Contraceptive update
Dr Christine Roke
National Medical Advisor,
Family Planning
March 2012
Long Acting Reversible
Contraception - LARC
• New emphasis because:
• Easier to use - action less often than
monthly
• Increased efficacy - all less than 1% failure
rate
Long Acting Reversible
Contraception - LARC
• Depo Provera injection
• Intrauterine contraception
• Implants
Longacting contraception
Why?
• Methods that require something with every act of
sexual intercourse or need to be taken every
day have higher user failure rates
• Combined pill has about 3% failure rate per year
in every day use and 8% in first year of use
• Women have first baby in NZ at about 30
• So average woman has more than 10 years
contraceptive use before first baby
• About 1 in 3 may therefore have an unintended
conception in that time
• Average woman has less than 2 children
• So many years of contraception required
when family complete with possible
contraceptive failure
WHO medical eligibility criteria for
contraceptive use
• WHO 1: Unrestricted use
• WHO 2: Advantages generally
outweigh theoretical or
proven risks
• WHO 3: Theoretical or proven risks
usually outweigh advantages
• WHO 4: Do not use
Depo Provera
• Problem with women returning on time for
subsequent injections
• Now internationally recommended that
“late” injection is more than 14 weeks
since last injection
• Still schedule next appointment for 12
weeks
Possible side effects
• Most don’t put on weight
• Most don’t have mood changes
Depo Provera and bone density
• Depo Provera may reduce bone density by
5 – 7% over the first 2 years of use – it
then plateaus
• Caused by suppression of oestrogen
• When Depo Provera discontinued, regain
this loss of bone density over next few
years
Bone density
• Maximum increase in bone mass age 1114, some sites reach peak bone mass by
18, others later
• Reduced in anorexia nervosa, exerciseinduced amenorrhoea etc
• Increased in Maori and Pacific nation
people
Depo Provera use re bone density
• Can be used by adolescents if other
methods unsuitable, especially if 18 or
older
• All ages - review at 2 years – risks and
benefits
– UK Faculty of Family Planning and
Reproductive Health care, WHO
Intrauterine
contraception
Action
• Primarily prevention of fertilisation – copper or
progestogen immobilise passage of sperm
• Can prevent implantation so copper IUD can be
used for emergency contraception
Intrauterine
contraception
• Now clear that STIs cause infection not IUDs,
beyond the initial insertion phase
• Ideal to exclude STIs before insertion
• If asymptomatic chlamydia found, can treat and
insert IUD if reinfection not likely
• If STI or PID diagnosed while IUD in situ, treat
and only remove if not settling
Intrauterine
contraception
• IUDs can be used by women who have not had
children
• No increased risk of PID or infertility unless
exposed to STIs
• Insertion may be more uncomfortable
• Slightly higher expulsion rate
Intrauterine
contraception
• Fertility declines in 40s
• Copper IUDs – if inserted when 40 or older,
can stay until postmenopausal if no problems
• Mirena - if inserted when 45 or older for
contraception, can stay until postmenopausal if
no problems
Mirena
• Efficacy not statistically different from copper
IUD
• Special authority if menorrhagia causing
anaemia and standard treatment for HMB
unsatisfactory
Jadelle
• Progestogen-releasing rods
• 2 rods of levonogestrel - lasts 5 years
• inserted subdermally into upper arm under
local anaesthetic by trained clinician
• Subsidised
• Available on individual prescription (obtain
trochar from Bayer NZ)
Action
Slow release of progestogen which works by
• Interfering with ovulation
• Thickening cervical mucus
• Oestrogen levels remain above threshold
for loss of bone density
Jadelle efficacy
Women 60kg
or more
Year 1
Annual
pregnancy
rate
0.1
Year 2
0.1
0.2
Year 3
0.1
0.3
Year 4
0.0
0.0
Year 5
0.8
1.1
0.2
Side effects
• Main side effect is change in bleeding
pattern
• Can have other hormonal side effects
but lower hormonal levels than POP –
headache, weight gain, mood changes,
libido – randomised control trials do not
confirm difference in these side effect
rates
• Scar for insertion and removal occasionally local wound problem
Jadelle bleeding pattern
• Irregular bleeding and amenorrhoea common
• Settles to long term pattern over first 3 - 6 months
• Bleeding less likely to settle with time than Depo Provera
or Mirena
• Bleeding problems are commonest reason for
discontinuation in international studies
• Spotting and irregular bleeding common – 14% (1 in 7)
discontinue for this reason:
– 5% for prolonged episodes of vaginal bleeding and
spotting
– 4% for irregular bleeding
– 3% for heavy bleeding
Bleeding
• Discussion of possible bleeding problems essential
before insertion
• Consider other causes of irregular bleeding
• Management of irregular bleeding
– COC as long as oestrogen not contraindicated
– NSAIDs 5 -10 days
Advantages
•
•
•
•
•
Efficacy
Long timeframe
Rapid return of fertility when removed
Lower PID rates
Less dysmenorrhoea
Insertion
• By day 7 or reliable contraception
• Contraceptively effective immediately if inserted by day
5, otherwise 7 days
• Contraindicated if breast cancer within last 5 years
• Should not be used by those on enzyme inducing
medication
• Otherwise suitable for all ages provided able to manage
possible bleeding problems
• Superficial placement essential
Removal
• Do not attempt removal if implants impalpable
• Refer to interventional radiologist
Combined Oral Contraceptive
Major WHO 4 categories
Past or present circulatory disease - arterial or
venous
Disease of the liver – cirrhosis, jaundice
Breast cancer – current within last 5 years
COC and arterial disease (MI, CVA)

