Contraception

The importance of contraception

Family planning is not only an individual choice; it is a pressing global concern.

"Should we now explain to UK couples who plan a family that stopping at two children, or at least having one less than first intended, is the simplest and biggest contribution anyone can make to leaving a habitable planet for our grandchildren?" Professor John Guillebaud, Patron of Population Matters, Emeritus Professor of Family Planning and Reproductive Health, University College, London and former Medical Director, Margaret Pyke Centre for Family Planning.

• The current projection for global population is that it will rise from a current 7 billion to 8-10.5 billion by 2050.¹

• In the UK the population has grown from 55,928,000 in 1971 to 67,081,000.² The current total population is estimated to rise to 70 million by 2027.³

Whilst considering and respecting different religious and cultural values, we should strive to ensure that every woman, who wishes to, has access to safe and effective contraception.

Current contraceptive usage in the UK

The last survey on contraceptive use was done by the Office for National Statistics (ONS) in 2008-9 and at that time showed:⁴

• 75% of women aged 16-49 years use some type of contraception.

• 25% of women use the combined oral contraceptive (COC) pill.

• 25% of women rely on male condom use.

• In women aged 18-29 years, similar numbers of women use the COC pill as they do condoms (the most frequent methods).

• Approximately one third of women aged 16-19 years use contraceptives - half using condoms and half taking the COC pill.

• A woman or partner has been sterilised in 17% of reported use.

• Sterilisation is used more frequently in women aged over 30 years.

However, statistics from community contraceptive clinics in England in 2013-2014 (and therefore involving a more limited group of the population) published by the Health and Social Care Information Centre (HSCIC) showed:⁵

• 1.34 million people accessed sexual and reproductive health services in the one-year time frame, of whom 89% were women.

• The service was mostly used by women aged 18-19.

• Oral contraceptives were the most commonly used form of contraception across all ages, used by 47% of women.

• 31% used long-acting reversible contraceptives (LARCs), an increase from 18% in 2003-2004.

Failure rates of contraception

Two types of contraceptive failure:

• User failure: when the contraceptive method was not being used properly.

• Method failure: pregnancy results even though the contraceptive method was used properly.

User failure rates are much higher than method failure rates, especially in first year of use.

Published failure rates are usually based on the 'Trussell table' below, based on failure rates in the USA.⁶ Where the National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS) has calculated these differently when taking other UK-based guidelines and reviews into account, these figures are in brackets.

Methods of contraception

Issues to consider when discussing contraceptive choice

• The individual woman's preferences and choice.

• Education. Make sure she is aware of all appropriate options and fully informed. Address any misconceptions.

• Comorbidity. Consider conditions which may rule out certain options as choices.

• Medication. Consider concurrent medication which may affect choice - eg, anti-epileptic medication.

• Age and parity. This will influence the most appropriate choice.

• Smoking history and weight.

• Family plans. The need for short-term or long-term contraception will affect choice.

• Protection from sexually transmitted infection. Encourage use of condoms in addition to the contraceptive method chosen, where appropriate.

• Exclude pregnancy.

• Ethical issues: prescribing for girls aged under 16 or women with learning difficulties.

Contraception and special groups

Several groups of women have special requirements. Extra attention, for example, may be needed when considering:

• Contraception for the mature woman - >40 years old.

• Women who are breastfeeding.

• Smokers.

• Contraception for younger women.

• Women who have diabetes.

See also the separate Contraception and Special Groups, Emergency Contraceptives and Ethnocultural Issues in Contraception articles.

Brief summaries of reversible contraceptive methods are shown below. Sterilisation for men and women, although technically reversible, should be viewed as permanent. They are covered in the separate Sterilisation (Vasectomy and Female Sterilisation) article.

Combined oral contraceptive pill^{7 8}

For more comprehensive information, see the separate articles Combined Oral Contraceptive Pill (First Prescription), and Combined Oral Contraceptive Pill (Follow-up and Common Problems).

The COC pill is a highly effective form of contraception and is the most commonly used method of contraception in the UK.⁹

The COC pill contains a combination of synthetic oestrogen and a progestogen. They have been classified into first-, second- and third-generation preparations reflecting their hormonal content and period of development. All current brands contain 20-40 micrograms of oestrogen. The hormonal combination is also available as a transdermal patch, Evra®, and a contraceptive vaginal ring, NuvaRing®. Both have approximately similar efficacy to the COC pill.¹⁰

Contraceptive pill action

The COC pill prevents conception by acting on:

• The hypothalamic-pituitary-ovarian axis, to suppress synthesis and secretion of follicle-stimulating hormone and the mid-cycle surge of luteinising hormone, thus inhibiting the development of ovarian follicles and ovulation. (Primary method of action.)

