Contraception Guidance

Women requiring contraception should be given information about and offered a choice of all contraceptive methods, including long-acting reversible contraception (NICE CG30 update September 2014). They should be provided with the method that is most acceptable to them provided it is not contraindicated. Contraceptive service providers who do not provide LARC in their practice or service should have an agreed mechanism in place for referring women for LARC. Devon is working towards a consistent reduction in pregnancy rates, particularly among teenagers, and the promotion of LARC methods is part of this approach.

All currently available LARC methods including intrauterine devices (IUDs), intrauterine systems (IUS), injectable contraceptives and implants, are more cost effective than the combined oral contraceptive pill at 1 year of use

IUDs, IUSs and implants are more cost effective than injectable contraceptives

The following QOF indicators apply to LARC provision:

  • Percentage of women prescribed an oral or patch contraceptive method in the last year who have received information from the practice about LARC in the previous 15 months
  • Percentage of women prescribed emergency hormonal contraceptive at least once in the year by the practice who have received information from the practice about LARC at the time of, or within one month of, the prescription.

Detailed clinical guidance on contraception is available on the Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit

UK Medical eligibility criteria (UKMEC)

UK Medical Eligibility Criteria (UKMEC) is a classification system of risk factors and contraindications for all contraceptive methods. It is available as a summary sheet. The four UKMEC levels are:

  • UKMEC 1: No restriction
  • UKMEC 2: Advantages generally outweigh the risks e.g. CHC in smoker aged 20
  • UKMEC 3: Theoretical or proven risks usually outweigh advantages of using method. Provision of a method to a woman with UKMEC 3 requires expert clinical judgement and/or referral to a specialist contraceptive provider since the use of the method is not usually recommended unless other methods are not available or not acceptable.
  • UKMEC 4: A condition which represents an unacceptable health risk if the contraceptive method is used e.g. migraine with aura

Consider in general that, where more than one condition applies, the situation is moved up one category, e.g. two category 2 conditions, move the situation to category 3. The addition of a category 2 or 3 condition to another category condition moves the situation to category 4.

Assess risk factors for VTE and arterial disease carefully and separately.

Failure rates

User-failure rates at one year per 100 women for different methods of contraception.

Range in world literature (excludes atypical studies and all extended-use studies)

MethodFailure rate at 1 year*
Sterilization *(lifetime failure rate)Male (after azoospermia)
Female
0 - 0.1
0 - 0.5
Subcutaneous implant - Nexplanon®
0 - 0.07
Injectable depot medroxyprogesterone acetate 0 - 1.0
Combined pills50 microgram oestrogen
Less than 50 microgram oestrogen
Evra (patch)
0.1 - 3
0.2 - 3
0.6 - 1.5
Progestogen only pillDesogestrel
Old type progesterone only pill
0.7 - 1.1
0.3 - 4
IUDNova-T 380®
Multiload Cu 375®
T-Safe Cu 380A®
0.6
0.2 - 1.5
0.3 - 0.8
IUS Levonorgestrel IUD-20 (Mirena®)0 - 0.6
CondomMale
Female
2 - 15
5 - 15
Coitus interruptus 4 - 19
Spermicides alone 4 - 25
Diaphragm 6 - 20
Fertility awareness 2 - 25
'Persona'® 6 -?
No methodYoung women
At age 40
At age 45
At age 50 (if still having menses)
80 - 90
40 - 50
10 - 20
0 - 5

Quick starting contraception

If a health professional is reasonably sure that a woman is not pregnant or at risk of pregnancy from recent unprotected sexual intercourse (UPSI):

  • contraception can be started immediately unless the woman prefers to wait until her next period (such practice may be outside the product licence/device instructions)
  • if a woman's preferred contraceptive method is not available, combined hormonal contraception (CHC) (excluding co-cyprindiol 2000/35), the progestogen-only pill (POP) or progestogen-only injectable can be used as a bridging method
  • women requesting the progestogen-only injectable should ideally be offered a bridging method if pregnancy cannot be excluded, but immediate start is acceptable if other methods are not appropriate or acceptable
  • the progestogen-only injectable should only be considered as a bridging method if other methods are not appropriate or acceptable

If pregnancy cannot be excluded (e.g. following administration of emergency contraception) but a woman is likely to continue to be at risk of pregnancy, or has expressed a preference to start contraception without delay, immediate 'quick starting' of CHC (except co-cyprindiol 2000/35), the POP, or progestogen-only implant may be considered. The woman should be informed of the potential risks and the need to have a pregnancy test no later than 3 weeks after the last episode of UPSI (see Emergency Contraception for further information on quick-starting contraception after EC).

