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Side effects
• Menstrual disturbance (regular, irregular, or even amenorrhoea).
• Delayed conception (fertility may not return for 6–12mths).
• Weight gain (probably due to progestagen increased appetite).
• Bone loss (small risk of decreased bone density with prolonged use).
Progestagen-only subdermal implant
Nexplanon® (has replaced Implanon® in the UK):
• Contains etonogestrel.
• Insertion and removal involves a small procedure under local anaesthetic
(inserted into the arm).
• It lasts for 3yrs.
• Is radio-opaque.
• Specially designed applicator to minimize incorrect insertion.
Highly effective (failure rate reported as <0.1 per 100 woman-years).
Side effects
Menstrual disturbance—20% amenorrhoea, 50% erratic bleeding.
Copper-bearing IUCD
• Provides long-term reversible contraception.
• Insertion is usually easy.
• May be retained beyond the menopause.
Very effective (failure rate of 0.6–0.8 per 100
woman-years).
Mode of action
• Foreign body reaction in the endometrium
prevents implantation.
• Copper content may inhibit spermatozoa
motility.
Complications
• Irregular PV bleeding, especially first 3–6mths.
• Risk of infection: screen for Chlamydia prior to
insertion.
• IUCD expulsion: most common in the fi rst
3mths after insertion.
• Perforation: poor insertion technique or <4wks
post-partum.
• Dysmenorrhoea.
• Missing threads. ‘Missing’ threads may indicate
pregnancy, expulsion or perforation.
Timing of IUCD insertion
• Insert any time during cycle (as long as pregnancy excluded).
• Post-partum:.
• Following TOP:.
• Switching from other contraception:
Contraindications to copper-bearing IUCD
• Pregnancy.
• Undiagnosed genital tract bleeding.
• Active genital tract infection or PID.
• Uterine anomalies or fi broids distorting cavity.
• Copper allergy.
Levonorgestrel-releasing system
(Mirena® IUS)
The LNG-releasing system has a T-shaped
rod containing 52mg LNG
(20 micrograms released daily). It is a
reversible, highly effective contraceptive
with a failure rate of 0.18 per 100
woman-years.
.
Mode of action
• It acts on the endometrium, leading to endometrial atrophy and
preventing implantation.
• Thickened cervical mucus inhibits sperm penetration.
• It is particularly useful when oestrogen is contraindicated.
• May be used in patients with a history of breast cancer: no disease for 5yrs
and after consultation with breast surgeon.
• Breast-feeding: can be inserted 4 or more weeks post-partum.
Side effects
• Irregular PV bleeding is common in the fi rst 3–4mths: amenorrhoea in up
to 30% by 1yr.
• Hormonal symptoms: nausea, headache, breast tenderness, bloating.
Barrier contraception
Condoms
Male condoms are cheap and widely available.
They protect against STIs including HIV. They
are the only reversible male method. Typical
failure rates are in the region of 24% since they
rely on the user to put it on it correctly, before
penetration and before every act of sex. The
female condom is a lubricated polyurethane
condom that is inserted into the vagina. It also
protects against STIs.
Diaphragm and cap
These are latex or non-latex devices that are inserted into the
vagina to prevent passage of sperm to the cervix. They can be
inserted in advance of sex. Caps fit over the cervix whereas
diaphragms form a hammock between the post-fornix and the
symphysis pubis. Caps and diaphragms are often used in
conjunction with a spermicide.
Disadvantages are that women need to be taught how to
insert and remove the device and typical failure rates in the
region of 18% are reported. In some women their use may be
associated with increased vaginal discharge and urinary tract
infections.
Spermicides
Spermicide alone is not recommended for prevention of
pregnancy as it is of low effectiveness.
Nonoxynol 9 (N-9) is a spermicidal product sold as a gel,
cream, foam, sponge or pessary for use with diaphragms
or caps. Some data have suggested that frequent use of
N-9 might increase the risk of HIV
transmission. It is therefore no longer recommended for
women who are at high risk of HIV infection.
