Contraception

COC prescribing guidelines and contraindications
WHO1	A	Always Usable no restrictions
WHO2	B	Broadly Usable Be alert	advantages outweigh risks
WHO3	C	Caution Counselling	Risks outweigh benefits – alternatives usually preferred but can sometimes be used by informed patient accepting risk rejecting alternative methods
WHO4	D	Do not use

COC gp training.net

medscape.com/viewarticle/421497_7

InfoPoems 1 yr prescription of COC

http://www.managingcontraception.com/shopping/product.php?productid=16161&cat=0&page=1

http://emedicine.medscape.com/article/258507-overview

http://library.med.utah.edu/kw/human_reprod/seminars/seminar1A4.html

Reproductive techniques.com COC absolute and relative contraindications

Prerequisites for prescribing: careful personal and family history (for contraindications) BP BMI.

COC Health Risks

http://www.who.int/reproductivehealth/publications/family_planning/9789241547710/en/

COC and cancer

Risks: Liver benign and malignant (exceedingly rare) Cervix ? Breast
Benefits: Endometrium Ovary ? Colorectal

Women who are apparently cured by local radical surgery for neoplasia of the ovary, cervix and uterus and for malignant melanoma may all use COCs.

Populations using the Pill may develop different benign or malignant neoplasms from control populations, but It does not appear from computer modelling studies that the overall risk of neoplasia is increased.

Choriocarcinoma/trophoblastic disease
http://hacking-medschool.com/molar-pregnancy
There is a theoretical risk that the COC may promote metastatic disease or drug resistant disease.
While HCG levels are raised, COC should be avoided – thereafter there are no restrictions on use.

Clinical implications
Women are advised not to conceive for 6 months after hCG levels are normal, and for at least 12 months from conclusion of any chemotherapy (because of a risk of recurrent disease and teratogenic effects of the chemotherapy).
So what contraception should be used?
While hCG levels are above 5000 iU/l, ovulation is very improbable, so barrier methods should be effective and these are first choice for what is usually a short time.
The progestogen only methods are all WHO 3 while hCG is elevated and emergency contraception (EC) is also permitted (WHO 3) see UKMEC.

Intrauterine methods are not recommended (WHO 4) until a normal menstrual cycle is established.
If frank cancer is diagnosed, with chemotherapy in progress, take advice from the regional centre: a progestogen only method such as Cerazette would often be best.

After the all clear with respect to hCG monitoring has been given by the regional centre,past history becomes irrelevant: any hormonal or intrauterine method is usable

COCs and circulatory disease

http://reproductivetechniques.com/index.php/cardiovascular-disease

http://www.medscape.com/viewarticle/421027_4

COCs and thrombophilias

hacking-medschool/thrombophilia

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2194308

thrombosis-charity.org.uk

clotconnectmd.wordpress.com/thrombophilias

http://www.patient.co.uk/doctor/Thrombophilia.htm

Only indication for screening is a strong family history of one or more siblings or parents having had a spontaneous VTE under the age of 45.

Which COC to choose

First, all marketed pills are ‘in the frame’ for prescribing. Given the tiny possible difference in VTE mortality between the two ‘generations’, the woman’s own choice (initially or at any later stage) of a DSG or GSD or other estrogen dominant product rather than a LNG or NET one after (well documented) discussion must be respected.

First-time users.
Despite what has just been said, it is generally agreed that a low-dose LNG or NET product should remain the usual first choice.
This is in partbecause first-timers will include an unknown subgroup who are VTE predisposed, VTE being a more relevant consideration than arterial disease at this age, and the pills suit the majority and cost less.
(Consider also offering the use of an ED pill type, to aid in remembering to restart after the pill-free time see below).

In the presence of a single WHO 2 or 3 risk factor for venous thrombosis, the Summary of Product Characteristics (SPCs) for COCs state that DSG/GSD
products are contraindicated.
This policy has merit if the COC is to be used solely for contraception.
However, if there is a clear therapeutic indication for the CDC, such as the polycystic ovarian syndrome (PCOS) with moderately severe acne, a different risk-benefit balance may apply.
Extra therapeutic benefits from a more estrogenic product may be judged to outweigh any expected extra risks (on a WHO 3 basis) because, for example, the woman has a BMI of 32.
Relevant choices might be Marvelon 30, Yasmin or Dianette. These probably all share the same (estrogendominant) category but only because they lack LNG, with its antagonizing EE effect.

Women with a single definite arterial risk factor (e.g. smokers or diabetics) after a number of years VTE free use or if used at all by healthy women above the age of 35. As we have seen, in premenopausal women, AMI is almost exclusively a disease of smokers. But the hazard is higher when such risk factors are present (the RCGP’s relative risk estimate for AMI was 20.8 for smoking Pilltakers) , it increases with age, and the case fatality rate for AMI in Pilltakers is also higher.

There is some suggestive evidence that DSG/GSD Pills might have relative advantages for arterial wall disease. Therefore for such higherrisk women, or older women aged 35 to 50/51 (provided they are otherwise arterial riskfree), using a 20/1g DSG or GSD product might be (at least) discussed. Any advantages in so doing are far from established, and changing to a different method altogether would usually be a better course.
In the UK, Femodette (Schering) (GSD) or Mercilon (Organon) (DSG) are the relevant 20/1g EE products.
Loestrin 20 (Galen) would also be acceptable and preferable if there were any WHO 3level concern about VTE risk since it contains a NETgroup progestogen.

Finally, the primary reason for ever changing COC brands is the control of side effects, for the woman’s quality of life.
If, for any indication, she moves to using a product not containing LNG or NET, it should be documented that she accepts a possible tiny increase in the risk of VTE. This can be explained as ‘in the ballpark’ of the risk of driving for 2 hours in the next year.

COC first prescription

Faculty of Sexual & Reproductive Healthcare Medical history before a first prescription of COC

In order to advise on eligibility for combined oral contraception (COC) use, clinicians should take a clinical history including: medical conditions (past and present), drugs use (prescription, non-prescription and herbal remedies) and family history
When considering a first prescription of COC, clinicians should specifically enquire about migraine and cardiovascular risk factors (smoking, obesity, hypertension, thrombophilia, previous venous thromboembolism and hyperlipidaemia)
User preference and individual concerns about COC use should be addressed

Age COC can be used from the menarche to age 50 years if there are no other risk factors

Smoking very small increased risk of myocardial infarction (MI) with current COC use in non-smokers which increases further for smokers
Use of COC by women over 35 years who smoke is not recommended
Use of COC may be considered by women aged ?35 years who have stopped smoking for ?1 year

Obesity
Use of COC by women with a BMI ?35 is associated with an increased risk of MI and VTE and is not generally recommended

Hypertension
Use of COC is not generally recommended when blood pressure is consistently >140 mmHg systolic and/or >90 mmHg diastolic

VTE
Use of COC by women with a personal history of venous thromboembolism (VTE) or known thrombogenic mutations is not recommended
Clinicians should be aware that the relative risk of VTE with COC use can increase up to five-fold, but in absolute terms the risk is still very low
A thrombophilia screen is not recommended routinely before prescribing COC
For women with a family history of VTE, a negative thrombophilia screen does not necessarily exclude all thrombogenic mutations
The interpretation of a thrombophilia screen should be undertaken in consultation with a haematologist or other expert and in combination with a detailed family history

Stroke Clinicians should be aware that there is a very small increase in the absolute risk of ischaemic stroke with COC use

Migraine Use of COC by women of any age who have migraine with aura is not recommended
Use of COC by women ?35 years of age who have migraine without aura is not generally recommended

Breast cancer Clinicians should be aware that any increased risk of breast cancer with COC use is likely to be small, is in addition to background risk, and is reduced to no increased risk 10 years after stopping COC use

Cervical cancer Clinicians should be aware that there may be a very small increase in the risk of cervical cancer with COC use, which increases with increasing duration of use

