7.3.2.1 Oral progestogen-only contraceptives

Additional information can be found on the contraception guidance page

Desogestrel

• Tablets 75micrograms (£2.40 = 84 tablets)

Indications and dose

• Contraception in females of childbearing potential
  • 75micrograms daily, to be taken at the same time each day, starting on day 1 of cycle then continuously. “Quick starting” at any time in the cycle is also supported (although outside the product licence). For further information refer to formulary guidance on “Quick starting contraception” or the FSRH guideline on quick starting contraception
  • Additional contraceptive precautions are not required if desogestrel is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days.
  • If administration delayed for 12 hours or more it should be regarded as a ‘missed pill'
  • Refer to FSRH guidance on progestogen-only pills for information regarding switching from alternative methods of hormonal contraception, or starting after childbirth, miscarriage or abortion

Notes

1. Desogestrel (DSG) pills may have potential benefits over traditional (norethisterone or levonorgestrel containing) POPs because ovulation is inhibited in up to 97% of cycles and DSG have a 12-hour window for missed pills. DSG may have some benefits in management of dysmenorrhea
2. Desogestrel is also available over-the-counter (OTC) from pharmacies

Norethisterone

• Tablets 350micrograms (£2.10 = 84 tablets)

Indications and dose

• Contraception in females of childbearing potential
  • 350micrograms daily, dose to be taken at same time each day, starting on day 1 of cycle then continuously. “Quick starting” at any time in the cycle is also supported (although outside the product licence). For further information refer to formulary guidance on “Quick starting contraception” or the FSRH guideline on quick starting contraception
  • Additional contraceptive precautions are not required if norethisterone is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days.
  • If administration delayed for 3 hours or more it should be regarded as a ‘missed pill'
  • Refer to FSRH guidance on progestogen-only pills for information regarding switching from alternative methods of hormonal contraception, or starting after childbirth, miscarriage or abortion

Notes

1. For other presentations and indications, refer to 6.4.1 Female sex hormones and their modulators

Levonorgestrel

• Tablets 30micrograms (£0.92 = 35 tablets)

Indications and dose

• Contraception in females of childbearing potential
  • 30micrograms daily, dose to be taken at same time each day, starting on day 1 of cycle then continuously. “Quick starting” at any time in the cycle is also supported (although outside the product licence). For further information refer to formulary guidance on “Quick starting contraception” or the FSRH guideline on quick starting contraception
  • Additional contraceptive precautions are not required if levonorgestrel is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days.
  • If administration delayed for 3 hours or more it should be regarded as a ‘missed pill'
  • Refer to FSRH guidance on progestogen-only pills for information regarding switching from alternative methods of hormonal contraception, or starting after childbirth, miscarriage or abortion

Notes

1. For use in emergency contraception, refer to 7.3.5 Emergency contraception

7.3.2.2 Parenteral progestogen-only contraceptives

Additional information can be found on the contraception guidance page

Please also refer to: NICE CG30 Long-acting reversible contraception

Depo-Provera

(Medroxyprogesterone acetate)

• Suspension for intramuscular injection pre-filled syringe 150mg/1ml (£6.01 per injection)

Indications and dose

• Contraception in females of childbearing potential
  • 150mg by deep intramuscular injection every 13 weeks (this FSRH advice is outside the product licence of every 12 weeks). First dose to be administered within the first 5 days of cycle. “Quick starting” at any time in the cycle is also supported (although outside the product licence). For further information refer to formulary guidance on “Quick starting contraception” or the FSRH guideline on quick starting contraception
  • Advice in relation to missed / late injections can be found in table 4 of the FSRH guidance on progestogen-only injectable contraception
  • Refer to FSRH guidance for information regarding switching from alternative methods of hormonal contraception, or starting after childbirth (including if breastfeeding)

Notes

1. Prescribe by brand (to prevent confusion since injectable medroxyprogesterone acetate products have different routes of administration and dosage frequency)
2. In adolescents (12-18 years), Depo-Provera may be used, but only after other methods of contraception have been discussed with the patient and considered unsuitable or unacceptable

Sayana Press

(Medroxyprogesterone acetate)

