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Contraception

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Combined Oral Contraceptive Pill (COCP)

Progestin Only Pill (minipill)

Implanon-NXT

Depot-Provera

Intrauterine-devices

Nuvaring

Permanent Contraception

Emergency-Contraception

Range of options includes:

  • Natural methods: rhythm, body temperature, cervical mucus  monitoring
  • Barrier methods: condoms, diaphragm, female condom
  • Oral hormonal contraceptive: COCP, minipill
  • Injectable or implantable hormonal contraceptive:  depo provera, implanon, IUD
  • Vaginal rings
  • Permanent (if fertility not to be preserved): essure, vasectomy, tubal  ligation

Combined Oral Contraceptive Pill (COCP)

Mechanism of Action

  1. Inhibition of Ovulation: COCPs prevent the release of an egg from the ovary.
    • constant level of synthetic estrogen and progestogen reduces the pulsatile release of GnRH
    • decreased pulsatile release of GnRH leads to a reduced secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.
    • Follicular Development: FSH is crucial for the recruitment and maturation of ovarian follicles. Reduced FSH levels mean fewer follicles develop to the point of maturity.
    • LH Surge Prevention: LH is necessary for the final maturation and release (ovulation) of the egg from the dominant follicle. Without the LH surge, triggered by high-frequency GnRH pulses, ovulation does not occur.
    • Anovulation: The absence of the LH surge means the mature follicle does not release an egg, leading to anovulation.
  2. Thickening of Cervical Mucus: This creates a barrier to sperm penetration, preventing fertilization.
    • Progestogen Effect: The progestogen component thickens the cervical mucus, making it more viscous. This creates a physical barrier that is difficult for sperm to penetrate, thus preventing fertilization.
  3. Endometrial Alteration
    • Thinning of the Endometrium: COCPs cause the endometrial lining to become thinner and less receptive to implantation. If fertilization does occur, the altered endometrium makes it less likely for the fertilized egg to implant and develop.
  4. Decreased Tubal Motility
    • Slowing of Tubal Motility: COCPs can affect the movement of the fallopian tubes, slowing the transport of the egg from the ovary to the uterus, which may reduce the chances of fertilization.

Hormonal Components

  • Estrogen Component: Ethinyl estradiol (EE)
  • Progestogen Components: These vary by generation and have different effects and indications.

Generations and Progestogens

GenerationProgestogenExample OCPsEffectIndication
1stNorethisteroneBrevinor
Brevinor-1
Synphasic
Norimin		Low potency, non-androgenic; potential for breast tenderness, nausea, light bleedingGeneral use
1stLevonorgestrelMicrogynon
Nordette

Biphasic: Biphasil, Sequilar,

Triphasic: Trilquilar		Androgenic side effects such as irritability, weight gain, acneGeneral use
2ndCyproteroneDiane-35Anti-androgenic; binds androgen receptors, preventing testosterone actionSignificant hirsutism, acne
3rdDesogestrelMarvelon
Femoden-ED, Minulet 28
Trioden-ED
Tri-Minulet 28		Low androgenic; antioestrogenic, antimineralocorticoid activitiesWomen experiencing progestogen side effects
3rdDrospirenoneYasminRelated to spironolactone
mild diuretic and antiandrogenic effects		Fluid retention, weight loss due to fluid loss

Types of COCP

COCPs come in two main types: monophasic and multiphasic. Both types contain synthetic estrogen and progestogen but differ in the dosing regimen.

1. Monophasic Pills

Description:

  • All active pills contain the same fixed dose of hormones.

Advantages:

  • Extended Regimen: Up to 12 weeks of active pills can be taken continuously before a 1-week break, allowing menstrual periods only 4 times a year.
  • Simplicity: Easier to manage and remember, as each pill in the pack has the same hormone dose.
  • Consistent Hormone Levels: Provides stable hormone levels, reducing hormonal fluctuations and associated side effects.

Usage:

  • Typically taken for 21 days followed by a 7-day hormone-free interval (sugar pills) to allow withdrawal bleeding.
  • Can be tailored for extended use, reducing the frequency of withdrawal bleeding to once every 3 months or less.

2. Multiphasic Pills

Description:

  • Contain varying doses of hormones, designed to be taken in a specific sequence to mimic the natural menstrual cycle.
  • Can be biphasic (two different doses) or triphasic (three different doses).

Advantages:

  • Reduced Estrogen Load: May reduce overall exposure to estrogen, which can decrease estrogen-related side effects.
  • Hormonal Mimicry: Designed to more closely mimic the natural fluctuations in hormone levels during the menstrual cycle.

Usage:

  • Typically taken for 21 days with varying doses, followed by a 7-day hormone-free interval.
  • Some formulations have a 24-day regimen followed by a 4-day hormone-free interval.

Hormone-Free Interval and Withdrawal Bleeding

Withdrawal Bleeding:

  • Occurs during the hormone-free interval (usually 7 days) when hormone levels drop, leading to shedding of the endometrial lining.
  • Lighter and shorter than a natural menstrual bleed due to the thinning effect of COCPs on the endometrium.

Recent Evidence:

  • No Physiological Requirement: There is no medical necessity to have a monthly withdrawal bleed.
  • Tailor-Made Regimens: Women can be advised on customized regimes, including back-to-back or flexible use of COCPs.
  • Shorter Hormone-Free Interval: A 4-day hormone-free interval has been shown to provide greater contraceptive safety, efficacy, and a reduction in menstrual pain, bleeding days, and the need for emergency contraception.

