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The combined contraceptive
Executive Editor, InnovAiT E-mail: chantal.simon{at}oxfordjournals.org
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Abstract |
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Abstract
The GP curriculum and...Eighty percent of women receive contraceptive advice and treatment through their GP. A sexually active woman has an 85% chance of becoming pregnant within a year without contraception and roughly one in three pregnancies are unplanned. Inadequate advice and choice results in women being dissatisfied with their method of contraception and not using methods correctly. Combined contraceptives are preferred by many women because they are reliable, yet easily and rapidly reversible, and are generally well tolerated. This article aims to give an overview guiding GPs in training on choice of the combined contraceptive as a method of contraception and prescription and monitoring of combined contraceptives in primary care.
GP curriculum statement 11: Sexual health requires GPs in training to recognize the central role of GPs and other primary health care team members in the prevention of unwanted pregnancy. In particular, GPs must have knowledge of effectiveness rates, risks, benefits and appropriate selection of patients for all methods of contraception and be able to provide oral contraception safely.
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Types of combined contraceptive |
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Contraceptives containing oestrogen and progestogen are known as combined contraceptives. Two forms of combined contraceptive are now available—the combined oral contraceptive (COC) pill and combined patch. All prescriptions for contraceptives are free of charge to the patients throughout the UK.
COC pills differ by oestrogen content, type of progestogen and method of administration (Tables 1 and 2). Most COC pills come in packets of 28 pills. The woman takes the entire packet starting on the first day of her cycle and taking one pill every day, and then has a 7-day ‘pill-free’ break before starting the next packet. The contraceptive patch (Evra) contains 20 mcgm ethinylestradiol and norelgestromin in a transdermal patch. It is an alternative to the contraceptive pill if compliance with daily pill taking is problematic. Combined pills vary by:
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Oestrogen content
Oestrogen content varies from 20–40 mcgm of ethinylestradiol or equivalent. Choose a pill with the lowest oestrogen and progestogen content which gives good cycle control with minimal side effects (35 mcgm or less for first-time COC users):
- Low strength preparations—contain ethinylestradiol 20 mcgm. These are appropriate for women with risk factors for circulatory disease where the COC is not contraindicated or if the woman suffers from oestrogen-related side effects.
- Standard strength preparations—contain ethinylestradiol 30 or 35 mcgm (or 30–40 mcgm in phased preparations). These are suitable for use for most women.
- Phased preparations—dose of oestrogen and progestogen varies through the cycle (Table 2). These are useful for women who do not have withdrawal bleeding or have breakthrough bleeding with monophasic products.
- Every day (ED) preparations—have 21 active pills and 7 ‘inactive’ pills to cover the pill-free week. They are taken continuously and can be helpful for women who find remembering to start a new packet difficult.
Progestogen type
COC pills containing several different types of progestogen are available in the UK. Each has its advantages and disadvantages:
- Levonorgestrel or norethisterone— are suitable for most women. Choose for first-time COC pill users.
- Desogestrel—consider if a woman has side effects such as acne, headache, depression, weight gain, breast symptoms or breakthrough bleeding with other progestogens. Desogestrel and gestodene have both been associated with increased risk of venous thromboembolism.
- Drospirenone—has anti-androgenic effects and also anti-mineralocorticoid activity.
- Cyproterone acetate (Dianette)—licensed for treatment of acne but not for contraception, although it does provide effective contraception. Use for 3–4 months after resolution of acne. Its use is associated with a 4-times increased risk of venous thromboembolism compared to COC pills containing levonorgestrel.
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Factors to consider before prescribing |
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There is no ideal method of contraception. Table 3 compares the commonly used methods of contraception in the UK. Choice of contraceptive method involves matching the method that best fits to the individual woman. Consider:
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Age and lifestyle
For older women, the risk of using combined contraception outweighs the benefits if the woman is aged more than 35 years and a smoker, or aged greater than 50 years and a non-smoker (Box 1). Alternatives in this age group include the progestogen-only methods, a copper-containing intrauterine device (IUD) or intrauterine system (IUS—Mirena). If considering the combined contraceptive as a method of contraception in a woman over 35 years of age, consider using a lower dose pill (e.g. one containing 20 mcgm of oestrogen) and using a pill with a lipid-friendly progestogen (such as gestodene or desogestrel). Combined contraception is also contraindicated in women of any age who smoke more than 40 cigarettes per day (Box 1).
| Box 1. Risk factors for arterial disease Use the combined contraceptive with caution (i.e. only use if alternatives are unsuitable and with close monitoring) if one risk factor is present, avoid if more than 1 risk factor is present:
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Sexual and reproductive history
In all cases, it is important to take a sexual and reproductive history. Ask about:
- the woman's normal cycle—investigate any undiagnosed vaginal bleeding before starting the combined contraceptive
- past gynaecological history
- history of sexually transmitted infection (STI)
- previous experience with contraception
- past pregnancies and whether the woman is currently breast feeding
- future plans for pregnancy—does the method of contraception need to be permanent, long- or short term?
