PMY3304- CONTRACEPTION- METHODS OF DELIVERY

What are the methods of delivery of contraception?

• combined hormonal contraception (CHC): combined oral contraception (COC), transdermal patch, and vaginal ring

• Progestogen-only: progestogen-only pill (POP), progestogen-only implant and progestogen only injectable

• Intrauterine: copper intrauterine device (Cu-IUD) and levonorgestrel intrauterine device (LNG-IUD) (also progestogen only)

what are the risks of CHC?

• thromboembolism- venous and arterial

• cancer- breast and cervical

what are the benefits of CHC?

• reduced risk of ovarian, endometrial and colorectal cancer

• reduced dysmenorrhoea and menorrhagia (heavy menstrual bleeding) and management of symptoms of polycystic ovary syndrome, endometriosis and premenstrual syndrome

• may improve acne

• reduced menopausal symptoms

• maintaining bone mineral density in peri-menopausal females under the age of 50 years

what are the contraindications for combined hormonal contraceptives?

• person having various cardiovascular conditions, also current breast cancer, migraine with aura, less than 6 weeks postpartum in BF women and major surgery with prolonged immobilisation

what are the benefits of the progestogen- only pill?

alternative to those who cannot take COC (although similar drug interaction profile which could limit use) and can be continued into mid-fifties when natural loss of fertility can be assumed for most women.

what are the risks of progestogen-only pill?

• BNF c/i innclude ‘current breast cancer’

• BNF cautions (breast cancer): there is a small increase in the risk of having breast cancer diagnosed in women using, or who have recently used, a progestogen-only contraceptive pill. A possible small increase in the risk of breast cancer should be weighed against the benefits.

• manufacturers will provide guidance on thrombosis risk

• changed in bleeding pattern

what are the additional considerations with the progestogen-only implant and progestogen-only injectable?

• not the same user-error/user dependency as CHC, POP and barrier methods

• breast cancer risk and caution in relation to breast cancer

• the manufacturer provides guidance on thrombosis risk

• can cause menstrual disturbances

• osteoporosis risk with injectable progestogen-only (due to reduction in bone mineral density)

• potential for delay in return to full fertility with injectable progestogen-only

what are the additional considerations for a woman considering intrauterine contraception (IUC)- Cu-IUD or LNG-IUD?

• not the same user-error/user dependency as CHC, POP and barrier methods

• a pelvic examination should be done before inserting the device

• unexplained vaginal bleeding: do not insert the device until the cause has been established. Heavy menstrual bleeding: consider the need for additional investigations first

• LNG-IUD use may be associated with an increased incidence of ovarian cysts (does not appear to be clinically significant)

• risk in relation to procedure (insertion). Women should seek medical device if uterine perforation is suspected

• Breast cancer risk- there may be an association between recent hormonal contraception use (including LNG-IUD) and breast cancer. any potential increased risk appears to be small.

what is the MHRA advice on uterine perforation with intrauterine contraception?

• most often occurs during insertion, but may not be detected until sometime later

• higher risk of perforation when the device is inserted up to 36 weeks postpartum or in patients who are BF

What are the additional considerations for a woman considering FAM (fertility awareness method)?

• check if the woman (or her partner) is taking a teratogenic drug or the woman has a condition that makes pregnancy an unacceptable health risk. If so reliance on fertility indicators is not recommended

• the use of FAM should be delayed or used with caution: in women taking hormonal contraception or other drugs which can affect cycle regularity, hormones, and/or fertility signs (until regular menstrual cycles have been established and they have had a minimum of three cycles after stopping,,,, in conditions that can make the use if FAM more complex

what are the additional considerations for a woman considering LAM?

• the criteria for LAM are met

• check if the woman (or her partner) is taking a teratogenic drug or the woman has a health condition that makes pregnancy an unacceptable health risk. If so, reliance on LAM is not recommende

what are factors that impact on BF and therefore on LAM?

• conditions affecting the newborn where breastfeeding can be difficult or contraindicated, and in newborns in intensive care

  • the presence of any maternal condition in which breastfeeding is not advisable, for example HIV

  • the woman is taking medicines that are contraindicated in breastfeeding

what are additional considerations for a woman considering barrier methods?