General Recommendations

  1. Cycle Control: The lowest effective dose that provides good cycle control should be used.
  2. Flexible Regimens: Women can be offered flexible regimes based on their preferences and medical needs.
  3. Adherence: Ensuring consistent use of COCPs is crucial for maintaining contraceptive efficacy.
  4. Individualized Counseling: Women should receive personalized advice and education about the options available to them, including the benefits and potential side effects of different COCP types.

Initiating COCPs

  1. Counseling:
    • Establish Reason: Understand why the patient wants to use OCPs.
    • Alternative Methods: Discuss other contraceptive options.
    • Personal Context: Consider the patient’s past experiences, cultural background, and beliefs.
    • Empowerment: Provide comprehensive information to help the patient make an informed choice.
  2. Medical History:
    • Age: Risk factors increase with age, especially in smokers.
    • Medical History: Identify any contraindications such as thrombotic disorders, migraines, liver disorders.
    • Gynecological History: Assess for abnormal bleeding and previous OCP use.
    • Family History: Check for thrombotic disorders.
    • Social History: Assess for smoking and drug use.
  3. Examination:
    • Vital Signs: Weight, blood pressure.
    • Systemic Examination: Focus on signs of thromboembolic diseases (e.g., carotid bruits, calf tenderness).
    • Breast and Vaginal Examination: Pap smear if due.
  4. Investigations:
    • Lipid Studies: If relevant to the patient’s health profile.

Education and Counseling

Advantages:

  • Non-Contraceptive Benefits:
    • Lighter, predictable, and less painful periods.
    • Reduced risk of pelvic infections, acne, benign breast lumps, and anemia.
    • Maintains bone mass.
    • Reduces risks of endometrial, ovarian, and bowel cancers.
    • Manages menstrual problems such as premenstrual syndrome, heavy menstrual bleeding, and dysmenorrhea.
    • Beneficial for conditions like endometriosis, PCOS, and peri-menopausal symptoms.

Disadvantages:

  • Failure Rates: High with typical use.
  • Cost: Some formulations are relatively expensive.

Contraindications

Defined by the UK Medical Eligibility Criteria for contraceptive use:

  • Pregnancy
    1. Breast Feeding
    2. First 6 weeks post partum
      1. to avoid risk of thromboembolic complications
  • CVS Risk
    1. Smoker ≥35 year and ≥ 15 cigarettes/day
      1. normal BMI and nonsmoker: COCP safe, can be used until 50-55yo when
        1. COCP is not recommended for women ≥50 years, and other contraceptive methods should be used if required.
        2. The woman (≥50) who is amenorrhoeic for 1 year, no longer requires contraception. However other contraceptive methods should be considered if the woman menstruates after ceasing OVP
      2. Smoking, DM, obesity, HTN and migraine cause CV risk to outweigh benefit OCP
      3. Consider progestin only, IUD, sterilization
    2. Hypertension with systolic ≥160mmHg or diastolic ≥95mmHg
    3. Current or past history of Ischemic Heart Disease (IHD);
    4. Complicated valvular heart disease
    5. Diabetes complicated by nephropathy, retinopathy or vascular disease
    6. Vascular disease
  • CANCER
    1. Breast cancer
      1. Any increased risk for current users is small and there is no significant difference in risk between ever-users and never-users of CHCs.
      2. Use of CHCs has not been shown to be associated with increased mortality from breast cancer.
    2. Cervical cancer
      1. a small increase in the risk of cervical cancer in users of CHCs. This risk increases with duration of use and gradually decreases after cessation.
      2. The rate of cervical cancer in Australia is 4.9/10,000 women per year and is one of the lowest in the world
      3. Regular cervical screening minimises the risk of cervical cancer.
    3. Liver cancer
      1. increased risk of hepatocellular carcinoma
      2. Severe Liver disease including cirrhosis hepatocellular adenoma and hepatoma
  • Migraine with aura
  • Venous Thromboembolism
    1. Major surgery with prolonged immobilisation
    2. Current or past history of venous thromboembolism (VTE);
    3. Known thrombogenic mutations  (Factor V Leiden, Prothrombin mutation, Protein S, Protein C and Antithrombin deficiencies)
    4. Raynaud’s with lupus anticoagulant
    5. SLE with antiphospolipid antibodies

Side Effects

  • breakthrough bleeding
  • headache
  • weight gain
  • breast tenderness
  • nausea
  • chloasma (brown patches on face)
  • lowered libido and mood changes
  • acne
  • Circulatory effects
    1. Venous-deep vein thrombosis
    2. Pulmonary embolism
    3. Rarely: mesenteric, hepatic and renal thrombosis
    4. Arterial-Myocardial infarction
    5. Thrombotic stroke
    6. Haemorrhagic stroke
  • These risks have been decreased with low-oestrogen-content COCs
  • Cancer – possible effect (not absolutely proven)
    1. Cervix
    2. Breast

Important Advice

  • Menstrual Control: Periods are typically shorter, lighter, and more regular.
  • Hormone-Free Interval: Shortening to four days can reduce pregnancy risk if pills or rings are missed.
  • Unscheduled Bleeding: Common with continuous use; no break from the pill is necessary.
  • Drug Interactions: Includes vitamin C, antibiotics, griseofulvin, rifampicin, anticonvulsants, warfarin, and oral hypoglycemics.
  • Gastrointestinal Issues: Diarrhea and vomiting may reduce effectiveness.