Drug interactions
Clinicians should consider the possibility of drug interactions when prescribing COC
Liver enzyme-inducing drugs may reduce the efficacy of COC; therefore, if they are to be used long term, alternative contraceptives that are unaffected by enzyme-inducing drugs should be considered
If, after counselling, women using liver enzyme-inducing drugs still wish to use COC then a regimen with at least 50 µg ethinylestradiol (EE) should be used. In addition, barrier contraception is recommended while taking the liver enzyme-inducers and for 28 days after they are stopped
alA woman taking long-term non-liver enzyme-inducing antibiotics (?3 weeks) does not require additional contraceptive protection when starting COC
alWomen using COC who are prescribed a short course (<3 weeks) of non-liver enzyme-inducing antibiotics should be advised to use additional contraceptive protection while taking the antibiotic and for 7 days after the antibiotic is stopped

Dysmenorrhoea and menorrhagia menstrual pain and blood loss may be reduced with COC use

Ovarian cysts incidence of functional ovarian cysts and benign ovarian tumours is reduced with COC use

Ovarian and endometrial cancer Clinicians should be aware that there is at least a 50% reduction in the risk of ovarian and endometrial cancer with COC use which continues for 15 or more years after stopping

Colorectal cancer Clinicians should be aware that COC use is associated with a reduction in the risk of colorectal cancer

Acne vulgaris may improve

Weight gain No evidence of additional weight gain due to COC use

Bleeding patterns unscheduled bleeding can occur with COC use but in the absence of missed pills, vomiting within 2 hours of pill taking, severe diarrhoea or drug interactions it is not a measure of efficacy
Clinicians may wish to give women advice to alter the timing of the withdrawal bleeds but should be aware that this use is outside the terms of the product licences

Which examinations are needed before a first prescription of COC? BP BMI

When can COC be started? Ideally COC should be started on the first day of menstruation but can be started up to and including Day 5 of the cycle without the need for additional contraceptive protection
COC can be started at any other time in the cycle if it is reasonably certain the woman is not pregnant but additional contraceptive protection, such as condoms, is required for the first 7 days

Which pill is suitable for women being given a first prescription of COC?

A monophasic COC containing 30 µg EE with norethisterone or levonorgestrel is a suitable first pill

Follow-up arrangements A follow-up visit 3 months after a first prescription of COC allows an assessment of blood pressure, further instruction and assessment of any problems In the absence of special problems, women can be given up to 12 months’ supply of COC at follow-up and encouraged to return at any time if problems arise

What information should be given to all women when receiving a first prescription of COC?
Potential harms and benefits

At first prescription of COC all women should be informed that:
COC use is safe for the majority but can be associated with rare but serious harms
there is a small increase in the risk of blood clots with COC use
there is a very small increase in the risk of heart attack and stroke with COC use
any increased risk of breast cancer is likely to be small and returns to no increased risk 10 years after stopping COC
there may be a very small increase in the risk of cervical cancer that increases with increasing duration of use
the risk of ovarian and endometrial cancer is halved with COC use and this continues for at least 15 years after stopping

How to take the pill

Women should be advised to start COC on the first day of menstruation but it can be started up to and including Day 5 of the cycle without the need for additional contraceptive protection
Women can start COC at other times in the menstrual cycle if is reasonably certain that they are not pregnant but additional contraceptive protection is required for the first 7 days
Women should be encouraged to take one pill every day, at around the same time, for 21 consecutive days
Women should be advised that if all pills are taken consistently and correctly a COC is 99% effective at preventing pregnancy, even during the routine seven hormone-free days
Missing pills is not encouraged but women can be reassured that if one pill in the packet is missed at any time then contraceptive protection is not lost. If more pills are missed and they are unsure what to do they should seek help

Situations where efficacy may be reduced

If vomiting occurs within 2 hours of taking COC another pill should be taken as soon as possible
Women should be informed that if they are prescribed antibiotics (non-liver enzymeinducing) then additional contraceptive protection such as condoms should be used during the treatment and for 7 days after the antibiotic is stopped. If fewer than seven active pills are left in the pack after antibiotics are finished the woman should omit the pill-free interval (or discard any inactive pills). After using the same antibiotic for ?3 weeks additional contraception is no longer required

Other information

Women should be encouraged to continue with the first COC for at least 3 months before considering an alternative
Women should be given information on symptoms, which should prompt immediate medical consultation such as warning signs of VTE and new headache
Women can be advised about practising safer sex with the use of condoms in addition to COC
Women should be provided with appropriate written and verbal instructions regarding rules for missed pills, vomiting within 2 hours of taking a pill, severe diarrhoea, the use of new medication and when to seek help

Faculty of Sexual & Reproductive Healthcare http://www.fsrh.org First prescription of combined oral contraception. (July 2006).

Contraceptive choices for over 40s

http://www.eguidelines.co.uk/eguidelinesmain/gip/vol_14/melvin_contraception_jan11.php

http://www.fsrh.org/pages/clinical_guidance.asp

COC pill ladder

John Guillebaud Get Permissions

Pill ladder @ OnMedica (registration required)

COC horseshoe

Missed pill advice

fsrh.org clinical guidance

FFPRHS issues revised guidance on missed contraceptive pills May 2011

If one active Pill is missed, there is no need to take additional precautions
If two active Pills are missed, additional precautions should be taken for the next 7 days

If one Pill has been missed (more than 24 hours and up to 48 hours late)
Emergency contraception (EC) is not usually required but may need to be
considered if Pills have been missed earlier in the packet or in the last week of the previous packet.

Two or more missed pills (more than 48 hours late) within the first 7 days of a new packet patient will need emergency contraception if sexual intercourse has occurred. Extra precautions are needed for 7 days.
Pills missed in first week (Pills 1-7): consider EC if unprotected sex
occurred in pill-free interval or first week of pill-taking
Missed pills between days 7 and 14 of the packet patient should take next pill as soon as possible and use extra precautions for 7 days. Emergency contraception may be needed if more than four pills have been omitted.
Missed pills between days 14 and 21 patent should omit pill-free interval and take next packet of pills back-to-back with current packet. Use extra precautions for 7 days.

Pills missed in third week (Pills 15-21): finish Pills in current pack
(or discard placebo Pills) and start new pack the very next day. In
other words miss out the usual Pill-free interval.

Emergency contraception may be needed if more than four pills have been omitted.

There is a risk of ovulation if the pill-free interval is extended to 9 days or more.
Applies to all COCs with an estrogen dose of at least 20mcg (with the exception of the estradiol valerate-containing Pill), whether monophasic or phasic and including every day (ED) preparations.
The CEU explains that a missed Pill is defined as one that is more than 24 hours late. If more than one Pill is missed, the rule applies to consecutive Pills.
If it is reasonably certain that the woman is not pregnant, COCs can be initiated on any day of the menstrual cycle, not just the first day. Additional contraceptive precautions are required for the first 7 days if the Pills are started after day 5 of the cycle

Faculty of Sexual & Reproductive Health Clinical Guidance

Antibiotics and the pill

RCOG Revised Guidance Jan 2011 http://www.fsrh.org/pages/clinical_guidance.asp

Additional precautions are no longer necessary provided that women are taking the antibiotics for less than three weeks.
Rifampicin and rifabutin are the only enzyme-inducing antibiotics that are excluded from the guidance but women using these drugs long-term should be advised to switch to a method that is unaffected by enzyme-inducing drugs.
Women who do not wish to change from their contraceptive method while on short-term treatment with an enzyme-inducing drug can be advised to continue using a combined oral contraceptive containing at least 30mg ethinylestradiol, the patch or ring along with additional contraception, with a hormone-free interval of four days. Additional contraception should be continued for 28 days after stopping the enzyme-inducing drug.

Other changes

Avoid COC in women with epilepsy taking lamotrigine (risk of reduced seizure control, and the potential for toxicity in the contraceptive-free week)
Lansoprazole is no longer listed as an enzyme-inducer

Testing hormone levels in women on the COCP

Usual practice is to wait until the woman has been off the COCP for 6 weeks before testing an FSH level.
This can then be repeated in a further 1-2 months.
The progesterone-only pill (POP) does not interfere with hormonal

Combined contraceptive patch Evra

Contraceptive patch containing 20 micrograms of ethinylestradiol and 150 micrograms of norelgestromin

Each patch lasts for 1 week and then needs to be replaced. Women wear the patch for 3 weeks, and then have a patch-free week.