• Cervical mucus to prevent penetration of sperm. (Thickens cervical mucus.)

• The endometrium to inhibit blastocyst implantation. (Reduces endometrial receptivity.)

Contraceptive pill benefits

• Highly effective, easy to reverse and convenient to use.

• Can bring relief from menstrual problems.

• May protect against pelvic inflammatory disease (PID).

• Reduces incidence of benign breast disease, ovarian cysts, ovarian cancer and endometrial cancer.

Contraceptive pill side-effects

• Side-effects - eg, breakthrough bleeding, breast tenderness, mood swings.

• Increased risk of venous thromboembolism:

  • Twice the risk as compared to non-users across all brands but much less than the risk in pregnancy and immediately postpartum.

  • Ongoing debate about relative risks of different preparations but lowest risk thought to be associated with levonorgestrel, norgestimate and norethisterone preparations and the 2014 Cochrane review suggests the lowest risk option is the lowest possible dose of oestrogen combined with levonorgestrel.¹¹

• Increased risk of myocardial infarction; increased risk is most pronounced in women with risk factors - eg, smoking, hypertension, diabetes.

• Possible increased risk of stroke, increased in those with a history of migraine with aura and other risk factors for stroke generally.

• Slightly increased risk of breast cancer; as the incidence of breast cancer under age 40 years is low, absolute risk in young women is small.

• Possible small increased risk of cervical cancer; however, this may be related to other factors - eg, the number of sexual partners, non-barrier use during intercourse, human papillomavirus (HPV) exposure.

Progestogen-only contraceptive pill¹²

For more comprehensive information, see the separate article Progestogen-only Contraceptive Pill.

The contraceptive progestogen-only pill (POP) is particularly used when combined hormonal contraception is contra-indicated - eg, breastfeeding mothers or women with risk factors for the COC pill.

Progestogen-only contraceptive pill action

• Ovulation is inhibited to varying degrees. It is inhibited in about 60% of cycles for levonorgestrel-containing pills (although it does not occur in 100% of cycles normally) and in 97% of cycles with desogestrel.

• Transport of the ovum is delayed.

• The cervical mucus becomes more viscous and impenetrable to sperm.

• The endometrium becomes unsuitable for implantation.

Progestogen-only contraceptive pill benefits

• It is reliable if taken correctly, is easily reversible and convenient to use.

• Avoids the cardiovascular risks of oestrogen.

• It can often be used by many women with contra-indications to the COC pill. Few medical conditions restrict use of the POP.

• It can be used during breastfeeding.

• It can be used up to the age of 55.

Progestogen-only contraceptive pill side-effects

• Menstrual problems such as amenorrhoea and breakthrough bleeding.

• It has to be taken meticulously at the same time each day. (The error for forgotten pills is just three hours late for POPs other than desogestrel-containing pills which have a 12-hour window.)

• There is increased risk of functional ovarian cysts and the small possibility of an increased risk of breast cancer.

• Where pregnancy does occur on the POP, there may be a slightly increased risk that this is ectopic (estimated 1 in 10).

Levonelle® is progestogen-only emergency contraception.

Progestogen-only injectable contraceptives¹³

For more comprehensive information, see the separate article Progestogen-only Injectable Contraceptives.

A progestogen-only injection is a long-acting, reversible contraceptive. A synthetic progesterone, or progestogen, is slowly released into the systemic circulation following intramuscular or subcutaneous injection.

There are three forms of depot injection currently available on the UK market:

• Depo-Provera® is depot medroxyprogesterone acetate (DMPA) aqueous suspension 150 mg in 1 ml for deep intramuscular injection.

• Sayana Press® is DMPA 104 mg MPA in 0.65 ml for subcutaneous injection.

• Noristerat® is norethisterone enantate (oenanthate) 200 mg in 1 ml in an oily liquid. This is only licensed for short-term use - eg, for women whose partners have undergone vasectomy, until the vasectomy is effective.

Progestogen-only injectable contraceptive action

• Its main mechanism of action is to suppress ovulation.

• It also makes the endometrium unsuitable for implantation if fertilisation occurs.

• It also increases the viscosity of cervical mucus, making the mucus less easily penetrable to sperm.

Progestogen-only injectable contraceptive benefits

• Very effective and convenient. Provided that the injections are given on a regular basis (every 12 weeks for Depo-Provera®, every 13 weeks for Sayana Press®, every 8 weeks for Noristerat®), there is a very low failure rate.

• Can be used during breastfeeding.