Follow-Up

  • Regular Visits: Annual check-ups to update history, examination, and repeat Pap smears.


Management of Late or Missed COCP Pills

1. If a Hormone Pill is Less Than 24 Hours Late:

  • Action: Take the late hormone pill as soon as possible.
  • Continue: Continue taking the rest of the pills at the usual time (2 pills can be taken on the same day if necessary).
  • Contraception: No additional contraceptive methods are required.

2. If a Hormone Pill is More Than 24 Hours and Less Than 96 Hours Late:

  • Action: Take the most recent missed pill as soon as possible and discard any other missed pills.
  • Continue: Continue taking the remaining pills at the usual time (2 pills can be taken on the same day if necessary).
  • Contraception: Use additional contraceptive methods (e.g., condoms) or abstain from sexual intercourse until 7 consecutive active hormone pills have been taken.

3. Missing More Than 4 Consecutive Pills:

  • Classification: This is classified as having ‘stopped using the COCP.’
  • Action: Consider emergency contraception if unprotected intercourse occurred during this time.
  • New Packet: Commence a new packet of pills.

4. Missed Pill in the First Week of a New Packet:

  • Action: Use emergency contraception (morning-after pill) if unprotected intercourse occurred at or after the time the pills were missed.
  • Continue: Resume taking the COCP and use additional contraceptive methods as needed until 7 consecutive active hormone pills have been taken.
Summary of Actions:
  1. Less than 24 hours late:
    • Take the late pill immediately.
    • No additional contraception needed.
  2. More than 24 hours and less than 96 hours late:
    • Take the most recent missed pill immediately.
    • Use additional contraception until 7 consecutive active pills are taken.
  3. More than 4 consecutive pills missed:
    • Consider emergency contraception.
    • Start a new packet of pills.
  4. Missed pill in the first week:
    • Use emergency contraception if unprotected sex occurred.
    • Continue with the COCP and use additional contraception until 7 consecutive active pills are taken.

Initiation of COCP

SITUATION ACTIVE PILL COMMENCEMENT EFFECTIVE * 
No contraception or barriers Day 1 to 5 of menstrual cycle Any other time if pregnancy is excluded 
If starting CHCs any time other than day 1-5 of the menstrual cycle and if pregnancy excluded, inform women that an additional 7 days are required before there is contraceptive protection		Immediately Effective in 7 days 
COCP or vaginal ring Begin new packet on an active hormone pill or insert vaginal ring no later than the day following the last hormone-free day Immediately 
DMPA injection Anytime within 14 weeks of injection Immediately* 
ENG- implants Anytime within 3 years of insertion Immediately* If commenced on the same day as Implanon NXT® is removed, allow 7 days to become effective 
POP Anytime if pills have been correctly taken otherwise exclude pregnancy Effective in 7 days 
Cu- IUD Day 1-5 Other times: – Condoms for 7 days prior to removal of IUD, commence CHC on day of removal – Commence CHC 7 days before IUD removal Immediately Effective in 7 days Immediately 
LNG IUD Condoms for 7 days prior to removal of the IUD, commence CHC on day of removal. Commence CHC 7 days before IUD removal Effective in 7 days Immediately 
Termination or miscarriage ≤24weeks Up to and including day 5 post-procedure If taken>5 days exclude repeat pregnancy Immediately 7 days 
Post-partum (not breastfeeding) -includes stillbirth If no menstrual cycle – any time after 3-6 weeks post-delivery and pregnancy is excluded. All postpartum women must undergo VTE risk assessment prior to starting CHC. If menstrual cycle resumed – follow instructions as above for no contraception or barriers Effective in 7 days As above 
Post-partum (breastfeeding) >6weeks No menstrual cycle- anytime >6wks (exclude pregnancy). All postpartum women must undergo VTE risk assessment prior to starting CHC. Menstrual cycle resumed – As above for no contraception or barriers 7 days As above 

common reasons for COCP discontinuation:

Breakthrough bleeding (BTB)

  1. other causes of abnormal bleeding, particularly
    1. pregnancy
    2. cervical pathology (polyps, cancer) 
    3. infection related bleeding (chlamydia infection should always be excluded in any patient presenting with bleeding) abnormalities
    4. need to be considered before assuming bleeding is pill related
  2. Progestogen : usually for primary major contraceptive effect
  3. Estrogen : is added primarily to stabilise the bleeding pattern as an atrophic endometrium 
  4. estrogen may result in asynchronous ‘breakthrough’ bleeding (BTB). 
  5. Irregular bleeding is common in the first three to four months of combined oral 
  6. The rate of BTB usually declines over time
  7. however, at 12 months of use, around 10% of women taking lower dose COCPs still report some non-scheduled bleeding.
  1. Managing persistent irregular bleeding in women using COCP
    1. Reassure patient that bleeding will likely resolve in three to five cycles
    2. Change to an alternative progestogen
      1. preparations containing gestodene, or norethisterone at a dose of 1000 μg, may offer some advantages in terms of BTB control 
    3. Change the oestrogen dose or type
      1. COCPs containing 20 μg of ethinyloestradiol are associated with higher initial rates of BTB
      2. Consider increase estrogen dose if less than 20 mcg per day 
      3. alternatively, one of the newer oestradiol pills.
      4. Ethinyloestradiol 50 μg is sometimes recommended for women on known enzyme-inducing medications but, in general, has a minimal role in managing BTB because of an increased risk of significant side effects.
    4. Change the delivery system
      1. vaginal rings bypass issues of variable gastrointestinal absorption and daily commitment to use. 
      2. BTB in ring users was shown to be significantly less common than in those taking a 30 μg levonorgestrel COCP.
    5. There is no good evidence that triphasic preparations offer any advantage over monophasic in terms of cycle control
    6. In case of extended cycle (continuous contraceptive)
      1. Reassure patient that bleeding will likely diminish by the fourth month
      2. consider a hormone-free interval of three or four days beginning on the first day of breakthrough bleeding
      3. consider changing progestin from levonorgestrel to norethindrone

