• Reliable and reversible
• Can reduce dysmennorrhoae (painful menstruation) and menoorhagia (heavy bleeding)
• Can reduce PMT (pre-menstrual tension)
• Reduce the risk of ovarian, endometrial and colon cancer
• Reduce the risk of PID
• An effective treatment for acne and endometriosis
• Reduce risk of fibroids and ovarian cysts

Monophasic – each pill contains the same amount of progesterone and oestrogen.
Phasic – the concentrations of hormones in each pill varies with the time of the cycle.

• Both monophasic and phasic pills are in a 21 day supply, with a 7 day break from days to allow breakthrough bleeding. Patients are still protected from pregnancy during the 7 day period, provided all the other pills were taken correctly.

Every Day pills – 28 days supply, with 7 days of placebo pills in days 22-28. The pills must be taken in the right order.

• Note that it is perfectly safe to “run together” courses of the 21 days of active pills. This can be done for up to 12 months at a time if desired
• Most women have breakthrough bleeding within 120 days of doing this
• If this occurs, advise patients to stop the pills for 7 days to allow for a withdrawal bleed before recommencing

Prescribing the COCP is not a simple process of “just writing the prescription” although patients may feel frustrated at repeated thorough risk fact-checking at the time of prescription. In my career I have upset many women by refusing to prescribe the pill when contraindicated – even when they have been previously taking it for a long time. I have also seen the death of a teenage girl from massive PE shortly after starting on the pill, and several other cases of PE and huge DVT. This is rare but it certainly comes to mind whenever I write a prescription! – Dr Tom Leach

Summary

Efficacy

• Quoted as >99% effective
• Described as: if taken correctly, then during the course of 1 year, <1% of women taking the COCP will become pregnant
• With typical ‘real-world’ use efficacy is more like 91%

Mechanism

• Prevents ovulation by suppression of LH and FSH
  • LH and FSH levels should not be tested whilst on the pill as the result cannot be interpreted
  • It typically takes about 7 days of hormonal therapy to suppress ovarian function, and 7 days without the pill for it it start functioning again. However, it can take up to 3 months for fertility to return after ceasing the pill
• Thickens cervical mucous
• Alters uterine lining to prevent implantation

Side effects

Oestrogen increases the risk of cardiovascular disease (notably thromboembolus). It also causes:

• Nausea (progesterone does not)

Progestogens can cause: headache, depression, acne, breakthrough bleeding and breast symptoms. Many of these resolve themselves after several weeks/months of treatment, and can be solved if a different progestrogen is used, however, some progestogens are also associated with increased thromboembolic risk

• Thromboembolic risk – is increased in those taking the COCP, particularly during the first year of use, but the risk is small, and smaller than in pregnancy (when the risk is 60 per 100 000).
• In all patients the risk of thromboembolism increases with age.
• There is also an increased risk of DVT when travelling (>5 hour flights) and women should be informed of and encouraged to perform inflight exercises.
• Breakthrough bleeding is particularly common in the first few months, but usually resolves.
• The risk of weight gain on the COC is unproven

Missed doses

The general rule is that the combined pill can be taken within 24 hours of the usual time of administration, and still be effective.
If a pill is missed, the woman should take it as soon as she remembers, and then continue taking the rest of the pills at their normal time; even if this means taking two at once
A ‘missed pill’ is one that is >24 hours after she should have taken it

• Just missing one pill is not a problem, nor is starting a new pack one day late, as long as the missed pill is taken with the next one.

The greatest risk of pregnancy if a pill is missed is at the beginning and end of a cycle.
If 2 pills are missed (i.e. >24 after time should have been taken) then there is a risk of pregnancy – especially if the pill was missed in the first 7 days of the cycle.

• If the patient has had sexual contact during the missed period, emergency contraception is recommended.
• If not, then the advice is to continue taking the rest of the pills as normal, and use an additional method of contraception (e.g. condoms) for 7 days. If this 7 days includes the 7 days ‘break’ at the end of the cycle, the next packet should be started immediately, and the ‘break’ omitted.
• The patient should not take the missed pills if >2 pills were missed.

