An overview of

contraception
Ms C Domoney MRCOG

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Ideal contraception

100% reversible
100% effective
100% free side effects
100% protective from STDS
Sadly it doesnt exist !!

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Types of contraception

Natural family planning

Persona

Spermicides
Condoms
Diaphragms/caps

IUCD
IUS

Post coital contraception

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Combined oral contraceptive pill

Combined contraceptive ring
Combined contraceptive patch
Progesterone oral pill
Mini pill
Anovulatory Cerazette

Depot injection
Implant
Sterilisation
Female
Male

Pearl index
PI = total accidental pregnancies x1200 / total months of exposure

Method
Male sterilisation
Implanon
Depo provera
Female sterilisation
COC
POP (mini pill)
Diaphragm
Condom
No method < 35
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Pearl index
0.02
0-0.1
0.1
0.13
0.2
1.2
2
3.6
80-90

COCs
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)

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COCs which one?

General principles
Use lowest dose that gives cycle control
and 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
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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 2 nd
generation as first line
But consider 3rd generation pill for those with arterial
disease risk
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COCs how they work

Inhibit LH surge
Inhibit ovulation (-ve feedback)
Reduces endometrial receptivity
Reduces mucus sperm penetration

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COCs - risks

Thromboembolic disease
MI (smokers / over 40 years / high BP)
Wt gain
BTB
Breast cancer

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

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Diseases not affected by COC

Asthma/sarcoidosis
MS / Myasthenia gravis / Raynauds / RA
Spherocytosis / Thalassaemia major
Thyrotoxicosis
WPW
Renal dialysis

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

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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

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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)

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POP how it works

Cervical mucus hostility
Reduced endometrial receptivity
40-50% dont ovulate
(NB Cerazette anovulatory)

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POP
Advantages
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

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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

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Evra: COC patch

Efficacious
Good compliance esp in teenagers
Once weekly patch change
Ethinyl estradiol and norgestimate
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Depot 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

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Depot 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

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

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Implants

Implanon (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

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IUCDS(1)
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

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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

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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

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IUS - Mirena
5 years
Licensed for Tx of menorrhagia
(dysmenorrhoea/PMS/fibroids/etc)
Cant 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

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Condoms
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

Diaphragms
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
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Cervical 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)

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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

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Natural 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
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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

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Sterilisation
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
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Emergency contraception

Levonelle 2:

Over the counter for over 16s (

50% A&E)

Advance prescribing

750mcg levonorgestrel (1tab)

repeat 12 hrs
(Yuzpe:100mcg E2, 500mcg LNG
no longer used)

New regimen: 2 tablets stat

Failure rate = 3.2%

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IUD (not Mirena IUS) up to

5 days postcoital (or day
19)