Contraception

• Hormonal contraceptives have other indications besides preventing pregnancy


  • Managing pre-menstrual tension
  • Period delay
  • Dysmenorrhoea
  • Polycystic ovary syndrome
  • Endometriosis
• Types of hormonal contraception

  • Combined hormonal contraceptives
  • Progesterone only contraceptives
• Combined hormonal contraceptives


  Contain both oestrogen and progesterone
• Progesterone only contraceptives


  Contain only a progesterone of which there are many different types, including both natural and synthetic options
• Progesterone only contraceptives


  • Progesterone only pills
  • Parenteral preparations e.g. depot injection, implant
  • Intrauterine devices (the coil – available as a progesterone releasing or copper option)
• Factors to consider when deciding on an appropriate contraceptive for a patient

  • Age of the patient
  • Medical history – including any interacting drugs, co-morbidities, risk factors, BP and BMI
  • Family history
  • Lifestyle and social factors such as smoking
• Combined Hormonal Contraceptives


  Contain oestrogen and progesterone
• Combined Hormonal Contraceptives


  Inhibit ovulation by suppressing LH and FSH
• Options for Combined Hormonal Contraceptives

  • Tablets
  • Patches
• Tablets


  Traditionally, 21 tablets taken once daily for three weeks then a 7 day break during which a withdrawal bleed occurs. ED preparations have 7 placebo tablets which can help with compliance and still lead to a withdrawal bleed
• Patches


  Weekly patch applied once weekly for three weeks of the month and a withdrawal bleed occurs in the hormone free interval. Patches can be more convenient and encourage compliance for some patients but there is a risk of the patch detaching
• Start with the preparation with the lowest oestrogen and progestogen content that gives good cycle control and minimal side effects
• Low strength preparations containing ethinylestradiol 20microgram


  Useful in women with risk factors for circulatory disease
• Standard strength (30-40microgram ethinylestradiol)

  Suitable for most other women
• Monophasic or multiphasic


  • Monophasic – fixed preparations of oestrogen and progestogen in each tablet
  • Multiphasic – varying proportions of hormones and generally reserved for women who experience breakthrough bleeding with monophasic products
• Advantages of Combined Hormonal Contraceptives

  • Reliable when taken as instructed
  • Reversible
  • Can reduce dysmenorrhea
  • Can reduce incidence of pre menstrual tension (PMT)
  • Can help with fibroids and ovarian cysts
  • Reduce risk of ovarian and endometrial cancer and pelvic inflammatory disease
• Limitations of Combined Hormonal Contraceptives

  • Can only be used up until the age of 50-years-old; after this age women should be switched to a progesterone only or non hormonal method due to an increased risk of stroke and venous thromboembolism with age
  • Less effective than long acting reversible progesterone only methods - mainly due to more opportunity of user error via missed pills
  • There may be a short delay in return to fertility with patches but not with tablets
• Extended cycling and tailored regimes

  Traditional 21 day cycles designed to lead to withdrawal bleed each month mimicking the natural cycle. No health benefit achieved from a seven day hormone free interval. Can lead to unwanted symptoms and may increase risk of pregnancy when pills missed around hormone free interval. Women can safely take fewer or no hormone free intervals which avoids monthly bleeding and withdrawal effects such as headache and mood changes
• Extended cycling or tailored regimes can reduce withdrawal symptoms, reduce risk of escape ovulation and therefore reduce risk of pregnancy. They have been shown to be safe and effective for contraception
• Unscheduled bleeding is common when using extended cycling or tailored regimes
• Generally the extended cycling or tailored regimes are outside of the license but are supported by FSRH since they help reduce symptoms and reduce the risk of contraceptive failure
• Contraindications for Combined Hormonal Contraceptives

  • Migraine with aura (increased risk of stroke)
  • Personal history of venous or arterial thrombus
  • Current breast cancer
  • >35-years-old and smoking 15 or more cigarettes daily
  • Atrial fibrillation
  • Stroke
• Cautions for Combined Hormonal Contraceptives

  • Severe or multiple risk factors for VTE or CV disease including: Family history of VTE (specifically for VTE risk), Obesity, Age > 40-years-old, Smoker, Hypertension, Migraine (specifically a risk for CV/arterial disease)
  • Use with caution if one factor but avoid/seek specialist advice if multiple factors present
  • Past history of breast cancer
• Risks of Combined Hormonal Contraceptives

  • Small increase in risk of cervical and breast cancer which returns to normal 10 years after stopping
  • Reduced risk of ovarian and endometrial cancer for several decades after stopping
  • Increased risk of venous thromboembolism (VTE)
  • Very small increased risk of ischaemic stroke and MI
• Absolute risk of VTE and cardiovascular events is still very low and considerably less than in pregnancy
• Risk of VTE is higher in first year and if restarting after a break of >4 weeks
• Missed pill advice for Combined Hormonal Contraceptives

