Contraception
Background
Contraception and sexual health
Office for National Statistics October 2009 www.statistics.gov.uk
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Surveyed 4366 people (59% response)
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55% of women aged 16-49 had used family planning services in the last 5
years
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Service use greatest among 25-29y (73%)
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Primary methods:
 Oral contraception (25%)
 Male condom (25%)
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Emergency contraception used by 7% of women in last year
 42% obtained from a pharmacy (20% in 2001/2)
 31% obtained from a GP or practice nurse (43% in 2001/2)
 Condom failure cited as main reason for using EHC
Types and choice of contraception
Types of non-surgical contraception
BNF 58; September 2009
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Hormonal contraception
 Most effective method of fertility control
 Has major and minor side effects
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Intrauterine devices (IUD)
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Highly effective
May produce highly undesirable local effects eg menorrhagia
Background risk of PID
May be used in women of all ages irrespective of parity
Less appropriate for those with increased risk of PID
Can be used as emergency contraception
Barrier methods
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Less effective
Suitable for well-motivated couples if used with spermicide
Accessible
Safe
Contraceptive choice
Contraception and sexual health 2008/9. www.statistics.gov.uk
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At least one method (76%)
OC (25%)
Male condom (25%)
Male sterilisation (11%)
Female sterilisation (6%)
IUD (6%)
Withdrawal (4%)
Injection / implant (4%)
Safe period (2%)
Hormonal IUS (2%)
Emergency contraception (1%)
Cap (0%)
Use of oral contraception with age
Contraception and sexual health 2008/9. www.statistics.gov.uk
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In general, proportion of women using the pill decreases with
age
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Use of male condom more prevalent amongst younger couples
Types of hormonal contraceptives (1)
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Combined hormonal contraceptives
 Combined oral contraceptive (COC)
►Usually ethinyloestradiol with a progestogen
►1/2/3/4 generation
 Transdermal preparation
►Ethinyloestradiol with norelgestromin (an active
metabolite of norgestimate) (Evra)
 Vaginal preparation
►Ethinyloestradiol with etonorgestrel (NuvaRing)
Types of hormonal contraceptives (2)
1st generation
2nd generation
3rd generation
4th generation
Noerthisterone
(Loestrin)
Levonorgestrel
(Microgynon)
Desogestrel
(Mercilon)
(Marvelon)
Drospirenone
(Yasmin)
Gestodene
(Femodette)
(Femodene)
Dienogest (Qlaira
with estradiol
valerate
Etynodiol diacetate
(only in POP)
Norgestimate
(Cilest)
Types of hormonal contraceptives (3)
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Progestogen only contraceptives
 Progestogen only pill (POP)
► Suitable when COCs unsuitable (eg predisposition to VTE)
► Higher failure rate than COCs
► Norethisterone (Micronor)
► Etynodiol diacetate (Femulen)
► Levonorgestrel (Norgeston)
► Desogestrel (Cerazette)
 Parenteral progestogen-only contraceptive
► Injection
 Medroxyprogesterone acetate (Depo-Provera)
 Norethisterone enantate (Noristerat)
► Implant
 Etonorgestrel (Implanon)
 Progestogen-only intra-uterine device (IUD)
► Levonorgestrel (Mirena)
Types of hormonal contraceptives (4)
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Emergency hormonal contraceptives
 Levonorgestrel (Levonelle)
 Ulipristal acetate (ellaOne)
Effectiveness of different forms of
contraception
How do we measure effectiveness?
MeReC Bulletin 2006; 17: 1-9
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Judged by failure rates:
 Mode of action of the method
 Ease of use
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Typical use vs. perfect use
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Pearl Index (PI)
 No. of unintended pregnancies per 100 women years
 1 woman year is 13 menstrual cycles
 PI=1.0 if 100 women use a contraceptive method for 13
cycles and 1 becomes pregnant
Failure rates associated with different methods (1)
MeReC Bulletin 2006; 17: 1-9
% of women experiencing unintended pregnancy in 1st
year of use
Typical use (%)
Perfect use (%)
No method
85
85
Spermicides
29
15
Withdrawal
27
4
Periodic abstinence
Calendar
Ovulation method
Sympto-thermal
Post-ovulation
25
9
3
2
1
Cap plus spermicide
Parous women
Nulliparous women
32
16
26
9
Sponge
Parous women
Nulliparous women
32
16
20
9
Diapragm plus spermicide
16
6
Failure rates associated with different methods (2)
MeReC Bulletin 2006; 17: 1-9
% of women experiencing unintended pregnancy in 1st
year of use
Typical use (%)
Perfect use (%)
Female condom (without
spermicide)
21
5
Male condom (without
spermicide)
15
2
COC and POP
8
0.3
Evra patch
8
0.3
Depo-Provera injection
3
0.3
Mirena
0.1
0.1
Female sterilisation
0.5
0.5
Male sterilisation
0.15
0.10
Pregnancy rates associated with LARC methods
MeReC Bulletin 2006; 17: 1-9
Pregnancy rate (%)
Copper IUD
<2 over 5 years, for IUDs with at least
380mm copper
Progestogen-only intrauterine system
<1 over 5 years
Progestogen-only injectable contraceptives
<0.4 over 2 years
(when injections given at the
recommended intervals)
Progestogen-only subdermal implants
<0.1 over 3 years
What constitutes good prescribing?
