Progestogen-only contraception
E-mail: emman{at}doctors.org.uk
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Abstract |
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 TOP Abstract The GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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Progestogen-only contraception refers to the methods of contraception that contain a synthetic form of progesterone. In 2005/2006, 10% of all women aged 16–49 in the UK were using progestogen-only contraception. Such contraceptive methods include the progestogen-only contraceptive pill, injectable forms, the subdermal implant and the Mirena intrauterine system (IUS). In addition, emergency contraception in the form of Levonelle 1500 is progestogen only.
Statement 11 of the GP curriculum (Sexual health) requires the GP in training to be competent in:
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Initiating contraception—general points |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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In 2005/2006, 74% of UK women aged 16–49 were using one or more form of contraception. Consultations requesting contraception should be autonomous and patient centred, where the woman is given information to select the most appropriate method without imposing unnecessary restrictions. The woman may have predetermined ideas of which contraception she requires, but it is important to explore her understanding of the method and discuss with her other options that are available. Other factors need to be taken into account, such as her age, any co-existing medical conditions and treatments, previous experience of contraception, any future plans for having children and lifestyle and risk behaviour. The UK medical eligibility criteria (UKMEC) set out to determine the risk/benefit ratio of the use of various methods of contraception with certain patient clinical features. There are relative few circumstances where the risks of progestogen-only contraception are felt to outweigh the benefits (UKMEC 3 or 4). This grading scale does vary slightly between different methods of progestogen-only contraception and this is discussed in detail later.
Available progestogen-only contraceptives
- Ethynodiol diacetate 500 mcg (Femulen)
- Norethisterone 350 mcg (Micronor)
- Norethisterone 350 mcg (Noriday)
- Norethisterone enanthate 200 mg/ml (Noristerat)
- Levonorgestrel 30 mcg (Norgeston)
- Desogestrel 75 mcg (Cerazette)
- Medroxyprogesterone acetate 150 mg/ml (Depo-Provera)
- Etonogestrel 68 mg/rod (Implanon)
- Levonorgestrel IUS 20 mcg/24 hour (Mirena)
With each type of contraception, it is important to know the method and duration of action, the main indications and contraindications, potential side effects, how to use, the need for follow-up and the failure rates.
The failure rate is described as the number of pregnancies occurring in people using the method for 1 year. There are three main reasons why contraception may fail:
- Failure of the patient to use the method or to use it correctly (user failure)
- Error in provision of the method, that is incorrect insertion of the IUS or the subdermal implant (provider failure)
- Fail despite perfect usage/insertion (method failure). The method failure rate translates to the efficacy of a contraceptive method.
In reality, there is not perfect usage/insertion in 100% of cases. Therefore, the true failure rate based on typical use is referred to as the effectiveness of the contraceptive method.
Cost effectiveness
The NICE guidance on long-acting reversible contraception (LARC) states that despite the initial high costs of LARC (although here we are just looking at Depo-Provera, Implanon and Mirena), these methods are all more cost effective than the combined oral contraceptive pill by 1 year of use. The IUS and implants are more cost effective than injectable contraceptives.
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Progestogen-only oral contraceptive pill |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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This is the most commonly used form of progestogen-only contraception. It is often used when the combined oral contraceptive pill is contraindicated for medical reasons, for example in those with multiple cardiovascular risk factors (e.g. smoking, obesity, diabetes and hypertension), migraine (with aura at any age or without aura in women aged >35 years), history/risk of thromboembolic disease or lactation.
Mechanism of action
Traditional progestogen-only pill
These act mainly by thickening the cervical mucus thus making it impenetrable to sperm. They also have a variable effect on preventing ovulation and they cause endometrial changes which reduce the chance of implantation, should fertilization occur. This variable effect on ovulation is responsible for one of the main drawbacks of the mini-pill—bleeding problems. Normal ovulatory cycles occur in 40% of cases and these women will have roughly regular periods. In 23% of cases, there is cyclical follicular activity but no luteal function, that is no ovulation. In 21% of cases, there is follicular activity but reduced luteal activity. In both of these instances the bleeding pattern is very irregular. In just 16% of cases, there is neither follicular nor luteal activity and the patient is amenorrhoeic.