Vomiting and diarrhoea

• If vomiting occurs within 2 hours of taking a pill, another pill should be taken
• If there is vomiting or diarrhoea for >24 hours, then this should be treated the same as a missed pill – i.e: the pills should be taken as normal, but additional contraception (e.g. condoms) should be used for 7 days after the end of the period of illness. If this 7 days runs into the last 7 days of the cycle, the next packet of pills should be started straight away, and the ‘break’ omitted.

Drug interactions

• Carbamazepine
• Pheytoin
• Phenobarbital
• St John’s Wort
• Rifabutin
• Rifampicin

When taking a course of antibiotics

• Somewhat controversial
• Previous guidance advised this could affect pill efficacy
• More recent evidence suggests that it probably doesn’t
• Many s places still advise additional form of contraception:
  • e.g. use condoms during the course and for 7 days afterwards.
  • If you pass day 21 of the packet, then start a new packet immediately, even for everyday pills.
  • If the course of AB’s lasts longer than 2 weeks, alternative methods of contraception should be sought

Surgery

Contraindications / reasons to stop taking immediately

• BP >160/95
• Hepatitis, jaundice, hepatomegaly
• Prolonged immobility (e.g. usually after surgery)
• Sudden onset pain:
  • In chest (with/without radiation)
  • Headache
  • Stomach
• Sudden onset calf swelling
• Sudden breathlessness
• Migraine with aura, or migraine lasting >72 hours, or migraine resistant to treatment
  • Increased risk of ischaemic stroke in these patients
• Age over 50
• Smoker >40/day
• Diabetes with complications, or diabetes >20y
• Breast feeding – avoid during the first 6 months due to effects on lactation
• BMI >35, caution if BMI 30-35

Cautions

• Age over 35
• Obesity
  • BMI >30-35
• Migraine (without aura)
• BP >140/90
• Smoker <40/day
• FHx of arterial disease
• Diabetes <20y

Prescribing

Women with RF’s for cardiovascular disease should be prescribed the lowest does of oestrogen (20micrograms ethinylestradiol), or should be prescribed an alternative if >2 RF’s are present
Women >50 should not use the COC as better alternatives are available, and the cardiovascular disease risk is high
Inform patient to seek help immediately if:

• Migraines, sudden onset chest pain/breathlessness/haemoptysis, swollen calves, weakness is limbs / other signs of TIA/stroke

Missing the withdrawal bleed

• It is ok to use two packets one after the other (i.e. start the second packet on day 22). This can be done for up to 3 months in a row. Tell the patient the lining of the womb does not keep on growing during this time!
• Remember to tell patients on the everyday pill to start the new packed on day 22

Length of prescription

• Normally when first prescribed, given for 3 months. After this time, BP will be checked, and if no problems or additional RF’s, then will be prescribed for 1 year at a time.

Commencing treatment

No Previous contraception

• Start on day 1 of cycle, OR
• If starting after day 4 of cycle, use extra method (e.g. condom) for first 7 days

Changing from progesterone only pill

• Start on first day of cycle, OR
• If amenorrhoea, exclude pregnancy then start on any day

After child birth

• If not breastfeeding, start 3 weeks after birth (otherwise, ↑risk of thrombosis)
• If started after 3 weeks, other methods of contraception (e.g. condoms) required for first 7 days.
• DO NOT USE IN BREASTFEEDING – alters lactation

After miscarriage / abortion

• If less than 24 weeks, start pills straight away. If >24 weeks, seek advice

Examples

• Microgynon
• Qlaira

Alternative preparations

Skin patch

• May have a higher risk of thromboembolism than the oral preparation
• Treatment consists of three patches. First patch applied on day 1 of cycle, second on day 8, and third on day 15. Remove old patch each time, and remove third patch on day 22, and have a week with no patch.
• If the first patch is applied on any day other that day 1, another method of contraception (e.g. condoms) need to be used for 7 days
• Withdrawal bleeding occurs during patch-free week

Vaginal contraceptive ring

• A small rubber ring that can be inserted into the vagina by the patient, and then sits around the cervix. Stays in place for 3 weeks. Remove after 3 weeks, and have 1 week without ring present (similar to pill and patch)
• Withdrawal bleeding occurs during ring-free week

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Hinduism

Sikhism

Judaism

• In Orthodox Judaism, hormonal methods may be preferred, as they are perceived as more ‘natural’ than barrier methods.
• Calendar based methods are discouraged, as they typically co-inside with ‘Niddah’ (days when the women is menstruating).

