Emergency Contraception
March 8, 2017
Dr Joh and the team at Club de Mar Medical are thrilled to finally be accommodated in …
March 8, 2017

Hormonal Contraception

Having discussed all other forms of contraception, we now consider hormonal choices.  This is intended as a summary… to give a flavour of what is available, as the information provided is not “all encompassing”, but merely the highlights!  Neither, is the information to be used instead of a consultation with your preferred healthcare provider.

 

HORMONAL CONTRACEPTION

 

All hormonal methods are used by the lady.  All use various forms of the female hormone(s), progesterone plus or minus oestrogens.  These hormones cause bodily changes to prevent pregnancy. None of the hormonal contraception’s prevent STI transmission.

 

Hormonal methods come in a variety of forms including an oral pill, a patch worn on the skin, an injection, a ring inserted in the vagina, an implant in the arm, or a device inserted in the uterus (womb).

 

Oral Contraceptive

 

What is it?
“The pill” is a tablet that is swallowed once a day. It is one of the most researched (and often most misunderstood) drugs in the world. It is also one of the world’s most prescribed medications – about 100 million women across the globe rely on it!

 

With proper use, the Pill is over 99.0% effective. However, there can be up to an 8% user failure rate.

 

There are two forms:

  1. The combined oral contraceptive pill (COP) contains a combination of oestrogen and a progesterone (two types of female hormones.)
  2. The progesterone only pill (POP) contains only one hormone and it usually prescribed due to age or medical history issues.

 

How it Works

Both forms work by thickening the cervical mucus making it difficult for the sperm to reach the egg, and changing the lining of the uterus making implantation difficult.  Only the COP prevents the ovary from releasing an egg.

 

How to use it

To be most effective, the Pill should be taken at the same time each day.  Some women find that setting an alarm helps to remember!  Instructions are provided in the packet on what to do it a pill is missed or late.

 

Both the COP and POP contain either 21 or 28 tablets.  After the 21 pills are taken the lady has to remember to restart the Pill 7 days later.  The extra 7 tablets in a 28 tablet pack, contain no medication and are only provided to make starting the medication again easy.  The “no medication” week, is the week when a withdrawal bleed occurs.

 

Advantages and Disadvantages

 

Combined Oral Pill (COP)

 

ADVANTAGES DISADVANTAGES
Effective and reversible Must be taken every day, preferably at the same time (but can work up to 12 hours later)
Does not interfere with intercourse May cause irregular bleeding or spotting
Regulates menstrual cycle May cause breast tenderness, nausea, or headaches
Usually reduces menstrual blood loss and cramps May increase the risk of blood clots, (particularly in women with certain blood disorders or a family history of blood clots)
Decreases acne and hirsutism Effectiveness may be reduced by other medications
May reduce peri-menopausal symptoms Should not be used by women over the age of 35 who smoke
Decreases premenstrual symptoms Does not protect against STIs

 

Progesterone Only Pill (POP)

 

ADVANTAGES DISADVANTAGES
Effective and reversible Must be taken every day, preferably at the same time (but usually can work about 4 hours later.  There  are others, but they are  not widely available)
Does not interfere with intercourse May cause irregular bleeding or spotting
Regulates menstrual cycle May cause breast tenderness, abdominal bloating, acne or headaches
May reduce menstrual blood loss and cramps Effectiveness may be reduced by other medications
May be suitable for women who cannot take oestrogen Does not protect against STIs
May be suitable for women over the age of 35 who smoke  
May be suitable for breastfeeding women  

 

An option for women taking the Pill is to take it on a Continuous or Extended Cycle; meaning pills are taken every day for three months, and then stopped for a week during which a bleed would occur. Thus, it is possible to only have a period four times in a year.

 

Who should use it?
Women who can remember to take pills every day at the same time, non-smokers, or those who want lighter periods, fewer cramps or improved acne.

 

Myths and Fact
A common myth is that women who stop taking the Pill may not be able to get pregnant. This is completely inaccurate!  The Pill has no effect on long term fertility.

 

Another common myth is that the Pill causes cancer. Again, false. In fact, long term use of the Pill actually reduces the risk of certain cancers such as endometrial and ovarian. 

 

Contraceptive Patch (Evra®)

 

What is it?
The contraceptive patch is a 4 x 4 cm beige patch that sticks to a woman’s skin.  The Patch continuously releases oestrogen and a progesterone into the bloodstream.

 

Like the Combined Oral Pill, the patch is also more than 99% effective at preventing pregnancy when used perfectly.  It has about a 3% failure rate for typical users. It can be helpful for women who have trouble remembering to take a pill every day. It may be a bit less effective in women who weigh more than 90 kg.

