Contraception — general principles
  • Modern contraceptives help prevent, plan and space pregnancies
  • Modern contraceptives are generally safer than being pregnant
  • Some contraceptives help reduce period pain and bleeding problems
  • Clinics and communities should promote effective contraception for all who need or want it
    • At routine check ups and consultations
    • Especially if being pregnant is risky for woman
  • Consider what the woman wants from their contraception
    • Reliable prevention of pregnancy
    • Rapid return to fertility when stopped
    • Easy to use
    • Few side effects (problems), beneficial effects (eg improves acne), discrete, affordable
  • Contraception is reversible. Sterilisation is permanent

Emergency contraceptive pill (ECP) 

  • Offer ECP if woman
    • Had unprotected sex in the last 4 days (96 hours)
    • AND has no contraception
    • OR her contraception is late or overdue

Always offer ECP straight away it is very safe

Routine contraception check is simple, be opportunistic

Include in — STI checks for women, STI checks for young people, Cervical cancer prevention and screening, Combined checks for chronic diseases, Adult Health Check

  • Always do BP, BMI
  • Re-check contraception risk
  • Is their contraception appropriate, consider LARC
  • Ask about worries, including period problems
  • Check dates of contraceptive — when is it next due
  • Offer ECP if woman
    • Had unprotected sex in the last 4 days
    • ex in the last 4 days (96 hours)
    • AND has no contraception
    • OR her contraception is late or overdue

How effective are contraceptives

Long-acting reversible contraception (LARC) is the most effective.

  • Etonogestrel implant (ENG-implant)
  • Intrauterine devices
    • Copper IUD
    • Levonorgestrel-releasing IUD (LNG-IUD)

 

  • If 100 women used this method for 1 year, the percentage (%) number = how many don't get pregnant. This means that
    • Using ENG-implant — only 1 out of 1000 women become pregnant each year
    • Using contraceptive pills — 7 out of 100 women become pregnant each year

Be really safe — 'double-up' with contraceptive and condoms

  • Using condoms properly can prevent STIs

Table 7.2 Contraceptive effectiveness

Choosing a contraceptive method

Choosing the best contraceptive method may take time — explain that you may need to ask a lot of questions

Step 1 — talk about effectiveness

  • Use Table 7.3 Comparing contraceptives
  • Consider
    • Risk of pregnancy occurring with a particular method compared with no contraception at all
    • Risk of pregnancy itself, including woman's physical, emotional health, safety

Table 7.3 Comparing contraceptives

Step 2 — talk with woman about what method is practical for her

  • Has she used contraception before, was the method OK
  • LARC ​are very convenient. Only need to visit clinic
    • Every 3 months (12–14 weeks) for Depo-Provera
    • Every 3 years for ENG-implant
    • Every 5 years for LNG-IUD
    • Every 5–10 years for copper IUD
  • Would she mind feeling/seeing an implant in her arm
  • Could she take a pill reliably (every day)

Step 3 — talk with woman about her bleeding patterns

  • Many contraceptives change bleeding patterns (see individual methods)
    • So can STIs (eg chlamydia), pregnancy, or abnormal cervix
  • At suitable time in your consult, ask about
    • Periods — timing, number days of bleeding
    • Risk of STI — offer STI check — woman, young person
    • Recent cervical screening

If abnormal vaginal bleeding

  • Medical consult before starting contraception if woman
    • Bleeds straight after sex
    • Bleeds in-between her normal periods
    • Has periods that aren't regular
    • Has periods that are excessively heavy/painful
  • See — ​Abnormal vaginal bleeding in non-pregnant women​

Step 4 — exclude pregnancy

  • Can exclude pregnancy if
    • No sex since last normal period
    • Negative pregnancy test and no unprotected sex in last 3 weeks
    • Day 1–5 of normal period
    • Correct and consistent use of contraception (LARC, pills, condoms)
    • Less than 21 days after birth of child
    • Less than 5 days after miscarriage or abortion
    • Urine pregnancy test — negative test only excludes pregnancy if more than 21 days since last unprotected sex
  • If unprotected sex in last 5 days (120 hrs) 
  • If pregnant see — Unplanned pregnancy or Antenatal care

Step 5 — check woman's risk

  • Always get help with working out and talking about risk
  • Assessment includes
    • Contraindications
    • Risks associated with the contraception
    • Drug interactions
  • For young women 
    • LARC usually first line due to high fertility and need for effective contraception
    • Depo-Provera is second line due to possible impact on peak bone density
    • The COC/ring may improve cycle regulation or improve acne (common in adolescence)
    • POP can have higher failure rates in those younger than 25 compared to older users

