Contraception

Barrier Methods:

They are physical methods to stop sperm from reaching egg

  • hormone free option

  • offer STI protection

They require correct and consistent use for it to be effective and available in shops and on the NHS

Hormonal methods:

Examples like combined pill (COC), progesterone only (POP), patch, vaginal ring and injections.

  • highly effective if used correctly and on time

  • can help regulate periods

  • reduce pain and improve acne

  • can have mood changes, breast tenderness due to hormonal change

Free on NHS or can be accessed privately through pharmacies in person or online. 

Combined Oral Contraception (COC)

Contains oestrogen and progestogen

  • useful for lighter periods, reducing pain and improving acne

  • no protection from STDs however

It stops ovulation, makes it harder for sperm to reach egg by increasing cervical mucus and making it thicker. Uterine lining is also thinned so a fertilised egg cannot implant.

  • usually 1 tablet for 21 or 28 days with a pill free interval or placebo pills

  • 99% and above effective

  • monophasic - fixed amount of hormones in each active tablet

  • biphasic/triphasic - varying amounts in tablets across cycle

  • ED - has 7 placebo tablets

If pill is missed - efficacy is reduced. It takes 7 days of pill taking to put ovaries to sleep, therefore 7 days of no pills can awaken ovaries → therefore barrier methods are considered in this case. This does not include the withdrawal bleed/pill free days.

If one pill has been missed for 24-48hrs then pill should be taken as soon as and take next dose at usual time originally (may mean 2 in one day).

  • does not require extra protection

  • does not require EHC unless this is not the first occasion in current or previous packet.

If 2+ pills have been missed → 48hrs late then take pill as soon as and continue taking at usual time.

  • barrier or extra methods recommended to be used until the next 7 pills have been taken correctly.

  • EC only considered if pills were missed in week 1 after bleed as this would extend the 7 day efficacy window.

  • if pills were missed in week 3 then pills are omitted and withdrawal/pill free week is induced early → new pack started after.

Progesterone only pill (POP)

Only contains progesterone and taken everyday with no pill free interval. Suitable for those who cannot take oestrogens and is 99% effective with proper use.

  • thickens cervical mucus

  • thins uterine lining

  • can stop ovulation (usually cerazette)

It can alter periods to either thin out or completely stop or become irregular.

Traditional POPs - micronor, noriday, norgeston, fermulen → if more than 3hrs late: desogestrel - cerazette if more than 12hrs late

  • take pill as soon as and continue as usual for next dose at usual timing

  • may need barrier method for next 2 days

Long action reversible

Includes implants, injections, coil for long term and reversible options. Highly effective and minimal maintenance but require professional fitting and could cause side effects.

Permanent methods

Surgical procedures alter reproduction to permanently prevent pregnancy and eliminates need for ongoing contraception.

Vasectomy seals sperm tubes in males and tubal occlusion blocks fallopian tubes in female.

Needs thorough initial consultation and understanding with patient as this is not reversible

Fertility tracking

Use of monitoring own cycle based on body temperature and cervical mucus to find ovulation window. Require daily monitoring and recording and not for irregular or unpredictable lifestyles including smoking, drinking, stress etc. They are less effective and have higher risk of pregnancy outcome and do not protect against STDs.

Emergency contraception

There are options like IUD (most effective), ulipristal acetate (Ellaone) or levonorgestrel (levonelle). Usually given for unprotected intercourse and for unexpected protection against torn condoms, missed pills, late implant or no current contraception. → whilst initiating EC consultation must include discussion of long term contraception for patient as this may be more suitable. 

Levonorgesterel

Has high dose progesterone. 1 tablet taken as soon as with a 72hr window when prescribed. It prevents or delays ovulation, prevents fertilisation or implantation.

Ulipristal (EllaOne)

Selective progesterone receptor modulator to inhibit or delay ovulation. No later than 120hrs and this is usually preferred over levonorgesterel. If taken with other contraceptives then efficacy of other contraceptive is reduced so barrier method is used.

SBA QUESTIONS

Question 1

A key advantage of barrier methods of contraception, such as condoms, is that they:

a) Are highly effective at regulating menstrual cycles.

b) Provide protection against sexually transmitted infections (STIs).

c) Require no user intervention for correct use.

d) Are the most effective form of emergency contraception.

Answer

Answer: b) Provide protection against sexually transmitted infections (STIs).

Your notes state that barrier methods "offer STI protection," which is a primary advantage over hormonal methods.

Question 2

The primary mechanism of action for the Combined Oral Contraceptive (COC) pill is:

a) Thickening cervical mucus to impede sperm.

b) Thinning the uterine lining to prevent implantation.

c) Stimulating the release of an egg mid-cycle.

d) Stopping ovulation.

Answer

d) Stopping ovulation.

Your notes clearly state that the COC "stops ovulation." While it also thickens cervical mucus and thins the endometrium, the suppression of ovulation is its main mechanism.

Question 3

For a patient taking a traditional Progesterone-Only Pill (POP) like Noriday, if they are more than 3 hours late in taking their pill, what is the correct advice?

a) Take the missed pill as soon as possible and use extra barrier protection for the next 7 days.

b) Discard the missed pill and continue as normal.

c) Take the missed pill as soon as possible and use extra barrier protection for the next 2 days.

d) Take two pills the next day and consider Emergency Contraception.

Answer

Answer: c) Take the missed pill as soon as possible and use extra barrier protection for the next 2 days.

Your notes specify the 3-hour window for traditional POPs and advise a barrier method for the next 2 days.