Before providing contraception to any woman, it is important to exclude pregnancy. You can be reasonably certain that a woman is not pregnant if she:
- states that she has not had unprotected sexual intercourse since her last normal menstrual cycle
- has correctly and consistently been using a reliable method of contraception
- is within 7 days of the start of a normal menses
- is less than 4 weeks post-partum
- is less than 7 days post-abortion or miscarriage
- is fully breast feeding, amenorrhoeic and less than 6 months post-partum
If in doubt, support your assessment with a pregnancy test which should be at least 3 weeks since the last unprotected sexual intercourse.
Ovulation can occur within 10 days of termination of pregnancy (TOP) or miscarriage, so start the combined contraceptive immediately in these circumstances.
For women who have recently had a baby and are not breast feeding, ovulation can occur within 28 days of delivery. The combined contraceptive can be started 3 weeks after delivery (28 days for the contraceptive patch). There is an increased risk of thromboembolism prior to that time. If the woman had pre-eclampsia in pregnancy, start the combined contraceptive only when blood pressure (BP) and biochemical abnormalities have returned to normal.
Women less than 6 weeks post-partum who are breast feeding should not use combined contraception as it may inhibit lactation and enters breast milk in small quantities. Women less than 6 months post-partum who are amenorrhoeic and fully breast feeding have only a low chance of pregnancy (about two per 1000 women) without contraception. If there is any supplementary bottle feeding, the baby is weaned or there is any vaginal bleeding (except occasional spotting), then assume that the woman is fertile. Between 6 weeks and 6 months post-partum, in breastfeeding mothers, the combined contraceptive may be used but its use should be reserved for those women for whom there is no other suitable method of contraception.
When discussing contraception with women, always discuss the risk of transmission of STIs, especially if contemplating using a non-barrier method such as the combined contraceptive. Advise high-risk groups (those who are young, have multiple sexual partners or a past history of STI) to use barrier methods in addition to hormonal methods.
Past medical history
Ask about past medical history of cardiovascular disease (heart disease, stroke, transient ischaemic attack or peripheral vascular disease). The combined contraceptive is contraindicated if the patient has two or more risk factors for arterial disease (Box 1) or valvular heart disease with complications such as pulmonary hypertension, risk of atrial fibrillation or history of subacute bacterial endocarditis.
The combined contraceptive is also contraindicated in patients with:
- Past medical history of venous thromboembolism or more than one risk factor for venous thromboembolism (Box 2)
- Focal migraine (Figure 1) as this increases the risk of stroke
- Diabetes mellitus—if vascular complications or diabetes has been present for more than 20 years
- Liver disease—disorders of hepatic excretion (such as Dubin Johnson or Rotor syndrome), acute hepatitis until liver function is normal, liver adenoma and gallstones
- Porphyria
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The combined contraceptive is usually contraindicated in patients with a past history of female malignancy, such as breast or genital cancer. It is also contraindicated if a woman has had hormone-related problems in pregnancy, such as hydatidiform mole, pruritus, cholestasis, pemphigoid gestationis or otosclerosis.
In addition, use the combined contraceptive only if other methods are unsuitable and with close monitoring, if there is a history of severe depression, inflammatory bowel disease (especially, the COC pill if malabsorption may be a problem) or sickle cell disease. Consider seeking advice from the consultant overseeing the patient's care. If the patient has hyperprolactinaemia, always seek specialist advice.
Drug history
The combined contraceptive may not work in standard dose if the patient is taking long-term hepatic enzyme-inducing drugs, such as an epileptic patient taking phenytoin or carbamazepine.
| Box 2. Risk factors for venous thromboembolism Use combined contraception with caution (i.e. only if other methods are unsuitable and under close supervision) and avoid gestodene- or desogestrel-containing COCs if 1 risk factor is present, avoid if more than 1 risk factor is present:
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Family history
Family history of a female cancer is not a contraindication to the combined contraceptive. Consider:
- Referral to haematology for a routine thrombophilia screen if there is a family history of deep vein thrombosis (DVT) or pulmonary embolism in a first-degree relative aged under 45 at the time of the event or in multiple family members (Box 2).