Barber N. BMJ 1995; 310: 923-5
EFFECTIVE
Benificence
SAFE
Non-malfeasance
COST
Justice
PATIENT FACTORS
Patient autonomy
Risks of contraception
Increased risk of VTE
Current Problems in Pharmacovigilance 1999; 25: 12
Drug Safety Update Vol 1, Issue 9, April 2008
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All COCs increase the risk of VTE
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The risk associated with COCs containing desogestrel or
gestodene (2.5 per 10000 women years) is greater than that
associated with other COCs (1.5 per 10000 women years) and
with never users (0.5-1.0 per 10000 women years)
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The risk is still low and lower than the risk of VTE in pregnancy (6
per 10000 women years)
What about VTE risk with Evra?
Drug Safety Update Vol 1, Issue 9, April 2008
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The VTE risk in users of Evra may be slightly increased compared
with that of users of second-generation pills
What about VTE risk with Yasmin?
Drug Safety Update Vol 1, Issue 9, April 2008
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The risk is somewhere between pills containing levonorgestrel
(second generation) and those containing desogestrel or
gestodene (third generation)
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The risk is lower than that of pregnancy
Myocardial infarction
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Absolute risk of an MI in young women is very low
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Smoking and OC use increases risk significantly
Stroke
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Absolute risk of stroke is very small (1 additional stroke per year
per 24000 non-smoking, normotensive women using a low-dose
oestrogen)
Advice to older women
Faculty of Family Planning and Reproductive Healthcare Clinical Effectiveness Unit. Contraception for
women aged over 40 years. J Fam Plan Reprod Healthcare 2005; 31: 51-64
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Women aged over 40 can use combined hormonal contraception
unless there are co-existing diseases or risk factors
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The risks of using combined hormonal contraception outweight
the benefits for smokers aged ≥35 years
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Women who smoke are best advised to discontinue combined
hormonal contraceptives and find another contraceptive
method at 35 years
Cancer
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OC use does not increase a woman’s overall risk of cancer and may
slightly decrease it
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The risk of individual cancers may be increased or decreased
depending on duration of use and length of time since last use
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Small, if any, increased risk of breast cancer, but in addition to
background risk which increases with age
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Small increased risk of cervical cancer
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Decreased risk of cervical cancer
Newer agents
Cerazette
Which POP? RDTC. Drug Update. Sep 2007
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Desogestrel 75mcg
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Inhibits ovulation in addition to thickening cervical mucus, with
theoretical improved contraceptive efficacy vs. standard POPs
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Desogestrel has a 12h missed pill window
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As desogestrel is more expensive than standard POPs, reserve
for women who find the strict regimen of standard POPs difficult
to keep to
Yasmin
MeReC Bulletin Volume 17, Number 2, November 2006
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Ethinyloestradiol 30mcg / drospirenone 3mg
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An option for those women suitable for a COC. Yasmin has no
conclusive advantages over other standard strength COCs
Evra
MeReC Bulletin Volume 17, Number 2, November 2006
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Transdermal patch releasing ethinyloestradiol 33.9mcg and norelgestromin
203mcg per 24h
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Option for some women wishing to use a reversible method of contraception
and who are experiencing compliance problems with COCs
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Evra vs. oral COCs
 Better compliance with patch
 No evidence of improved efficacy, pregnancy rates or safety
 Similar overall tolerability to COCs
 VTE risk may be higher with Evra
NuvaRing
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Vaginal ring delivering ethinyloestradiol 15mcg and etonogestrel
120mcg per 24h
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One ring inserted vaginally for 3 week duration followed by 7
day ring-free break
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Contraceptive efficacy similar to COCs
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Possibly better cycle control than COCs
Qlaira
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Estradiol valerate / dienogest in complex quadriphasic dosage
regimen
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First COC containing estradiol
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Continuous 28 day cycle of 26 active tablets and 2 placebo
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Contraceptive effectiveness similar to COCs with comparable
side effects and tolerability
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Fewer have withdrawal bleeding
Long acting reversible contraception (LARC) (1)
