Contraception overview
- Pills (daily)
* Combined Oral Contraceptive Pill (COCP)
* Progesterone Only Pill (POP)- Extended Combined Options
- Nuvaring (3weeks + 1 week break)
- Patch
- Long Acting Reversible Contraception (LARC)
- Implanon (etonogestrel) (3 years)
- Norplant (levonorgestrel) (5 years)
- Depo-Provera/Depo-Ralovera (3 monthly)
- Intrauterine Devices (IUD)
- Barrier Methods
- Condoms
- Diaphragms / caps
- Natural Family Planning Methods
- Billings Method
- Permanent Methods
- Female Sterilisation
- Hysterectomy
- Essure - Fallopian tube ablation
- Male Sterilisation
- Female Sterilisation
- Emergency Contraception
- Progestin-only (POEC)
- Copper IUD (10 years)
- Mifepristone (RU-486)
- Extended Combined Options
Normal physiological role of progesterone
- Works with oestrogens to prepare endometrium for implantation
- Prepares mammary glands to secrete milk
- Inhibits the release of GnRH and LH
Normal physiological role of oestrogen
- Promote development and maintenance of female reproductive structures, feminine secondary sex characteristics, and breasts
- Increase protein anabolism
- Lower blood cholesterol
- Moderate levels inhibit release of GnRH, FSH, and LH
Progestin Contraception Effects
Progesterone analogue
- increased viscosity
- endometrial atrophy
- decreased fallopian tube motility
Oestrogen Contraception Effects
- Inhibition of mid-cycle LH surge
* Thus inhibiting ovulation
Oestrogen and Progestin Non-Contraceptive Benefits
Non-contraceptive benefits
- Cycle control
- Reducing frequency
- Reducing bleeding during and post cycle
- Improves bone density (oestrogen)
- Reduced acne and hirsutism
- Protects against endometriosis/fibroids
- Cervical & endometrial cancer risk reduced
Progestin Side Effects
Mastalgia Nausea Fluid retention Abdominal bloating Headaches Chloasma
Oestrogen Side Effects
Thromboembolic events Gallstones - constriction of Sphincter of Oddi Irregular vaginal bleeding Increased appetite/weight gain Acne Excess body hair Loss of libido Mood swings & depression
Types of Progestin only contraception
- Pills
* Progesterone Only Pill (POP)- Long Acting Reversible Contraception (LARC)
- Implanon
- Depo-Provera/Depo-Ralovera
- Intrauterine Devices (IUD)
- Emergency Contraception
- Progestin-only (POEC)
- Mifepristone (RU-486) (anti-progesterone)
- Long Acting Reversible Contraception (LARC)
Types of Progestin and Oestrogen Combined Contraception
- Pills
* Combined Oral Contraceptive Pill (COCP)- Extended Combined Options
- Patch
- Nuvaring
- Emergency Contraception
- Yuzpe method
- Extended Combined Options
Oestrogen component in Contraception
Ethinyloestradiol Ultra low 15µg Low 20µg Regular dose 30-35µg High >/=50µg
Progesterone component in Contraception
First Generation
Norethisterone (NET) and derivatives
Second Generation
Norgestrel group eg Levonorgestrel
Third Generation
Includes Desogestrel, Norgestimate, and Gestodene
Fourth Generation
Includes Cyproterone actetate and Drospirenone
COCP Contraindicated for
- Smokers aged ≥35 years 140–159 mmHg systolic or 90–94 mmHg diastolic
- Personal history of VTE or a thrombogenic mutation
- Personal history of cardiovascular disease or stroke
- When using long-term liver enzyme-inducing drugs
- Undiagnosed breast mass at initiation of COC
Starting the COCP
Immediate protection if begin active pills in the first 5 days of menstrual cycle (‘day one’ = first day of bleeding)
If start active pills after this time, need alternate contraception until 7 active pills are taken for 7 consecutive days
Quick start Technique of Giving the Pill
- Low pregnancy risk ie one or more (WHO guidelines):
- No intercourse since LNMP
- Correct use of another method
- Within 7 days of onset of menses, miscarriage or TOP
- Fully breastfeeding <6mths postpartum - Negative urine pregnancy test
- Start active pill in the office
- Mandatory condom use next 7 days
- Early follow-up for all with repeat pregnancy test
- Written and verbal information on method
Risk OCP Situations
Missed pills - rule
Vomiting within 2 hrs pill or
Diarrhoea – if ‘cholera-like’ or ≥24 hrs
Drug interactions - liver enzyme CYP3A4 induction
Give written instructions
Missed Pills
< 24 hours
- Take one immediately and next one at normal time
> 24 hours
- As above
- Use concurrent contraception (condoms) for next 7 days
If pill in last 7 active days (15-21 days)
- Finish cycle and skip break/sugar pills
If pill missed in first 7 active days (1-7 days)
- Consider emergency contraception
- Restart COCP
- Use concurrent contraception (condoms) for next 7 days
> 4 days missed (>120 hours)
- Start new packet of COCP
- Consider EC
COCP Drug interactions
Oestrogens and progestagens are metabolised by CYP3A4 so drugs that induce CYP3A4 may lead to contraceptive failure
Women taking CYP3A4 inducers should use
- Levonorgestrel IUD or
- Medroxyprogesterone acetate depot or (depo-provera)
- Copper IUD
Examples of drugs that interact with COCP metabolism
Antibiotics
- anti-tuberculous antibiotics - rifampicin, griseofulvin
Other
- carbamazepine (mood stabiliser and antiepileptic) phenytoin, phenobarb, primidone, ethosuxamide
Unscheduled bleeding on OCP
- Common in first few months
- In presence of daily pill taking does not imply lack of contraceptive effect
- Check if patient is tri-cycling or longer ie skipping inactive section for ≥3 cycles
- Exclude possible causes: missed pills, vomiting or diarrhoea or concurrent medication, pregnancy, cervical or other pathology eg STIs, especially chlamydia
If unscheduled bleeding persists for > 3months
- 4 day pill free interval or
- Change the pill formulation :
- – from monophasic to triphasic
- – increase the progesterone component
- – increase the oestrogen component
- – try a different progestogen eg gestodene
- Change to a vaginal ring
POP indications
Lactating women
Patient preference
Contraindications to the COCP
POP Contraindications
Pregnancy Undiagnosed vaginal bleeding PHx/increased risk ectopic pregnancy Malabsorption Severe liver disease Concomitant use enzyme inducing drugs
Implanon Side Effects
Change to bleeding pattern
Acne
Weight gain
Mood changes