- Checking a fasting lipid profile if there is a family history of arterial disease in a first-degree relative aged under 45 at the time of the event or in multiple family members (Box 1).
Examination findings
The combined contraceptive is contraindicated in any woman with a BP consistently elevated to a level greater than 140 mmHg systolic and/or 90 mmHg diastolic or body mass index (BMI) in excess of 39 kg/m2 (Box 1). Even for women with a BMI between 30 and 39 kg/m2, there is an increased risk of venous thromboembolism with the combined contraceptive (Box 2). Consider alternative methods of contraception in this group.
Personal factors
Take the woman's personal preferences and her cultural and religious views into consideration before deciding on the method of contraception to advise.
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Providing information |
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When discussing contraception with a woman, it is important to provide both verbal and written information that will enable the woman to choose a method suitable for her and to use it effectively. This information should take into consideration the woman's individual needs and include information about:
- Effectiveness of the preferred method (Table 1)
- Possible risks (Table 4) and side effects
- Non-contraceptive benefits—for the combined contraceptive, these include cycle control and the ability to easily postpone menstruation, reduction in menstrual symptoms (menorrhagia, dysmenorrhoea and premenstrual syndrome), reduction in benign breast disease, benign ovarian cysts, pelvic inflammatory disease, colorectal, ovarian and endometrial cancer and possible reduction in risk of osteoporosis
- The procedure for initiation (Table 5) and discontinuation
- Instructions for use
- What to do if a pill or patch is missed (Figure 2)
- When to seek help
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Good information leaflets for patients are available from the Family Planning Association (website: www.fpa.org.uk) and www.patient.co.uk website.
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Health promotion |
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Consultations about contraception are also ideal opportunities for health promotion. Offer urine chlamydia screening to high risk individuals and in areas where the NHS Chlamydia screening programme is in operation, offer screening to all those under 25 years of age. Discuss prevention of sexually transmitted diseases, cervical smears, smoking cessation, exercise and control of weight as appropriate.
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Instructions for use of COC pills |
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Starting routines for COC pills are summarized in Table 5. Women should take each tablet at approximately the same time each day. For 21-day preparations, the woman should take one pill daily for 21 days. Subsequent courses are repeated after a 7-day interval. Withdrawal bleeding occurs within the 7-day interval. For ED preparations, start the active tablets on day 1 of the cycle and then advise the woman to take one tablet daily. Withdrawal bleeding occurs when the inactive tablets are being taken. Subsequent courses are repeated without interval. If any active pill is delayed by more than 24 hours or if the woman vomits less than 2 hours after taking her pill or has very severe diarrhoea, then treat it as a missed pill (Figure 2).
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Instructions for use of contraceptive patches |
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If starting the contraceptive patch when the woman is not currently using any contraception, no additional contraception is required if the first patch is applied on day 1 of the woman's cycle (i.e. the first day of bleeding). The patch can be applied anywhere except on the breasts or areas of skin that are sore or broken. Advise the woman to apply subsequent patches at a different site on days 8 and 15 and to remove the third patch on day 22. Applying a new patch after a 7-day patch-free interval starts the next cycle. If the first patch is applied later than day 1, additional precautions in the form of abstinence or barrier methods should be used for the next 7 days. When starting the COC patch in other circumstances the following rules apply:
Changing from the COC pill: Apply the first patch on the first day of withdrawal bleeding. If there is no withdrawal bleeding within 5 days of taking the last active COC pill, rule out pregnancy before applying the first patch. Unless a patch is applied on first day of withdrawal bleeding, additional precautions should be used concurrently for first 7 days.
Changing from a progesterone-only method: In all cases, additional precautions should be used concurrently for first 7 days.
- From an implant—apply the first patch on the day the implant is removed
- From an injection—apply the first patch when the next injection is due
- From the progestogen-only pill (POP)—apply the first patch on any day after stopping the POP
After childbirth if not breast feeding: Start 4 weeks after birth; if started later than 4 weeks after birth additional precautions should be used for first 7 days.
After TOP or miscarriage:
- Before 20 weeks' gestation—start immediately. No additional contraception is required if started immediately.
- After 20 weeks' gestation—start on day 21 or on the first day of first spontaneous menstruation. Additional precautions should be used for first 7 days after applying the patch.