Irregular bleeding secondary to contraceptive use

  1. Adherence to recommended regimen – oral contraceptives require strict daily commitment.
  2. Poor gut absorption (ie significant vomiting, severe diarrhoea, chronic malabsorption) may compromise the efficacy and cycle control of oral contraceptives.
  3. Hormonal effects on the thickness/stability of the endometrium – this is intrinsic to progestogen-only contraception, but for combined methods depends on dose, formulation and delivery system.
  4. Interference with hormone metabolism – exogenous hormone metabolism is individually variable but can also be affected by smoking21 and the use of liver enzyme-inducing medications such as:
    1. antiepileptic medications (not all)
    2. anti-tuberculosis drugs
    3. several drugs used to treat human immunodeficiency virus (HIV)
    4. St John’s Wort (hypericum)
    5. other drugs (eg bosentan, aprepitant, modafinil, sugammadex)

Progestin Only Pill (minipill)

prevents pregnancy by

A. Cervical Mucus Thickening
  • Primary Mechanism: The primary action of POPs is to thicken the cervical mucus. This makes it more difficult for sperm to enter the uterus and fertilize an egg.
  • Consistency: This effect is maintained as long as the progestogen levels are consistent, hence the need to take the pill at the same time every day.
B. Endometrial Changes
  • Thinning of the Endometrial Lining: The continuous exposure to progestogen causes the endometrium (the lining of the uterus) to become thin and atrophic. A thinner endometrial lining is less likely to undergo the cyclical changes necessary for menstrual bleeding.
  • Reduced Vascularization: Progestogen reduces the blood supply to the endometrium, further contributing to its thinning and the likelihood of bleeding
C. Ovulation Inhibition (Less Consistent)
  • Higher-Dose POPs: Some higher-dose POPs (like those containing desogestrel) can also inhibit ovulation in a significant number of cycles.
  • Lower-Dose POPs: Lower-dose POPs do not consistently inhibit ovulation; their main effect is on cervical mucus and the endometrium.

Indications

According to the UK Medical Eligibility Criteria (UKMEC), POPs are suitable for:

  1. Breastfeeding Women: Safe for use during lactation.
  2. Women with Cardiovascular Risks: Suitable for women with hypertension, a history of thromboembolism, or smokers aged 35 and older.
  3. Women with Migraine: Safe for women with migraine, including those with aura.
  4. Women with Estrogen-Related Contraindications: Suitable for those who cannot use estrogen due to a history of hormone-related conditions or current health issues.
  5. Adolescents and Women of All Ages: Suitable across all reproductive age groups.

Contraindications:

specific contraindications based on the UKMEC guidelines:

  • Current Breast Cancer: Absolute contraindication.
  • Severe Liver Disease: Including active viral hepatitis, severe cirrhosis, or liver tumors.
  • Unexplained Vaginal Bleeding: Until a diagnosis is made.
  • Sensitivity to Progestogens: Allergic reactions to components of the POP.
  • Other
    • previous ectopic pregnancy
    • obesity (less effective)

Side Effects

POPs are associated with several side effects, most of which are related to the progestogen component. These can include:

  1. Menstrual Irregularities:
    • Irregular bleeding or spotting
    • Prolonged bleeding episodes
    • Amenorrhea (absence of periods)
  2. Hormonal Side Effects:
    • Breast tenderness
    • Mood changes, including depression or irritability
    • Headaches
    • Acne
    • Decreased libido
  3. Gastrointestinal Issues:
    • Nausea
  4. Weight Gain:
    • Some women may experience weight gain, though it is generally minimal.

Failure rates higher in heavier women >70kgs and over

  • consider using double dose
  • probably due to the oestrogen load that heavier women have
  • Slightly higher failure rates than combined pill (3-7%) but failure often due to user error

Starting

  • start on day 1-5 of a normal menstrual cycle (day 1 is first day of menses and day 5 is 4 days later) as it is then effective immediately. 
  • If started at any other time, additional methods of contraception or abstinence should be advised for the first 48 hours until contraceptive effect (3 consecutive pills) is reliably established. 
  • Same Time Every Day: Take the pill at the same time every day to maintain consistent hormone levels. Set a reminder or alarm if needed.
  • The packet contains 28 pills containing the same dose and one pill is taken daily at the same time without a break 
    • There are no placebo or sugar pills, and the user takes an active pill every day of the cycle.
    • This continuous exposure helps maintain the thickened cervical mucus and the altered endometrial environment.

Managing Side Effects

  1. Irregular Bleeding:
    • Common and Normal: Inform that irregular bleeding or spotting is common, especially during the first few months.
    • Monitoring: Keep a menstrual diary to track bleeding patterns.
  2. Other Potential Side Effects:
    • Breast Tenderness, Nausea, Headaches: These may occur initially but often improve over time. If severe or persistent, consult a healthcare provider.
    • Mood Changes: Monitor and discuss any significant mood changes with a healthcare provider.

