The Combined Pill
This pill contains oestrogen and progestogen. It is >99% effective when used correctly. The combined pill works via the prevention of ovulation, thickening the mucus plug and reducing implantation in a thinner uterine lining. Types of combined pills include Micogynon.
Effects of the combined pill include:
- Reduces or prevents dysmenorrhoea
- Reduces PMT
- Reduces risk of ovarian, endometrial and colon cancers
- Reduces the risk of pelvic inflammatory disease
- Helps in treating/preventing acne
- Reduces the risk of fibroids/cysts
- Nausea and vomiting
- Breast tenderness
- Fluid retention
- Mood changes
- Increased risk of thromboembolism
Absolute contraindications of the combined pill include:
- Past medical history of thrombosis
- Past medical history of heart or liver disease
- Blood pressure of > 160/95
- Age >50
- Age >35 + smoker
- Smoker of > 40 cigarettes daily
Other avoidances include at least 2 of:
- Family history of thromboembolism
Advice on taking the combined pill should include taking 21 pills and one week off. The lady should start on the first day of her period, and if one pill is missed, barrier contraception should be used for seven days.
The Progesterone-only Pill
This pill is 99% effective, and usually administered when the combined pill is contraindicated such as when the patient has a history of hypertension or previous DVT/PE. Examples of the POP include Cerazette. The POP thickens the mucus plug, thins the lining of the uterus and, in high doses, may prevent ovulation.
- Dysfunctional bleeding - this is true of all progesterone only contraception
- Breast tenderness
- Increased risk of ectopic pregnancy (note: this is compared to the COC, as there is a reduced rate of pregnancy in general than without pill)
- Increased risk of ovarian cysts
Contraindications include previous cysts, ectopic pregnancies, and breast cancer.
Advice on taking the progesterone only pill should include taking the pill continuously for 28 days at the same time each day.
If patient <25 years or has >1 partner over last year, then you should offer swabs for STIs before inserting coils. 1:20 chance of coming out spontaneously, and 1:1000 chance of perforating the uterus.
Inter Uterine System (Hormonal)
The mirena coil is a progesterone-only contraceptive that releases levonogestrel directly into the uterine cavity. The mirena coil is recommended for contraception for women with heavy periods, as it treats menorrhagia after 3–6 months. The IUS also prevents endometrial hyperplasia. The mirena coil works by reducing the proliferation of the endometrium, thickening cervical mucus and preventing ovulation.
Advantages (over copper IUD)
- Decreases the risk of pelvic inflammatory disease
- Decreases the risk of dysmenorrhoea
- Reduces periods and decreases the risks associated with blood loss
- Avoid five years following breast cancer
- Mood swings
- Increased risk of ectopic pregnancy if pregnancy already present.
Inter Uterine Device (Copper)
The mechanism of the copper IUD is not fully understood. It is believed that it induces a prolonged inflammatory state, which in turn reduces the chance of implantation. Furthermore it is believed that copper is toxic to sperm.
Risks associated with copper IUD include an increased risk of ectopic pregnancy, and an increased risk of pelvic inflammatory disease. Moreover, side effects can include longer and heavier periods . These side effects can be treated with tranexamic acid, an antifibrinolytic, or mefanemic acid, an NSAID.
- Implant – lasts for 3 years, progesterone only
- Depo injection – lasts 3 months, progesterone only
- Nuvaring -ring inserted into vagina which releases combined hormones, 3 weeks in 1 week out
- Morning after pill - emergency contraception, can be used 72–120 hours after sex
- Male or female condoms - the only way to prevent STIs
- Patch - releases combined hormones)
- Male or female sterilisation
- Natural family planning - withdrawal (not recommended as very ineffective and frankly impractical) or rhythm method (can be effective if done accurately)
If someone has intramenstrual bleeding on hormonal contraception check for the following things:
- Disease – chlamydia or cervical cancer
- Default bleeding– missed pill
- Drugs – enzyme inducing ABX (e.g. rifampicin)
- Disorders of pregnancy – miscarriage
- Duration – if short duration, could be pregnancy, light bleeding common at start of pregnancy as zygote attaches to endometrial lining
- D+V – therefore missed pills and returning to default
- Dose – irregular bleeding can be common in lose dose pills
In many of these situations the intramenstrual bleeding is due to pills being ‘missed’ and the menstrual cycle returning to the body’s own rhythm. Therefore these things will also make the contraception ineffective and barrier methods (such as condoms) should be used, in conjunction with the hormonal method, to avoid unwanted pregnancies.
These are the criteria for prescribing contraception to under 16s. If under 12s disclose any sexual activity, however, it must be reported to social services. The criteria to prescribe contraception is that the patient must:
- Demonstrate that they understand the advice they are given
- Continue to, or start, having sex regardless of whether they get contraception
- Have their mental or physical well-being suffer without contraception