1. Dr K Dissanayake Bute House Medical Centre
Contraception
Dr K Dissanayake
Bute House Medical Centre

2. Different Methods Hormonal Barrier methods IUD Natural methods
Sterilisation

3. Things to consider
Age, consider whether Fraser competent in <16 yrs
Medical History – UKMEC / WHOMEC
Current medications
Menstrual cycle
Patient preference – previous experience, hormonal/non-hormonal, amenorrhoea
Efficacy
Quick starting
Medical history – CV risk factors, diabetes, epilepsy, headache/migraine, hypertension, Uterine anomalies, weight, smoker, VTE
Current medications – Antibiotics that induce liver enzymes (rifamipicin/Rifabutin),

5. Table 4: Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use (modified from Trussell et al.)
Method
Typical use (%)
Perfect use (%)
Fertility awareness-based methods 24
0.4–5
Male condom 18 2
Combined hormonal contraception (CHC)
Progestogen only pill (POP) 9
0.3
Implant
0.05
DMPA 6
0.2
Cu-IUD
LNG- IUS
0.8
0.6
Female sterilisation
Vasectomy
0.5
0.15
0.1

6. UKMEC criteria
Provides guidance who can use the contraceptive methods safely – related to safety not efficacy
UKMEC
Definition 1
A condition for which there is no restriction of use of the method 2
A condition where the advantages of using the method generally outweigh the theoretical or proven risks 3
A condition where the theoretical or proven risks usually outweigh the advantages. Expert clinical judgement or referral advised 4
A condition which represents and unacceptable health risk if the method is used

7. Emergency Contraception
Levonorgestrel (Levonelle)
Ulipristal (Ella One)
Copper IUD

8. Considarations
Persistently elevated b-HCG levels (category4) or decreasing levels (Cat. 3) for Cu-IUD
Post partum < 4 week and distorted uterus are category 3 for Cu-IUD

9. Hormonal contraception
Combined hormonal contraception
COC
First line - Ethinylestradiol 30mcg +levonorgestrel or Norethisterone – eg Microgynon, Rigevidon.
Higher risk of VTE if the progestogen is Drospirenone (Yasmin), Gestodene (Femodene) and Desogestrel (Marvelon/Gedarel)
Transdermal patches –eg Evra
Vaginal ring - NuvaRing

11. CHC
Mechanism of action – Inhibition of ovulation, some effect on the cervical mucus and endometrium.
When to start
Missed pills
One missed pill
2 or more missed pills
Diarrhoea and vomiting

12. CHC and UKMEC
Postpartum (0-<6 weeks) and breastfeeding – category 4
Post partum (3-6 weeks) and non breast feeding
With other risk factors for VTE – category 3
Without other risk factors for VTE – category2
Age and smoking
<35 yrs – category2
>35 yrs - <15 cigarettes – cat. 3 and >15 cig cat. 4

13. CHC and UKMEC Obesity Hx of or current VTE – Cat. 4
BMI >= Cat.2
BMI>= 35 Cat.3
Hx of or current VTE – Cat. 4

14. Progestogen only contraception
POP
Depo injections
Subdermal implant
UKMEC
Current breast cancer Cat 4, past breast cancer Cat 3
Check if hx of stroke and IHD
IUS

15. POP
Mechanism of action – changes to cervical mucus, suppression of ovulation(Desogestrel>norgeston), suppression of midcycle peaks of LH and FSH, hostile endometrium, reduced activity of cilia in the fallopian tube
When to start
Delayed or missed pills
Vomiting and diarrhoea

16. LARC Progestogen only injections Subdermal implant IUS IUD
Depot medroxyprogesterone acetate 150mg deep IM(depo-provera)
Depot medroxyprogesterone acetate 104mg SC (Sayana Press)
Norethisterone enantate 200mg deep IM (Noristerat)
Subdermal implant
IUS
IUD

17. Progestogen only injectables

18. Progestogen only injectables
Mechanism of Action – Inhibition of ovulation and thickening of cervical mucus
When to start
Depo Provera – every 12 weeks and Sayana Presss – every 13 weeks
Loss of bone mineral density

19. Progestogen only implant
Nexplanon – Etonogestrel 68mg

20. Nexplanon
Mechanism of Action – Inhibition of ovulation, some changes to cervical mucus
When to start
3 years
Menstrual irregularities
Liver enzyme inducing drugs are likely to reduce efficacy
Deep implants/migration of implant

21. IUS Levonorgestrel intrauterine systems Mirena Levosert Jaydess Dose
52mg
13.5mg
Contraception
5 yrs
3 yrs
Endometrial protection
4yrs -
Menorrhagia
size
32mm(h) 32mm(w)
32mm(h)
32mm(w)
30mm(h)
28mm(w)

22. Mirena

23. IUS
Mechanism of Action – prevents implantation of the fertilised ovum and changes to cervical mucus
When to start

24. IUD Copper containing devices
Most effective devices contain at least 380mm 2 of copper and have copper bands on the transverse arms.

25. IUD TT380 Slimline – 10 years MiniTT380 Slimline – 5 years
T-Safe 380A QL – 10 years

26. IUD Mechanism of Action When to start Heavier and more painful periods
Toxic to the sperm and ovum thereby preventing fertilisation
Alteration in the copper content of the cervical mucus – inhibits penetration
Inflammatory reactions within endometrium – prevents implantation
When to start
Heavier and more painful periods

27. IUS/IUD Risk of Uterine Perforation – 1/1000
Risk of PID – related to insertion and background risk of STI
Educate patient to feel for threads
Risk of ectopic pregnancy
Actinomyces like organisms on smear

28. Permanent methods
Sterilisation
Vasectomy
Tubal Occlusion

29. Vasectomy Minor surgical procedure
Small risk of haematoma and infection
Potentially irreverisible
Need to use contraception for 12 weeks post procedure until azoospermia in confirmed
Risk of testicular/scrotal pain post vasectomy – can develop months or years later. 1-14%

30. Vasectomy

31. Tubal Occlusion Surgical procedure Potentially irreversible
If tubal occlusion fails the resulting the pregnancy might be ectopic
Filshie clips and modified Pomeroy technique – contraception for 4 weeks following the procedure
Hysteroscopic sterilisation – need contraception for 3 months until confirmation of occlusion

32. Tubal Occlusion