Not an independent risk factor

Amplifies other risk factors
- smoking
- obesity
- hypertension
- diabetes
- hyperlipidaemia : ↑ cholesterol
: family history of MI
and/or CVA
ARTERIAL RISK
FACTORS
WHO 4
CV disease in
parent or sibling
under 45
Cigarette smoking
Smoker over 35
years of age
Diabetes
WHO 3
WHO 2
Lipids abnormal
Lipids normal
Over 35, given up
< 1 year ago, no
other risk factors
Over 35, given up >1
year ago no other risk
factors.
Under 35
Has arterial disease
No arterial disease
BP over 160/100
BP 140 – 159
90 – 99
Hypertension in
pregnancy
BMI > 40
BMI 35 – 39
BMI 30 – 34 + no
other risk factor
Migraines
With aura or takes
ergotamine
Without aura
over 35
Without aura under 35
Age
35 or over & one
other risk factor
Hypertension
Overweight
35 or over and no
other risk factor
Migraine
Simple migraines present with:
• Throbbing or pulsating unilateral or
bilateral pain
• Nausea, vomiting, anorexia
• Sensitivity to light or sound
• Severe and not easily relieved by aspirin
or paracetamol
Visual symptoms in migraine with
aura
•
•
•
•
•
In 99% migraines with aura – usually before
headache
Usually symmetrical, affecting one hemifield of both
eyes, although subjectively, they may appear to affect
only one eye
Typically begins with small bright blind spot which
gradually increases in size to assume a C shape
Often develop scintillating edges round blind spot
which appear as zigzags
May include flashing lights
Neurological symptoms and signs of
focal migraine
•
•
•
•
•
Less common
Unilateral sensory disturbance typically pins
and needles, spreading up one arm or
affecting one side of the face or tongue – the
leg is rarely affected
Disturbance of speech – usually nominal
dysphasia
Loss of motor function is very unusual
These symptoms usually follow one another –
visual, then sensory, then dysphasia
Headaches
 Migraines (without aura) - COC OK if no other risk
 COC contraindicated
- migraine with aura
- migraine without aura
plus additional risk factor for stroke including
age over 35
Past history of migraine with aura and no other risk factors
– WHO 3
Risk of venous thrombosis
(DVT/PE)
RISK:
for non pregnant woman between 15-44 yr olds
- 5-10 per 100,000
 for pregnant woman
- up to 10 times risk
 on low dose second generation pills
- 3-4 times risk