If pregnancy is diagnosed after starting contraception and the woman wishes to continue with the pregnancy, the method should usually be stopped or removed. Intrauterine contraceptives should not be removed if pregnancy is diagnosed after 12 weeks' gestation.

Risk factors for CHCs

Assessment of risk factors

The majority of women can use CHCs without harm from menarche to age 50, when no other risk factors are present. However, it is necessary to have an overview of the health status of the individual woman before first prescription of a CHC in order to establish the safety of combined oral contraception.

History should include enquiry about:

  • Medical conditions (past and present)
  • Drug use (prescription, non-prescription and herbal remedies)
  • Family history
  • Specific enquiry about migraine and cardiovascular risk factors (smoking, obesity, hypertension, thrombophilia, previous VTE and hyperlipidaemia)

Examinations:

  • Blood pressure and BMI should be documented prior to a first prescription of CHC
  • A thrombophilia screen is not recommended routinely before prescribing CHC
  • Breast and pelvic examinations are unnecessary in asymptomatic women

Potential harms associated with CHC use should be discussed:

  • All CHCs increase the risk of VTE, MI and ischaemic stroke but the absolute risk is small.
  • Any increase in the risk of breast cancer associated with CHC use is likely to be small, is in addition to the background risk and is reduced to no increased risk 10 years after stopping.
  • There may be a very small increase in the risk of cervical cancer with CHC use, which increases with increasing duration of use.

Use of CHC is not recommended for women in the following circumstances:

  • Smokers aged 35 years or older
  • Migraine with aura at any age
  • Personal history of cardiovascular disease or stroke
  • When using long-term liver enzyme-inducing drugs
  • Migraine without aura when aged 35 years or older
  • BMI 35 kg/m2 or over
  • Blood pressure consistently greater than140–159 mmHg systolic or 90–94 mmHg diastolic
  • Personal history of VTE or a thrombogenic mutation

Venous thromboembolism (VTE) risk

The risk of blood clots with all low-dose CHCs is small. VTE risk may vary between products, depending on the progestogen. The benefits of any CHC far outweigh the risk of serious side effects but prescribers and women should be aware of the major risk factors for thromboembolism, and of the key signs and symptoms. All hormonal contraceptives are highly effective and safe, and have important health benefits, in addition to avoiding unplanned pregnancy. The risk of a venous thrombosis in women taking combined oral contraceptives is well below the risk of VTE associated with pregnancy. All risk factors for VTE should be considered when selecting which CHC to prescribe.

BMI is the most important risk factor for a VTE; use CHCs with caution for women with a BMI greater than 30kg/m2. See FRSH guidance for VTE risks associated with specific situations.

Summary of estimated VTE risks per 10,000 woman-years*:

  • Non-pregnant woman not taking CHC: 2
  • Using 1st or 2nd generation progestogen-containing CHC: 5-7
  • Using 3rd generation progestogen-containing CHC: 9-12
  • Pregnant woman: 29
  • Post-partum woman: 300-400

*MHRA Drug Safety Update (February 2014) (pregnancy and post-partum figures from the FSRH Clinical Guideline Combined Hormonal Contraception (2011).