Emergency contraception
Emergency contraception (EC) is licensed for use to protect women from
unwanted pregnancy following UPSI or contraceptive failure.
The two main forms are:
• Oral EC—LNG or ulipristal (ellaOne® ).
• Copper IUCD EC.
Levonogestrel (LNG EC)
• Consists of a single oral dose of 1.5mg of LNG.
• If taken within 72h of unprotected coitus it is estimated to prevent 85% of expected
pregnancies.
• It may be used up to 120h after, but effi cacy is uncertain and it is not
licensed for use after 72h.
• It may also be used more than once in a cycle if clinically indicated.
• It does not provide contraceptive cover for the remainder of the cycle,
another method of contraception must be used.
Side effects
• Nausea is common after ingestion.
• Vomiting only affects 1%.
• If a woman vomits within 2h of ingestion, she should take a further
dose as soon as possible.
• Erratic PV bleeding is common in the fi rst 7 days following
treatment.
Ulipristal
• Progesterone receptor modulator.
• Licensed for use within 120h of UPSI.
• Can only be used once per cycle.
• Due to mode of action may impair the effectiveness of progestagen
containing contraceptives for the remainder of the cycle and so
alternative contraceptive methods are advised.
Copper IUCD
• IUCD acts as an emergency contraceptive by inhibiting fertilization by
direct toxicity.
• Affects implantation by inducing an infl ammatory reaction in the
endometrium.
• The copper content may also inhibit sperm transport.
• IUCD EC can be inserted within 120h following UPSI.
• Failure rates are less than 1%.
The risks and complications for IUCD EC are similar to IUCD use in
general. It can be removed after the next menstruation provided that
no unprotected coitus has occurred since menstruation, or retained for
ongoing contraception.
Female sterilization: preoperative
considerations
Sterilization has become increasingly popular since the late 1960s and it is
now the most commonly used method of contraception in women over
40yrs of age.
History and examination
• This includes reasons for sterilization, menstrual history, current
contraception, obstetric history, previous abdominal surgery, chronic
medical conditions, and drug history.
• The patient’s BMI should be noted and abdominal examination
performed to look for scars from previous surgery or pelvic masses
(previous surgery, endometriosis, PID, or fi broids may make the
procedure technically difficult).
Counselling
It is important to establish that the woman is taking the decision of her
own free will.
• Alternatives to procedure must be discussed, including long-acting
reversible contraceptives (LARCs) and vasectomy.
• Must use effective contraception until her fi rst period following
sterilization. The commonest reason for failure is already being
pregnant when the procedure is performed or in the same cycle!
• Reassure that there is no increased risk of heavier periods in
women >30yrs of age. There is a small association with increased
hysterectomy rates, but the reason is unclear.
• Laparoscopy and tubal occlusion with Filshie clips is usually the
method of choice and must be explained, including the operative risks.
• Counselling must be supported by printed information leafl ets.
Consent for female sterilization
• Written informed consent must be taken from patient prior to
procedure: in case of doubt regarding mental capacity, case should
be referred to court for judgement.
• Patient must fully understand that the procedure is intended to be
permanent: success rates with reversal procedures are very small
and rarely provided by the NHS.
• Lifetime risk of failure with tubal occlusion is 1:200:
• pregnancies can occur several years after procedure
• longest follow-up data available for Filshie clips suggest failure
rate after 10yrs of 2–3 per 1000 procedures.
• In case of failure: i risk of ectopic pregnancy: advise women to seek
medical attention if pregnant/have abnormal pain and bleeding.
There is a risk of injury to the blood vessels, bowel, and bladder with
laparoscopic surgery: women must be warned about the possibility of a
laparotomy, particularly if they have had previous abdominal surgery.
Women at higher risk of regret
Care must be taken when considering sterilization for women from the
following groups, as they are more likely to have regret and present
requesting reversal:
• Under the age of 30yrs: current RCOG recommendation to avoid.
• Who do not have children.
• Who decide during pregnancy.
• Who have had recent relationship loss.