Avoid if body weight >90 kg.
Warn the user that the contraceptive is in the glue of the patch, so a dry patch that has fallen off should not be re-used!

As with the COC, it is essential never to lengthen the contraception-free (patch-free) interval
If this interval exceeds 8 days for any reason advise extra precautions for the duration of the first freshly applied patch (i.e. for 7 days). EC should be considered if there has been sexual exposure during the preceding patch-free time, particularly if that exceeded 9 days.

Absorption problems through vomiting/diarrhoea, and tetracycline (??) by mouth, have no effect on this method’s efficacy, but during any short-term enzyme-inducer therapy, and for 28 days after this ends, additional contraception (e.g. with condoms) is advised, plus elimination of any patch-free intervals during this time.
Relatively quite estrogen-dominant, with a bleeding and non-bleeding side-effect profile very like Cilest

Transvaginal COC NuvaRing

Contraceptive vaginal ring containing 15 micrograms ethinylestradiol and 120 micrograms etonogestre (cf Mercilon)
Each ring is used for 3 weeks, followed by a 1-week ‘ring-free’ interval.

POPs
Noriday	norethisterone 350mcg 28 tablets
Micronor	norethisterone 350mcg 28 tablets
Femulen	ethynodiol diacetate 500 mcg 28 tablets
Norgeston	levonorgestrel 30 mcg 35 tablets
Cerezette	desogestrel 75mcg 28 tablets

In general, unless the POP is started on the first day of the cycle or when a woman is lactating, extra precautions should be used for the first 7 days. It should be taken at the same time every day (there is a ‘missed pill window’ of 3 hours). Women over 70 kg should consider taking two POPs a day, particularly if they are young (eg < 30). If the 3-hour window period is missed, extra precautions should be used for 7 days and if sexual intercourse takes place within 48 hours following the delay, emergency contraception will be needed.

Cerazette® has a higher dose of progesterone than other pills and inhibits ovulation in most women who take it; it is now marketed as having a 12-hour ‘missed pill window’ period, compared with 3 hours for the other POPs. It is more effective than other POPs and may therefore be better for younger women. There is no need to increase the dose in obese women.

POPs
The progestogen-only oral preparations (POP) have a higher failure rate than combined preparations, but offer an alternative when estrogens are contra-indicated. Five varieties: four are of the old type that variably inhibit ovulation, while the fifth, Cerazette, is a primarily anovulant product.

Noriday® / Micronor® (Norethisterone) tablets 350micrograms
Femulen® (Etynodiol diacetate) tablets 500micrograms
Dose: 1 tablet daily at same time each day, starting on day 1 of cycle then continuously; if administration delayed for 3 hours or more it should be regarded as a missed pill

Cerazette® (Desogestrel) tablets 75micrograms
Dose: 1 tablet daily at same time each day, starting on day 1 of cycle then continuously; if administration delayed for 12 hours or more it should be regarded as a missed pill, see BNF for advice.

Cerazette® (as with other POP) should be restricted for use in women who cannot tolerate estrogen-containing contraceptives or in whom such preparations are contra-indicated. Cerazette® is more expensive but has been shown to inhibit ovulation to a substantially greater extent than other POP. It is therefore recommended as a second choice POP for those women who need a POP and in whom the first line formulary choices are not appropriate, and as a first choice POP for less compliant women and women with history of ectopic pregnancy who take a POP.

Despite this higher incidence of (more acceptable) oligomenorrhoea than with existing POPs, Cerazette (like other POPs and Implanon) still appears to provide adequate follicular phase levels of estradiol (see above).
Contraindications Very similar to those for old type POPs. The main difference is that Cerazette is more effective,
making it positively suitable for a past history of ectopic pregnancy

Femulen is the only lactose-free contraception available in the UK.

LARCS

Long acting reversible contraception LARCS

NICE CG30 Long-acting reversible contraception Oct 2005 QRG
intrauterine devices IUDs
the intrauterine system IUS
injectable contraceptives
implants

All LARCs are suitable for
nulliparous women
women who are breastfeeding
women who have had an abortion (at time of abortion or later)
women with BMI >30
women with HIV
women with diabetes
women with migraine with or without aura
women with contraindication to oestrogen

Women at risk of sexually transmitted infection
IUD, IUS: tests may be needed before insertion
DMPA, implants: no specific contraindications
provide advice on safer sex

Adolescents
IUD, IUS, implants: no specific restrictions to use
DMPA: care needed; use only if other methods unacceptable or not suitable

Women over 40 years
IUD, IUS, implants: no specific restrictions to use
DMPA: care needed, but generally benefits outweigh risks

Postpartum, including breastfeeding:
IUD, IUS: can be inserted from 4 weeks after childbirth (see page 4)
DMPA, implants: any time after childbirth

Women taking other medication:
IUS, DMPA: no evidence that effectiveness of other medication reduced
implants: not recommended for women taking enzymeinducing drugs

Epilepsy
IUD, IUS, DMPA: no specific contraindications; DMPA use may be associated with reduced seizure frequency
implants: not recommended for women taking enzymeinducing drugs

Injectable contraception

Injectable / Parenteral contraception

Depo-Provera® (Medroxyprogesterone) depot injection 150mg/ml Dose: 150mg deep IM injection repeated every 12 weeks
Noristerat (norethisterone enanthate; Schering Health Care) 200 mg every 8 weeks

Note that ovarian activity can take up to a year to recover after stopping depot medroxyprogesterone injections.
Consider risk of osteoporosis in relation to age and long-term use.

PROGESTERONE INJECTIONS
DepoProvera® can generally be used for about 5 years at a stretch before alternatives are considered, although the CSM recommends reviewing the
patient every 2 years to assess whether the benefits still outweigh the risks.
Oestrogen levels should be checked if a woman has been receiving injections for >5 years or if she has symptoms of hypooestrogenism, eg dry vagina, low libido, depression, acne, breakthrough bleeding . If oestrogen levels are going to be checked, a blood sample should be taken just before the next injection is due. Levels of <1 00 pmolll are considered low, and alternative forms of contraception should be discussed.
amenorrhoea alone is not a good reason for checking oestradiol levels; this does not automatically indicate hypooestrogenism, just as having periods isnot a sufficient reassurance. However, women who have been amenorrhoeic for >3 years should be questioned about symptoms of hypooestrogenism.

Contraindications
Women who are >45
Women with osteoporosis or strong risk factors for osteoporosis (eg heavy smoking, anorexia, longterm steroid use)
CVD or strong risk factors for CVD
History of symptomatic ovarian cysts.

DepoProvera® is given every 12 weeks. If there is up to a week’s delay, the next injection should be given as normal, and the patient advised to use
condoms for 7 days. If the delay is >1 week, emergency contraception may be needed. If the delay is >2 weeks, the next injection should not be given until the patient has been abstinent for at least 10 days and a pregnancy test is negative. This does not apply if no sexual intercourse has taken place since the date when the next injection was due.

Administration
There are actually two injectable agents available: DMPA 150 mg every 12 weeks, and, both given by deep intramuscular injection in the first 5 days of the menstrual cycle. Injections may also be given beyond day 5, with 7 days added precautions if it is near certain that a conception risk has not been taken.

IM usually in the right upper quadrant of either buttock, should notbe massaged.

indications
Choice
A past history of ectopic pregnancy or thrombosis
endometriosis
past symptomatic functional cysts
sickle cell anaemia
epilepsy, in which it often reduces the frequency of seizures.

Injectibles contraindications

Absolute contraindications for DMPA
Past severe arterial diseases, or current very high risk thereof
(because of the above evidence about low estrogen levels
coupled with reports of lowered HDL cholesterol)
Osteopenia /risk factor(s) for osteoporosis, including chronic steroid treatment
Any serious adverse effect of COCs not certainly related solely to the estrogen (e.g. liver adenoma or cancer)
Recent breast cancer not yet clearly in remission
Porphyria (progestogens as well as estrogens can ppt)
Undiagnosed genital tract bleeding
Actual or possible pregnancy
Hypersensitivity to any component.