• check if the woman (or her partner) is taking a teratogenic drug or the woman has a condition that makes pregnancy an unacceptable health risk. If so, reliance on barrier methods is not recommended.

• Diaphragm and cap may be unsuitable for anatomical and other reasons. For example, in women with very poor vaginal muscle tone, those with a shallow pubic ledge (applies to diaphragm only), those who have a markedly distorted cervical anatomy (applies to the cap), those who cannot touch their genital area with comfort, and severe obesity may make diaphragm and cap placement difficult.

• diaphragms and caps are not appropriate for women who are <6 weeks psotpartum or 6 weeks following second trimester termination of pregnancy. additionally, a different size of cap or diaphragm may be needed postpartum.

what are the additional considerations for those considering sterilisation?

• doubt about mental capacity, seek advice from appropriately experienced colleagues

• check motivation for wanting this method (and risk of coercion), level of understanding of the advantages and disadvantages, procedures involved, and relative failure rates.

• There may be reasons preventing a man from having a vasectomy or a woman from having tubal occlusion (which makes it preferable for the other person to be sterilised)

what methods of contraception are suitable for girls under 18 years of age?

• all methods of contraception can be considered, provided there are no contraindications (be cautious with hormonal contraception use in girls who have not yet started menstruating but are sexually active)

• condoms- contraceptive and to prevent STIs

• consider the progestogen only injectable only if all other methods of contraception are unsuitable or unacceptable. It is associated with a small loss of bone mineral density with long term use (more than 1 year). Do not initial it in girls with significant risk factors for osteoporosis

what methods of contraception are suitable for women aged over 40-50 years?

• CHC can be used in eligible women <50 years of age as an alternative to HRT for relief of menopausal symptoms and prevention of loss of bone mineral density. Women should switch to a progestogen-only method of contraception at 50 years of age, if needed.

• check product license for age range/limit

• WHEN IN PRACTICE REFER TO THE FSRH GUIDELINE ABOUT CONTRACEPTION FOR WOMEN AGED OVER 40 YEARS

what methods of contraception are suitable for women taking medication with teratogenic potential?

• highly effective contraception should be used during treatment and for the recommended duration after the discontinuation to avoid unintended pregnancy

• methods include male and female sterilisation, and long acting reversible contraception (Cu-IUD, LNG-IUD and progestogen only implant

what methods of contraception are suitable for women taking griseofulvin?

copper IUD and LNG-IUD

What methods of contraception are suitable for women taking enzyme inducers such as carbamazepine?

-            CU-IUD, levonorgestrel- IUD and the progesterone only injectable

-            Applies if the enzyme inducer has been taken in the past 4 weeks

what methods of contraception are suitable for women taking lamotrigine?

Cu-IUD, LNG-IUD, progestogen implant and injectable

what are the potential components of CHC?

• oestrogen component

• [co-cyprindiol (containing ethinylestradiol with cyproterone acetate)]

• progestogens

give additional information about the oestrogen component of CHC

Most combined oral contraceptives contain the synthetic oestrogen, ethinylestradiol. Other COCs contain 17B-estradiol or estetrol (E4). These others could have improved safety profiles (such as a lower thrombotic risk) but this has not yet been established

give more info about co-cyprindiol (containing ethinylestradiol with cyproterone acetate)

is indicated for moderate to severe acne and hirsutism (excessive hair growth in women). women using it for this indication don’t require additional contraception (unless there are drug interactions or other factors affecting effectiveness)

what are progestogens?

synthetic steroids with properties of progesterone

how have newer progestogens been developed?

developed to have fewer androgenic and glucocorticoid effects. CHC containing some newer progestogens in combination with ethinylestradiol seem to be linked to a greater risk of venous thrombotic events (VTE) than COC containing other progestogens

how are CHC progestogens grouped?