 

How it works
The patch prevents pregnancy primarily by stopping the ovaries from releasing an egg, but it may also thicken the cervical mucus and make the uterine lining thin. Its method of action is very similar to the Combined Oral Pill.

 

How to use it
Each patch is worn on the skin for seven days. One patch is worn each week for 3 weeks. The patch should be changed on the same day each week (the “Patch Change Day”). The fourth week is patch-free, allowing a withdrawal bleed to occur. The patch should never be off for more than seven days. Following the seven patch-free days, a new cycle is started with the application of another patch on Patch Change Day.

 

The patch can be worn on the buttocks, stomach, back or upper arms, but not on the breasts. It can be helpful to change the location each week. The patch should be applied to clean, dry skin. The patch is very “sticky”, allowing normal exercise, shower, swimming or a sauna etc and it still sticks 98% of the time.

 

How to start
Ideally the patch should be applied on the first day of the period, as protection is then immediate.  If more than 24 hours has passed since the beginning of the period pregnancy protection occurs one week later, so a condom must be additionally used for 7 days.

 

Women switching from the Pill should also start the patch on their first day of bleeding (not the start of the next pack of pills).

 

Advantages and Disadvantages

 

ADVANTAGES DISADVANTAGES
Effective and reversible Must be applied weekly and remember when to restart after the withdrawal bleed
Does not interfere with intercourse May cause irregular bleeding or spotting
Regulates menstrual cycle May cause breast tenderness, nausea, or headaches
Usually reduces menstrual blood loss and cramps May increase the risk of blood clots, (particularly in women with certain blood disorders or a family history of blood clots)
Decreases premenstrual symptoms Possible skin irritation under the patch
  Should not be used by women over the age of 35 who smoke
  Does not protect against STIs

 

Troubleshooting

 

Daily Check Make sure the patch is still applied fully.
Poor Adhesion Try to smooth the patch back on by pressing with the hand for 10 seconds. If it does not stick back on, or comes off completely, apply a new patch. Still change this new patch on the same Patch Change Day.  Protection against pregnancy is maintained.
Patch fallen off for more than 24 hours Put a new patch right away.  7 days of additional protection is required.  The Patch Change Day changes to the replacement patch day.
Forgetting to change the patch If the change is forgotten for 1 or 2 days, remove the patch as soon as possible and apply a new patch. The Patch Change Day remains the same.  Pregnancy prevention is maintained.

If the change happens more than 2 days late, a new Patch Change Day occurs and additional contraception should be used for 7 days.

Forgetting to take the patch off If removing the patch is forgotten (at the start of the Patch-free week), take it off when remembered and start the next cycle at the usual time. The withdrawal bleed may be shorter, or bleeding may still be occurring when the next patch is applied.
Forgetting to put a new patch on after the patch free week This means that more than 7 days are patch-free week.  Apply the patch as soon as remembered.  Additional protection is required for 7 days and the Patch Change Day changes.

 

Who should use it?
Ortho Evra® can be a good choice for women who cannot remember to take a pill every day, but may remember a weekly event.

Some women may choose the patch because the hormones are absorbed through the skin rather than through the liver, such as with the Pill.

 

Vaginal Ring (NuvaRing®)

 

What is it?
The vaginal ring is a soft, flexible, clear plastic ring measuring 54mm in diameter.  It is inserted into a woman’s vagina where it slowly releases the two female hormones (oestrogen and a progesterone) for three weeks.

 

The ring is at least as effective as the Pill, and it may be more effective if there is difficult remembering a daily Pill.

 

How does it work?
These hormones enter into the woman’s bloodstream and prevent pregnancy mainly by stopping the ovaries from releasing an egg. It may also thicken the cervical mucous and make the uterine lining thin. The ring’s method of action is very similar to the COP.

 

How to use it

The ring comes in only one size.  It does not need to be in a particular position in the vagina to be effective. It is held in place by the walls of the vagina and a woman usually cannot feel the ring once it is in. The woman inserts and removes the ring herself and most women find this easy to do. The vagina is a closed space and there is no way for the ring to get “lost” or go anywhere else!

 

The ring is worn for three weeks, followed by a 7 day ring-free interval. When the ring is removed, the withdrawal bleed occurs. At the end of the ring-free week, another ring is inserted and a new 4 week cycle begins.

 

The ring should be left in place during sex. Most men and women do not notice it during intercourse, and even for those who do, it is not usually find it problematic.