Cerazette
The traditional ‘mini-pills’ vary from the newer progestogen-only pill (POP), Cerazette, in main mode of action and how it is taken. Cerazette contains a newer progestogen—desogestrel—which is metabolized to etonogestrel. Etonogestrel has a high affinity for progesterone receptors and therefore can be tolerated in higher doses. This means that ovulation is inhibited in more cycles. The manufacturers state that ovulation is inhibited in 97% of cycles with Cerazette in comparison with only 50% of cycles with traditional mini pills. This is therefore its main mechanism of action. Its secondary action is the main mechanism of action of traditional progestogen-only pills—thickening of cervical mucus.
Advantages
Particularly for short-term use, this is an inexpensive method of contraception. There are few circumstances when it is medically contraindicated, thus it is useful in many women who wish to take the pill, but in whom the combined oral contraceptive pill is not recommended. With the arrival of Cerazette on the market, the window for taking the POP is the same as the COCP and efficacy is higher than traditional POPs. It is a non-invasive method of contraception and therefore particularly useful for those who are unsure of what method is appropriate for them or the suitability of progestogen-only contraception.
Taking the POP
*These requirements for additional precautions for 2 days is based on guidance from the Faculty of Sexual and Reproductive Healthcare. The summary of product characteristics has different recommendations and therefore, this is an out of license recommendation.
The pill ideally needs to be taken at the same time every day. If a traditional pill is more than 3 hours late, then the missed pill should be taken as soon as possible and additional precautions need to be used for 48 hours. However, Cerazette can be up to 12 hours late before additional precautions are needed. Unlike the combined pill, the progestogen-only pill only requires additional precautions for 48 hours because the effect on the cervical mucus is achieved within this time frame. If a woman vomits within 2 hours of taking a pill, the dose should be repeated as soon as possible. If vomiting or severe diarrhoea persist for more than 24 hours, then additional contraceptive cover is required for the duration of the illness and 2 days afterwards. Antibiotics that are not enzyme inducers do not interfere with the effectiveness of POPs.
Table 2 uses information from NICE guideline on LARC.
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Side effects
The main disadvantages of the progestogen-only pill are as follows:
- Breast tenderness/pain
- Mood swings usually temporary, due to metabolites of the progestogen
- Acne
- Bloating
- Unpredictable bleeding or amenorrhoea: common but tend to resolve with time
- Weight gain
- Increased risk of functional ovarian cysts (about 30% increase in risk): risk lower with Cerazette
- No protection against sexually transmitted infections
- May not be suitable in patients weighing over 70 kg: consider double dose traditional POP or use Cerazette instead
- Risk of ectopic pregnancy is slightly higher (except with Cerazette) although the absolute risk is lower than if not using contraception at all. This is due to the effect of progestogens on tubal motility.
- Breast cancer: there is a small increase in the risk of having breast cancer diagnosed in women using, or who have recently used, a progestogen-only contraceptive pill; this relative risk may be due to an earlier diagnosis. The most important risk factor appears to be the age at which the contraceptive is stopped rather than the duration of use; the risk disappears gradually during the 10 years after stopping and there is no excess risk by 10 years. The CSM has advised that a possible small increase in the risk of breast cancer should be weighed against the benefits.
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Injectable contraceptives |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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There are two injectable contraceptives available. Depo-Provera is the most commonly used and contains DMPA. There is also Noristerat which is only used short term, for example when waiting for a vasectomy to become effective or following rubella immunization. It lasts 8 weeks and can be repeated once. Injection is often painful with this preparation. They are both given by deep intramuscular injection, preferably into the gluteal region. In obese women, where it is felt that the needle may not reach muscle, they may be given into the deltoid.