Relative contraindications for DMPA
Arterial disease
Familial hyperlipidaemia (UKMEC) longstanding DM – other
progestogen only methods such as the POP are preferred
Shortterm steroid treatment, recovered anorexia nervosa with
normal menstrual cycling (see above these are usually WHO
3)
Under 18 or over 45 years of age are WHO 2 with respect to
the bones (see above)
Active liver disease with abnormal liver function tests caution
required (WHO 3) but WHO 2 with normal biochemistry
Recent trophoblastic disease is WHO 3 (UKMEC) until hCG is
undetectable in blood as well as urine, then WHO 1
DMPA is usable in all nonacute porphyrias (WHO 2)
Sexsteroiddependent cancer, including breast cancer, in
complete remission is WHO 3 (after 5 years according to
WHOMEC). However, a POP or LNGIUS would be preferable
(lower dose, more reversible)
Unacceptability despite reassurance of menstrual irregularities,
especially cultural/religious taboos whether associated with
bleeding or amenorrhoea
Obesity, although further weight gain is not inevitable (see
below)
Past severe endogenous depression
Planning a pregnancy in the near future
Bleeding tendency

Counselling
1 The effects, whether wanted (contraceptive) or unwanted,
are not reversIble for the duration of the injection: this fact is unique among current contraceptives.
2 Weight gain is probable due to increased appetite
3 Irregular, sometimes prolonged, bleeding usually followedafter a few months by amenorrhoea
4 After the last dose, conception is commonly delayed with a delay up to 9-12 months, So there is no evidence of permanent infertiliity
caused by the drug.
With respect to continuing postDMPA amenorrhoea:
if conception is not wanted, alternative contraception must begin for about 13 weeks since the last injection
If conception is wanted, spontaneous ovulation can be anticipated in most cases: if not, refer for
investigation/treatment at about 12 months after the last injection.

Follow up
BP is normally checked initially, but no need thereafter.

DMPA frequent or prolonged bleeding

First, check that it does not have a non DMPA related cause (e.g. Chlamydia)
Usually an early problem that is then generally followed by amenorrhoea after 36 months.
If it does not resolve, the next injection may be given early (but not less than 4 weeks since the last dose).
http://apps.who.int/rhl/fertility/contraception/vbcom/en/index.html

http://www.medscape.com/viewarticle/732231_9

http://www.fsrh.org/pages/clinical_guidance.asp

http://www.aafp.org/afp/2002/0515/p2073.html

http://www.rcog.org.uk/womens-health/clinical-guidance/heavy-bleeding-depo-provera-query-bank

http://www.rcog.org.uk/management-unscheduled-bleeding-women-using-hormonal-contraception

Gynae problems related to contraception

LARCS contraceptive implants

Nexplanon® (Etonogestrel) implant 68mg in one radiopaque flexible rod 40 mm by 2mm
Dose: by subdermal implantation by suitable qualified practitioner, no previous hormonal contraceptive, 1 implant inserted during first 5 days of cycle. For further dose information refer to SPC; remove within 3 years of insertion. Return of fertility after removal is rapid and appears to be complete. Return of fertility after removal is rapid and appears to be complete.

http://www.nexplanontraining.co.uk/

Works primarily by ovulation inhibition, supplemented mainly by the usual spermblocking mucus effect. It is a single
Etonogestrel is the chief active metabolite of desogestrel and so has much in common with Cerazette.

Clinically:
Implanon is inserted subdermally but very superficially under the skin over the biceps, medially in the upper arm, under local
anaesthesia

After an initial phase of several weeks giving higher blood levels, Implanon delivers almost constant low daily levels of the
hormone, for a recommended duration of use of 3 years.

Effect of body mass: in the international studies, serum levels tended to be lower in heavier women, but, given the high margin of
efficacy, subsequently failures attributed to 8MI have not occurred. May be advisable to remove earlier eg 3rd year if patient began cycling regularly

Enzyme inducer drug treatment
Hepatic enzyme inducers may lower the blood levels of etonogestrel.
Users are advised to use a barrier method in addition and (because reversal of enzyme induction always E
takes time) for 28 days thereafter. During long term enzymeinducer drug treatment, Organon recommends transfer to a nonhormonal
method and removal of the Implanon. This seems a
bit wasteful and may be resisted by satisfied users; moreover,
those in monogamous relationships may reject the longterm
use of barriers. So, despite the absence of specific trials, one
might instead consider compensating for the enzyme induction
by, for example, a daily Cerazette or even (expensively!) by a
second Implanon. These prescriptions would be unlicensed and
therefore used on a ‘namedpatient’ basis (see p. 150).

However, since enzymeinducer drug users do so well with DMPA or the LNGIUS, these might be better as well as cheaper
options, for longterm users.

Reversibility and removal problems
Reversal is normally simple, with almost immediate effect. Under local anaesthesia, steady digital pressure on the proximal end
of the Implanon with a 2 mm incision over the distal end leads to delivery of that end of the rod, removal being completed by
grasping it with mosquito forceps. Again, removal training is crucial, using the ‘model arm’ and live under supervision.
Removal problems can be minimized by good training, in both the insertion and removal techniques. Difficult removals correlate
with initially toodeep insertion. Beware particularly of the thin or very muscular woman with very little subcutaneous
tissue. Insertion can easily permit a segment of the rod to enter the (biceps) muscle, with deep migration following.
Specialized ultrasound techniques are required to localize ‘lost’ Implanons, and removal may need to be under ultrasound control:
therefore Organon should be contacted for advice in all such cases.

Advantages and indications
The main indication is the woman’s desire for a highly effective yet at all times rapidly reversible method, without the finality of
sterilization, which is independent of intercourse: especially when other options are contraindicated or disliked.
Above all, it provides efficacy and convenience: if the bleeding
pattern suits, it is a ‘forgettable’ contraceptive.
There is a long duration of action with one treatment (3 years),
and high continuation rates.
There is no initial peak dose given orally to the liver.
Blood levels are low and steady, rather than fluctuating (as with
the POP) or initially too high (as with injectables); this, with the
previous point, means metabolic changes are minimal and
negligible.

Implanon is estrogen free, and therefore definitely usable if there is a history of VTE (WHO 2).
Median systolic and diastolic BP were unchanged in trials for up to 4 years.
Being an anovulant, special indications include past ectopic
pregnancy and as a possibility for menstrual disorders, although
the outcome is not reliably beneficial (because of irregular
bleeding see below).
The effects are rapidly reversible, an advantage over DMPA
which is worth emphasising. After removal, serum etonogestrel
levels were undetectable within one week, so return of fertility
must be assumed to be almost immediate.

Contraindications are very similar to Cerazette since, like it but unlike DMPA, Implanon is an anovulant yet immediately
reversible (and they contain essentially the same progestogen).

Absolute contralndlcatlons (WHO 4) for Implanon
Any serious adverse effect of COCs not certainly related solely to the estrogen (e.g. liver adenoma or cancer)
Recent breast cancer not yet clearly in remission
Acute porphyria with history of actual attack precipitated by hormones; otherwise WHO 3
Known or suspected pregnancy
Undiagnosed genital tract bleeding
Hypersensitivity to any component.
The manufacturer adds ‘severe hepatic disease’, which WHOMEC
classifies as WHO 3, and ‘active venous thromboembolic disorder’,
which presumably means a current episode which is only WHO 2
according to UKMEC. There is no evidence that Implanon (like all other
progestogenonly methods) can increase VTE risk.
Relative contralndlcatlons (WHO 3)
Acute porphyria, latent, with no previous attack (use with
forewarning/monitoring); Implanon is also usable in all the nonacute
porphyrias
Current severe liver disorder with persistent biochemical change
Recent trophoblastic disease until hCG is undetectable in blood
as well as urine; then WHO 1
Sexsteroiddependent cancer, including breast cancer, in
complete remission (WHO advises 5 years). In all cases, agreement
of the relevant hospital consultant should be obtained and
the woman’s autonomy respected: record that she understands it
is unknown whether progestogen alone in Implanon alters the
recurrence risk
Enzymeinducers discussed above (but another method such as an DMPA, IUD or LNGIUS would be preferable)
Past symptomatic functional ovarian cysts might recur using Implanon, especially in the third year.