• The views on contraception grew from the historical use of the ‘withdrawal method’, which was widely accepted in Islam. Thus as newer methods have become available, as contraception was already accepted, so were the new methods.

Christianity

• Even within those who would consider themselves Catholic, the uptake for the use of Natural Family Planning (NFP) is very low (one study suggested 1 in 25 Catholics).
• The Roman Catholic Church has traditionally forbidden all types of contraception through history. The only acceptable method to the Church, is abstinence.
• In light of this, the Church recommends the use of Natural family planning to anticipate when the woman is least fertile.
  • These methods are sometimes used outside of the Catholic context, in which case it is usually called fertility-awareness based contraception.
• Natural family planning can involve:
  • Symptom analysis – the basal body temperature can be used to measure the time of the cycle. This is the lowest temperature attained by the body during rest. It is best measured as soon as the woman wakes in the morning. It varies between 36.4’ and 36.7’ during the menstrual cycle
  • This temperature is also often monitored by women when trying to conceive.
  • It is suggested that pregnancy is unlikely to result after the third day after ovulation – thus the third day after the increase in temperature.

 

• Other symptoms, such as cervical position and cervical mucus may also be measured to help determine the day of the cycle. Once the day of the cycle has been determined, then the couple can chose to only have sexual intercourse during the least fertile period of the cycle.
  • Typically, for pregnancy to occur, the sperm much reach the egg within 24 hours after ovulation. However, sperm can survive inside the female for up to 7 days.
  • The calendar method – the woman needs to carefully monitor her cycle length, and can use this to determine the most fertile period, by knowing that this occurs typically 12-16 days before the next predicted menstruation. This means the least fertile period is typically around the time of menstruation.
• Efficacy of Natural Family Planning
  • Studies show that this varies from between 85-95% per year, and that the highest efficacy rates are in Developed countries, suggesting that thorough education of the individuals who wish to use this method, results in increased efficacy.
• ‘Persona’ – is a brand of urine dipstick, used to analyse hormonal changes in the urine. It costs about £65, and dipstick refills cost £10. With a sample of urine it gives a red or a green light, designed to inform the patient whether pregnancy is likely or unlikely if sex occurs at that time.
• If the device is used correctly, the risk of pregnancy during the course of 1 year is around 10%

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• Can be controversial in some cultures
• Should only be undertaken in stable relationships where the couple is certain they do not want any more children

Epidemiology

Rates falling in developed countries
UK is unusual as the number of men receiving the operation is greater than the number of women

• 18% of men between 18-69 have had a vasectomy
  • Only 64% of these were done on the NHS
  • 95% of female sterilisations are performed on the NHS

Consent

• Under 30
• No children
• Not in a long-term relationship

Reversal

The procedure should be treated as irreversible – and discussed as such with the patient. For example, you should point out that if unseen circumstanced were to occur, whereby their current children were to become ill or die, they would be unable to have further children.
Instances where couples are likely to express regret:

• Under 25
• Fewer than 2 children
• Unstable relationship
• Vasectomy during a partner’s pregnancy
• Tubal ligation at C-section
• Sterilisation at TOP

Failure

• 30x less likely to fail
• 20x less likely to result in complications
• Less invasive
• Performed under local anaesthetic, and thus is a more minor procedure. Usually a day case.

Threat of pregnancy to the mother

• It is not a good idea to perform vasectomy on the partner in these instances, as it could be possible that the man would be widowed, and left infertile.