Mechanism of action
Depo-Provera contains relatively high doses of progestogen and works mainly through the inhibition of follicle development and thus ovulation. Like the POP, it also has effects on the cervical mucus and brings about changes to the endometrium including atrophy. As both follicle development and ovulation are completely suppressed, amenorrhoea results in many cases.
Advantages
The main advantages of injectable progestogens are that they are unaffected by other medications (including enzyme inducers), they may reduce menorrhagia and dysmenorrhoea and help with premenstrual symptoms and they are also suitable for use in women with a high body mass index (BMI >35 kg/m2). Additionally, they may reduce the frequency of seizures in women with epilepsy and may offer some protection against endometrial cancer.
Using Depo-Provera
If the injection is given within days 1–5 of the menstrual cycle, no additional precautions are needed. If it is given outside of this time, then additional contraception is required for a period of 7 days. If starting postpartum, it is not recommended for use before 6 weeks particularly in breastfeeding women. If it must be used before 6 weeks postpartum because of the risk of pregnancy, it should be delayed until at least day 21 after delivery. When used beyond 21 days, additional contraception should be used for 7 days. Following miscarriage or termination of pregnancy, Depo-Provera can be used immediately. If used more than 7 days following the event, extra-contraceptive measures should be taken for 7 days.
Routinely, Depo-Provera is given every 12 weeks. It can be given up to 2 weeks early. The UK license is for 12 weeks and 5 days (89 days). However, the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit recommend that DMPA can be given up to 14 weeks (98 days) with no additional contraception needed. If it is given later, the use of emergency contraception should be considered and extra precautions should be used for 7 days. However, if pregnancy cannot be excluded immediately, delay repeating the injection until there is a negative pregnancy test at least 3 weeks after the last episode of sexual intercourse.
Side effects
DMPA use may be less associated with acne, depression or headaches.
- Weight gain: use may be connected to weight gain, typically 2–3 kg over 1 year
- Decrease in HDL cholesterol with injectable contraceptives: hence it is not recommended in the presence of cardiovascular disease or multiple cardiovascular risk factors
- Bleeding problems: the most common complaint. The overall discontinuation rate of DMPA for all reasons is approximately 50% at 1 year. The discontinuation rate due to abnormal bleeding is 30–40%. It has been shown that providing counselling to women about bleeding problems prior to starting the injection will reduce discontinuation rates. The woman should be reassured that amenorrhoea is not harmful. Almost two-thirds of women using DMPA will be amenorrhoeic at 1 year and this number increases as time goes by. DMPA may also cause persistent bleeding, but heavy and prolonged bleeding occurs in less than 10% of women. This may be treated with ethinylestradiol (either alone or in the form of the combined oral contraceptive pill) or with mefenamic acid. Despite these reported problems with troublesome bleeding, DMPA can also be beneficial in some women suffering with heavy menstrual bleeding. As such, is it actually recommended as a third line agent in the recent NICE guidance on management of menorrhagia.
- Loss of bone mineral density: as Depo-Provera delivers higher doses of progestogen, there is suppression of ovarian activity which causes hypoestrogenism and loss of bone mineral density. This loss of bone mineral density is largely recovered when DMPA is discontinued. There is no evidence to suggest that the risk of fracture is increased. The reduction in bone mineral density is duration dependent for the first few years, after which the effect appears to plateau. Therefore, it is recommended that the use of DMPA is reviewed after 2 years on an individual basis. The benefits versus risks should be discussed with the woman, who should be supported in her choice of whether or not to continue. The CSM has advised that in adolescents, DMPA is only used where other methods of contraception are inappropriate. NICE recommends that care should also be taken in recommending DMPA to women over the age of 40, but it may be given if other methods are not suitable or acceptable. This is felt to be good practice because of the reduced ability to recover bone mineral density following the menopause rather than based on any studies which have shown proven reduction in bone mineral density in perimenopausal women. In women with risk factors for osteoporosis, other methods should be considered.
- Delayed return to fertility: this can be up to 1 year. However, if a woman does not wish to conceive following stopping the contraceptive injection, she should be advised to use an alternative method of contraception immediately, even if amenorrhoea persists.
