Hormonal contraception

What is the combines oral contraceptive pill?

tablet containing oestrogen and progesterone

generally taken for 21 days with a 7 day break

99% effective with perfect use, 91% effective with typical use

licensed up to 5 years

What is the mechanism of action of the COCP?

suppresses ovulation

• progesterone thickens cervical mucus

• progesterone inhibits proliferation of the endometrium reducing chance of successful implantations

How does the COCP work?

oestrogen and progesterone have a negative feedback effect on the hypothalamus and anterior pituitary suppressing release of gonadotrophic releasing hormone, luteinising hormone, and follicular stimulating hormone

this suppresses ovulation

What are pros of taking the COCP?

reliable

independent of sexual intercourse

helps to regulate bleeding and dysmenorrhoea

improve premenstrual symptoms

reduced risk of endometrial, ovarian, and colon cancer

reduced risk of benign ovarian cysts

What are cons of taking COCP?

risk of DVT, stroke, breast cancer

missed pills

failure rate 9% in first year with typical use

What regimes are there for COCP?

• 21 days on and 7 days off

• 63 days on (three packs) and 7 days off (“tricycling“)

• Continuous use without a pill-free period

What are side effects of COCOP?

• unscheduled bleeding

• breast pain and tenderness

• mood changes and depression

• headaches

• hypertension

• venous thromboembolism

• small increase in breast and cervical cancer returning to normal after stopping

• small increase in MI and stroke

What are CI of COCP?

• uncontrolled HTN

• migraine with aura

• breast cancer

• history of VTE

• ages >30 and smoking >15 cigarettes per day

• vascular disease of stroke

• IIHD, cardiomyopathy, AF

• liver cirrhosis/tumours

• SLE or antiphospholipid syndrome

BMI >35 is UKMEC 3

How is the COCP started?

• start on day 1 of cycle offers instant protection

• starting after day 5 requires contraception for 7 days

• when switching from POP to COCP can swap at any time but needs 7 days protection

• when swapping from desogestrel they can swap at any time with no additional contraception

What are missed pill rules for COCP?

• 1 missed pill (more than 24 hours late)- no extra precautions take pill as soon as remembered

• 2 or more missed pills (72 hours since last pill)- take last pills when remember, condoms used for 7 days

Is emergency contraception needed for missed pills on COCP?

• If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex

• If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required

• If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.

Should COCP be stopped before surgery?

stops four weeks before major operation or any procedure that requires the lower limb to be immobilised

What is the progesterone only pill?

tablet containing progesterone that is taken continuously

>99% with perfect use but 91% effective with typical use

What are two types of POP?

• traditional - 3 hours delay to take the pill

• desogestrel- 12 hours late

What is the mechanism of action of traditional POP?

• thickens cervical mucus

• altering endometrium making it less accepting of implantation

• reducing ciliary action in the fallopian tubes

What is the mechanism of action of desogestrel?

• inhibits ovulation

• Thickening the cervical mucus

• Altering the endometrium

• Reducing ciliary action in the fallopian tubes

 

How is POP started?

started on day 1-5 means protected immediately

start any other day requires contraception for extra 48 hours

What are SE of POP?

• unscheduled bleeding

• breast tenderness

• headaches

• acne

increased risk of ovarian cysts, ectopic pregnancy with traditional POPs, minimal increased risk of breast cancer that returns to normal 10 years after stopping

What are missed pill rules for POP?

use extra contraception for 48 hours

What is a CI for POP?

active breast cancer

What is the progesterone injection?

IM or SC injection of progesterone given every 12-14 weeks (depot medroxyprogesterone acetate)

99% effective with perfect use 94% effective with typical use

What are absolute CI for progesterone injection?

active breast cancer

What are probable CI for progesterone injection?

• ischaemic heart disease and stroke

• unexplained vaginal bleeding

• severe liver cirrhosis

• liver cancer

can cause osteoporosis so be mindful for patients on steroids or in older women

What is the mechanism of action of the progesterone injection?

inhibit ovulation by inhibiting FSH secretion by the pituitary gland preventing development of follicles in the ovaries

• thickens cervical mucus

• alters endometrium

What are cons of progesterone injection?

takes up to 12 months for fertility to return

osteoporosis risk

can cause weight gain

When is the progesterone injections started?

• start day 1-5 immediate protection

• start after day 5 requires 7 days of contraception before it becomes effective

What are SE of progesterone injection?

• irregular bleeding

• weight gain

• acne

• reduced libido

• mood changes

• flushes

• hair loss

• skin reactions

• reduced mineral bone density

small increased risk of breast and cervical cancer

What can be used to settle bleeding with the progesterone injection?

COCP for three months in addition to the injection to settle bleeding

What are pros of the progesterone injection?

very reliable

improves painful periods and endometriosis

reduces risk of ovarian and endometrial cancer

reduced severity of sickle cell crisis in patients with sickle cell anaemia

What is the progesterone implant?

small 4cm plastic rod inserted in the upper arm beneath the skin above the SC fat that slowly releases progesterone

lasts for 3 years

99% effective

What implant is used in the UK?

Nexplanon- contains 68mg of etonogestrel

licensed between ages 18-40

What is the mechanism of action of progesterone implant?

• inhibits ovulation

• thickens cervical mucus

• alters endometrium

How is the implant inserted?

• inserted 1-5 immediate protection

• after day 5 requires 7 days contraception

uses lidocaine to insert and remove

What are pros of the implant?

very reliable

not user dependent

no delay in return to fertility

can improve painful periods, make periods lighter

doesn’t cause weight gain

no effect on bone mineral density

no thrombosis risk

no restriction for use in obese patients

What are cons of the implant?

irregular bleeding

requires minor procedure for inserting

can lead to acne

can become impalpable and move occasionally into vessels and migrating around the body

How can Nexplanon be identified on scans?

has barium sulphate manufactured into it to make it radio-opaque so can be seen on X-rays