Female sterilisation

Efficacy

• The ‘lifetime failure rate’ – is about 1 in 200
• If the surgery fails, there is an increased risk of ectopic pregnancy

Procedure

• Usually carried out at the isthsmus (the bit next to the uterus)
• The ovaries and uterus are left intact
  • Ovulation may still occur, but the ovum is absorbed by surrounding tissues
• May be laparotomy or laparoscopy.
• Salpingectomy – is a particular procedure where the tubes are cut, and then sutured over.
• Clips – some surgeons prefer to clip, rather than suture the tubes. The clip inhibits blood flow to the clipped area, and the region typically undergoes fibrosis and scarring which help to block the passage.
• Rings – similar to a clip
• Cauterization
• Usually performed under general anaesthetic – however in some situations – e.g. directly after a caesarean, may be performed under local.

After Surgery

• Women can consider themselves infertile straight after the procedure – but there is a risk of pregnancy in the menstrual cycle immediately prior to the surgery.

Complications

• Laparoscopic surgery may need to be converted to open surgery if there are complications.
  • This is more likely in obese patients, and in those with previous abdominal surgery
• Advise patients to seek urgent medical advice if they have vaginal bleeding, or abdominal pain, to rule out ectopic pregnancy
• Associated with increased need for hysterectomy
• Not associated with increased risk of heavy, irregular periods

Male sterilisation

Efficacy

0.3% if there is:

• Ligation of the vas, PLUS
• Cauterisation of the ends, PLUS
• Insertion of a fascia between the two ends

Around 1% if cauterisation only is used
Late failure occurs in 0.2% of cases

Surgical technique

• The vas is palpated, and moved as close to the scrotal skin as possible. Local anaesthetic (lidocaine 1-2ml) is administered.
• Through a small inscision in the scrotal skin, the vas is identified and clamped in two places, about 5cm apart
• A small segment (e.g. 1cm) is removed and sent for histology to confirm it is actually the vas deferens.
• Of the two ends, the testicular end is tied back on itself to reduce the risk of anastomosis, and the top end is also occluded, with non-absorbable stitching.
  • Some surgeons may insert an artificial fascia between the two ends to further reduce the risk of anastomoses
• Suture up the skin

Alternative methods

• Cauterisation of the vas

Measuring success

• There needs to be two negative sperm count samples 1 month apart, taken after a minimum of 20 ejaculations.

After surgery

• Normal ejaculation and orgasm occur, however, there is no sperm in the ejaculate.
• May be painful, and men advised to take several days off work, and not do anything too strenuous for 1 week

Complications

Bleeding

• Mild – 1:400
• Major – 1:1000

Infection – 1:100
Epididymitis – 1:100
Persistent pain – 1:1000
perm granuloma – 1:500

• This is a tender scrotal swelling at the proximal end of the cut vas, and will require excision.

• Testicular / prostate cancer
• Immune complex disease
• Ischaemic heart disease
• Loss of libido

References

Read more about our sources

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The contraceptive injection is a common form of progesterone only contraception given to women. Injections are typically given every 3 months. Hormonal injections and generally considered >99% effective for contraception, but provide no protection against STIs.

There can be a slightly erratic return to normal period after the medication is ceased. There is also a risk of weight gain compared to some other methods of contraception.

There are two brands available in the UK:

Depo-Provera – administered every 12 weeks

• Injection of choice
• Aka Medroxyprogesterone acetate

Noristerat – administered every 8 weeks

• Depo-provera is more effective than Noristerat
• Usually only offered as short-term treatment – e.g. for women waiting for sterilisation

Summary

CONTRACEPTION	INJECTABLE PROGESTERONE
EFFECTIVENESS	> 99% effective
PREPARATIONS	Depot (every 12 wks) Noristerat (every 8 wks)
HOW IT WORKS	slow release of progesterone into body – thinning endometrium, preventing ovulation and thickening cervical mucus
ADVANTAGES	No oestrogen content Reduces PID Can use in Breastfeeding and epileptics
DISADVANTAGES	May cause irregular bleeding – amenorrhoea, irregular , longer Fertility may take time to return to normal (~10m) Weight gain ~ 3kg in 1st yr SE = headache, mood change and breast tenderness , acne and hirtuism
Contra-indications	Abnormal undiagnosed vaginal bleeding, severe cardiac disease, acute liver disease