Choice of CHC

Features of CHCs to discuss with women

How it works

  • primarily by preventing ovulation

Duration of use

  • from menarche to age 50 if there are no other risk factors

Failure rate

  • "perfect" use: 0.3%
  • "typical" use (actual use including inconsistent or incorrect use) is 9%

Effects on periods

  • menstrual pain and blood loss may be reduced with CHC use

Other risks

  • VTE risk: see notes above
  • Ischaemic stroke: two fold increase in risk with CHCs but annual incidence in women less than 35 years of age is low (3 cases per 100,000),
  • Coronary artery disease: see notes above
  • Breast cancer: any risk of breast cancer associated with CHC use is likely to be small, and will reduce with time after stopping
    • A family history of breast cancer is a UKMEC score of 1. Among CHC users with a family history of breast cancer, there was no increased risk of breast cancer compared with non-CHC users with a family history of breast cancer. Among women with BRCA1 mutations, CHC users may have a small increased risk of breast cancer compared with nonusers.
  • Cervical cancer: (11 cases per 100 000 in non-CHC users), small increase with CHC use after 5 years and two fold increase after 10 years
  • Risk of ovarian and endometrial cancer halved with CHC use and effect lasts for 15 years after stopping
  • CHC use is associated with a reduction in the risk of colorectal cancer
  • No evidence of effect on weight gain

Return to fertility

  • No delay

Initial choice on prescribing of CHC

All combined oral contraceptives should be prescribed by brand name to minimise patient confusion and reduce the risk of dispensing error. Where two brands exist for the same formulation the cheaper option should be prescribed. Generally a preparation with the lowest oestrogen and progestogen content that gives good cycle control and minimal side effects in the individual woman should be chosen.

There is no reason to choose one pill over another in the majority of women, the product of lowest acquisition cost should be chosen in the first instance.

Woman has never used CHC:

  • Start with Rigevidon®

Woman has used CHC in past and there are no new contraindications:

  • Return to previously tolerated CHC, if unknown follow 'never used CHC' above

Progestogenic side effects (e.g. depression, sustained weight gain, loss of libido with mood change, acne, hirsutism, vaginal dryness, breast tenderness):

  • Try an oestrogen dominant CHC e.g. Gedarel®, Cilest®, Marvelon®, Femodene®, Yasmin®

Oestrogenic excess (e.g. nausea, bloating, breast tenderness, cyclical weight gain, vaginal discharge with no infection, loss of libido with no mood change, benign breast disease, fibroids, endometriosis):

  • Try a progestogen dominant COC e.g. Rigevidon® or a low-dose oestrogen COC, e.g. Gedarel® 20/150

Breakthrough bleeding:

  • exclude other causes then try Millinette® 30/75 or Femodene® or a phasic CHC Logynon®

Poor compliance and not wanting a long-acting reversible method:

  • Try Evra®

At follow-up appointments women should be encouraged to use a CHC for at least 3 months before considering an alternative. A follow-up at 3 months allows an assessment of blood pressure and problems and re-instruction if required. In the absence of special problems, a 12-month supply of CHC can be given. Women should be encouraged to return if any problems arise.

Potential non-contraceptive benefits associated with CHC use can be considered:

  • Menstrual pain and blood loss may be reduced.
  • The incidence of functional ovarian cysts and benign ovarian tumours is reduced.
  • The risk of colorectal cancer is reduced.
  • The risk of ovarian and endometrial cancer is reduced by at least 50% during use and for at least 15 years after stopping.
  • Improvement in symptoms of acne vulgaris.

Starting routines for CHC

Women having menstrual cycles:

  • Start CHC up to and including day 5, no additional protection required
  • At any other time if it is reasonably certain there is no pregnancy, additional protection required for 7 days

Women who are amenorrhoeic:

  • CHC can be started at any time, if it is reasonably certain there is no pregnancy, additional protection required for 7 days

Following abortion:

  • Can start CHCs within 7 days of surgical or medical abortion at gestations less than 24 weeks, no additional protection required

Postpartum (not breastfeeding):

  • Start CHC on day 21 postpartum if vaginal delivery and no additional risk factors for VTE, no additional protection required
  • If more than 21 days postpartum and menstrual cycles have returned, start CHC as for other women having menstrual cycles. (See above for additional protection advice)
  • If more than 21 days postpartum and menstrual cycles have not returned treat as amenorrhoeic. (See above for additional protection advice)