Relative contralndlcatlons (WHO 2)
Past VTE or severe risk factors for VTE; clinically, In fact, this is often an indication (see above)
Risk factors for arterial disease; more than one risk factor can be present
Current liver disorder, now with normal biochemistry
Most other chronic severe systemic diseases
Unacceptability of irregular menstrual bleeding which remains a problem with all progestogenonly methods, certainly including
Implanon.

Timing of Imp/anon insertion
In the woman’s natural cycle, day 15 is usual timing; if
any later than day 5 (assuming no sexual exposure up to
that day), recommend additional contraception for 7 days.
If a woman is on COC or POP/Cerazette or DMPA, the
implant can normally be inserted at any time, with no
added precautions.
Clinical implications
Insertions only during the above tiny naturalcycle window are a
logistic and conception risk nightmare! So a useful practice tip
is actively to recommend use of an anovulant method (i.e. one
of those in the second point, in the above box) at counselling,
for use until the Implanon insertion. If the COC is chosen, it may
usefully be run on (‘tricycled’), so the implant is placed during
alreadyestablished amenorrhoea
Timing In noncycling states
Following delivery (not breastfeeding) or secondtrimester
abortion, insertion on about day 21 is recommended, or if later
with additional contraception for 7 days. If later and still amenorrhoeic,
pregnancy risk should be excluded.
If breastfeeding, insert on day 2128 (UKMEC), with no need for
added contraception for 7 days.
Following firsttrimester abortion, immediate insertion is best:
on the day of surgically induced abortion or the second part
of a medical abortion, or
up to 7 days later
if >7 days later, an added method such as condoms is
recommended for 7 days.
Counselling and ongoing supervision
Explain the likely changes to the bleeding pattern and the possibility
of ‘hormonal’ side effects (see below). This discussion
should as always be backed by a good leaflet, such as the FPA
one, and welldocumented.
No treatmentspecific followup is necessary (including no need
for BP checks). The SPC recommends one followup visit at 3
months. More important is an explicit ‘openhouse’ policy, so the
95
woman knows she can return at any time to discuss possible
side effects, without any provider pressure to persevere if the
woman really wants the implant removed (the standard for the
maximum wait for removal should be no more than 2 weeks).
Bleeding problems
In the premarketing randomized controlled trial comparing
Implanon with the old siximplant Norplant, the bleeding patterns
were very similar:
Amenorrhoea was significantly more common, as expected for an
anovulant method.
The infrequent bleeding and spotting rate (normally an acceptable
pattern) was about 26%.
Normal cycling was reported by 35% of women.
However, the combined rates for the more annoying ‘frequent
bleeding and spotting’ and ‘prolonged bleeding and spotting’
totalled 18% with Implanon.
Clinical management
With reassurance, most women are happy to accept one of the
patterns in the first three points above. For the fourth group, perseverance
beyond 3 months is rewarded less often than with DMPA.
After eliminating unrelated causes for the bleeding (p. 57):
The best shortterm treatment is cyclical estrogen therapy to
produce some ‘pharmacological curettages’ (i.e. withdrawal
bleeds), on a similar basis to the above regimen for DMPA. This
may most easily be provided by three cycles of Mercilon or
Marvelon, after which the bleeding may (or sometimes may not!)
become acceptable. As above, the plan should be explained to
the woman, who should also understand that it is not certain to
work. Courses may be repeated if an acceptable bleeding
pattern does not follow. Or,
If the woman has a WHO 4 contraindication to EE, an
alternative that was effective short term in a pilot study is
doxycycline 100 mg bd for 5 days. The mechanism is believed
to be an effect on endometrial enzymes and is probably
independent of treating any Chlamydial endometritis. But one
should test for Chlamydia first, as usual with irregular bleeding.
96
Minor side effects
Reported in frequency order, minor sideeffects were:
Acne (but this also sometimes improved I)
Headache
Abdominal pain
Breast pain
‘Dizziness’
Mood changes (depression, emotional lability)
Libido decrease
Hair loss.
Weight gain
In the premarketing randomized controlled trial, the mean body
weight increase over 2 years was 2.6% with Implanon and 2.9%
with Norplant, while in a parallel study, similar users of an IUD
showed weight increases of 2.4% in the same timescale. Weight
seems to be less of a problem than with DMPA, although some
individuals do find their weight gain unacceptable.

Bone mineral density
Since Implanon suppresses ovulation and does not supply any
estrogen, the same questions as with DMPA arise over possible
hypoestrogenism However, it appears that, like Cerazette
and other POPs, the suppression of FSH levels with Implanon
is less complete, allowing higher follicular estrogen levels.
In a nonrandomized comparative study, no bone density
changes or differences in the means, ranges or standard errors
were detected between 44 users of Implanonusers and 29
users of copper IUDs over 2 years, which is reassuring.

Hormone releasing intra-uterine systems
The progestogen-only intra-uterine system, Mirena®, releases levonorgestrel directly into the uterine cavity.
It is licensed for use as a contraceptive and for the treatment of primary (idiopathic) menorrhagia. This may therefore be a contraceptive method of choice for women who have excessively heavy menses. Return of fertility after removal is rapid and appears to be complete. Mirena® is also licensed for four years as the progestogen component of an HRT regimen.

IUD / IUS

IUD PUK

IUS PUK

mirena-us.com

IUD insertion medicalvideos.us

IUD ffprhc/eguidelines.co.uk

Two types
1 Copper IUDs – eg Copper T 380 slimline coil (Cu 380 S) – Cu is released from a band or wire on a plastic carrier It is extremely effective and can be left in situ for 8-10 years or till menopause if fitted after 40

2 LNG IUS (mirena) levonorgestrel releasing intrauterine system , which releases that progestogen (20 micrograms per day)
can be left in situ for up to 5 years if used as a contraceptive, or longer if used to control symptoms of dysmenorrhoea or menorrhagia.

Cu 380 S
Women should routinely have a check-up 6 weeks post-insertion
and then annually. The best time to insert a coil is between days 4 and 14 of the cycle (and certainly before day 20). Removal is usually arranged when
the woman is menstruating, but can be done at any time providing that she starts using an alternative form of contraception at least 7 days prior to
removal. This is of course not necessary for a patient who wants to become pregnant.
Women who do conceive while the IUD is in situ should be advised to have it removed, ideally in the first trimester. If the threads are not visible and
therefore the IUD cannot be removed, there is an increased risk of second trimester abortion. If the woman goes on to delivery suite with the IUD still
in situ, she must warn the midwife to check that it has been expelled with the products of conception. If not, she will need to have a radiograph to
identify where it is; it could otherwise cause her ongoing pain and fertilityproblems.

Assessing and managing STIs and other infections
Before inserting an IUD or IUS, test for:
Chlamydia trachomatis in women at risk of STIs
+ Neisseria gonorrhoeae in women at risk of STIs in areas where it is prevalent
+ any STIs in women who request it
For women at increased risk of STIs, give prophylactic antibiotics before inserting an IUD or IUS if testing has not been completed

For women with identified risks associated with uterine or systemic infection, arrange investigations, and give appropriate prophylaxis or treatment before inserting an IUD or IUS

When fitting
The risk of uterine perforation is related to the skill of the healthcare professional inserting the IUD or IUS
IUDs only: When choosing an IUD, consider the licensed duration of use, and the fact that the most effective IUDs contain at least 380 mm2 of copper and have banded copper on the arms
Provided it is reasonably certain that the woman is not pregnant, an IUD or IUS may be inserted:
at any time during the menstrual cycle (but, for the IUS, if the woman is amenorrhoeic or it is more than 5 days since her period started, she should use barrier contraception for the first 7 days after insertion)
immediately after first or second trimester abortion (or at any time afterwards)
from 4 weeks postpartum, irrespective of the mode of delivery
If the woman has epilepsy, have emergency drugs including antiepileptic medication available because seizure risk may be increased at the time of fitting an IUD or IUS

Women with a history of venous thromboembolism may use the IUS
Give the woman information about followup and when to seek help about problems (see table on pages 67)

Followup and managing problems
At first followup visit (after the first menses, or 36 weeks after insertion), exclude infection, perforation or expulsion