Missed Pill

  • take at same time each day with in 3 hour window
  • A pill is considered missed if more than 3 hours late
  • if missed take immediately and use barrier contraception for 3 days

Bleeding Patterns with POPs

Irregular/Breakthrough Bleeding:

  • Prevalence: Occurs in approximately 25% of women using POPs.
  • Frequent Spotting: Many women experience frequent spotting or light bleeding, especially during the initial months of use.
  • Unpredictable Timing: Bleeding can occur at any time during the cycle without a predictable pattern. Despite continuous hormone administration, the endometrial lining, although kept thin, can sometimes shed unpredictably.

Prolonged Bleeding:

  • Extended Periods of Bleeding: Some women may have prolonged episodes of light bleeding or spotting that can last for several days or even weeks.

Amenorrhea:

  • No Bleeding: Some women may experience amenorrhea (the absence of menstrual periods) after several months of consistent POP use. This is due to the atrophic effect of progestogen on the endometrial lining.

Regular Bleeding:

  • Monthly Periods: A minority of women may continue to have regular menstrual-like bleeding each month, though this is less common with POPs compared to COCPs.

Lactation:

  • excreted in breast milk. Dosage to infant is extremely small and not found to affect milk quality, quantity or infant growth or development. Suitable for breastfeeding women

Vomiting and/or severe diarrhoea:

  • due to the risk of incomplete absorption, additional methods of contraception should be used during the illness and for 48 hours (3 consecutive pills) following

There are two types available in Australia

  • Norethisterone (Locilan 28, Micronor, and Noriday 28)
  • Levonorgestrel (Microlut 30 mcg)
  • Desogestrel 75 mcg (Cerazette, Azalia)
    • 12-Hour Window: Desogestrel POPs offer a 12-hour window for taking the pill each day, compared to the 3-hour window for other progestogen-only pills.

Long-acting reversible contraceptives (LARCs)

Managing irregular bleeding on LARC

  1. First-line options
    1. A combined hormonal contraceptive taken continuously or cyclically for three months
    2. Five-day course of NSAID (eg mefenamic acid 500 mg bd or tds)
    3. Five-day course of tranexamic acid 500 mg bd
  2. Second-line option
    1. Norethisterone 5 mg tds for 21 days
    2. Unlikely to be effective
  3. Doxycycline – although early studies showed promise, this was not borne out when larger trials were conducted

Implanon NXT

  • Etonogestrel implant, subcutaneous, lasts 3 years
  • Relative Contraindications
    • Breast cancer(Current/past)
    • Current and history of ischaemic heart disease
    • Stroke (history of cerebrovascular accident, including TIA)
    • Unexplained vaginal bleeding (suspicious for serious condition) before evaluation
    • Cirrhosis – Severe (decompensated)
  • Inserted days
    • 1-5 of menstruation (must use barrier contraception for 7 days if inserted otherwise)
    • day after last OCP
    • day of removal previous implant
  • Advantages
    • women who cannot take oestrogen or who experience side effects while using it-
    • breastfeeding mothers
    • No effect on bone density
  • Possible side effects
    • bleeding irregularities
      • 20% frequent bleeding/spotting
      • 20% amenorrhoea
      • 60% normal or infrequent bleeding/spotting
      • bleeding patterns in the first 3 months of use are generally predictive of future bleeding 
      • Breakthrough bleeding (continuous)=No treatment has been proven effective; consider changing contraceptive method
    • Acne:   A retrospective study of Implanon users found that 11 percent had acne after insertion.2 If acne worsens with a progestin-only contraceptive, a combination method can be tried if the patient is medically eligible.
    • local reaction to the insertion site
    • scarring
    • weight gain
    • emotional lability
    • breast tenderness
    • acne
    • deep insertion may lead to difficult removal later
  • no delay in return of (pre-existing) fertility following removal of the ENG implant.
  • Follow up
    • Need to palpate after insertion, and check regularly
    • Irregular bleeding
      • Consider other causes – chlamydia, pregnancy, medication interaction, cervical cancer, endometrial cancer, endometrial polyps
    • Management option
      • Wait and watch
      • Trial COCP for 3 moths
      • NSAIDS or tranexamic acid for 5 days
      • Switch methods
      • Take oral progesterone for 21 days – norethisterone or levonogestrel
      • Early replacment of implant
      • If switching from COCP – continue taking for 7 days