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Subdermal implant |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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Implanon consists of a single flexible rod which releases etonogestrel. This is the same substance that Cerazette is metabolized to. It is inserted subdermally into the skin of the upper arm and lasts for 3 years. Insertion and removal requires specialist training. It is relatively painless as it is inserted under local anaesthetic. After the procedure, a pressure dressing is applied to reduce the risk of bruising. Following insertion, the woman should be shown how to palpate the implant to check position and so that she knows that it has not migrated. It should be palpable beneath the skin but is not usually noticeably visible. Implants which are not palpable need to be localized by ultrasound scan. This is usually because they are inserted too deep. No routine follow-up is required after insertion.
Mechanism of action
The dose of etonogestrel is sufficient to prevent ovulation in every cycle throughout the 3 years of use. It also causes changes in the cervical mucus.
Advantages
It has advantages in that it provides contraception for a long period, fertility returns to normal as soon as the implant is removed (94% ovulate within 3 weeks) and it is effective in women of all weights. Although the manufacturer advises earlier replacement of the implant in ‘heavier women’ (BMI >35 kg/m2) the FRSH states that women with a BMI >30 kg/m2 can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of licensed use.
Using Implanon
Ideally, Implanon should be inserted in days 1–5 of a cycle. If inserted outside this time, additional contraception is required for 7 days. It can be inserted from day 21 postpartum. If it is inserted after day 21, additional protection is needed for 7 days. It can be used immediately following miscarriage or termination, but if insertion occurs more than 5 days following the event, extra contraception must be used for 7 days.
Side effects
- Irregular bleeding: up to 43% of women stop using Implanon within 3 years. About 33% of women stop using it because of irregular bleeding. Therefore, it is important to inform women that bleeding patterns are likely to change while using Implanon. About 20% of women will have no bleeding (more likely in older women) and 50% of women will have infrequent, frequent or prolonged bleeding. The erratic nature of the bleeding is likely to continue over time. Like with the injection, irregular bleeding can be managed with mefenamic acid or ethinylestradiol or the combined oral contraceptive pill, provided that other causes for irregular vaginal bleeding (such as sexually transmitted infections, pregnancy and cervical cancer) have been excluded.
- Acne: may be associated with its use but it may also improve while using Implanon
Unlike the injection, Implanon is affected by enzyme inducing drugs. Weight gain, mood changes and headaches may be less associated with Implanon.
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Levonorgestrel-releasing IUS: Mirena |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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The IUS has a plastic T-frame with a reservoir containing 52 mg of levonorgestrel and releasing 20 mcg/24 hours. It lasts for 5 years in most women in whom it is used for contraceptive purposes. However, NICE recommends that if a woman aged
45 at insertion is amenorrhoeic with Mirena, it can be left in place until contraception is no longer required. This is outside of the product license. The levonorgestrel-releasing intrauterine system (LNG-IUS) can also be used to provide the progestogenic component to HRT for endometrial protection. In this context, it needs replacing after 4 years. This is potentially advantageous as it causes minimal systemic absorption of progestogen, given the concerns about increased risk of breast cancer with combined HRT. Unlike the copper IUD, it cannot be used as emergency contraception. Insertion requires specialist training, although removal does not. Correct placement is necessary to ensure the hormone is delivered over the whole endometrial tissue. Occasionally, local anaesthesia and dilatation of the cervical canal are required to aid insertion, particularly in nulliparous or post-menopausal women. Instrumentation of the cervix can also cause transient increase in vagal tone. Insertion usually causes mild cramping of the uterus and for this reason it is often recommended that women taken analgesia prior to insertion of the LNG-IUS.
Mechanism of action
The main mode of action is by preventing implantation. The local progestogen suppresses endometrial proliferation. There is also thickening of cervical mucus inhibiting the passage of sperm. Ovulation is suppressed in <25% of women. The mechanism of action may be of concern to some women, who may be worried that this constitutes a termination of pregnancy. However, the legal definition of pregnancy in the UK is when implantation occurs. Therefore, this contraceptive method is not an abortion in the legal sense of the word.