on other combined pills
- 6 times risk or more
Fatality rate 3%
Risk factors for
venous disease
WHO
Category 4
WHO
Category 3
VTE in parent
or sibling
under 45
Abnormal
clotting factor
or tests not
available
Overweight
BMI over 39
BMI 35 – 39
Immobility
Confined to
bed
Wheelchair
Past
Thrombosis
Extensive
varicose
veins
Varicose
Veins
WHO
Category 2
Normal
clotting
factors
BMI 30-34
Superficial
thrombophlebitis
First line COCs – second generation pills
Oestrogen
35mcg
Norethisterone
Levonorgestrel
*Brevinor 1
*Norimin
*Brevinor
Norinyl-1
30mcg
20mcg
* Government subsidised pills
*Levlen
Microgynon
30
*Monofeme
Nordette
Loette
Microgynon 20
Other combined pills
Higher VTE risk
Oestrogen
Progestogen
Brand name
Use
30mcg
20mcg
Desogestrel
Marvelon
Mercilon
Third generation
35 mcg
Cyproterone
acetate
*Ginet 84
Moderate/severe
acne, PCOS
30 mcg
20 mcg
Drosperinone
Yasmin
Yaz
Acne, PMS,
bloating
50mcg
Levonorgestrel
*Microgynon 50
Enzyme
inducers, BTB
Side effects
• Irregular bleeding and chloasma are linked
to COC use
• Randomised control trials do not show that
COC causes weight gain, headaches,
breast tenderness, nausea or change in
libido
• Nocebo effect – experience symptoms
because aware they are possible
Starting instructions for COC
If starting with a hormone pill:
 Day 1 - 5 of cycle safe = straight away
 Any other time not safe until 7 hormone pills
have been taken (one each day)
Missing COC pills
• WHO: additional precautions required only
if:
• Miss 3 x 30mcg pills in a row
• Miss 2 x 20mcg pills in a row
• UK FFPRHC: 2 missed pills in a row
• Data sheets still recommend additional
precautions if 12 hours late
• NZ Family Planning teach missing any 2
pills within a week
Missed pills
 One missed pill, take it as soon as
remembered, taking the next pill at
the usual time – this may mean
taking 2 hormone pills together
 Any 2 pills missed within a week of
each other, follow the 7 day rule.
7 day rule



Not contraceptively safe until 7 hormone pills
have been taken in a row
Use another method of contraception such as
condoms or do not have sexual intercourse
while taking the 7 hormone pills
If during this time a condom breaks or slips off,
the emergency contraceptive pill (ECP) is
indicated.
If there are less than 7 hormone pills left in the pack,
finish the hormone pills and start the new pack
immediately (miss the 7 inactive pills or the 7 day
break)
Vomiting, diarrhoea and other
medications



Vomiting or severe diarrhoea for more than 24
hours, follow the 7 day rule and miss the 7
inactive pills (or 7 day break) if necessary
Enzyme inducing medications reduce efficacy
– need to use higher dose COCs and shorten
break between hormone pills of each packet
Antibiotics no longer thought to cause
significant interaction
Missed pills
FIRST WEEK:
 Danger of ovulation following pill free week
 7 day rule essential
 Emergency contraception required if additional precautions
not taken
 If any UPSI during the 7 days before missed pills, client
needs ECP (may be > 72 hours)
SECOND WEEK:
 No additional precautions required
THIRD WEEK:
 Miss pill free week, no additional precautions required
 If pill free week taken, emergency contraception may be
required.
New ways of taking COC
• Tricycling = taking 3 packets of pills in a
row without a break
• Continuous = no breaks
• Less risk of contraceptive failure
• Less breakthrough bleeding with time but
some women will find this spotting a
problem – take 7 day break
• No known medical concerns
Continuous pill taking
• Family Planning is offering as a choice
• Should be better efficacy
• With 21 hormone pill regimen, missing
more than 1 pill prejudices efficacy
• With continuous pill regimen, need to miss
more than 8 pills before efficacy
prejudiced
Mortality associated with COC
 39 year follow up of cohort of 46000 women
from Royal College of General Practitioners
Oral Contraception Study
 Pill users had a lower mortality rate than non
users
 Increase in cervical cancer and
cerebrovascular deaths balanced by decrease
in ovarian cancer deaths
BMJ 2010
Causes of breakthrough bleeding
Late or missed pill
Diarrhoea or vomiting
Medications - enzyme inducers, antibiotics
Infection - chlamydia
Abnormal cervix – ectropion, cancer
Pregnancy
First few months of new pill
Hormone dose too low
Running packets together
Progestogen only pills
 Use when oestrogen contraindicated or
side effects with COC
 No increased risk of arterial or venous
disease or cancer
Progestogen only pills
 Noriday and Microlut work mainly by
altering cervical mucus
Variable suppression of ovulation
Cerazette reliably suppresses ovulation
Distance penetrated (cm)
Sperm penetration test
3
Repeat
Dose
2
1
0
0
2
4
6
8 10 12 14 16 18 20 22 24 26
Time (hours)
Progestogen only pills
 Noriday and Microlut – missed pill = 3
hours late, 2 days before protection reestablished
 Cerazette – missed pill = 12 hours late, 2
days for cervical mucus protection, 7 days
if waiting for ovulation suppression
Timing of ECP
• UK FFPRHC recommend taking LNG ECP
up to 72 hours – registered use
• No statistical difference between first 4
days
• Can be given on 4th day
• No evidence that ECP effective on 5th day