• first e.g. norethisterone

• second e.g. levonorgestrel

• third e.g. desogestrel, gestodene, norgestimate

• newer/other e.g. drospirenone, dienogest, nomegestrol acetate

what is the norelgestromin?

a metabolite of norgestimate

what is etonogestrel?

the active metabolite of desogestrel

what are the first line options of COC?

monophasic preparations containing 30 micrograms of oestrogen, plus either norethisterone or levonorgestrel. However, any COC can be offered first-line if the woman has a personal preference

what are monophasic COCs?

• the amount of oestrogen and progesterone in each active table is constatnt throughout the cycle

what are phasic COCs?

can be biphasic (two different sets of active pills), triphasic (three different sets of active pills), or quadraphasic (four different sets of active pills)

what hormones are contained in COC?

oestrogen and progesterone

what is contained in an EVRA transdermal patch?

an average of 203 micrograms of norelgestromin and 33.9 micrograms of ethinylestradiol per 24 hours

what are the application sites of the combined transdermal patch?

intact healthy skin on the buttock, abdomen, upper outer arm or upper torso

how is the combined transdermal patch used?

used as directed for three weeks (a single patch is applied and worn for one full week). the fourth week is transdermal patch free

what ages have safety and efficacy of the combined transdermal patch been established?

aged 18 to 45 years

do vomiting and diarrhoea affect the bioavailability of the transdermal patch?

no

what can happen after discontinuation of EVRA (CTP)?

women may experience a delay in conception

what ages have safety and efficacy of contraceptive vaginal ring been established?

18 to 40 years

what is the contraceptive vaginal ring?

a flexible, transparent and colourless to almost colourless ring, diameter 54mm and cross-sectional diameter 4mm

what can contraceptive vaginal ring interact with?

may interfere with the correct placement and position of female barrier methods, such as a diaphragm, cervical cap, or female conndom. these should not be used as back up methods with NuvaRing

how does the NuvaRing work (contraceptive vaginal ring)?

once it has been inserted, it is left in the vagina continuously for 3 weeks. the presence of the ring should be checked regularly, as it may be expelled if it is not inserted properly, while removing a tampon, during sexual intercourse, or during episodes of chronic constipation

when does NuvaRing become ineffective?

• f the NuvaRing has been out of the vagina for less than 3 hours contraceptive efficacy is not reduced. The woman should reinsert the ring as soon as possible, but at the latest within 3 hours.

do vomiting and diarrhoea affect bioavailability of contraceptive vaginal ring?

no

what is the difference between contraceptive effectiveness of POPs?

insufficient evidence to compare the contraceptive effectiveness of POPs with each other—— Desogestrel (75mcg), levonorgestrel (30mcg), norethisterone (350mcg), drospirenone (4mg)

which POP suppresses ovulation more consistently?

desogestrel- may improve symptoms of dysmenorrhoea

how should POPs be taken?

• should be taken at the same time every day

• traditional POP is considered missed if it is taken more than 3 hours late, a desogestrel POP if it is taken more than 12 hours late, and a drospirenone POP if more than 24 hours late

what are long acting reversible contraceptives?

contraceptive methods that require administration less than once per cycle or month

Cu-IUD, progestogen-only (LNG)-IUD, progestogen only injectable, progestogen only implant

can any contraception other than emergency be bought OTC?

• recent deregulations from POM to P medicines

• POP desogestrel 75microgram tablets can be bought OTC

who are progesterone only pills recommended for?

• may be advised for people who cannot take COC e.g. hypertension

• useful option for women who have experienced side effects from the COC

• May be taken when breastfeeding

• as an alternative to COC before major surgery

• thought to have a lower risk of thrombosis than COC

• Most important risk factor for breast cancer appears to be the age the contraceptive is stopped rather than the duration of use. The risk gradually disappears during the ten years after stopping POP

why should different insertion sites be used with progestogen only injectable and implant?

to reduce the rare risk of neurovascular injury and implant migration

what must be done before insertion of intrauterine contraception?

bimanual pelvic examination

how do intrauterine contraception systems work?

release 20 micrograms per 24 hours of levonorgestrel can have benefits like improving pain associated with dysmenorrhoea, endometriosis, or adenomyosis (Adenomyosis is a gynecological condition where tissue similar to the lining of the uterus grows into the muscular wall of the uterus)