Instructions for women on what to do if patches fall off, are missed or are left on too long are summarized in Box 3.
| Box 3. Troubleshooting problems with combined contraceptive patches If patch is partly detached for less than 24 hours: Reapply the patch to the same site or replace it with a new patch immediately—no additional contraception is needed and the next patch should be applied on the usual ‘change day’. If patch is detached for greater than 24 hours or the woman is unaware when the patch became detached: Stop the current contraceptive cycle and start a new cycle by applying a new patch, giving a new ‘day 1’. Use additional non-hormonal contraception for the first 7 days of the new cycle. If first patch of a new cycle is delayed: Contraceptive protection is lost. Apply a new patch as soon as it is remembered and give a new day 1. Advise additional non-hormonal contraception for the first 7 days of the new cycle. If intercourse has occurred during the patch-free interval, consider emergency contraception. If patch in the middle of the cycle is delayed (i.e. the patch is not changed on day 8 or 15) for:
If patch is not removed at the end of the cycle (day 22): Remove as soon as possible and start the next cycle on the usual change day (i.e. after day 28)—no additional contraception is needed.
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Follow-up |
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Follow up women 3 months after starting or changing COC pill or contraceptive patch—earlier if complications arise. At follow up, assess risk factors, as these may have changed, and side effects. Check BP. Provide health education. Once established on the combined contraceptive, review the woman every 6–12 months. In older women, combined contraception may mask the signs of the menopause. An increase in serum follicle-stimulating hormone at the end of the pill-free week is suggestive of the menopause.
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Side effects |
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Most side effects of the combined contraceptive are harmless, short term and resolve spontaneously within 2–3 cycles. Reasons to stop the combined contraceptive immediately are listed in Box 4. Common side effects can be divided into those due to relative oestrogen excess and those due to relative progestogen excess:
Relative oestrogen excess: side effects include breast tenderness (3.6% women), nausea (1.5% women), dizziness, cyclical weight gain, bloating and vaginal discharge without infection. Use a more progestogen-dominated pill (Table 1).
Relative progestogen excess: side effects include depression (3.9% women), premenstrual syndrome, dry vagina, sustained weight gain, loss of libido, lassitude and acne. Use a more oestrogen dominant pill or pill with anti-androgenic activity such as Yasmin (Table 1).
Box 4. Reasons to stop the combined contraceptive immediately (pending investigation if needed)
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Headache
Headache affects 2.9% of women using the combined contraceptive. Ask women to report any increase in headache frequency or onset of focal symptoms when taking combined contraceptives. If headache continue, then consider switching the brand of combined contraceptive or to an alternative method of contraception. If new focal symptoms develop, discontinue the combined contraceptive immediately and, if not typical of migraine aura and symptoms last longer than an hour, admit the woman to hospital.
Breakthrough bleeding
Breakthrough bleeding is most common in the first few months of combined contraceptive use. After 6 cycles, it affects 1.1% of women (spotting affects 3.3% of women). In all cases, check compliance. Have there been any missed pills? Breakthrough bleeding may start 2–3 days after a missed pill. Has there been any diarrhoea or vomiting that may have led to poor absorption? Does the woman drink heavily? Women who drink a lot of alcohol are more likely to miss combined pills or patches and less likely to remember that they have missed one.
If there has been no vomiting or diarrhoea and no missed pills, breakthrough bleeding does not indicate reduced efficacy. If breakthrough bleeding persists, check for gynaecological causes. Check that the woman is not pregnant. Examine the cervix, check that the woman's smear is up to date and take a smear if overdue. Exclude sexually transmitted diseases. Chlamydial cervicitis is the most common cause of breakthrough bleeding in young sexually active women.
If the woman is taking the pill as directed, gynaecological causes have been excluded, and breakthrough bleeding continues, increase the oestrogen content of the combined contraceptive if on a low-dose preparation. If the problem persists, change the progestogen. If the problem still persists, increase the dose of progestogen and/or try a phased preparation.
| Box 5. Hepatic enzyme-inducing drugs affecting combined contraceptive efficacy Antibacterials: rifamycins (rifampicin, rifabutin) Antidepressants: St John's Wort Anticonvulsants: phenytoin, carbamazepine, oxcarbazepine, phenobarbital, primidone and topiramate Antifungals: griseofulvin Antivirals: nelfinavir, nevirapine and ritonavir Modafinil
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Drug interactions |
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Many drugs affect efficacy of the COC pill and contraceptive patch. These broadly fall into 2 categories—hepatic enzyme-inducing drugs (Box 5) and broad-spectrum antibiotics. Management of drug interactions with the COC is summarized in Table 6. Anticonvulsants that do not affect pill efficacy include sodium valproate and lamotrigine, but seizure frequency may increase when the COC and lamotrigine are used together, and side effects of lamotrigine may be increased when the COC is stopped.