NICE Clinical Guideline No 30, October 2005
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Uptake low
 8% of women aged 16-49 in 2003-4
 25% pill
 23% male condoms
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LARC includes:
 Copper intrauterine devices (IUD)
 Progestogen-only intrauterine systems (IUS) eg Mirena
 Progestogen-only injectable contraceptives eg Dep-provera
 Progestogen-only subdermal implants eg Implanon
Long acting reversible contraception (LARC) (2)
NICE Clinical Guideline No 30, October 2005
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All currently available LARC methods are more cost effective
than COCs even at 1 year of use
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IUDs, IUS and implants are more cost effective than the
injectable contraceptives
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Increasing the uptake of LARC methods will reduce the numbers
of unintended pregnancies
Depo-Provera: effect on bones
MHRA, 18th November 2004
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The CSM advised:
 In adolescents may be used as first line contraception but
only after discussion about other methods
 In women of all ages, careful re-evaluation of the risks and
benefits of treatment should be carried out in those who
wish to continue use for more than 2 years
 In women with significant lifestyle and/or medical risk factors
for osteoporosis other methods of contraception should be
considered
Emergency contraception
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Levonelle (levonorgestrel 1.5mg)
 1 tablet preferably taken within 12h but no later than 72h
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Non-hormonal IUD
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EllaOne (ulipristal acetate 30mg)
 1 tablet ASAP but no later than 120h
Case study
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Nicola is a 35y old sales manager. Before the birth of her
children she took marvelon for 12 years. She has a
complete family and is about to return from maternity
leave to work in 2 weeks. She has a BMI of 29kg/m² and
smokes. She had a DVT in her second pregnancy in her
calf which was treated with heparin
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She would like to recommence the COC. She has gained
weight since her children and is concerned the COC will
cause more gain. She has heard yasmin does not have this
side effect
What type of COC is marvelon?
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Third generation COC containing ethinyloestradiol and
desogestrel
Is there any evidence that Yasmin is less likely
to cause weight gain than other COCs?
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For a woman concerned about weight gain with COCs, there is
no good evidence upon which to recommend Yasmin instead of
other preparations
What background questions would you ask in
order to identify a preferred method of
contraception for Nicola?
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The primary goal is to allow choice of the method with which
they feel most comfortable taking into account their lifestyle,
preferences and concerns
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Effectiveness compared with alternatives
How it works
Correct use
Health risks and benefits
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Medical history
 Medical risk factors for / personal history of VTE?
Family history
 Breast cancer in 1st degree relatives?
Social circumstances
 Will she travel long distances by car?
Personal preferences
 As family is complete would she prefer the convenience and
effectiveness of long-acting method?
Exclude pregnancy
 Menstrual and sexual history
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During further discussion, her job involves long car journeys of
up to 4-5 hours. She has completed her family and is seeking a
highly reliable form of contraception
How would this new information influence
the advice which you might offer to her?
The “pill scare” – Current Problems in
Pharmacovigilance 1999; 25: 12
Risk of VTE associated with COC use and non-use
Circumstance
Risk of VTE per 100000 women
Healthy, non-pregnant women (not taking
any oral contraceptive)
5 cases per year
Women taking COCs containing
levonorgestrel
15 cases per year of use
Women taking COCs containing desogestrel
or gestodene
25 cases per year of use
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Risk of VTE in pregnancy 60 per 100000
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Risk of dying on the road 6 in 100000
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A family history of VTE and continuous travel of more than 3
hours are both risk factors for VTE
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Obesity is also a risk factor
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Her risk of VTE is increased by her personal history of VTE, she
travels long distances, and she is overweight
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There is also a small additional risk of MI and stroke from her
age, smoking and body weight
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She requests more information on LARC
What information and advice would you offer
her?
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Contraceptive efficacy
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Duration of use
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Risks and possible side effects
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Non-contraceptive benefits
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Procedure for initiation and removal / discontinuation
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When to seek help when using the method
End