Postpartum (breastfeeding):

  • If more than 6 months postpartum and menstrual cycles have returned start CHC as for other women having menstrual cycles. (Women breastfeeding less than 6 weeks postpartum should not use CHCs and between 6 weeks and 6 months. CHC can be started as for those who are postpartum and not breastfeeding (see above)

Switching from other hormonal methods (other than IUS):

  • CHC can be started immediately if using the hormonal method consistently and correctly, or if it is reasonably certain there is no pregnancy. There is no need to wait for next menstrual period. No additional protection required
  • If previous method was an injectable or an implant (which inhibit ovulation), CHC can be started any time up to when the repeat injection is due or the implant is removed. No additional protection required

Switching from other non-hormonal methods (other than IUS):

  • As for women having menstrual cycles (see above)

Switching from IUD or IUS:

  • CHC can be started up to and including day 5 after the start of menstrual bleeding. IUD/IUS can be removed at that time, no additional protection required
  • CHC can be started at any other time, if it is reasonably certain there is no pregnancy. Ideally IUS/IUD can provide contraceptive protection until seven or more pills have been taken. The IUS/IUD can then be removed. If the IUD/IUS removed at the time of starting CHC then additional contraception is required for 7 days as ovulation still occurs for women using intrauterine methods

Reasons to stop CHC immediately

Combined oral contraceptives (and HRT) should be stopped pending investigation in the following circumstances:

  • Sudden severe chest pain (even if not radiating to left arm).
  • Sudden breathlessness (or cough with blood-stained sputum).
  • Severe pain in calf of one leg.
  • Severe stomach pain.
  • Serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body.
  • Hepatitis, jaundice, liver enlargement.
  • Blood pressure above systolic 160mmHg and diastolic 95mmHg.
  • Detection of a risk factor

CHC drug interactions

Antiepileptic drugs and anti-retrovirals

  • Epilepsy itself does not impose any restrictions on the use of contraceptive methods, but restrictions may apply if certain antiepileptic drugs (AEDs) are used
  • Women started on an enzyme-inducing AED should be advised to use a reliable contraceptive method that is unaffected by enzyme inducers: injectable progestogen, Cu-IUD, levonorgestrel-releasing IUS, or non-hormonal methods
  • Liver enzyme-inducing AEDs may reduce the contraceptive efficacy of CHCs, progestogen-only pills and progestogen-only implants. Progestogen-only pills (POP) and progestogen-only implants are NOT recommended as reliable contraception in women taking enzyme-inducing AEDs
  • The combination of CHC and lamotrigine is classified as a UKMEC 3 - the theoretical or proven risks generally outweigh the advantages of using the method. Lamotrigine clearance is increased by CHCs. Women using lamotrigine should be advised of the risk of reduced seizure control whilst on the CHC and the potential for toxicity in the CHC-free week. There is evidence that progestogen-only methods do not affect lamotrigine levels
  • CHC may increase the clearance of sodium valproate; the clinical significance of this interaction is unknown
  • Long-term treatment with carbamazepine, phenytoin, primidone and sodium valproate is associated with loss of bone mineral density (BMD) and fracture. It is unclear if concomitant use of DMPA leads to further loss of BMD, or an increased fracture risk
  • CHCs and PO implant effectiveness may be reduced by newer AEDs and antiretrovirals. Progestogen only injectable or intrauterine methods are preferred. For more information see FSRH guidance.
  • For guidance on epilepsy and pregnancy see the Epilepsy guidance, Chapter 4
  • Women who are HIV positive have special contraception needs and preconception needs in particular. Seek expert advice from Contraception/GUM services.

Other drug interactions

Specialist advice can be obtained from the Contraception Service (01392 284982 or 284931).

If a woman taking an enzyme inducing drug requires emergency hormonal contraception:

  • Preferably use a non-hormonal emergency contraceptive, i.e. a copper intrauterine device
  • If the above is not an option, the dose of levonorgestrel 1.5mg should be doubled; give 2 tabs in a single dose.

CHCs and antibacterials

Additional contraceptive precautions are not required when antibiotics that do not induce enzymes are used by women taking CHCs.