Depot Provera

  • Depot medroxyprogesterone acetate 150mg 12 weekly
  • Effective- failure rate 0.03%
  • Deep IM injection 12 weekly +/ 14 days
  • initial injection during first 5 days of cycle (barrier contraception for 7 days otherwise and exclude pregnancy)
  • Assess risk factor for low BMD and CVD annually
  • Do not give to > 50 years
  • Starting
    • Immediately effective if started
      • day 1-5 menstrual cycle
      • <21 days post partum
      • Wihtin 5 days abortion
      • Repeating
      • Switching from implanon
      • Switching from Copper IUD in days 1-5 of menstual cycle
    • Otherwise 7 days to become effective – see Quick start
    • If switching from COCP – continue for a further 7 days
  • Advantages
    • Amenorrhoea occurs in up to 47% of DMPA users after one year of use, which may be beneficial in women particularly with menstrual problems. 
    • improve dysmenorrhoea especially associated with endometriosis.
  • Disadvantages
    • Return to fertility may be delayed up to 18 months from last DMPA injection
    • DMPA does not offer protection against sexually transmitted infections including HIV and at-risk women should be advised on the concurrent use of condoms
  • Side Effects
    • erratic bleeding- 1% experience daily spotting
    • weight gain
      • is the only hormonal contraceptive that is consistently associated with weight gain. 
      • A prospective study found that women who used Depo- Provera gained an average of 5.1 kg over 36 months, whereas women who used combined oral contraceptives did not gain weight
    • Mood changes/Depression
    • Hirsutism
      • 6% of Depo-Provera users report new- onset facial hair at six months of use. Combined oral contraceptives are used to treat hirsutism
    • bone loss with prolonged use
      • bone loss is due to anovulatory (hypoestrogenic) effect of DMPA and mostly occurs in the first year of use. It is reversible after discontinuation.
      • Lower BMI, low calcium intake and greater alcohol use were associated with greater BMD loss in adolescents using DMPA. 
      • After 2 years of DMPA use, if the woman wishes to continue use, re-evaluation of risks and benefits, and alternative methods of contraception need to be discussed. 
      • There is limited evidence on fracture risk.
      • Alternative contraceptive methods should be considered first for women who are over 50 years of age before prescribing DPMA, due to concerns regarding bone loss on DMPA
  • Counselling
    • Long delay 8 months for fertility to return
    • Disrupted menstrual cycle – amenorrhea
    • Accelerated bone loss with long term use
    • Contraceptive effects only 14 weeks – need regularly
    • Breast tenderness
  • Altered bleeding pattern
    • Irregular/prolong/frequent is common
    • 50 – 70% amenorrheic after 1 year
    • Exclude otehr causes of bleeidng – prgnancy, STI, vaginal/cervical/uterine pathology
    • Consider
      • adding COCP for up to 3 months
      • NSAIDs
      • Oral norithesteon
      • POP for 20 days
  • If > 14 weeks since last injection
    • need to exclude pregnancy
    • If unprotected intercourse in the last 3 weeks – quick start method
    • Consider emergency contraception

Intrauterine devices 

  •  LARCs with duration of action ranging from 5 to 10 years. 
  • They are most effective contraceptive options with failure rates less than 1 in 100 and are very cost effective with high patient satisfaction and continuation rates with minimal follow up required after insertion.
  • There is no delay in return to fertility after removal of IUD 
  • In breastfeeding women, IUD can be inserted 6 weeks after delivery (if no contraindications) with no adverse effects on breastfeeding or infant
  • Avoid IUD in Patients with:
    • Postpartum sepsis 
    • Leiomyomas with distortion of the uterine cavity 
    • Anatomic abnormalities with distortion of the uterine cavity
    • Septic abortion (immediately following)
  • Avoid in Initiation of IUD (may continue if already placed) :
    • Pelvic inflammatory disease 
    • Endometrial cancer 
    • Cervical cancer (untreated)
    • Chlamydia, gonorrhea, or current purulent cervicitis
  • Women who are deemed at increased risk of STI, should be encouraged to use barrier contraception in addition to IUD
  •  Use of 2% lignocaine gel or 10% lignocaine spray with long instillation syringe may reduce the pain at the time of insertion.
  • In women with history of fainting / vasovagal reaction to cervical instruments, consider sedation in hospital setting.
  • Post procedure management
    • Discuss the symptoms of pelvic infection
    • Advise the woman to check the IUD strings after first menstruation
    • Inform the woman to use condoms in addition to the IUD if she is at risk for STIs.
  • Mechanism of action
    • foreign body effect induced by the IUD frame 
    • When uterus is exposed to a foreign body, a sterile inflammatory reaction occurs, which is toxic to sperm and ova and impairs implantation 
    • The production of cytotoxic peptides and activation of enzymes lead to inhibition of sperm motility, reduced sperm capacitation and survival, and sperm phagocytosis
  • Insertion
    • Via speculum, cramps common
    • 1 in 300 – infection in first 3 weeks
    • Complications
      • Perforation 1-2 in 1000
      • Malposition
      • Possible expulsion
      • ecoptic pregnancy – very rare
  • Irregular bleeding on LARCs
    • Consider pregnancy, infection, other pathology, position of device
    • Can coanisder addition or COCP if no contraindications – off licence
    • 5 day course NSAID
    • 5 day course tranexamic acid
    • 2nd line – norethisterone 5mg TDS for 21 days
    • Early replacement, reduce depot interval to 10 weeks
    • Copper IUDs will increase menstrual loss
Mechanism of actionAdvantagesDisadvantages
Copper bearing (non-hormonal) (Cu-IUD)copper IUCD inserted after the age of 40 can be left in place as contraception until 12 months after LNMP if menopause at > 50 years old or 2 years after LNMP if menopause at < 50 years
TT380 regular  – effective for 10 years

TT380 short  – effective for 5 years

Copper multi load 375  – effective for 5 years

Monalisa Cu 375   –effective for 5 years

Monalisa Cu 375 SL – effective for 5 years		Copper  enhances the cytotoxic inflammatory response within the endometrium

impairs sperm migration, viability, and acrosomal reaction; and impairs implantation 

Copper IUDs have no impact on ovulation		continued menstrual cyclicity

reduced risk of cervical cancer

reduction in endometrial cancer

In women >40 years, Cu-IUD of >300mm can be considered to remain in situ as a contraception until 12 months after final menstrual period		Copper IUD does not provide protection against upper genital tract infections. 