Table 7.4 Best contraception choices for common clinical indications

Risks with contraception

Absolute risks for hormonal contraception

  • Abnormal vaginal bleeding
  • Past or current breast cancer
  • Liver tumour

Women with absolute risks cannot use hormonal contraception — need non-hormonal method — medical consult

High risks for combined hormonal contraceptives (COC and vaginal ring)

  • Contraceptives containing oestrogen (including COC and vaginal ring) increase the risk of clots compared to other methods
  • Blood clots are uncommon but can cause severe problems
  • Rural and remote women generally have increased risk factors for clots and hormonal contraception may add to these. The more risk factors the higher the risk with hormonal contraception
  • Women with risk factors for clots still need contraception — medical consult

Risk factors for clots

  • Do not use contraceptives containing oestrogen (COC, vaginal ring) if woman has risk factors for clots 
    • Moderate or high cardiovascular risk or multiple CVD risk factors
    • Previous stroke, heart attack, angina, AF
    • Vascular disease (eg peripheral vascular disease)
    • Mechanical heart valve or complicated valvular/congenital heart disease
    • Cardiomyopathy with impaired heart function
    • Anticoagulant use
    • Diabetes and any of — poor control (HbA1c more than 84mmol/mol [9.8%]), nerve pain (neuropathy), eye damage, kidney disease, vascular disease
    • Chronic kidney disease — stage 2 or worse
    • High BP
    • Obesity — BMI more than 30
    • Migraine with aura
    • Smoker aged 35 years or over
    • Previous venous thromboembolism (VTE)  or family history of VTE — first degree relative under 45 years
    • Thrombogenic mutation (eg Factor V Leiden)
    • SLE (antiphospholipid positive)
    • Over 49 years old
    • Breastfeeding — less than 6 weeks after delivery (if not breastfeeding can start after 3 weeks if no risk factors for VTE)
    • Organ transplant — with complications
    • Immobility (eg surgery, wheelchair use)
    • Current gallbladder disease (or medically treated)

Other risks with individual methods

Quick Start — hormonal contraception

We used to wait until a period before starting contraception (day 1–5) — but some women got pregnant while waiting for their contraception

  • If a woman has her usual period (day 1–5) — she is not pregnant and any type of contraception may be started and is immediately effective
  • Some women do experience an implantation bleed 10-14 days after conception and confuse this with their usual period
  • Quick Start supports starting a hormonal contraceptive method straight away. This means
    • Better chance of woman starting and understanding method
    • Less unplanned pregnancies
  • Very early pregnancy can't always be excluded
    • No known problems for foetus or pregnancy from LARC, COC, POP
    • Not recommended for quick start, IUDs or COC containing cyproterone acetate due to risk of harm to the foetus
  • Must do repeat urine pregnancy test in 4 weeks — high priority recall

Quick Start — only 3 steps

Step 1 — exclude pregnancy

Can be confident not pregnant if

  • No sex since last normal period
  • Negative pregnancy test and no unprotected sex in last 3 weeks
    • Negative urine pregnancy test only excludes pregnancy if more than 21 days since last unprotected sex
  • Day 1–5 of normal period
  • Correct and consistent use of contraception (LARC, pills, condoms)
  • Less than 21 days after birth of child
  • Less than 5 days after miscarriage or abortion

Step 2 — start contraceptive method

  • Always check BP, BMI when starting contraception — see Check woman’s risk
  • If pregnancy can be excluded, contraception can be started immediately
    • Explain that hormonal methods take 7 days to work so use condoms or avoid sex during this time
  • If pregnancy cannot be excluded offer contraception today and explain that 
    • The pregnancy test today is negative but very early pregnancy is possible 
    • No known adverse outcomes on foetus or pregnancy from hormonal contraceptives 
    • Hormonal methods take 7 days to work so use condoms or avoid sex during this time
    • If first choice method not available on the day — consider other effective contraceptive methods for short-term cover — Table 7.3

Step 3 — follow-up

  • Must do repeat urine pregnancy test in 4 weeks — high priority medical follow up
  • If woman pregnant at follow-up
  • Repeat BP, BMI 

Stopping contraception

Ask why they stopped or want to stop

  • If woman wants another type of contraception — Table 7.3
  • If woman declining contraception or not using current method properly — tell her that risk of pregnancy is high
    • ​Fertility returns very quickly when stopping modern contraception — except for Depo-Provera
  • Offer pre-pregnancy counselling
    • Advise woman to consider continuing contraception until after pre-pregnancy counselling is complete