogen-only injectable acts primarily by inhibition of ovulation.
· The pregnancy rate with progestogen-only injectables is <4 in 1000 over 2 years.
· The efficacy of progestogen-only injectables is not reduced by antibiotics or liver enzyme-inducing drugs and injections can be continued at the usual intervals.
· Women should be informed about the possible bleeding patterns that may occur with a progestogen-only injectable, in particular up to 70% of users are amenorrhoeic in the first year of use. [Around 50% of users have discontinued by 1 year, the main reason for discontinuation being changes to bleeding patterns.]
Potential harms
· Weight gain
· delay in return to fertility of up to 1 year after discontinuation
· a small loss of bone mineral density, which is usually recovered after discontinuation.
· no increased fracture risk.
· Can be used in under 18’s if other methods considered
STARTING PROGESTOGEN-ONLY INJECTABLES
Immediate cover
· up to and including Day 5 of the menstrual cycle
· within 21 days of delivery (vaginal or operative)
· within 5 days of a surgical abortion, the second part of a medical abortion, or after a spontaneous
· pregnancy loss (first- or second-trimester or immediate post-septic abortion).
If started at other times an additional method of contraception such as condoms is required for 7 days.
.
ONGOING USE AND FOLLOW-UP
· Re discuss use every 2 years if increased risk osteoporosis consider other forms of contraception
· Women should be advised to attend for repeat injections of DMPA every 12 weeks. When necessary a repeat injection can be given up to 2 weeks late (14 weeks since the last injection) without the need for additional contraceptives. [NB. This use is unlicensed.]
· Women who experience unacceptable bleeding assess for STI or other gynae condition
· If bleeding is unacceptable and the woman wishes to continue with this method of contraception, mefenamic acid or cocp can be considered
INDICATIONS FOR EMERGENCY CONTRACEPTION FOLLOWING LATE PROGESTOGEN-ONLY INJECTABLE INJECTIONS
_ These are summarised in Table 3. http://www.fsrh.org/pdfs/CEUGuidanceProgestogenOnlyInjectables09.pdf
Implant
o Lasts 3 years
o First 5 days of cycle
o Low dose progestagen,
o Side effects those of POP acne, mood swings irregular bleeding
§ 20% amenorrhoea
§ Very irregular in some can take POP or COCP at same time to regulate bleeding
§ The primary mode of action is prevention of ovulation.
· The ectopic pregnancy risk is reduced
· Women with a BMI >30 kg/m2 can use progestogen-only implants without restriction
· There is no evidence of a delay in fertility following removal of a progestogen-only implant.
· Bleeding patterns
o 20 % amenorrhoea
o 50% irregular bleeding .
· supposed not to effect weight change, moodchange, loss of libido or headache.
· Acne may improve, occur or worsen during use of a progestogen-only implant.