Progesteron-only Methods
Progestogen only pill (POP/mini-pill)
- Number of different POPs made of different progestogens e.g levonorgestrel, norethisterone, and desogestrel (Cerazette)
- works primarily by thickening cervical mucus preventing sperm entering the uterus, but also thins the endometrium.
- variable effect on ovulation (apart from Cerazette which inhibits ovulation consistently)
- Correct use:
- §
- §
- § may be started anytime during cycle (if started on day 1 woman has immediate contraceptive protection, otherwise takes 48 hours to become effective)
- § start 21 days postpartum and immediately post-abortion
- Effectiveness: 96 – 99.7% effective (dependent on compliance). Most effective in >40y.o and lactating women. Least effective in young women.
- Side-effects:
- § irregular bleeding in 40% and amenorrhoea in 20%
- §
- § functional ovarian cysts
- § increased risk of ectopic pregnancy
- Indications:
- § while breastfeeding
- § if combined oral contraceptive pill is contraindicated
- § patient choice
- Contraindications:
- § Pregnancy
- § Undiagnosed genital tract bleeding
- § Recent trophoblastic disease if β-HCG is high
- § Porphyria
- § Use of liver enzyme inducing drugs as they will cause the contraceptive to fail
- § History of ectopic pregnancy (although may consider use of Cerazette as it inhibits ovulation)
- § Severe artery disease and history of breast cancer, as with the combined oral contraceptive, but more of a relative contraindication with POP
- Advantages:
- § Fewer adverse effects due to lack of oestrogen in pill
- § Rapid return of fertility on discontinuation
- § Safe with breastfeeding
- § Harmless in overdose
- § Effective if used correctly
- § Does not interfere with sex
- Disadvantages:
- § Irregular bleeding
- § Inconvenient taking at same time each day (better with Cerazette)
- § Increased failure rate in young women
- § Failure with use of liver enzyme inducing drugs
Injection
- Depo-Provera = intramuscular depot injection of 150mg medroxyprogesterone given every 12 weeks
- (Norethisterone enanthate = injectable progestogen given 8 weekly, but uncommonly used in UK)
- Releases progestogen gradually into circulation which at this dose inhibits ovulation.
- Like POP it also thickens cervical mucus and thins the endometrium
- Correct use:
- § Administered by a health professional every 12 weeks (although effective up to 14 weeks)
- § Normally given in 1st 5 days of cycle (use extra precautions for 7 days after first injection if short cycles or given at any other time in cycle)
- § If repeat dose is overdue beyond 14 weeks a repeat injection can be given if woman is not pregnant and advise use of extra precautions for next 7 days
- § If doubt do pregnancy test in 3 weeks, as although not teratogenic may have virilising effect on female foetus if repeated doses during pregnancy
- § Administer 6 weeks postpartum and immediately post-abortion
- Effectiveness: Over 99% effective
- Advantages:
- § Highly effective
- § Long lasting (no need to remember on daily basis)
- § Does not interfere with sex
- § Can be used with liver enzyme inducing drugs
- § Decreases heavy menstrual bleeding
- § May decrease PMT, menstrual related epilepsy and migraine
- § May be beneficial in endometriosis
- § Can be used while breastfeeding
- § Protective against some uterine cancer and PID
- § No oestrogen side effects and can be used in those with previous venous thrombosis
- § Protective against ectopic pregnancy
- § Beneficial in sickle cell disease as stabilizes red blood cell membrane
- Disadvantages:
- § Irregular bleeding for first few months, then amenorrhoea in the long-term
- § Cannot be removed once administered if adverse effects
- § Weight gain ~2kg
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- § Delay in return of fertility ~9 months after last injection administered
- § Hypo-oestrogenism which may reduce bone mass (important in young) and possible osteoporosis in later life
- Contraindications:
- § Similar to POP but can be used in those with history of ectopic pregnancy
- § Unsuitable for short-term contraceptive use
- § Arterial Disease, Ischaemic Heart Disease, Stroke
- § Active thromboembolism
- § Hepatitis/Cirrhosis
- § Osteoporosis
- § Porphyrias
Implant
- Nexplanon replaced Implanon in October 2010 in the UK as Nexplanon is radioopaque (barium sulphate) so can be found if it moves.
- It is a flexible tube containing etonorgestrel which is released through a rate controlling membrane
- Effective for 3 years after which it must be removed
- Hormone release inhibits ovulation as the main mechanism of action but also thickens the cervical mucus and thins the endometrium
- Insertion:
- § Usually put in during 1st 5 days of cycle for immediate protection
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- § Inserted subdermally in the non-dominant upper arm by a health professional under local anaesthetic
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- § Keep area clean and dry for 2 days after
- § Insert 21 days postpartum and immediately post-abortion
- Removal (after maximum of 3 years):
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- §
- Effectiveness: Very high, >99% with most failures probably being due to pre-insertion conceptions or drug interactions.