have a greater risk of pelvic inflammatory disease (PID) if exposed to sexually transmitted infections (STIs)

heavier menstrual bleeding while LNg IUDs (menses may be heavier, longer, or more painful, particularly in the first several cycles after insertion)
Hormonal levonorgestrel (LNG) IUD / IUS 
– contains levonorgestrel that is released continuously for at least 5 years
– Mirena® inserted for menorrhagia or contraception after the age of 45 years, may be retained up to the age of 55 years, or until post-menopausal if she is amenorrhoeic
Mirena- effective for 5
years

Kyleena- effective for 5 years










Progestins thicken cervical mucus 🡪 which acts as a barrier to the upper genital tract

impairs implantation inhibit the binding of the sperm and egg

ovulation rates vary based upon the initial progestin dose and then increase as the progestin level falls over time. Most cycles are ovulatory.

reduction in   
-Menorrhagia 
-Anemia  
-Dysmenorrhea  
-Endometriosis Pain  
-Endometrial Hyperplasia   
-PID  
-Cervical Cancer

Advantage over copper-progestin-mediated reduction in upper-tract STD infection-

can cause lighter bleeding, amenorrhea, or minimal change, depending on the levonorgestrel dose		Acne
breast tenderness
weight gain
head ache
mood changes

Erratic bleeding and spotting in first 35 months 
– prolonged bleeding (59%)
– unscheduled bleeding (up to 52%) 
– amenorrhea (6 to 20 %) 
– spotting (23 to 31%) 



Kyleena smaller framenarrower insertion devicebetter visibility on ultrasoundlower dose of LNG. effective contraception for 5 yearsnot advised for treatment of heavy menstrual bleeding or endometrial protection.

Complications

  • PID
    • the risk of PID is 1:400 in the first 20 days. After that the risk of PID reflects the woman’s risk of exposure to STI
  • Non-palpable strings
    • Non-visible strings – If the IUD strings are not visible on speculum examination, a cytobrush can be placed in the cervix and gently twisted in attempt to pull the strings down and out of the cervical os. An IUD hook can be used in a similar manner if the cytobrush does not extract the strings. If these maneuvers are not successful
    • USS to check location of IUD
  • Expulsion
    • First do a pregnancy test then advising additional contraception until the location of the device is established
    • Ectopic pregnancy – if pregnancy occurs with an IUCD in place there is a higher risk of ectopic
  • Perforation
    • Uterine perforation is rare – approximately 2.3 per 1000 insertions, but is a serious complication

Nuvaring

  • The combined vaginal ring is a 54mm ethylene vinyl acetate copolymer ring and releases a combination of 15mcg EE and 120mcg ENG daily. It is available in Australia as NuvaRing®. It is placed in the vagina for 3 weeks. It is then removed, disposed of and the woman then has a 7 day hormone free week before a new ring is inserted. It is 91-99.7% effective at preventing pregnancy depending on perfect use.
  • Ethinyloestrodial and ethonorgestrel ring inserted high into vagina for 21 days and removed for 7
  • Withdrawl bleed during 7 day break and new ring inserted
  • Effective
  • Low dose – less side effects
  • High patient acceptability
  • Equivalent dose but better cycle control than 15mcgm pills 
  • “bit of the yuck factor”
    • meant to fit in the posterior vaginal cervical fornix