Advantages
The main advantages of the LNG-IUS are in its duration of efficacy, the rapid return to fertility and its beneficial effect on menorrhagia. (This in itself is a licensed indication for the use of Mirena, a first-line agent according to NICE guidance.) As the effects of Mirena are mainly local, there are no known interactions with any medications and the weight of the woman does not affect efficacy.
Using Mirena
Mirena should ideally be inserted in the first 7 days of the menstrual cycle. If this occurs, then no additional precautions are necessary. It can be inserted elsewhere in the cycle provided it is reasonably certain that the woman is not pregnant. Extra contraception is then required for 7 days. Replacement of the device can occur at any time in the menstrual cycle, although the woman should avoid intercourse or use barrier methods for the 7 days prior to the procedure in case reinsertion fails. Insertion following termination of pregnancy should take place on the same day. Otherwise, insertion should be delayed until 4 weeks after miscarriage or termination, with additional contraceptive protection from 1 week after the event, until insertion. Postpartum, the LNG-IUS can be inserted within the first 48 hour after delivery (although this is not recommended). Otherwise, insertion should be delayed until 4 weeks postpartum. After insertion, follow-up should be after the first menses or 3–6 weeks later, to exclude infection, perforation or expulsion.
Side effects
- Bleeding problems: up to 60% of women stop using the IUS within 5 years. The most common reasons for discontinuation are unacceptable vaginal bleeding and pain. Menstrual changes are common in the first 6 months. Periods may become lighter or may continue to be irregular. About 20% have amenorrhoea at 1 year. Proper counselling about the expected bleeding changes can reduce the discontinuation rate.
- Expulsion: expulsion of the device can occur but the rate is stated as less than 1 in 20 women over 5 years. Women should be shown how to check for threads, as undetected expulsion is a common cause of failure of this method. Expulsion is most common with heavy menstruation and in the first 3 months after insertion.
- Infection: the risk of pelvic inflammatory disease is higher than background risk only in the 3 weeks following insertion. A careful risk assessment ± swabs will reduce this risk. It is also a good opportunity to give advice regarding sexual health promotion. If deemed necessary, azithromycin 1 g stat can be used at the time of insertion. Actinomyces israelii are commensal bacteria of the female genital tract. Actinomyces-like organisms (ALOs) are found in women with and without an IUS. They have not been shown to be predictive of any disease. The presence of ALOs on a cervical smear in a woman with an IUS requires an assessment to exclude pelvic infection. Routine removal is not indicated in women without signs of pelvic infection.
- Perforation: the risk of uterine perforation is very low: less than 0.1%. It is mainly related to the skill of the inserter, but timing of insertion and the condition of the uterine wall are also important. Women should be warned about symptoms of uterine perforation or infection which would warrant early review of IUS use.
- Ectopic pregnancy: the absolute risk of ectopic pregnancy with the LNG-IUS approximately 1 : 1000 over 5 years. This compares to an ectopic pregnancy rate of 1 : 100 in women using no contraception. Therefore, the risk of ectopic pregnancy is lower in users of the IUS than in those on no contraception, by virtue of the reduced incidence of pregnancy. However, if pregnancy does occur with the IUS, around 1 : 20 are ectopic. Should pregnancy occur with the IUS in situ, it is advised that an early scan is carried out to exclude ectopic pregnancy, and the IUS should be removed before 12 weeks gestation, whether or not the woman intends to continue with the pregnancy.
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UKMEC for use of progestogen-only contraceptives |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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The UKMEC is a UK adaptation of the WHO guidance on the effect of medical conditions on the use of various contraceptives. Each contraceptive method is ranked as being in one of four categories:
- UKMEC1: No restrictions to use
- UKMEC2: Advantages generally outweigh risks
- UKMEC3: Risks probably outweigh benefits
- UKMEC4: Unacceptable risk
There is considerable overlap between the progestogen-only contraceptive methods in terms of UKMEC classification. However, there are some important differences. The UKMEC criteria for the progestogen-only contraceptive methods are considered here.