- Advantages:
- § Highly effective
- § Long lasting (no need to remember on daily basis)
- § Does not interfere with sex
- § Low steady levels of hormone
- § Can be used while breastfeeding
- § No oestrogen side-effects
- § Safe with history of ectopic pregnancy
- §
- § Rapidly reversible: within 1 week of removal hormone is undetectable in blood
- § No hypo-oestrogenism as etonorgestrel inhibits LH but not FSH
- Disadvantages:
- § Change in periods: 20% have irregular bleeding, 35% regular periods, 45% amenorrhoea
- §
- § Rarely infection in the arm or allergic reactions
- § Scarring on removal of deep implants
- § Drug interaction with use of liver enzyme inducing drugs (extra precautions to be taken while on such drugs and for 4 weeks after
- Contraindications:
- § Undiagnosed genital tract bleeding
- § Active venous thromboembolic disorder
- § Liver disease
- § Porphyria
- § Presence or history of any sex steroid sensitive malignancies
Emergency contraceptive pill
- Levonelle (1500mcg levonorgesterel) is a single dose which can be given up to 72 hours after unprotected sex
- ellaOne (30mg Ullipristal acetate) is a selective progesterone receptor modulator so blocking its action and is licensed up to 120 hours when an IUD is contraindicated.
- Act by disrupting ovulation/delaying release of ovum
- More effective the sooner they are taken
- Side effects: nausea and vomiting, and menstrual change for that cycle
- Contraindications: Pregnancy, allergy, porphyria and liver disease
Combined Hormonal Contraceptive Methods
Combined Oral Contraceptive Pill (COCP)
- contains both oestrogen and progestogen, although type and dosage varies between different makes.
- 3 types:
- § most common = monophasic 21 day pills (same amount of hormone in each)
- § phasic 21 day pills with variable amounts of hormone in pills
- § everyday pills where 21 hormone tablets and 7 inactive pills in packet and a new packet is started immediately after finishing each packet
- Can have progestogen variants developed for specific effects e.g drospirenone in Yasmin less likely to cause acne
- Acts chiefly by suppressing ovulation as well as increasing cervical mucus and thinning the endometrium
- Correct use:
- § 21 days of pills then 7 pill-free days
- § If started on day 1-5 of cycle provides immediate protection
- § Always start a new packet on the same day of the week as previous packet
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- §
- § Patients should be seen every 6-12months to check BP, weight, BMI, risk factors and symptoms
- Effectiveness: Perfect use: >99% Typical use: 95%
- Efficacy also reduced by; missed pills, vomiting, severe diarrhoea, liver enzyme inducing drugs and broad spectrum antibiotics
- Side Effects: (often wane after 3months)
- § Breast tenderness
- § Nausea
- § Weight gain
- § Loss of libido
- § Low mood
- § Breakthrough bleeding
- § Should see a doctor if: leg swelling, chest pain, haemoptysis, severe or persistent headache, neurological symptoms or jaundice
- Advantages:
- § Highly effective
- § Effective
- § Convenient
- § Reversible
- § Does not interfere with sex
- § Regular predictable menstrual flow
- §
- § Decreased PID, ovarian cysts, ovarian cancer and endometrium cancer
- § Can help improve acne
- § No adverse effect on future fertility
- Disadvantages:
- § Necessity to take everyday
- § Failure with use of liver enzyme inducing drugs
- §
- § Increased risk of breast cancer, hepatocellular cancer and cervical cancer
- § Oestrogen and Progestogen side effects
- § Cannot use while breastfeeding
- Contraindications:
- o Absolute: - Cardiovascular disease/ multiple risk factors for arterial disease
- Current or History of IHD, stroke, valvular heart disease, AF, pulmonary hypertension, sub-acute bacterial endocarditis
- Smokers >35y.o
- History of migraines with focal neurological signs
- BMI >35
- Hypertension: > 140/90
- Current or History of venous thromboembolic disease
- Breastfeeding
- Pregnancy
- Undiagnosed genital tract bleeding
- Diabetes with systemic complications
- Liver tumours
- Severe decompensated cirrhosis
- Use with liver enzyme inducing drugs
- o Relative: (2 relative = 1 absolute)
- Simple migraine
- BMI >30
- High altitude
- Uncomplicated diabetes
- Partial immobility
Transdermal Patches
- EVRA is a transdermal patch which releases norelgestromin and ethinylestradiol preventing ovulation
- Each patch is worn for 7 days on buttock/upper arm/torso
- 1 patch every week for 3 weeks and then a patch-free week
- Similar efficacy, side-effects and contraindications to COC, but more expensive
- If patch is detached for >24 hours replace and use extra precautions for 7 days.
Vaginal Rings
- NuvaRing is a small plastic ring releasing etonorgestrel and ethinylestradiol which is placed inside the vagina and prevents ovulation
- The ring is placed in the vagina by user on day 1 of cycle and removed it 21 days
- A new ring is then used for the next cycle.
- Similar efficacy, side-effects and contraindications to COC
- Advantages:
- § Good cycle control with a low dose of oestrogen
- § Does not interfere with sex
- § Still effective after vomiting or diarrhoea
- Disadvantages:
- § Higher cost than COC
- § Needs cold chain for storage