Efficacy

• Quoted as >99% effective
• Described as: if taken correctly, then during the course of 1 year, <1% of women using the injection will become pregnant

Mechanism

Prevent ovulation – and may stop periods

• Other methods of progesterone only contraception will often make periods lighter, and may prevent them in some women. However, progestogen injection will be more likely to prevent ovulation and regular menstrual bleeding in a higher proportion of women.
• This is the main benefit of this treatment over other options
• Some women may get heavier or irregular periods

Thickens cervical mucus
Alters lining of the uterus, making it difficult for implantation to take place

Cautions and contraindications

Should not be first line in women <18 or >45 due to risk of reduction in bone density

• In women <18 can alter the formation of new bone, as bones are still developing
• In women over 45 can increase the rate of bone density reduction
• The reduction in bone density is greatest in the first 2-3 years of use, then stabilises.

Should be avoided when other RF’s for osteoporosis are present

• Low oestrogen due to amenorrhoea for >6 months – e.g. due to extreme dieting, exercise or eating disorder
• Smoker
• Heavy drinker
• Long-term steroid use
• FH of osteoporosis (1^st degree relatives)

 

Side effects

• Bleeding may be heavier for the first 3-4 months, but will usually settle down, and most women ultimately do not have periods
• Mood swings
• Reduction in bone density / increased risk of osteoporosis in later life
• Weight gain – typically 2-3Kg per year

Benefits over oral POP

More likely to inhibit ovulation, thus:

• Less likelyhood of periods
• Recued risk of ovarian cysts and ectopic pregnancy
• Also, no interaction with non-enzyme inducing antibacterials

Drug interactions

Enzyme-inducing drugs

• E.g. St John’s Wort
• TB, epilepsy and HIV medications
• If the patient also takes any of these, it is recommended to use additional contraception (e.g. condoms) for the duration of the treatment and for 4 weeks after

Prescribing and administration

Given IM, usually into the gluteal muscles. Depo-provera may be given in the leg or arm

• Noristat is a more viscous solution and may be more painful during administration

If there is any chance of pregnancy, the patient must have a pregnancy test before commencing treatment.

• Administration during pregnancy can masculinise the fetus

Treatment should be commenced within 5 days of the start of the cycle

• If started at any other day in the cycle, another method of contraception (e.g. condoms) should be used for the first 7 days.

After pregnancy

• o   Usually started 6 weeks after pregnancy. This reduces the risk of heavy / irregular periods.
  • Can be given after 21 days on request
  • If given at 6 weeks, then an alternative form of contraception (e.g. condoms) should be used between 21 days and 6 weeks
  • Pregnancy cannot occur in the first 21 days after the birth of a previous child

After miscarriage / abortion

• Treatment can be started immediately, and will be immediately effective

General advice

• Breast-feeding is not affected
• Missing an injection
• You can be up to two weeks late for the next appointment, and still be fully ptorected:
  • i.e. 10 weeks for Noristerat
  • 14 weeks for Depo-Provera
• Duration of treatment – Providing there are no contra-indications, or RF’s for osteoporosis, treatment can be continued until menopause
• topping treatment
  • Fertility can take several months to return after treatment is stopped.
  • Important to warn patients they can get pregnant after cessation of treatment but before their first normal period.