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Emergency contraception |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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In the UK, the two options for emergency contraception are a single dose of levonorgestrel 1.5 mg or the copper IUD. Levonorgestrel can be prescribed as Levonelle 1500 or purchased as Levonelle One Step from a pharmacy to over 16s at a cost of £25. It is not a form of regular contraception. The risk of pregnancy from unprotected sexual intercourse is highest in days 9–15 of a regular 28-day cycle. There is no time during the cycle when there is no risk of pregnancy, although the risk in the first 3 days appears negligible. It needs to be taken as soon as possible after unprotected intercourse as efficacy is greatest the sooner it is taken. If taken within 24 hours of intercourse, it prevents 95% of pregnancies; 24–48 hours prevents 85% and 48–72 hours prevents 58%. It is sometimes used beyond the licensed 72 hours, up to 120 hours, on a named patient basis. If outside of the 72 hours, the patient should be referred to specialist services for further advice, including the consideration of insertion of a copper IUD, the alternative. Overall comparison rates between progestogen-only emergency contraception and the IUD are as follows:
Percentage of expected pregnancies prevented:
- IUD insertion (within 5 days): 99%
- Levonelle 1500 within 72 hours: 84%
- Levonelle 1500 over 72 hours: 63%
Emergency progestogen-only contraception is not protective against further episodes of unprotected intercourse beyond 12 hours from the time of taking. The new single dose Levonelle causes fewer side effects than the previous split dose regime and vomiting is uncommon. However, if it does occur within 2 hours of taking, it should be repeated. As with the progestogen-only pill, it is unaffected by antibiotics, but is affected by enzyme inducers. Current advice, although unlicensed, is to double the dose in patients taking enzyme inducing drugs (repeated dose after 12 hours). Slight menstrual disturbance is a common side effect, but 95% menstruate within 7 days of the expected date. The woman should be advised to take a pregnancy test and return for review if menstruation is more than 7 days late or unusually light.
Contraindications
UKMEC advises that there are no medical contraindications to progestogen-only contraception. However, one should avoid giving it if there is known severe allergy to a constituent. Caution should be exercised in patients with:
- Acute intermittent porphyria
- Severe liver disease with abnormal LFTs
- Past or present breast cancer
- Gestational trophoblastic disease with abnormal hCG
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Progestogen-only contraception in special groups |
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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As mentioned earlier, it is important to tailor contraception to the needs of the individual. Providing appropriate counselling and making a shared decision will reduce discontinuation rates and thus reduce the risk of unwanted pregnancy.
Young people
- Confidentiality in under 16s may be broken if maltreatment, exploitation or coercion is suspected. She needs to be aware of this, and informed if confidentiality is to be broken.
- The legal age of consent is 16. Sexual activity under this age is an offence, even if consensual. It is considered statutory rape when the person is less than 13 years of age.
- When contraceptive services are provided to under 16s without their parent's knowledge, the Fraser guidelines must be followed:
- The young person understands the advice
- She cannot be persuaded to inform her parents or to allow the health professional to inform them
- It is likely that she will continue to have sexual intercourse, with or without the use of contraception
- Her physical or mental health may suffer as a result of withholding contraception
- It is in the best interests of the young person for the clinician to provide contraception without parental consent
- The young person understands the advice
- Competence must also be assessed. She needs to be able to understand the information, weigh up the risks and benefits and to express her own wishes.