If antibiotics (and/or the illness) are causing vomiting or diarrhoea, then the usual additional precautions relating to these conditions should be observed (see below).

Postponement of menstruation

Women already using CHC: Continue next packet without a break. Omit dummy tablets if using an Every Day pack.

Women not taking an oral contraceptive: Start a progestogen, e.g. norethisterone 5-10mg three times a day, about 3-5 days before next expected period. Continue until a withdrawal bleed is desired

Progestogen-only contraceptive pill (POP)

See section 7.3 Contraceptives

Progestogen-only contraceptives POPs are suitable when oestrogens are contra-indicated (e.g. VTE or a past history or predisposition to venous thrombosis). If used consistently and correctly, POPs are more than 99% effective. They are suitable for older women, for heavy smokers, and for those with hypertension, valvular heart disease, diabetes mellitus, and migraine.

Changes in bleeding patterns associated with the POP are common and women should be informed about such changes. If a woman experiences bleeding problems or "minor" side-effects such as breast discomfort and acne an alternative progestogen may be tried as side-effects appear to depend on target-organ sensitivity.

Available evidence has not shown an increased risk of pregnancy in POP users with a heavier body weight or a higher body mass index. There is insufficient evidence to support a dose of more than one pill per day for women who are heavy or overweight.

POP users taking enzyme-inducing drugs should be advised to switch to the progestogen-only injectable or intrauterine contraception. For short durations of enzyme-inducing treatment (under 2 months) women can continue the POP providing they use additional precautions during treatment and for 28 days afterwards. Women wishing to start the POP after stopping enzyme-inducing drugs should be advised to use condoms until 28 days after the last dose of enzyme-inducing drug. Progestogen-only contraceptives (POPs) are not affected by broad spectrum antibiotics.

In the absence of any other clinical reason, the product of lowest acquisition cost should be chosen.

How it works

  • Traditional POPs work by altering cervical mucus to prevent sperm penetration. Ovulation is inhibited in some women
  • Desogestrel-only pill works primarily through inhibition of ovulation

Duration of use

  • From menarche until age 55 years (when natural loss of fertility assumed)

Failure rate

  • Failure rates for traditional POPs vary (0.3 and 8.0 per 100 woman years) but are lower in women aged over 40 years (0.3 per 100 woman years) than younger women

Effects on periods

  • Changes are common: 2 in 10 women have no bleeding, 4 in 10 women have a regular bleeding pattern, 4 in 10 women have irregular bleeding

Other risks

  • Data suggests there is little or no increase in risk of VTE, stroke or myocardial infarction associated with POP use.
  • Breast cancer: any risk of breast cancer associated with COC use is likely to be small, and will reduce with time after stopping

Return to fertility

No delay

Missed pills (CHCs and POPs)

Combined hormonal contraceptive pill (CHC)

Advice for women missing oral combined hormonal contraceptive pills (adapted from FSRH).

N.B. Refer to manufacturer's guidance for women taking Qlaira.

A CHC pill is classed as being "missed" if 24 hours have elapsed since it should have been taken.

Advice to women if one pill has been missed from anywhere in the pack (including the first day):

  • Take the last pill you missed now even if it means taking two pills in one day
  • Continue taking the rest of the pack as usual
  • No additional contraception needed but see notes below
  • Take your 7-day break as normal.

Advice to women if two or more pills have been missed from anywhere in the pack:

  • Take the last pill you missed now even if it means taking two pills in one day
  • Leave any earlier missed pills
  • Continue taking the rest of the pack as usual and use an extra method of contraception, or avoid intercourse, for the next 7 days
  • Emergency contraception (EC) may be needed (see below)
  • You may need to start the next pack of pills without a break (see below).

If missed pills are from the first week of the pack:

  • EC may be needed if UPSI has occurred in the pill-free interval or the first week of pill taking.