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

Read more about our sources

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• Oral progesterone-only emergency contraception (POEC) – levonorgestrel (LNG)
  • The traditional ‘morning after pill’. More effective the sooner it is taken. Should be taken within 72 hours of intercourse.
  • Pregnancy rate if taken within 120 hours – 2.2%
• Selective progesterone receptor modulator (SPRM) – ulipristal acetate (UPA)
  • A newer drug – widely used in Australia – use may be more limited in UK
  • More effective than levonorgestrel and can be used up to 120 hours (5 days) after unprotected sex
  • Pregnancy rate if taken within 120 hours – 1.4%
• Copper intra-uterine contraceptive device (Copper IUD)
  • Intra-uterine device is the most effective method (99% effective), and should be offered to all women, even those presenting after 72 hours
  • The IUS (intrauterine system) aka progesterone containing intrauterine system (e.g. mirena) is NOT indicated
  • Pregnancy rate if taken within 120 hours – <1%

Assessment and History

• Document date of LMP (last menstrual period)
• Ask about:
  • Timing of unprotected sexual intercourse
    • If >72 hours – IUD or ulipristal recommended, <72 hours any of the three options
  • Current contraceptive methods
    • If on the pill, ask about missed pills
    • May be appropriate to talk about proper use of barrier methods and assess if they are being used correctly
  • Possibility of non-consensual sex and offer support and referral if appropriate
• Remember: there is no time in the menstrual cycle where there is no risk of pregnancy. The risk is lowest in the first 3 days. 
• Important to advise the patient that:
  • Methods are not 100% effective
  • Their next period may be early or late
  • They should have a pregnancy test if their next period is >7 days late
  • They should see a doctor immediately if they develop lower abdominal pain
  • They should consider ongoing long-term contraceptive options
  • Discuss the risk of STI – and consider sexual health screening
• As well as emergency contraception – don’t forget to offer ongoing long-term contraception

Emergency oral preparations

Levonorgestrel

The same progestrogen found in the IUS (Mirena). It is a progestrogen only pill. Thus it is safe in breastfeeding, and for women in whom oestrogens are contraindicated.

Dose – 1.5mg

• Consider 3mg dose if raised BMI (>26) or on liver-enzyme inducing medications
  • Phenytoin and carbamazepine are likely the most commonly seen examples
  • Raised BMI reduces the efficacy of LNG
• In emergency situations when only 30mcg levonorgestrel pills are available (e.g. the progesterone-only contraceptive pill such as Microlut) – this may be taken as an alternative – but 25 tablets (!) will need to be taken TWICE – 12 hours apart – for a total of 50 tablets.

Contraindications

• Severe liver disease
• Known allergy to levonorgestrel

Side effects

• Menstrual irregularities
• For most women the next period will be normal, but it can be 2-7 days late.
• There may be irregular bleeding during the next menstrual cycle
• Nausea
• Vomiting
• Breast tenderness

Efficacy

• Most effective within 12 hours after sexual intercourse
• 95% if <24h
• 85% if 24-48h
• 58% if 49-72h
• May be given up to 120h, but is not recommended. Between 72-120h, an IUD or ulipristal is recommended as they are more effective

Vomiting

• If vomiting occurs within 2 hours of administration, another pill should be given. If vomiting continues, consider IUD, or consider another dose, with an antiemetic (domperidone recommended).
• Another form of contraception – e.g. COCP or POP can be started immediately

Prescribing

Can be taken as many times as necessary, even within the same menstrual cycle however, not recommended, as it is not as reliable as regular contraception.

A barrier method of contraception needs to be used for 7 days (COCP), or 3 days for POCP.

• If due to missed oral contraceptive pill advise to take the next one within 12 hours of taking levonorgestrel – but re-iterate she will need to use barrier contraceptive for the time periods outlined above

If there is any lower abdominal pain before the next period, she should consult immediately to rule out ectopic pregnancy
If she has any concerns (e.g. if next period is late, could be pregnant) to seek medical advice.