  Effectiveness relies on regular pill taking - biggest cause of failure is user error. Most important time is at beginning or end of pack since missed pills here lengthens the hormone free interval. If pill is missed (>24 hours late) it should be taken ASAP even if this means taking 2 pills together. If only one missed and rest are taken as instructed no additional precautions needed. If vomiting occurs within 3 hours of taking the pill or severe diarrhoea for >24 hours follow missed pill advice
• Missed pill advice for Combined Hormonal Contraceptives

  If 2 or more pills are missed, especially from the first 7 days of a pack then contraceptive protection can be lost. She should carry on taking pill as normal but abstain from sex or use additional contraception for the next 7 days. If those 7 days run beyond the end of the packet she should start the next packet immediately and omit the hormone free interval. Emergency contraception will be required if 2 or more pills missed from the first 7 and UPSI occurred since finishing last packet
• Progesterone Only Contraceptives


  Contains only progesterone but there are different types – some carry higher risks than others. Given once daily continuously with no hormone free interval. Thicken cervical mucus to prevent sperm penetration and some progesterones may inhibit ovulation. Fewer contraindications and therefore useful in women contraindicated to combined pills. Cause irregular bleeding in the first few months which is usually transient and eventually leads to amenorrhoea in many women
• Progesterone only contraceptives - desogestrel


  Desogestrel is the most commonly prescribed progesterone. Benefits over traditional progesterone only pills include: ovulation in inhibited in up to 97% of cycles, there is a 12 hour window for missed pills as opposed to 3 hours for traditional progesterone pills, ovulation is more consistently suppressed and this is the main mechanism of action for desogestrel (along with thickening of cervical mucus). Additional contraception not required if started up to and including day 5 of menstrual cycle
• Risks of Progesterone Only Contraceptives

  • Can be used up to the age of 55-years-old when natural loss of fertility can be assumed
  • Can initially lead to irregular bleeding
  • No evidence for any link to cardiovascular disease or VTE
  • Less conclusive evidence for an increased risk of breast cancer
  • No delay in return to fertility with the pill but can be with some long acting methods
• Contraindications for Progesterone Only Contraceptives

  • Current breast cancer (may be used after 5 years)
  • Acute porphyrias
• Missed pill advice for Progesterone Only Contraceptives - Desogestrel

  If missed, take ASAP and take next at normal time. If missed by >12 hours contraceptive effective could be lost. Continue taking pills as normal but add barrier method for next 2 days. Emergency contraception required if one or more tablets missed/taken >12 hours late and UPSI occurs before 2 further tablets taken correctly
• Progesterone only contraceptives


  • Can be used up to the age of 55-years-old when natural loss of fertility can be assumed
  • Can initially lead to irregular bleeding
  • No evidence for any link to cardiovascular disease or VTE
  • Less conclusive evidence for an increased risk of breast cancer
  • No delay in return to fertility with the pill but can be with some long acting methods
• Progesterone only contraceptives are contraindicated in current breast cancer (may be used after 5 years) and acute porphyrias
• Progesterone only contraceptives - Missed pill advice (desogestrel)

  1. If missed, take ASAP and take next at normal time

  2. If missed by >12 hours contraceptive effective could be lost

  3. Continue taking pills as normal but add barrier method for next 2 days

  4. Emergency contraception required if one or more tablets missed/taken >12 hours late and UPSI occurs before 2 further tablets taken correctly
• Progesterone only contraceptives - Missed pill advice (other progesterone only pills)

  1. Missed pill window is much shorter

  2. Take pill ASAP and continue taking at normal time

  3. If missed by >3 hours contraceptive effect may be lost

  4. If taken ASAP and continue taking properly then needs additional barrier methods for 2 days

  5. Emergency contraception required if one or more tablets taken more than 3 hours late and UPSI occurred before 2 more tablets taken correctly
• Long acting reversible contraception (LARC)

  Progesterone only methods that are long acting but reversible
• LARC options


  • Depot injection – given by IM injection every few months
  • Implant – replaced every 3 years
  • Intra-uterine system (IUS) - replaced every 3-5 years (8 years)
• LARC


  • Good long term options with a very low failure rate as compared to oral methods which have potential for user error (i.e. missed pills)
  • Although highly effective they can have undesirable local side effects
  • Potential for some delay in return to fertility with some options
  • Can initially cause irregular bleeding but in most cases lead to amenorrhoea eventually