If missed pills from the second week of the pack where UPSI has occurred in the previous seven days and the pills in the first week had been taken consistently and correctly (assuming the pills thereafter are taken correctly and additional contraception is used):

  • EC is not needed

If missed pills from the third week:

  • EC should not be needed provided the woman omits the pill-free interval after finishing the pills in the current pack (discarding any placebo tablets from an ED pack) by starting a new pack the next day.

Progestogen only contraception (POP)

The Faculty of Sexual and Reproductive Healthcare recommends emergency contraception if one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours (12 hours for desogestrel) late and unprotected intercourse has occurred before 2 further tablets have been correctly taken

See Emergency contraception below

Diarrhoea and vomiting, surgery and travel

Vomiting up to 2 hours after taking a CHC may render it ineffective. Very severe diarrhoea can reduce the absorption of the active ingredients. Use additional methods until 7 pills have been correctly taken after recovery. If the diarrhoea or vomiting occurs during the last 7 tablets of a packet, omit the pill free interval and commence the next packet the following day.

If a woman vomits within 2 hours of taking a POP, another pill should be taken as soon as possible. If the subsequent pill is missed, additional precautions are required until 48 hours after pill taking has been resumed.

VTE risk is increased by oestrogens. The BNF advises that they are stopped 4 weeks before major elective surgery or any surgery of the legs or which involves prolonged immobilisation of a lower limb. They may be recommenced at the first menses occurring at least 2 weeks after full mobilisation. Use thromboprophylaxis if it has not been possible to stop the oestrogen. Progestogen-only methods can be continued during major surgery.

The risk of DVT may be increased if any mode of travel involves immobility for more than 5 hours. The risk may be reduced by exercise, adequate hydration, avoidance of alcohol and the use of compression hosiery.

Injectable Medroxyprogesterone acetate (DMPA)

For further details refer to FSRH Guidance (December 2014): Progestogen-only Injectable Contraception

Medroxyprogesterone acetate

How it works

  • Primarily by inhibiting ovulation

General prescribing notes

  • Frequency of administration:
    • every 12 weeks for Depo-Provera® - intramuscular injection of DMPA
    • every 13 weeks for Sayana® Press – subcutaneous injection of DMPA
  • Women using DMPA who wish to continue use should be reviewed every 2 years to assess individual situations, and to discuss the benefits and potential risks.
  • Women are generally advised to switch to another method at age 50 years.
  • In women aged under 18 years DMPA may be used as first-line contraception after all options have been discussed and considered unsuitable or unacceptable.
  • For women with significant lifestyle and/or medical risk factors for osteoporosis other methods of contraception should be considered.
  • The efficacy of DMPA contraception is not reduced with concurrent use of enzyme inducing drugs.

Failure rate

  • When administered at the recommended dosing interval (used consistently and correctly) the failure rate of progestogen-only injectable contraception is approximately 0.2% in the first year of use, but with typical use (includes incorrect/inconsistent use) the failure rate is approximately 6%.

Effects on periods

  • Altered bleeding patterns are commonly experienced by women using DMPA but there is a trend towards less bleeding and amenorrhoea with increased duration of use
  • DMPA use may reduce pain associated with endometriosis.

Other risks

  • The side-effect profiles for subcutaneous DMPA are broadly similar to those of intramuscular DMPA.
  • Whilst there is little evidence available to demonstrate causation, a number of possible side effects such as acne, decreased libido, mood swings, headache, hot flushes and vaginitis have been reported with use of DMPA.
  • Use of DMPA appears to be associated with weight gain, particularly in women under 18 years of age with a body mass index (BMI) ≥30 kg/m2. Women who gain more than 5% of their baseline body weight in the first 6 months of DMPA use are likely to experience continued weight gain.
  • Progestogen-only injectable use is associated with a small loss of bone mineral density, which is usually recovered after discontinuation.
  • The clinical significance of changes in BMD with use of DMPA is unclear and it is not known whether this translates to an increased risk of fracture.
  • Use of DMPA is not associated with an increased risk of ovarian or endometrial cancer and may offer some protection.
  • There is possibly a weak association between current use of DMPA and breast cancer
  • There is a weak association between cervical cancer and use of DMPA for 5 years or longer.
  • A causal association between DMPA and venous thrombosis has not been demonstrated
  • Health professionals should ensure that women requesting DMPA are up-to-date with cervical cytology screening and, if relevant, have completed the human papillomavirus vaccination programme.