- Specific contraceptive points in women <18 years of age:
- Sexually active girls who have not started menstruating should be advised against hormonal contraception
- Progestogen-only injectables can be used, if the patient chooses, provided she is not at increased risk of osteoporosis
- The occurrence of acne can be a reason for discontinuation of progestogen-only implants and injectables
- Sexually active girls who have not started menstruating should be advised against hormonal contraception
Women approaching the menopause
- Women under the age of 50 should continue contraception for 2 years after the last period
- Women aged 50 or more should continue contraception for 1 year after the last period
- The IUS may reduce menorrhagia and dysmenorrhoea associated with dysfunctional uterine bleeding in the perimenopausal period
- The IUS can be left in place for 7 years if inserted over age 45 or until contraception is no longer required if over 45 years at insertion and amenorrhoeic
- Progestogen-only methods are useful as other forms of contraception are often contraindicated by this age. However, more careful consideration should be given to the use of DMPA due to the effects on bone mineral density.
- A progestogen-only pill can be used with combined sequential HRT to provide effective contraception and adequate endometrial protection. The use of a POP- and oestrogen-only HRT will provide insufficient endometrial protection.
- The LNG-IUS can be used to as the progestogenic component to HRT for 4 years in addition to providing contraception
Key points
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TOPAbstractThe GP curriculum and...Initiating contraception-...Progestogen-only oral...Injectable contraceptivesSubdermal implantLevonorgestrel-releasing IUS:...UKMEC for use of...Emergency contraceptionProgestogen-only contraception...References |
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British National Formulary Issue 55. (2008) www.bnf.org.uk.
Clinical Knowledge Summaries. Contraception. (2007) www.cks.library.nhs.uk.
Faculty of Sexual and Reproductive Healthcare. www.ffprhc.org.uk.
Progestogen only implants. (2008) www.ffprhc.org.uk/admin/uploads/CEUGuidanceProgestogenOnlyImplants.pdf [date last accessed 09.07.2008].
IUS—The levonorgestrel-releasing intrauterine system in contraception and reproductive health. (2004) www.ffprhc.org.uk/admin/uploads/IUSfinal.pdf [date last accessed 09.07.2008].
Depo-Provera and young people—Faculty statement. (2004) www.ffprhc.org.uk/admin/uploads/Depo_Provera_alert_statement.pdf [date last accessed 09.07.2008].
Emergency contraception guidance. (2006) www.ffprhc.org.uk/admin/uploads/449_EmergencyContraceptionCEUguidance.pdf [date last accessed 09.07.2008].
Emergency contraception (Levonelle 1500) and liver enzyme inducing drugs. (2005) www.ffprhc.org.uk/admin/uploads/563_Levonelle1500KeyStatement.pdf [date last accessed 09.07.2008].
Contraception for women over 40 years. (2005) www.ffprhc.org.uk/admin/uploads/ContraceptionOver40.pdf [date last accessed 09.07.2008].
Contraceptive choices for breastfeeding women. (2004) www.ffprhc.org.uk/admin/uploads/breastfeeding.pdf [date last accessed 09.07.2008].
Contraceptive choices for young people. (2004) www.ffprhc.org.uk/admin/uploads/YoungPeople.pdf [date last accessed 09.07.2008].
The UK medical eligibility criteria for contraceptive use. (2005/2006) www.ffprhc.org.uk/admin/uploads/298_UKMEC_200506.pdf [date last accessed 09.07.2008].
Cerazette—Desogestrel only pill. (2003) www.ffprhc.org.uk/pdfs/Cerazette%20CEC%20Approved%2029.04.03.pdf [date last accessed 09.07.2008].
NICE. Heavy menstrual bleeding. (2007) Accessed via www.nice.org.uk/nicemedia/pdf/CG44FullGuideline.pdf [date last accessed 09.07.2008].
NICE. Long acting reversible contraception. (2005) Accessed via www.nice.org.uk/nicemedia/pdf/CG030fullguideline.pdf [date last accessed 09.07.2008].
NICE. Prophylaxis against infective endocarditis. (2008) Accessed via www.nice.org.uk/guidance/index.jsp?action=byID&;o=11938 [date last accessed 09.07.2008].
Patient UK. www.patient.co.uk.
RCGP Curriculum statement 11: Sexual health. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_11_Sexual_Health.pdf [date last accessed 09.07.2008].
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