• Amenorrhoea is common, which may be an advantage for women with menorrhagia or dysmenorrhoea.

• Self-administration may be an option for Sayana Press® in the future, although is currently outside the product licence.

Progestogen-only injectable contraceptive side-effects

• It is not quickly reversible.

• There is an associated small loss of bone mineral density and possibly a subsequent increased fracture risk, which recovers after stopping.¹⁴ The Medicines and Healthcare products Regulatory Agency (MHRA) and the Faculty for Sexual and Reproductive Healthcare (FSRH) advice is therefore:

  • Contraceptive injections should not be used for women aged under 18 unless no other option is suitable.

  • Risks and benefits should be reviewed every two years.

  • Consider other contraceptive options in women with other risk factors for osteoporosis.

• Menstrual irregularities common in women using this method, with irregular bleeding being a common reason for stopping. Amenorrhoea commonly develops with time, however, and women should be counselled about the possibility of early bleeding and encouraged to persevere.

• Weight gain of up to 2-3 kg in one year may occur. A higher initial BMI (≥30 kg/m²) makes this more likely, particularly in women aged less than 18.

• Delayed return of fertility of up to one year after stopping.

• Possible increased risk of breast cancer; not clearly shown yet; also, a weak association with cervical cancer.

Progestogen-only subdermal implant^{15 16}

For more comprehensive information, see the separate article Progestogen-only Subdermal Implants.

The progestogen-only subdermal implant (POSDI) is a long-acting reversible contraceptive. Etonogestrel (a progestogen) contained in a rod is released slowly into the systemic circulation following subdermal insertion in the upper arm.

Nexplanon® is now the only contraceptive implant on the UK market. It is a 4 cm flexible rod containing 68 mg etonogestrel. Nexplanon® must be removed after three years when it can then be replaced.

Progestogen-only subdermal implant action

The main mechanism of action of Nexplanon® is to inhibit ovulation. It also thickens the cervical mucus, inhibiting the passage of sperm to the uterus, as well as thinning the endometrium, preventing implantation were an egg to be fertilised.¹⁷

Progestogen-only subdermal implant benefits

• Highly effective with very few pregnancies reported. NICE quotes a failure rate of less than 1 in 1,000 women in three years' use.¹⁸ The main reason for 'failure' is incorrect timing of insertion, conception prior to insertion and failure of insertion.

• Long duration of action.

• Reversible. There is no evidence of delay in return to fertility on removal of Nexplanon®.

• It is very convenient.

• Reduction in menstrual problems such as dysmenorrhoea.

Progestogen-only subdermal implant side-effects

• Irregular bleeding; common in the first year but declines thereafter.

• Changes in weight, mood and libido have been reported; however, no causal association has been found..

Intrauterine contraceptive device¹⁹

For more comprehensive information, see the separate article Intrauterine Contraceptive Device.

The IUCD is a safe and effective method of contraception. Evidence suggests that the latest banded copper IUCDs are better than the COC pill and as effective as reversible sterilisation.

The most effective devices are T-shaped, with 380 mm² of copper, and additional copper bands on the transverse arms.

IUCDs have a monofilament thread to permit checking of presence and to allow removal.

Intrauterine contraceptive action

• Fertilisation is prevented by the effect of copper on ova and sperm.

• Reduced penetration by sperm due to the effect of copper on cervical mucus.

• Endometrial inflammatory reaction giving an anti-implantation effect.

Intrauterine contraceptive benefits

• Highly effective, reversible and convenient.

• Effective directly following fitting.

• Can be used for emergency contraception.

• No hormones involved, reducing potential for risks and adverse effects.

• Effective for up to 10 years.

• Possibly reduces risk of endometrial cancer.

Intrauterine contraceptive side-effects

• Insertion may be uncomfortable, but local anaesthetic can be used.

• Spotting and bleeding between periods. Many patients request removal within five years.

• Pelvic pain.

• Increased blood loss and more painful periods especially during the first few cycles.

• Displacement or expulsion: 1 in 20 women.

• Increased risk of PID: six-fold risk in the first 20 days only and women should be screened before insertion.

• Uterine perforation: approximately 2/1,000 insertions.

• Ectopic pregnancy: absolute risk very low; however, in pregnancies which occur with an IUCD in place, up to half of them may be ectopic.

Levonorgestrel-releasing intrauterine system¹⁹

The levonorgestrel-releasing intrauterine system (LNG-IUS) has been licensed as a contraceptive in the UK since May 1995. There are two systems available (Mirena® and Jaydess®). These are both T-shaped devices for intrauterine use. Mirena® is effective for five years or until contraception is no longer required. Jaydess® is effective for three years. Mirena® now also has a licence for the management of idiopathic menorrhagia and also for endometrial protection with HRT and may therefore be used by women who do not require contraception.