IUD only: For heavier and/or prolonged bleeding associated with use of an IUD:
treat with nonsteroidal antiinflammatory drugs and tranexamic acid
or suggest changing to the IUS if the woman finds bleeding unacceptable
If Actinomyceslike organisms are seen on a cervical smear, assess for pelvic infection, and remove the IUD or IUS if there are signs of infection

Post-insertion infection: After 5 years of having an IUD in situ, 20% of patients become colonised by Actinomyces israeli, which is usually a gut
commensal. The presence of A. israeli is often only discovered when a cervical smear report comments on the presence of ‘Actinomyces-like
organisms’ (ALOs). There is a small chance that these women will go on to develop systemic infection, which can be fatal. They should therefore be
offered a vaginal examination and the coil removed if there are any symptoms of pelvic tenderness or if a mass is detected. Asymptomatic women
can either have the coil removed, or have regular 6-monthly examinations and be given information on symptoms of PID; in practice, many
gynaecologists prefer to simply remove the IUD. It would be usual practice to wait for a few months before replacing the coil.
Women who develop vaginal discharge while they have the IUD in situ
should have swabs taken and be treated with antibiotics as appropriate (eg
doxycycline for possible Chlamydia and metronidazole for anaerobic
infection). In general, the IUD should be left in situ initially, but be removed
if the symptoms do not improve with treatment.

youtu.be/FuPFbgSm0QQ

IUS: Women who are aged 45 years or older when their IUS is inserted and are amenorrhoeic may keep it until they no longer need contraception, even if this is beyond the duration of UK Marketing Authorisation

FibroPlant®

IUD lost threads

Lost threads = pregnancy or high risk of pregnancy

Causes
1 unrecognised expulsion
2 perforation
3 device in situ but short threads or malposition
(all three can exist with or without pregnancy)

When IUD threads cannot be seen, pregnancy should always be excluded
The cervical canal can be gently explored using narrow artery forceps.
A pelvic ultrasound may be necessary and if the IUD is in the correct position, no action needs to be taken until it is time for the IUD to be changed; this can usually be achieved using an Emmett retriever or a Retrievette

If a woman becomes pregnant with an intrauterine pregnancy, advise removal of the IUD or IUS before 12 weeks gestation, whether or not she intends to continue the pregnancy

IUD and infections

Endocervical swab should be taken and insertion of the IUD delayed until the results are back.
If this is not possible, antibiotic prophylaxis should be given at the time of insertion, eg doxycycline 100 mg bd for 7 days.
If a woman is in a long-term monogamous relationship, antibiotics can be withheld until the swab results come through.
Group B Streptococcus is a common finding and does not need to be treated.
Women are at greatest risk of infection within the first 20 days after insertionof the coil; it is thought that these patients are carriers of Chlamydia anyway and that insertion of an IUD allows the infection to spread from the lower genital tract.
Women who have a coil fitted should always be informed of the symptoms of pelvic inflammatory disease (PID).

Emergency oral contraception

Levonelle

Ella one

CKS emergency contraception

RCOG FSRH

RCOG FSRH Emergency Contraception Aug 2011

levonelle.co.uk

If the problem is complex you, or the patient, can ring the Family Planning Association (FPA) helpline for advice on +44 (0)845 310 1334

Ella one

http://www.netdoctor.co.uk/medicines/100005232.html

ellaone.com

Emergency contraception IUD

http://www.ippf.org/en/Resources/Contraception/Emergency+contraception+with+the+copper+Intrauterine+Device+IUD.htm

Postpartum contraception (Breastfeeding)

Contraceptive choices for breastfeeding women Faculty of Sexual & Reproductive Healthcare

lactational amenorrhoea method (LAM)
breastfeeding delays the return of ovulation
all contraceptive methods have low failure rates when used consistently and correctly
awaiting the onset of menstruation before starting contraception is not advised, as it might put them at risk of unintended pregnancy
if they are <6 months postpartum, amenorrhoeic, and fully breastfeeding, the LAM is over 98% effective in preventing pregnancy
risk of pregnancy is increased if breastfeeding decreases (particularly stopping night feeds), when menstruation recurs, or when >6 months postpartum

hormonal contraception
+ women should be informed that the level of hormone in breast milk when using a hormonal method of contraception is comparable to levels observed when they have an ovulatory cycle
+ women should be advised that the available evidence is unable to prove if hormonal contraception has any effect on breast milk volume
+ women should be advised that the available evidence indicates that hormonal contraception has no adverse effect on infant growth
combined hormonal contraception
+ women should be advised that use of combined oral contraception (COC) in the first 6 weeks postpartum may have an adverse effect on breast milk volume
+ breastfeeding women should be advised to avoid COC in the first 6 weeks postpartum
+ breastfeeding women should be advised that COC can be used without restriction from 6 months postpartum
+ breastfeeding women should be advised that COC is not recommended between 6 weeks and 6 months postpartum. However, if breastfeeding is established, COC may be considered if other contraceptive methods are unacceptable

progestogen-only contraception
use of progestogen-only methods in the first 6 weeks postpartum does not appear to have an adverse effect on breast milk volume
use of progestogen-only methods when breastfeeding provides over 99% efficacy
problematic bleeding associated with progestogen-only methods appears to be more acceptable than that experienced by women who are not breastfeeding
breastfeeding women may choose to use a progestogen only method of contraception before 6 weeks postpartum if other contraceptive methods are unacceptable

non-hormonal methods
intrauterine device (IUD): unless an IUD can be inserted within the first 48 hours postpartum, insertion should be delayed until 4 weeks postpartum
barrier methods, spermicides and fertility awareness: women can be advised that the use of diaphragms and cervical caps should be delayed until uterine involution is complete (from 6 weeks postpartum)

When can breastfeeding women be advised to start contraception?
lactational amenorrhoea method
+ women should be advised to start the LAM immediately postpartum
combined hormonal contraception
+ if breastfeeding is established, a woman who is more than 6 weeks postpartum may start COC at any time if it is reasonably certain she is not pregnant. Additional contraceptive protection is required for 7 days
+ breastfeeding women who are more than 6 weeks postpartum and having regular menstrual cycles can start COC as for non-breastfeeding women
+ women should be advised that using COC while breastfeeding is outside product licences
progestogen-only pills (POP)
+ a breastfeeding woman can start a POP up to day 21 postpartum without the need for additional contraceptive protection
+ a breastfeeding woman can start POP after day 21 postpartum if it is reasonably certain she is not pregnant. Additional contraceptive protection is required for 2 days
+ a breastfeeding woman who chooses to use a POP before 6 weeks postpartum should be informed that this is outside the product licence for some pills
progestogen-only injectable
+ breastfeeding women should be advised that DMPA use before 6 weeks postpartum is not usually recommended
+ women should be advised that troublesome bleeding can occur with DMPA use in the early postpartum period
+ breastfeeding women who choose DMPA will not require the injection until day 21 postpartum, but if the risk of immediate subsequent pregnancy is high it may be given before this time
+ breastfeeding women who choose to use DMPA before 6 weeks postpartum should be informed that such use is outside the product licence
progestogen-only implants
+ breastfeeding women may choose to use a progestogen-only implant before day 28 without the need for additional contraceptive protection
+ breastfeeding women should be advised that the use of a progestogen-only implant before day 21 postpartum is outside the product licence
levonorgestrel-releasing intrauterine system
+ breastfeeding women may have an LNGIUS inserted from 4 weeks postpartum
intrauterine device (IUD)
+ breastfeeding women may have an IUD inserted within the first 48 hours postpartum, otherwise insertion should be delayed until 4 weeks postpartum
diaphragms and cervical caps
breastfeeding women who choose a diaphragm/cervical cap should be advised to wait until at least 6 weeks postpartum before attending for assessment of size required

When do breastfeeding women require emergency contraception (EC)?
breastfeeding women can be advised that unprotected sexual intercourse or contraceptive failure before day 21 postpartum is not an indication for EC
once hormonal contraception has been initiated, potential contraceptive failures should be managed in the same way as for women not breastfeeding
breastfeeding women may be offered an IUD as EC from 4 weeks postpartum

Postpartum contraception (bottle-feeding)

Barrier methods

Used consistently and correctly, male condoms are up to 98% effective at preventing pregnancy and female condoms are up to 95% effective