Question 4

Which of the following Emergency Contraception (EC) options has the longest window of efficacy after unprotected intercourse and is also the most effective?

a) Levonorgestrel (Levonelle)

b) Ulipristal acetate (EllaOne)

c) Combined Oral Contraceptive Pill (Yuzpe method)

d) Copper Intrauterine Device (IUD)

Answer

Answer: d) Copper Intrauterine Device (IUD)

Your notes state the IUD is the "most effective" EC. While Ulipristal has a 120-hour window, the IUD can be inserted for up to 5 days and is more effective at preventing pregnancy.

EMQ

Questions 5-7:

A patient presents with a specific need or side effect. Which contraceptive method is MOST suitable?

Options:

A. Combined Oral Contraceptive (COC)

B. Progesterone-Only Pill (POP)

C. Fertility Tracking

D. Barrier Methods

E. Permanent Method (e.g., Vasectomy)

Question 5

A 28-year-old patient who is breastfeeding and requires a reliable, hormonal contraception.

Answer

Answer: B. Progesterone-Only Pill (POP)

POPs are safe for use during breastfeeding, whereas oestrogen-containing methods like the COC are not recommended as they can reduce milk supply.

Question 6

A 35-year-old patient who suffers from severe menstrual cramps and acne and is a non-smoker.

Answer

Answer: A. Combined Oral Contraceptive (COC)

Your notes highlight that the COC is "useful for lighter periods, reducing pain and improving acne."

Question 7

A 40-year-old patient who has decided they do not want any (more) children and is certain of this decision.

Answer

Answer: E. Permanent Method (e.g., Vasectomy)

This patient has a definitive desire for no future fertility, making a permanent method the most appropriate long-term solution.

Clinical Scenarios (OSCE/Patient Style)

Scenario 1: The Missed Pill

Patient: "Hi, I'm really worried. I take Microgynon (a COC) and I completely forgot to take my pill for the last two days. I'm in the second week of my pack. What should I do? Am I protected?"

How do you, as the pharmacist, respond?

* Acknowledge & Advise: "It's good that you came to ask. Since you've missed two pills, which is more than 48 hours late, the advice is to take the most recent missed pill as soon as you can, and then continue taking the rest of your pack at your usual time. This might mean taking two pills in one day."

* Recommend Extra Protection: "Because of this, your protection against pregnancy is reduced. I strongly advise you to use an additional barrier method, like condoms, until you have taken your pills correctly for 7 days in a row."

* Assess for EC: "Let's check – was the unprotected sex in the 7 days before you missed these pills? ... Since the missed pills were in Week 2, and you had taken the first 7 pills correctly, you may not need Emergency Contraception (EC). However, if you had unprotected sex in the pill-free interval or the first week of this pack, we should discuss EC. Based on what you've said, it's not immediately indicated, but we should confirm the dates."

* Future Advice: "To prevent this, try setting a daily alarm on your phone."

Scenario 2: Emergency Contraception Consultation

Patient: (Quietly, at the pharmacy counter) "I need the morning-after pill. The condom broke last night, which was about 14 hours ago."

What key questions do you need to ask to determine the most suitable EC?

1. "To make sure I recommend the right product for you, can I ask a few quick questions?"

2. Timing: "You said 14 hours ago, that's confirmed?"

3. Other Contraception: "Are you currently using any other form of contraception, like the pill, patch, or implant?" (This is crucial for Ulipristal interaction).

4. Medical History: "Could you possibly be pregnant already? Are you taking any other medications? For example, any medicines for epilepsy or TB?" (These can induce liver enzymes and reduce efficacy of hormonal EC).

5. Allergies: "Do you have any allergies to any medications?"

Based on her answers (no other meds/contraception), what is the most appropriate EC and why?

"Based on our chat, you have two good options. Levonorgestrel (Levonelle) is effective within 72 hours, and Ulipristal (EllaOne) is effective within 120 hours. Since you are within the time frame for both, Ulipristal is often preferred as it may be more effective at this point in your cycle. However, if you were to start a hormonal method like the pill immediately after taking it, Ulipristal can make it less effective, so you'd need to use condoms for longer. We can discuss which fits your situation best."

Scenario 3: Initiating Long-Term Contraception

Patient: "This is the second time I've needed the morning-after pill this year. I'm just not good at remembering to take a pill every day. What else can I do?"

How do you counsel this patient?

* Empathize and Educate: "It's very common to find the daily pill challenging. Thank you for thinking about a longer-term solution. This is a perfect time to discuss this."

* Introduce LARCs: "There are highly effective options called Long-Acting Reversible Contraceptives, or LARCs. These include the contraceptive implant that goes in your arm and lasts for 3 years, or hormonal and non-hormonal coils (IUDs) that can last for 5-10 years once fitted."

* Highlight Benefits: "Their biggest advantage is that you don't have to remember to do anything every day or month. They are 'fit and forget,' and are actually more effective than the pill because there's no user error."

* Next Steps: "The next step would be to have a consultation with your GP or a sexual health clinic to discuss which LARC option might be best for you. They can talk you through the pros and cons of each and book the fitting appointment."

Scenario 4: Progesterone-Only Pill (POP) Advice

Patient: "I've just been prescribed Cerazette. The doctor said I have to take it at the same time every day. What happens if I'm late?"

What is your specific advice for Cerazette?

* "Cerazette is a type of progestogen-only pill called desogestrel. It's very effective, but the timing is important. The window for being 'on time' is 12 hours."

* If Late: "If you are more than 12 hours late taking it, the advice is to take the missed pill as soon as you remember, and then take the next pill at your usual time."

* Extra Precautions: "You should also use an additional barrier method, like condoms, for the next 2 days to ensure you are fully protected."

* Reinforce Habit: "Try to link taking it to another daily habit, like brushing your teeth, to help you remember."