• Suspension for subcutaneous injection pre-filled disposable device 104mg/0.65ml (£6.90 per injection)

Indications and dose

• Contraception in females of childbearing potential
  • 104mg by subcutaneous injection into the anterior thigh or abdomen every 13 weeks, first dose to be administered within the first 5 days of cycle. “Quick starting” at any time in the cycle is also supported (although outside the product licence). For further information refer to formulary guidance on “Quick starting contraception” or the FSRH guideline on quick starting contraception
  • Advice in relation to missed / late injections can be found in table 4 of the FSRH guidance on progestogen-only injectable contraception
  • Refer to FSRH guidance for information regarding switching from alternative methods of hormonal contraception, or starting after childbirth (including if breastfeeding)

Notes

1. Prescribe by brand (to prevent confusion since injectable medroxyprogesterone acetate products have different routes of administration and dosage frequency)
2. In adolescents (12-18 years), use of Sayana Press is only indicated when other contraceptive methods are considered unsuitable or unacceptable, due to unknown long-term effects of bone loss associated with Sayana Press during the critical period of bone accretion. Sayana Press has not been studied in women under the age of 18 years, but data are available for intramuscular medroxyprogesterone acetate (above) in this population
3. Administration should be initiated under the supervision of a healthcare professional (HCP). After proper training in injection technique and schedule of administration, patients may self-inject with Sayana Press if their HCP determines that it is appropriate and with medical follow-up as necessary

Etonogestrel

• Nexplanon implant 68mg in radiopaque flexible rod (£83.43 each)

Indications and dose

• Contraception in females of childbearing potential
  • 1 implant inserted between day 1 and day 5 of cycle. The implant can be left in place for up to 3 years. “Quick starting” at any time in the cycle is also supported (although outside the product licence). For further information refer to formulary guidance on “Quick starting contraception” or the FSRH guideline on quick starting contraception
  • When inserted during the first 5 days of cycle, no additional contraceptive precautions are needed, when inserted at any other time, additional precautions (e.g. barrier methods) are advised for next 7 days
  • Refer to FSRH guideline on progestogen-only implants for information regarding switching from alternative methods of hormonal contraception, or starting after childbirth, miscarriage or abortion

Notes

1. Nexplanon implant should be inserted and removed only by healthcare professionals who have completed training for the use of the applicator and the techniques for insertion and removal of the implant (refer to SPC for more information). Relevant theoretical and practical training is also available from FSRH here
2. MHRA Drug Safety Update (February 2020): Etonogestrel (Nexplanon) contraceptive implants: new insertion site to reduce rare risk of neurovascular injury and implant migration

7.3.2.3 Intrauterine progestogen-only devices

For information on heavy and/or painful periods please refer to: NICE NG88 Heavy menstrual bleeding: assessment and management (March 2018)

Levonorgestrel intrauterine devices (LNG-IUD) should not be considered as direct alternatives to each other; they should all be considered as distinct different options to discuss with women seeking contraceptive advice.

All LNG-IUD should only be inserted by physicians/healthcare professionals who are experienced in IUD insertions and/ or have undergone training on the individual products’ insertion procedures.

Irregular bleeding and spotting are common with the use of IUD but reduce with time; patients should be informed to seek medical advice if there is increased menstrual flow or unexpected bleeding.

Additional information can be found on the contraception guidance page

MHRA Drug Safety Update (June 2015): Before inserting an intrauterine system (IUS) or intrauterine device (IUD), inform women that perforation occurs in less than 1 in 1,000 women and that the symptoms include:

• severe pelvic pain after insertion (worse than period cramps)
• pain or heavy bleeding after insertion which continues for more than a few weeks
• sudden changes in periods
• pain during sex
• not being able to feel the threads

Explain to women how to check their threads and tell them to return for a check-up if they cannot feel them (especially if they also have significant pain). Partial perforation may have occurred even if the threads can still be seen; consider this if there is severe pain following insertion.

For information on local services commissioned to fit / refit LNG-IUD for HRT or heavy menstrual bleeding, refer to non-contraceptive LARC fitting.