Reducing the risk of sexually transmitted infection

In general, evidence supports the use of condoms to reduce the risk of sexually transmitted infection (STI) transmission; however, even with correct and consistent use, transmission may occur
Men and women with latex sensitivity or allergy can use polyurethane or deproteinised latex condoms
Condoms lubricated with nonspermicidal lubricant are recommended for use
Additional lubricant should be recommended for use with condoms for anal sex to reduce the risk of breakage
Nonoilbased lubricants are recommended as they can be used safely with latex and nonlatex condoms
Condom users should be made aware of the risk of pregnancy and STIs should a condom fail
STI testing should be offered after a condom has burst. Although STI testing can be done at the time of presentation, it is recommended at 2 and 12 weeks after a condom failure

Diaphragms

Diaphragms can be inserted at any time prior to sexual intercourse, but must
remain in place for at least 6 hours afterwards. Two 10cm strips of
spermicide need to be applied to the side of the diaphragm facing the cervix
and will need to be reapplied if the diaphragm is inserted more than 3 hours
before intercourse (this can be done by inserting a pessary or inserting cream
with the help of an applicator). They should be rinsed with soap and water
after use. Diaphragms usually last for about 2 years before they need
replacing.
Fitting the diaphragm
Diaphragms come in various sizes, from 55 mm to 100 mm in diameter.
Exact fitting is not important, but a diaphragm that is too big will be
uncomfortable and one that is too small may not cover the whole cervix or
may dislodge. Most women will require a diaphragm with a diameter of
between 65 mm and 85 mm and, in general, the largest diaphragm that is
comfortable is probably the correct size. Fitting can be done in the following
way:
Do a pelvic examination to exclude uterine or vaginal wall prolapse
as these are contraindications to use.
Measure the distance from the pubis to the posterior fornix. This
gives an idea of the size of diaphragm that will be needed.
Compress the ring of the diaphragm between the finger and thumb
(the dome usually points upwards, but this is not important) and
insert the diaphragm along the posterior vaginal wall, until it is in the
posterior fornix.
Push the anterior rim up, behind the pubis. The diaphragm should
completely cover the cervix and most of the anterior vaginal wall.
Most women insert their diaphragms when squatting or with one foot raised.
Technique should be assessed 1 week after the diaphragm is first given to the
patient. Diaphragms should not cause discomfort, and if they do the size is
probably incorrect. Size should be checked after any significant change in
weight (>5 kg) or after a pregnancy.

Female barrier methods

Efficacy
When used consistently and correctly and with spermicide, diaphragms and cervical caps are estimated to be between 92% and 96% effective at preventing pregnancy
When used consistently and correctly, female condoms are 95% effective at preventing pregnancy, and the contraceptive sponge is estimated to be between 80% and 90% effective at preventing pregnancy

Reducing the risk of sexually transmitted infections
There is limited evidence on the use of diaphragms, cervical caps, or the contraceptive sponge in reducing the risk of STIs. There may be some protection against cervical intraepithelial neoplasia (CIN) with diaphragms
In general, evidence supports the use of female condoms to reduce the risk of STIs. However, even with consistent and correct use, transmission may occur. Evidence on use of male condoms suggests they offer better protection against STIs than female barrier methods

Eligibility for use
Women with sensitivity to latex proteins can use a silicone diaphragm or cervical cap, or a polyurethane female condom
The use of a diaphragm, cervical cap, or contraceptive sponge by women who have or are at high risk of HIV or AIDS is not generally recommended
For women with a history of toxic shock syndrome the use of diaphragms, cervical caps, and the contraceptive sponge is not generally recommended

Instructions for use
Initial assessment of diaphragm and cervical caps should be done by a competent healthcare professional
All methods can be inserted any time before intercourse
The use of spermicide is recommended when using diaphragms and cervical caps
If intercourse is repeated or occurs ?3 hours after insertion more spermicide is required and should be inserted with an applicator or as a pessary without removing the diaphragm or cervical cap
The diaphragm or cervical cap must be left in situ for at least 6 hours after the last episode of intercourse. Sperm in the lower reproductive tract are unlikely to be alive after 6 hours
Oilbased lubricants can damage latex and women should be advised to avoid their use when using latex diaphragms or cervical caps
Women should be advised to check their diaphragm or cervical cap regularly for tears, holes, or cracks
There is no evidence that a colour change or change in shape of the outer ring of a diaphragm reduces efficacy
Women should be advised on the use of emergency contraception should female barrier methods be used incorrectly

Followup
Women should be advised to attend for a review of contraception if they have:
any problems with the method
lost or gained more than 3 kg (7 lb) in weight
had a pregnancy

Emergency hormonal contraception
An advance provision of emergency hormonal contraception can be offered to women relying on female barrier methods for contraception

fsrh.org

FFPRHC Guidance (January 2007): Male and female condoms. January 2007
FFPRHC Guidance (June 2007): Female barrier methods. June 2007
Updated May 2009

Fertility awareness

Mucous Temp Persona Billings Natural Family Planning

billings-ovulation-method.org.au

Fertility wheel

Male and female sterilisation

Indications for or against sterilisation
if there is any question of a person not having the mental capacity to consent to a procedure that will permanently remove their fertility, the case should be referred to the courts for judgment
additional care must be taken when counselling people under 30 years of age or people without children who request sterilisation

What is required before the procedure is performed?
all verbal counselling advice must be supported by accurate, impartial printed or recorded information (in translation, where appropriate and possible), which the person requesting sterilisation may take away and read before the operation
counselling and advice on sterilisation procedures should be provided to women and men within the context of a service providing a full range of information about and access to other long-term reversible methods of contraception. This should include information on the advantages, disadvantages and relative failure rates of each method
both vasectomy and tubal occlusion should be discussed with all men and women requesting sterilisation
women in particular should be informed that vasectomy carries a lower failure rate in terms of postprocedure pregnancies and that there is less risk related to the procedure
a history should be taken and an examination should be performed on all men and women requesting vasectomy or tubal occlusion
the operating doctor will need to ensure that the counselling, information exchange, history and examination have been completed and be satisfied that the patient does not suffer from concurrent conditions which may require an additional or alternative procedure or precaution

Tubal occlusion
culdoscopy should not be used as a method of approach for sterilisation
where equipment and trained staff are available, the laparoscopic approach to the fallopian tubes is quicker and results in less minor morbidity compared with mini-laparotomy
any effective surgical or mechanical method of tubal occlusion can be used when a mini-laparotomy is used as the method of approach for an interval sterilisation
a modified Pomeroy procedure rather than Filshie clip application may be preferable for postpartum sterilisation performed by mini-laparotomy or at the time of caesarean section, as this leads to lower failure rates
mechanical occlusion of the tubes by either Filshie clips or rings should be the method of choice for laparoscopic tubal occlusion
the routine use of more than one Filshie clip is not recommended – diathermy should not be used as the primary method of tubal occlusion because it increases the risk of subsequent ectopic pregnancy and is less easy to reverse than mechanical occlusive methods
hysteroscopic methods of tubal occlusion are still under evaluation and should only be used within the present guidance system for new surgical interventions

Information
women, particularly those at increased risk from conditions such as previous abdominal surgery or obesity, should be informed of the risks of laparoscopy and the chances of laparotomy being necessary if there are problems with laparoscopy
women should be informed of the method of access and tubal occlusion being recommended in their case, the reasons for preferring it over other methods, and the method to be used if the intended method fails for any reason
women should be advised after the operation of the method of tubal occlusion actually used and of any complications that occurred during the procedure

Anaesthesia
while recognising that general anaesthesia is usually used in the UK for laparoscopic tubal occlusion, local anaesthesia is an acceptable alternative
laparoscopic tubal occlusion should be performed as a day case wherever possible
topical application of local anaesthesia to the fallopian tubes should be used whenever mechanical occlusive devices are being applied either under general or local anaesthesia

Failure
women should be informed that tubal occlusion is associated with a failure rate and that pregnancy can occur several years after the procedure. The lifetime risk of failure in general is estimated to be one in 200. The longest period of follow-up data available for the most common method used in the UK, the Filshie clip, suggests a failure rate after ten years of two to three per 1000 procedures
women should be informed that if tubal occlusion fails, the resulting pregnancy may be ectopic
after tubal occlusion, women should be advised to seek medical advice if they think they might be pregnant or if they have abnormal abdominal pain or vaginal bleeding