Levonorgestrel-releasing intrauterine system action

• This is mainly by reducing endometrial growth and preventing implantation. There is endometrial atrophy within one month of insertion.

• Progestogenic effects on cervical mucus reduce penetration by sperm.

• Ovulation is usually not inhibited.

Levonorgestrel-releasing intrauterine system benefits

• It is very effective, convenient and reversible.

• It reduces blood loss and dysmenorrhoea.

• It may reduce the risk of PID compared with normal IUCDs, because of thickening of cervical mucus.

• It does not significantly interact with other drugs, as its action is principally local.

• No demonstrable effect on bone density.

Levonorgestrel-releasing intrauterine side-effects

• Insertion may be unpleasant.

• Menstrual irregularities are common in the first six months. By 12 months, amenorrhoea or light bleeding is common.

• There are typical progestogenic side-effects (potentially acne/breast tenderness/headache/mood changes). These may resolve over time.

• Dysfunctional ovarian cysts; however, these usually resolve spontaneously.

• Ectopic pregnancy. Absolute risk is low but risk of ectopic pregnancy where pregnancy occurs is high. Possibly higher for the lower-dose preparation Jaydess®.

• Expulsion. Probably a similar risk to the copper IUCD although results of studies vary.

• Risk of perforation around 2 in 1,000 insertions - may be six times higher in breastfeeding women.

Diaphragms and caps²⁰

For more comprehensive information, see the separate Female Barrier Methods of Contraception article.

Popularity of diaphragms and caps as forms of contraception has declined with the availability of more effective methods and with awareness of the need to protect against sexually transmitted infections.

Diaphragms are thin, dome-shaped devices made of latex or silicone. They come in a range in sizes and types of spring. Diaphragms should lie diagonally between the posterior fornix and behind the pubic bone. Caps are smaller than diaphragms, fitting closely over the cervix. Both should be used with spermicides.

Mode of action

Diaphragms and caps form a physical barrier, preventing entrance of sperm to the cervix.

Benefits

• Compared with the timing of use required by condoms, insertion of diaphragms or caps before intercourse can allow more spontaneity.

• No serious side-effects and no hormonal effects.

Problems with diaphragms and caps

• Women need to be well motivated and careful in its use.

• Not as effective as some of the methods above.

• Spermicides can cause a local reaction.

• Little evidence of protection from sexually transmitted infections, unlike other barrier methods.

• Urinary tract infection incidence may be increased with diaphragms.

Female condoms²⁰

The female condom (Femidom®) has been available in Great Britain since 1992. It is made of soft pliable polyurethane, pre-lubricated and with two flexible rings.

Female condom action

This is a barrier method.

Female condom benefits

• There are no known side-effects.

• Helps to prevent sexually transmitted infection and possibly reduces risk of cervical carcinoma.

• Can be inserted prior to intercourse.

• No fitting required.

Female condom problems

• Needs careful insertion.

• Can be pushed into the vagina or bypassed.

• May be uncomfortable or noisy, or interfere with sensation.

• Not as effective as some of the other methods of contraception above.

Male condoms²⁰

The only contra-indication to the use of latex condoms is for people with sensitivity or allergy to latex proteins, as risks generally outweigh benefits. Men and women with sensitivity to latex may use male or female polyurethane condoms or deproteinised latex male condoms.

Male condom action

This is a barrier method.

Male condom benefits

• Ready availability.

• Protects against sexually transmitted infection and may protect women against cervical cancer.

Male condom problems

• They are relatively expensive if purchased (free condom uptake at family planning clinics is low).

• There is the need for prior planning.

• Lacks spontaneity.

• Requires co-operation of both partners.

• May reduce sensitivity.

• Can break or slip off, although research shows failures due to breakage or slippage decrease with increasing experience of use.

• Relatively low efficacy.

Natural family planning ²¹

Several methods are available, including calendar, temperature, observation of cervical mucus, and palpating the cervix. Devices (such as Persona®) and dipsticks can be purchased to help a woman keep track of her cycle and fertile times.

The lactational amenorrhoea method (LAM) is also an effective natural family planning option for breastfeeding mothers. For LAM to be effective, a woman must be fully breastfeeding, have amenorrhoea and a baby who is less than 6 months old.

Benefits

• There are no side-effects.

• It complies with the religious practices of some patients.

Problems

• Considerable commitment from both partners is required.

• Unreliable with unpredictable cycles.

• Less effective than some other methods described above.