Jaydess

• Intrauterine device containing 13.5mg total dose levonorgestrel (£69.22 per device)
  • Initial release rate of levonorgestrel 14micrograms per 24 hours

Indications

• Contraception for up to 3 years

Notes

1. Prescribe by brand (to prevent confusion since different LNG-IUD products have different indications, durations of use, and introducers). Refer to MHRA Drug Safety Update (January 2016)
2. Jaydess is not recommended as a first choice IUD for contraception in nulliparous women as clinical experience is limited
3. The routine commissioning of Jaydess is accepted in Devon for the prevention of pregnancy (see Commissioning Policy for more details).
   
4. Refer to notes above regarding the risk of uterine perforation

Kyleena

• Intrauterine device containing 19.5mg total dose levonorgestrel (£76.00 per device)
  • Initial release rate of levonorgestrel 17.5micrograms per 24 hours

Indications

• Contraception for up to 5 years

Notes

1. Prescribe by brand (to prevent confusion since different LNG-IUD products have different indications, durations of use, and introducers). Refer to MHRA Drug Safety Update (January 2016)
2. Kyleena is suitable for nulliparous and parous women
3. Refer to notes above regarding the risk of uterine perforation
   

Levosert

• Intrauterine device containing 52mg total dose levonorgestrel (£66.00 per device)
  • Initial release rate of levonorgestrel 20micograms per 24 hours

Indications

• Contraception for up to 8 years (but see note 4)
• Menorrhagia for up to 3 years (but see note 5)
• Prevention of endometrial hyperplasia during oestrogen HRT for up to 5 years (off label, see note 6)
• Treatment of endometrial hyperplasia (off label) (specialist)

Notes

1. Prescribe by brand (to prevent confusion since different LNG-IUD products have different indications, durations of use, and introducers). Refer to MHRA Drug Safety Update (January 2016)
2. Levosert is suitable for nulliparous and parous women
3. Refer to notes above regarding the risk of uterine perforation
4. FSRH states that if a 52mg LNG-IUD is inserted over the age of 45, it can be used for contraception until the age of 55.
5. Levosert is known to be effective for 3 years for menorrhagia but may remain effective beyond this. Levosert should be removed or exchanged if symptoms return, and no later than 8 years.
6. Levosert is not licensed for endometrial protection as part of HRT, however FSRH supports use of any 52mg LNG-IUD for endometrial protection as part of HRT for 5 years.
   1. If at 4 years of use, new unscheduled bleeding develops, offer a change of 52mg LNG-IUD if cancer exclusion investigations are normal – particularly in women using over licensed oestrogen dosages and in those with a BMI ≥ 40.

Mirena

• Intrauterine device containing 52mg total dose levonorgestrel (£88.00 per device)
  • Initial release rate of levonorgestrel 20micrograms per 24 hours

Indications

• Contraception for up to 8 years (but see note 4)
• Menorrhagia for up to 5 years (but see note 5)
• Prevention of endometrial hyperplasia during oestrogen HRT for up to 4 years (licensed duration) or up to 5 years (see note 6)
• Treatment of endometrial hyperplasia (off label) (specialist)

Notes

1. Prescribe by brand (to prevent confusion since different LNG-IUD products have different indications, durations of use, and introducers). Refer to MHRA Drug Safety Update (January 2016)
2. Mirena is suitable for nulliparous and parous women
3. Refer to notes above regarding the risk of uterine perforation
   
4. FSRH states that if a 52mg LNG-IUD is inserted over the age of 45, it can be used for contraception until the age of 55.
5. Mirena is known to be effective for 5 years for menorrhagia but may remain effective beyond this. Mirena should be removed or exchanged if symptoms return, and no later than 8 years.
6. The Mirena licensed duration of use for endometrial protection as part of HRT is 4 years, however FSRH supports use of any 52mg LNG-IUD for endometrial protection as part of HRT for 5 years.
   1. If at 4 years of use, new unscheduled bleeding develops, offer a change of 52mg LNG-IUD if cancer exclusion investigations are normal – particularly in women using over licensed oestrogen dosages and in those with a BMI ≥ 40.