Return to fertility

  • There can be a delay of up to 1 year in the return of fertility after discontinuation of IM or SC DMPA
  • Women who do not want to get pregnant should be advised to start another contraceptive method before or at the time of their next scheduled injection even if amenorrhoeic.

Etonogestrel Implant

Etonogestrel (Nexplanon® implant)

How it works

  • Preventing ovulation

Duration of action

  • 3 years

Failure rate

  • Very low: fewer than 1 in 1000 over 3 years

Effects on periods

  • Irregular bleeding is common. 20% of women have no periods, and almost 50% have infrequent or prolonged bleeding; bleeding patterns likely to remain irregular but dysmenorrhoea may improve. It is important that the patient is made aware of this before the implant is fitted. Women who have had gynaecological pathology excluded and for whom oestrogen is not contra-indicated may be offered a COC for treatment (unlicensed). This may be used for up to three months and can be given in the usual cyclic manner or continuously. Data to support this treatment option is limited

Other risks

  • Up to 43% of women stop using Nexplanon® within 3 years; 33% because of irregular bleeding, and less than 10% for other reasons including hormonal (non-bleeding) problems
  • 'Minor' progestogenic side effects, e.g. acne, breast pain
  • No evidence of effect on: weight, mood, libido, headaches or bone mineral density

Return to fertility

  • No evidence of delay

Advice at time of administration

  • Insertion and removal may cause discomfort and bruising but technical problems occur in fewer than 1 in 100 procedures
  • Local adverse effects at site of insertion. Difficulty with removal and scarring are very infrequent
  • If an implant cannot be localised by ultrasound before being removed; deeply inserted implants often need to be removed by an expert
  • No routine follow-up but return at any time if problems or to change/ discontinue method

Levonorgestrel Intra-Uterine System

Jaydess®

Levosert®

Mirena®

How it works

  • Mainly by preventing implantation; sometimes by preventing fertilisation

Duration of action

  • 3 (Levosert®, Jaydess®) or 5 (Mirena®) years depending on product (7/10 years if aged 45 or over at time of insertion)

Failure rate

  • Very low: fewer than 10 in 1000 women over 5 years. Expulsion occurs in fewer than 1 in 20 women in 5 years

Effects on periods

  • Irregular bleeding and spotting common in first 6 months, oligomenorrhoea or amenorrhoea likely by end of first year

Other risks

  • Up to 60% of women stop using the IUS within 5 years; most common reasons are unacceptable vaginal bleeding and pain, less common reason is hormonal (non-bleeding) problems
  • Ectopic pregnancy: overall rates lower than with no contraception but if a woman becomes pregnant with IUS in situ, risk is about 1 in 20 so she should seek advice to exclude it
  • Pelvic inflammatory disease: less than 1% for women at low risk of STI
  • Uterine perforation: less than 1 in 1000 (risk is related to the skill of the healthcare professional inserting the device)
  • Change in mood or libido: may be a small effect, similar for IUD and IUS
  • Acne: risk may be increased, but is an uncommon reason for stopping use
  • No evidence of effect on weight gain

Return to fertility

  • No evidence of delay

Advice at time of fitting

  • There may be pain and discomfort for a few hours and light bleeding for a few days
  • Watch for symptoms of uterine perforation
  • Follow-up visit after first menses or 3–6 weeks after insertion
  • Return at any time if problems or to change method
  • Check for threads regularly

Copper IUDs

See section 7.3 Contraceptives

How it works

  • Preventing fertilisation and inhibiting implantation

Duration of action

  • Women under 40 years: 5-10years for IUDs with 380mm2 copper, depending on type
  • Until contraception no longer needed if woman 40 years or older at time of insertion

Failure rate

  • Fewer than 2 in 100 women over 5 years for IUDs with at least 380mm2 copper.
  • Expulsion occurs in fewer than 1 in 20 women in 5 years

