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Contraceptive methods

Dr Rajesh Varma

Percentage of women experiencing an unintended pregnancy within the first year of use with TYPICAL USE and PERFECT USE contraceptive method

CONTRACEPTIVE METHOD
IMP Progestogen-only implant
Vasectomy, male sterilisation
LNG-IUS Levonorgestrel intrauterine system
Female sterilisation (laparoscopic, hysteroscopic)
Cu-IUD Copper intrauterine device
DMPA Progestogen-only injectable
CHC Combined hormonal pill, patch or vaginal ring
POP Progestogen-only pill
Female diaphragm
Condom (male and female)
Fertility awareness-based methods
No method

TYPICAL USE
0.05
0.15
0.20
0.50
0.80
6.00
9.00
9.00
12.00
18.00
24.00
85.00

PERFECT USE
0.05
0.10
0.20
0.50
0.60
0.20
0.30
0.30
6.00
2.00
0.4-5.00
85.00

Cost-effectiveness

  • All LARCs (IUDs, IUS, DMPA, IMP) are more cost effective than the CHC, even at one year of use. 

  • IUD, IUS and IMP are more cost effective than the DMPA

Extra notes

  1. Long-acting reversible contraception LARC is assigned to: IMP, LNG-IUS, Cu-IUD and DMPA.
    LARCs have low contraceptive failure and do not depend on the patient remembering to take them to be effective.
    Women using DMPA may experience a delayed return to fertility

  2. Epilepsy: avoid IMP as it interferes with liver enzyme-inducing anti-epileptic drugs

Hormone abbreviations

Estrogens
1st generation progestogen
2nd generation progestogen
3rd generation progestogen
4th generation progestogen
17-hydroxyprogesterone derivative

Ethinylestradiol EE, Estradiol valerate EV, Estradiol hemihydrate EH
Norethisterone NE
Levonorgestrel LNG
Gestodene GSD, Norgestimate NGM, Norelgestromin NGMN, Desogestrel DSG, Etonorgestrel ENG
Drospirenone DRSP, Dienogest DNG, Nomegestrol NOM
Cyproterone Acetate (CPA), Depot medroxyprogesterone acetate (DMPA)

Combined Hormonal Contraception CHC

  • Typical failure rate 9%

  • Most brands are cyclical use 21d ‘active’ + 7d ‘pill-free’ OR
    Option to undertake extended pill taking (2-monthly or 3-monthly then 7d ‘pill-free break’)
    Option to undertake continuous use (no ‘pill-free break’, off-licence)

  • Treatment reduces risk of uterus, ovary and bowel cancer

  • Uses: contraception, treatment of HMB, treatment of endometriosis

Contraindications:

Migraine with aura, transient cerebral attacks without headaches
History or risk of arterial or venous thrombotic disease
Heart disease associated with pulmonary hypertension or risk of emobolus
Breast cancer
Acute porphyria, gallstones, pregnancy-induced diseases (cholestatic jaundice, chorea, pemphigoid gestations, pruritus), haemolytic uraemia syndrome
Systemic lupus erythematosus (SLE), Antiphospholipid syndrome (APLS)

Cautions:

Active trophoblastic disease (until urine/blood HCG normalised)
Crohn’s inflammatory bowel disease
Migraine
Sickle-cell disease

Brand name of CHC:

15mcg EE + 120mcg/24hr ENG (NuvaRing)
20mcg EE + (Loestrin NE, Femodette GSD, Mercilon DSG, Eloine DRSP)
30mcg EE + (Loestrin NE, Microgynon LNG, Femodene GSD, Marvelon DSG, Yasmin DRSP
35mcg EE + (Bevinor/Norimin/BiNovum/Synphase/TriNovum NE, Triadene GSD, Cilest NGM, Evra patch 203mcg/24hr NGMN, Dianette CPA
50mcg Mestranol + (Norinyl-1 NE)
1-3mg EV + (Qlaira: EV 0-3mg + DNG 0-3mg, quadriphasic, 26d/2d)
2.5mg EH + (Zoely: EH 1.5mg + NOM 2.5mg, monophasic, 24d/4d)


Venous thromboembolism (VTE) risk with CHC and other comparative risks

Non-contraceptive user, not pregnant 2
Pregnant women 29
Postpartum period 300-400
CHC containing NE, LNG, NGM (first and second generation) 5-7
CHC containing ENG (NuvaRing) or NGMN (Evra patch) 6-12
CHC containing GSD, DSG, DRSP or CPA (mainly third generation) 9-12

Missed CHC Pill

Need ≥ 7 days continuous COC to achieve ovulation inhibition

Missed 1 pill? take the last pill you missed now, even if this means taking 2 pills in 1 day, carry on taking the rest of the pack as normal

Missed 2 or more pills? Contraceptive effect compromised

  1. take the last pill you missed, carry on taking the rest of the pack, this may mean taking 2 pills on the same day 

  2. use extra contraception, such as condoms, for the next 7 days

  3. if there ≥ 7 active pills left in the pack after the last missed pill – finish the pack, take your 7-day pill-free break as normal
    if there <7 pills left in the pack after the missed pill – finish the pack- start next pack immediately the next day i.e.NO PILL FREE BREAK (or no inactive pills)

  4. Consider Emergency contraception if you have missed 2 or more pills in the first week of a pack and had unprotected sex in the previous 7 days.

Progestogen-only contraception (POP, LNG-IUS, DMPA)

POP Micronor (NE), Norgeston (LNG), Cerazette (DSG)
LNG-IUS Mirena (52mcg LNG, 5y licence), Levosert (52mcg LNG, 4yr licence), Kyleena (19.5mcg LNG, 5yr licence), Jaydess (13.5mcg LNG, 3yr licence)
IMP Nexplanon (68mg ENG subdermal implant)
DMPA DepoProvera (150mg intramuscular injection, every 13w) OR SayanaPress (DMPA 104mg subcutaneous injection, every 13w)

Interval that is considered ‘missed pill’ for POP (risk of contraceptive failure)

  • 3hr for 2nd generation POP

  • 12hr for 3rd generation POP [Cerazette (Desogestrel)]

Missed POP pill

Interval that is considered ‘missed pill’ for POP (contraceptive effect compromised)

>3hr for 2nd generation POP
>12hr for 3rd generation POP [Cerazette (Desogestrel)]

It takes 2 days for POP to adequately thicken cervical mucous and achieve its contraceptive effect

  1. Take the last pill you delayed/missed, carry on taking the rest of the pack at the usual time, this may mean taking 2 pills on the same day 

  2. Use extra contraception, such as condoms, for the next 48h

  3. Consider Emergency contraception if UPSI occurs during the two days of correctly taking the POP after the delayed/missed pill.

Main mode of action is by ovulation suppression

  • IMP Nexplanon

  • DMPA DepoProvera OR SayanaPress

  • CHC Continuous use

  • POP Cerazette (Desogestrel)

  • CHC Cyclical use

Only minimal ovulation suppression occurs with Mirena LNG-IUS, second generation POPs