Timing
tubal occlusion should be performed after an appropriate interval following pregnancy wherever possible. Should tubal occlusion be requested in association with pregnancy (either postpartum or post-abortion), the woman should be made aware of the increased regret rate and the possible increased failure rate
if tubal occlusion is to be performed at the same time as a caesarean section, counselling and agreement should have been given at least one week prior to the procedure
tubal occlusion can be performed at any time during the menstrual cycle, provided that the clinician is confident that the woman has used effective contraception up to the day of the operation. If this is not the case, the operation should be deferred until the follicular phase of a subsequent cycle. The woman should be advised to continue to use effective contraception until her next menstrual period
a pregnancy test must be performed before the operation to exclude the possibility of a pre-existing pregnancy. However, a negative test does not exclude the possibility of a luteal-phase pregnancy
routine curettage at the time of tubal occlusion, in order to prevent a luteal-phase pregnancy, is not recommended

Reversal
although women requesting sterilisation should understand that the procedure is intended to be permanent, they should be given information about the success rates associated with reversal, should this procedure be necessary
women should be informed that reversal operations are rarely provided by the NHS

Risks
women should be reassured that tubal occlusion is not associated with an increased risk of heavier or irregular periods when performed after 30 years of age. There is an association with subsequent increased hysterectomy rate, although there is no evidence that tubal occlusion leads to problems that require a hysterectomy. Data are limited on the effect on menstruation when tubal occlusion is performed on women under 30 years of age

Equipment and facilities
all equipment involved in performing tubal occlusions should be properly maintained
laparoscopic tubal occlusion should only be performed at a site where there are facilities to perform a laparotomy safely

Training
trainees should perform at least 25 supervised laparoscopic tubal occlusions before operating without supervision

Vasectomy

Methods
except when technical considerations dictate otherwise, a no-scalpel approach should be used to identify the vas, as this results in a lower rate of early complications
division of the vas on its own is not an acceptable technique because of its failure rate. It should be accompanied by fascial interposition or diathermy
clips should not be used for occluding the vas, as failure rates are unacceptably high
Anaesthesia
vasectomy should be performed under local anaesthetic wherever possible
Histological examination
excised portions of vas should only be sent for histological examination if there is any doubt about their identity

Post-vasectomy semen analysis
men should be advised to use effective contraception until azoospermia has been confirmed. The way in which azoospermia is confirmed will depend upon local protocols
irrigation of the vas during vasectomy does not reduce failure rates or time to clearance

Special clearance
in a small minority of men, non-motile sperm persist after vasectomy. In such cases, special clearance to stop contraception may be given when less than 10 000 non-motile sperm/ml are found in a fresh specimen examined at least seven months after vasectomy, as no pregnancies have yet been reported under these circumstances
Failure
men should be informed that vasectomy has an associated failure rate and that pregnancies can occur several years after vasectomy. The rate should be quoted as approximately one in 2000 after clearance has been given
Reversal
although men requesting vasectomy should understand that the procedure is intended to be permanent, they should be given information on the success rates associated with reversal, should this procedure be necessary
men should be informed that reversal operations or intracytoplasmic sperm injections are rarely provided within the NHS
Risks
men requesting vasectomy can be reassured that there is no increase in testicular cancer or heart disease associated with vasectomy. The association, in some reports, of an increased risk of being diagnosed with prostate cancer is at present considered likely to be noncausative
men should be informed about the possibility of chronic testicular pain after vasectomy

Training
practitioners who are being trained to perform vasectomies should ensure that their training conforms to that advocated by the Faculty of Family Planning and Reproductive Health Care. Doctors with no prior experience should be supervised for ten operating sessions or 40 procedures, while doctors with relevant prior surgical experience should perform eight supervised procedures

Audit
a national register and audit of failed sterilisations is needed. Hospital-based registers of sterilisation procedure failures would assist this

RCOG http://www.rcog.org.uk
Royal College of Obstetricians and Gynaecologists. Male and female sterilisation. January 2004

youtu.be/MOaL93xoHRk

youtu.be/whwmCbeYU1I

Abortion TOP

http://www.fpa.org.uk/professionals/factsheets/abortion

Under 7 weeks Medical abortion, e.g. Mifepristone orally followed after 48 h by Gemeprost vaginally.
7-15 Weeks Conventional suction termination is appropriate. Local or general anaesthesia.
Medical abortion may be preferable above 12 weeks.
Terminations at >15 weeks gestation Dilatation and evacuation, preceded by preparation or medical abortion.

Medical termination

effective until 24 weeks’ gestation, although its use is most commonly restricted to pregnancies of <9 weeks.

Mifepristone (200 mg) is given orally, followed 1-3 days later by 800 fJg vaginal misoprostol. Further 400 micrograms doses of vaginal misoprostol
may be required if abortion has not occurred within 4 hours, especially for second trimester pregnancies.

SURGICAL METHODS
Conventional suction termination should be avoided at gestations below 7 weeks because there is an unacceptably high failure rate. However, it is an
appropriate method at gestations of 7-15 weeks. Cervical preparation will be needed for pregnancies of >10 weeks or if the patient is <18 years of age;this is usually achieved with 400 fJg vaginal misoprostol given 3 hours before surgery. For gestations above 15 weeks, surgical abortion is done by dilation and evacuation (preceded by cervical preparation).

Most centres offer routine peri-abortion antibiotic prophylaxis, with either 1 g rectal metronidazole plus 7 days of bd doxycycline or metronidazole plus a stat l-g dose of azithromycin.

Medical Termination Mifegynae
Mifepristone acts by blocking progesterone receptors in the uterus and this reduces the effectiveness of the natural hormone progesterone.
Progesterone plays an important role in the maintainance of pregnancy such as the successful implantation of the fertilised egg
into the wall of the uterus and prevention of uterine contractions during pregnancy. By blocking progesterone receptors in the uterus,
mifepristone significantly reduces progesterone levels so that pregnancy cannot be maintained. Abortion may occur solely as a
result of the actions of mifepristone, but surgery may also be necessary to remove the foetus.
If required, contraception can be started 3 to 9 days after taking mifepristone.

What is it used for?
Medical alternative to surgical termination of pregnancy of up
to 63 days
Softening and dilation of the cervix (neck of the womb) prior
to surgical termination of pregnancy
Termination of pregnancy between weeks 13 and 20 weeks
gestation, used in combination with gemeprost.

Warning!
Mifepristone may only be used for pregnancy termination in accordance with the Abortion Act 1967 as amended by The
Human Fertilisation and Embryology Act 1990. Mifepristone must be given under the supervision of a registered medical doctor.
Both administration of mifepristone and followup must take place in an NHS hospital or place approved by the Secretary of
State under section 1 (3) of the Abortion Act 1967 and which has received approval by the department of health to
undertake medical terminations with mifepristone.
A follow up visit is recommended at an appropriate interval (usually 8 to 12 days) after taking mifepristone.
Mifepristone must not be given if there is doubt as to the existence and age of the pregnancy. The prescribing doctor
should perform the appropriate tests to determine the age of the foetus e.g. an ultrasound scan.
If treatment fails or is interrupted, the pregnancy is likely to continue to develop. Exposure to mifepristone may present a
high risk of malformation to the foetus. In this event, termination by another method is advised to be undertaken at
the follow up visit.

Use with caution in
Asthma
Cardiovascular disease or individuals with risk factors
COPD
Infective Endocarditis
Artificial heart valves

Not to be used in
Bleeding disorders
Ectopic pregnancy
Adrenal insufficiency
Kidney failure
Liver failure
Long term corticosteriod therapy
Smokers over the age of 35 when used in combination with gemeprost

TOP legal aspects

Human Fertilisation and Embryology Act UK 1990
social termination up to 24 weeks to prevent ‘grave permanent injury to the physical or mental health of the pregnant woman’
there is no upper limit when there is ‘substantial risk of serious handicap’ there is no upper limit

Failure Rates

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