Effects on periods

  • Heavier bleeding and/or dysmenorrhoea likely

Other risks

  • Up to 50% of women stop using IUDs within 5 years; most common reasons are unacceptable vaginal bleeding and pain.
  • Ectopic pregnancy: overall rates lower than with no contraception but if a woman becomes pregnant with IUS in situ, risk is about 1 in 20 so she should seek advice to exclude it
  • Pelvic inflammatory disease: less than 1% for women at low risk of STI
  • Uterine perforation: less than 1 in 1000
  • Change in mood or libido: may be a small effect, similar for IUD and IUS
  • No evidence of effect on weight gain

Return to fertility

  • No evidence of delay

Advice at time of fitting

  • There may be pain and discomfort for a few hours and light bleeding for a few days
  • Watch for symptoms of uterine perforation
  • Follow-up visit after first menses or 3–6 weeks after insertion
  • Return at any time if problems or to change method
  • Check for threads regularly

Emergency contraception

Intrauterine device (IUD)

A copper IUD is more effective than hormonal methods of emergency contraception (98% effective, regardless of delay). It can be inserted up to 5 days after unprotected sexual intercourse (USI) or up to 5 days after the earliest likely day of ovulation (i.e. before implantation). The IUD can then be removed with the next period or left in situ for long-term contraception. Please see section 7.3 Contraceptives

The effectiveness of Levonorgestrel and possibly Ulipristal Acetate is reduced in women taking enzyme inducing drugs (and possibly for 4 weeks after stopping). A copper IUD may be the preferred option in this circumstance.

If a surgery is unable to provide an IUD insertion, patients can arrange a fitting by contacting:

  • Community Contraception and Sexual Health Service (CCASH Plymouth)
    • Telephone: 01752 434429
  • Sexual Medicine Service (Torbay and South Devon)
    • Telephone: 01803 656500
Patient or GP must mention the appointment is for an emergency fitting.

Emergency hormonal contraception (EHC)

Ulipristal Acetate (UPA) and Levonorgestrel work by delaying ovulation. UPA 30mg single dose can be given up to 120 hours after USI and Levonorgestrel 1.5mg single dose can be given up to 96 hours after USI (licensed for 72 hours only).

The earlier the treatment is commenced the more reliable it is. Therefore, women should be advised to take the dose as soon as possible after USI, and be advised that treatment failure may occur.

Weight and EHC

If a woman is over 70kg or has a BMI > 26kg/m 2, the efficacy of Levonorgestrel 1.5mg single dose may be impaired and she could have UPA single dose or Levonorgestrel double dose (unlicensed use).

If a woman has a BMI > 30kg/m 2 or weight > 85kg, consider emergency contraception if IUD not appropriate, but understand the efficacy of UPA may be reduced.

Progestogens and UPA

UPA is the most effective method mid-cycle, but it cannot be given if any progestogen (including Hormone Replacement Therapy and Levonorgestrel EHC) has been taken in the preceding 7 days.

Delay quick starting any progestogens for 5 days after UPA as this may interfere with the action of this method.

Other considerations

At the request of EHC by a patient consider sexually transmitted infection (STI) screening. In all patients less than 18 years of age and vulnerable adults consider safeguarding issues.

Patients should be advised that if a period is lighter than usual or more than 7 days late, they should return to clinic for pregnancy testing 3 weeks after taking oral EHC or IUD fitting.

After taking UPA and Levonorgestrel EHC, condoms or avoidance of sex should be advised for 7 days after starting Combined Hormonal Contraceptive (CHC), 9 days for Qlaira (non-formulary) CHC or 2 days after Progesterone only pill.

For further information

For further clinical guidance regarding specific methods of contraception, please refer to The Faculty of Sexual & Reproductive Healthcare Website.

See FSRH algorithms to help with deciding the best method of emergency contraception. (Reproduced under licence from FSRH. Copyright© Faculty of Sexual and Reproductive Healthcare 2011 to 2017)

 

Home > Formulary > Chapters > 7. Obstetrics, gynaecology, and urinary-tract disorders > Contraception Guidance

 

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