Ulipristal Acetate

Dose

• 30mg as soon as possible after intercourse. Should not be used >120 hours after intercourse
• Should not be used more than once in one menstrual cycle
• The only oral method licensed for use between 72 and 120 hours

Contraindications

• Contraindicated in uncontrolled asthma
• Avoid breast-feeding for 36 hours (precautionary, no evidence)
  • LNG and copper coil are both safe with breast-feeding
• Severe liver disease

Efficacy

• More effective than LNG, but less effective than copper coil
  • Efficacy also reduced by increased BMI, but not to the same extent as LNG and the dose does NOT alter

Side effects

• Reduces efficacy of COC and POP
  • As such, when (re-)starting long term progestogen containing contraceptives – patients need to wait 5 days before starting – AND then use a barrier method until the long-term contraceptive method becomes effective
• Side effects – GI disturbance, dizziness, fatigue, headaches, menstrual irregularities
• Advise repeat dose of vomiting within 3 hours of taking (note this timeframe is different for LNG)

IUD (copper coil) as emergency contraception

• More effective than levonorgestrel – around 99% effective
• Maintains its efficacy right up until 5 days after sexual intercourse
• Copper has multiple effect on the fertilisation and implantation process
  • Inhibits sperm penetration of cervical mucus
  • Toxic effects on the ovum
  • Inflammatory reaction effects on the endometrium prevent implantation
• Effective up to 5 days after intercourse
  • Ensure that the patient has only had unprotected sex once since the last period – if not, the IUD is only effective if fitted within 5 days of the earliest date of ovulation.
• Also provides ongoing contraception for up to 10 years
• Is not affected by diarrhoea or malabsorption
• Efficacy – 99% effective
• Risk factors and side effects – same as the IUD in normal circumstances
  • Remember; risk of infection within 20 days of fitting, and increased risk of PID. Recommended to perform sexual health screening at time of insertion
• Fitting – same as IUD in normal circumstances, except:
  • Swabs for STI recommended to be taken in all instances
  • Antibiotic prophylaxis may be given at the time of insertion if deemed to be high risk for PID: age <=25, new sexual partner, >1 sexual partner in last 12 months
• Next period – should be at the normal time
• Follow up –same as IUD in normal circumstances. Check up at 3-6 weeks. IUD can then be removed if the patient does not wish to use it as a form of long term contraception
• NB – Mirena (progesterone containing IUD) is NOT indicated for emergency contraception

Ethics

Those who believe life begins at fertilisation may argue that abortion can occur with these methods, and may have moral objections. However, the methods do not cause any alteration to an embryo after implantation.

• In the UK, a 2002 Judicial Review concluded that – legally – life begins at implantation and not at fertilisation.

References

• Emergency Contraception – Helath Pathways ACT
• Emergency Contraception – patient.info
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

Read more about our sources

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• It is the only form of contraception that protects from STD’s
• 98% effective – when used correctly

• Other things that can affect the structural integrity of condoms include ice-cream and lipstick!
• There are condoms specifically produced men who have sex with men (MSM), which are made of thicker rubber, and come with more lubricant.
• Most condoms are made from latex, or a thin plastic, e.g. polyisoprene or polyurethane

Female condoms

• 95% effective – when used correctly

Diaphragm

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• 1/3 of pregnancies are unplanned
• The UK government now promotes long acting reversible contraception (LARC) (e.g. IUD, IUS, implant)as the best method of contraception because:
  • Reduced chance of patient error – e.g. forgetting to take the pill, not using condoms
  • It is also cheaper! – it requires fewer primary health care appointments than e.g. the pill, which has to be reviewed every 3-12 months.
• Prescribing contraception to under 16’s – you should do so under the Fraser Guidelines (aka Gillick competance) – i.e. the doctor should believe that:
  • The patient is able to retain and recall information, and understands advice given
  • The patient should be encouraged to discuss issues with parents; however in the case that this is not possible, the doctor is still able to proceed
  • The patient is likely to have an active sexual life anyway, even if contraceptives are not given
  • The patients mental or physical health may suffer if contraceptives are not given
  • It is in the patients best interests to receive contraceptives and contraceptive advice, with or without parental consent.
• Without contraception – 80-90% of women will become pregnant within a year if having regular sexual intercourse.
• All methods of contraception are free to all men and women on the NHS
• You should always ask if there is any chance the patient is pregnant before commencing contraception! – If there is any doubt, then just do the test.
• No contraception is 100% effective!

It is important that before any method of hormonal (and also IUD) contraception, the patient is counselled by a trained individual, and provided with information leaflets, and allowed to make their own informed decision.

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