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Broad-spectrum antibiotics, such as amoxicillin and tetracyclines, interfere with absorption by affecting gut flora. They do not affect the efficacy of combined patches. Antibiotics that do not affect combined contraceptive efficacy include erythromycin, cotrimoxazole and sulphonamides.
If long-term antibiotics are prescribed, additional barrier precautions are needed for the first 3 weeks, continuing the COC through the pill-free week if it occurs during that time. Additional precautions are unnecessary if a woman starting a COC has been on a course of an antibacterial for 3 weeks or more prior to the start date. If the antibiotic type is changed or the dose is increased, an additional barrier method is required for 3 weeks, continuing the COC through the pill-free week if it occurs during that time.
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Long journeys |
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Women taking combined contraceptives are at increased risk of DVT during travel involving periods of immobility in excess of 5 hours. Advise women to drink plenty of non-alcoholic fluids and to keep their legs moving while sitting or walk up and down the aisle. Graduated compression hosiery is available for purchase over the counter and does reduce risk of DVT. If travelling on long-haul flights, advise women to continue taking their combined contraceptive at the usual time and to alter the time when they reach their destination.
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Surgery |
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Combined contraceptives should be discontinued and alternative contraceptive arrangements made (e.g. depo injection or barrier methods) 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilization of a lower limb. Restart the combined contraceptive on the first day of the next period occurring 2 weeks or more after full mobilization.
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Contraceptive services and the GP contract |
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Contraceptive services are provided by practices as an ‘additional service’. This means that most practices are expected to provide this service and payment is included in the global sum. If a practice ‘opts out’, the global sum paid to the practice is reduced by 2.4%. Practices providing contraceptive services must make contraceptive services available to all their patients who request them. This should include:
- Advice and inform about the full range of contraceptive methods
- Advice and inform about sexual health and sexually transmitted diseases
- Where appropriate, medical examination of patients requesting contraceptive advice
- Provision of contraceptives (excluding fitting of intrauterine devices/systems and implantation of contraceptive implants—both these can be provided as an enhanced service)
- Advice and inform about emergency contraception and, where appropriate, provision of emergency hormonal contraception
- Advice and referral in cases of unwanted or unplanned pregnancy including advice about free pregnancy testing within the practice area
- Referral as necessary to specialist sexual health services, including referral for testing for sexually transmitted diseases
Key points
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References |
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British National Formulary. Issue 55. (March 2008) Accessed via www.bnf.org.
Faculty of family planning and reproductive health care (FFPRH).
UK selected practice recommendations for contraceptive use. (2002) Accessed via www.ffprhc.org.uk/admin/uploads/Final%20UK%20recommendations1.pdf [date last accessed 22.06.2008].
UK medical eligibility criteria for contraceptive use. (2005/6) Accessed via www.ffprhc.org.uk/admin/uploads/298_UKMEC_200506.pdf [date last accessed 22.06.2008].
First prescription of the combined oral contraception. (2007) Accessed via www.ffprhc.org.uk/admin/uploads/FirstPrescCombOralContJan06.pdf [date last accessed 22.06.2008].
Missed pills. (2005) Accessed via www.ffprhc.org.uk/admin/uploads/MissedPillRules%20.pdf [date last accessed 22.06.2008].
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Hannaford P, Selvaraja S, Elliot A, Angus V, Iversen L, Lee A. Cancer risk among users of oral contraceptives: cohort data from the royal College of General Practitioner's oral contraceptive study. British Medical Journal (2007) 335:651. Accessed via www.bmj.com/cgi/reprint_abr/335/7621/651?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=hannaford+cancer+contraceptive&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT [date last accessed 22.06.2008].
RCGP. GP curriculum statement 11: Sexual health. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_11_Sexual_Health.pdf [date last accessed 22.06.2008].
Sadler C, White J, Everitt H, Simon C. Oxford GP Library: Women's health (2007) Oxford:: Oxford University Press OUP ISBN. 9780199235438.
World Health Organization (WHO).
Medical eligibility criteria for contraceptive use. (2004) 3rd edition. Accessed via www.who.int/reproductive-health/publications/mec/mec.pdf [date last accessed 22.06.2008].
Selected practice recommendations for contraceptive use. (2004) 2nd edition. Accessed via www.who.int/reproductive-health/publications/spr/spr.pdf [date last accessed 22.06.2008].
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