Emergency Contraception

  • Emergency contraception is offered, when indicated, without regard to day of the menstrual cycle due to uncertainty in timing of ovulation
  • Both the levonorgestrel and estradiol plus levonorgestrel regimens are most effective when given as soon as possible after unprotected intercourse
  • there is a linear relationship between efficacy and the time from intercourse to treatment
  • LNG 1.5mg
    • take ASAP within 72 hours of unprotected intercourse
    • Can also take 25 30ug LNG tablets twice 12 hours apart (50 tabs total)
    • Some efficacy up to 96 hours/4 days
    • If taking liver enzyme inducing drugs should have copper IUD, or consider soubling the dose
    • Failure risk greater if obese
    • If vomit within 2 hours repeat dose
    • Safe with breastfeeding
    • Can initiate hormonal contraception immediately with quick start
  • Ulipristal acetate
    • Selective progesterone receptor modulator 30mg tablet within 120 hours/ 5 days
    • Best within 24 hours
    • More effective within 24 hours
    • Don’t start any other hormonal contraception until 5 days after UPA Discard breastmilk for 1 week
    • Reduced effectiveness liver enzyme inducing Reduced efficacy obesity – but better than LNG Vomit within 3 hours repeat dose
  • Copper IUD
    •  Insert up to 5 days after ovulation
    • most effective method – can leave in for 10 years
    • Copper ions have toxic effect on sperm, and inflammatory response in endometrium prevents implantation
    • Screen for STIs if indicated but don’t need to delay insertion unless known pelvic infection
    • Can use after 4 weeks postnatal
    • SE’s – altered bleeding pattern, increase menstrual loss, risk of insertion
    • Discuss ongoing contraception
    • Can quick start after LNG – but cannot put in IUD as need to exclude pregnancy
    • UPA can’t start any prosteogen within 5 days
 Levonorgestrel (LNG)emergency contraceptiveUlipristal acetate (UPA)Copper intrauterine device (IUD)
Pregnancy rate if method taken within 120 hours2.2%Least effective1.4%<1% most effective of the three methods
cost$18–25$40–50$90–100 for device plus additional insertion fee
selective progesterone receptor modulator
MechanismLNG and UPA work by preventing or delaying ovulation (ie before the luteinising hormone [LH] surge) and are not effective once ovulation has occurred (ie after the LH surge) 
Unlike LNG, however, UPA can prevent pregnancy even if taken during the LH surge but before its peak		inhibition of fertilisation as the copper ions released from the device have a toxic effect on sperm, which affects their mobility and viability, and on ova. In rare cases where fertilisation does occur, implantation is prevented because of the inflammatory response in the endometrium
Efficacyreduced efficacy with increased BMI >30 kg/m2reduced efficacy with increased body mass index >30 kg/m2
concurrent or subsequent use within 5 days of progestogen-containing contraception can reduce efficacy and therefore Hormonal contraception should not start until five days after UPA administration		Most effective methodNot affected by body weight
Time frame after unprotected intercourse and Dose1.5 mg tablet – within 72 hours(3 days) If 1.5mg not available, take 25 levonorgestrel 30µg tablets twice, 12 hours apart (50 tablets in total)30 mg tablet  – within 120 hours (five days) 
120 hours with no loss of efficacy for five days
Major contraindications, precautions and medication interactionsAllergy and hypersensitivitySevere liver diseaseKnown pregnancy
Interaction with liver enzyme-inducing medications – rifabutin, rifampicin, phenytoin, phenobarbital, carbamazepine, St John’s wort – (advise double dose 3mg)		Allergy and hypersensitivitySevere liver diseaseSevere asthmaKnown pregnancyInteraction with liver enzyme-inducing medications (no recommendation regarding a double dose)Current pelvic infection or distortion of uterine cavityKnown pregnancyNo medication interactions
Potentially affected by diarrhoea or malabsorptionYes-  If vomiting occurs within 2hr of LNG ingestion, the dose should be repeated.Yes – If vomiting occurs within three hours of ingestion, need a repeat doseNo
Side effects and risksHeadache, dysmenorrhoea, nausea, vomiting and altered vaginal bleeding pattern Possible initial altered bleeding pattern and probable ongoing increased menstrual blood loss. Small risk of perforation, infection and expulsion
Advise repeat dose if vomiting within two hours (according to product information)Advise repeat dose if vomiting within three hours (according to product information)
BreastfeedingEvidence suggests that it can be used safely in breastfeeding women with no need to interrupt feeding (off-label recommendation)Breastfeeding women are advised to express and discard breast milk for one week after UPA is takenSafe to use after four weeks postnatal
Ongoing contraceptionWomen can choose to initiate a hormonal method of contraception immediately using Quick StartCannot initiate or restart hormonal method of contraception immediately using Quick Start because of potential reduction in UPA effectiveness (a delay of five days is advised with use of condoms or abstinence in the interim and then until the method becomes effective)Provides ongoing effective long-term contraception for up to 10 years

Ensure the following: 

  • the woman is clear on how to take the tablet(s)
  • advise barrier methods until the next period
  • Advise woman:
    • levonorgestrel does not induce a withdrawal bleed, although sometimes irregular bleeding or spotting can occur 
    • next period occurs within 3 days of expected time in > 50% of women
    • advise return for review if period delayed by > 1 week or if unusually light or heavy 

Permanent Contraception

Caution 

  1. Young age (particularly <30)
  2. obesity (≥30 BMI- increased surgical &anaesthetic risk)
  3. post-partum (at time of caesarean)
  4. concurrent with elective abdominal surgery
  5. Depression
  6. Risk of future regre
    1. if situation changes (e.g. death of children/partner, breakup of relationship/marriage)
    2. is more common if permanent contraception is performed with a caesarean section, with unstable personal relationships, in younger or nulliparous women, if coercion from health professional or partner, or if psychosexual issues present. 
    3. More care is required when counselling women under 30 years old, and those without children. 
    4. If permanent contraception is to occur at caesarean section, counsel at least 2 weeks in advance

Options

  1. tubal occlusion
    1. Transection
    2. Ligation
    3. Diathermy
    4. removal of fallopian tube 
  2. Vasectomy
    1. A lot of men are concerned about the potential effects on their sexual function and it’s important to counsel them that it doesn’t have a major effect on their sexual function and in terms of post-operative recovery, most men do really well.
    2. Explore
      1. Discussed with partner
      2. Why choosing
      3. History of scrotal surgery
      4. Permanent nature
      5. Bleeding disorder
      6. Beware if – unmarried, young < 35 years, no children, emotional crisis, spouse not invovled
    3. Counselling
      1. Permanent nature
      2. Needs 20 ejaculations/ 3 months for effect
      3. Need to confirm in 3 months with sperm analysis
      4. Haematoma
      5. Infection
      6. Post-vasectomy pain syndrome
      7. Sperm antibodies, sperm granuloma
      8. Congestive epididymitis
      9. Timing/ recover
      10. Small risk failure
  1. The Essure
    1. cancelled from the Australian Register of Therapeutic Goods (ARTG) on 9 February 2018. ( due to reported adverse effects of Essure, which included corrosion or displacement of the device exposing women to nickel, causing bleeding, hypersensitivity, inflammation and chronic pelvic pain)

UKMEC

UKMEC guidelines

  • Initiation – starting with that medical condition
  • Continuation – develops a new medical condition (e.g. Has a stroke on POP- need expert advice)
  • Breastfeeding
    • COCP is MEC 4 < 6 weeks postparum, MEC 2 < 6 months
Definition of category
Category1A condition for which there is no restriction for the use of the method
Category2A condition where the advantages of using the method generally outweigh the theoretical or proven risks
Category3A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
Category4A condition which represents an unacceptable health risk if the method is used

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