 

Advantages and Disadvantages

ADVANTAGES DISADVANTAGES
Effective and reversible Inserted once per month.
Does not interfere with intercourse May cause irregular bleeding or spotting
Regulates menstrual cycle May cause breast tenderness, nausea,  vaginal irritation or discomfort
Usually reduces menstrual blood loss and cramps May increase the risk of blood clots, (particularly in women with certain blood disorders or a family history of blood clots)
Believed to decreases acne and hirsutism Should not be used by women over the age of 35 who smoke
Believed to decrease premenstrual symptoms Does not protect against STIs

 

Troubleshooting

 

What to do if the ring falls out The ring should be rinsed off and replaced as soon as possible.

If it has been out for less than 3 hours, pregnancy protection is maintained.

If it has been out for more than 3 hours, a back-up method of birth control is needed for the next 7 days.

The ring must stay in for at least 7 more days after being out for longer than 3 hours; this may mean that it is in place for more than 21 days in total that month. Following this, a 7 day ring-free interval should occur as usual and the next ring inserted.

What to do if removal of the ring is forgotten If it has been in for less than 28 days (ie up to one week too long) it should be removed, a 7 day ring free interval commenced, then the next ring inserted. Pregnancy protection is maintained.

If the ring has been in for more than 28 days, it should be immediately removed and the next ring inserted.  Back-up contraception for the next 7 days is required. Irregular bleeding or no withdrawal bleed can occur that month.

What to do if reinsertion of the ring is forgotten Insert the ring as soon as remembered.  Use additional contraception for 7 days.

Consider using emergency contraception unprotected sex has occurred.

 

Injection (Depo-Provera®)

 

What is it?
Depo-Provera® is a hormonal contraceptive method that only contains a progesterone (no oestrogen).  It is 99.7% effective in preventing pregnancy.

 

How it works
It stops ovulation and thins the lining of the uterus.  It is administered by a needle in the muscle of the arm or buttocks every 12-13 weeks.

 

How to take it
The first injection should be given during the first 5 days of the menstrual cycle. It becomes fully effective 24 hours after the injection. The next injection is given within 12-13 weeks of the previous injection.

 

ADVANTAGES DISADVANTAGES
4 times per year Associated with a decrease in bone mineral density, similar to that seen in women who have breastfed for 6 months. Bone density improves when the injections are stopped. This bone density loss is of particular concern for young women in their teens, whose bones are still hardening.

The impact of this decrease in bone density is unknown for peri-menopausal or postmenopausal women.

Women using Depo-Provera® should make sure that they get enough Calcium and Vitamin D, either in their diet or in vitamin supplements, in order to help protect their bones.

Effective and reversible Must return to Healthcare provider 4 times per year for the injection
Does not interfere with intercourse May cause irregular bleeding or spotting (especially with the first 3 month injection)
Regulates menstrual cycle May cause breast tenderness, abdominal bloating, acne or headaches
Reduces menstrual blood loss and cramps (50% of women stop periods altogether within the first year) Weight gain (average 2.5kg in the first year).  Thought to be related to increased appetite and therefore increased food intake.
May be suitable for women who cannot take oestrogen Return to natural fertility be longer than with the oral contraceptive pill. It takes an average of 9 months after the last injection to return to a regular menstrual cycle pattern.
May be suitable for women over the age of 35 who smoke Does not protect against STIs
Suitable for breastfeeding women  

 

Troubleshooting

 

Late for the injection? For contraception, it is important to have the next injection within 12 weeks of the last injection.

If the next injection is longer than 14 weeks, a pregnancy test should be carried out before the next injection. And, a non-hormonal method of contraception should be used until the late injection is obtained, as well as for two weeks after.

 

Who should use it?
Depo-Provera® is a good choice of contraception for users who are not afraid of injections, want a reliable method of birth control and prefer not to take a pill every day.

 

Intra-uterine System (“a coil”) (Mirena or Jaydess)® 

 

What is it?
The IUS is made up of a small T-shaped frame and cylinder containing a progesterone. It does not contain oestrogen. The intra-uterine system (IUS) provides reliable, reversible contraception for up to five years. It is more than 99.5% effective.

 

How does it work?
The IUS slowly releases the hormone that acts on the lining of the uterus. The progesterone does not circulate into the rest of the body. The IUS itself prevents pregnancy by interfering with the movement of sperm inside the uterus and the progesterone prevents some women from ovulating (releasing an egg) at all.

 

Advantages and Disadvantages

 

ADVANTAGES DISADVANTAGES
Lasts 3 or 5 years (depending on size) May cause irregular bleeding or spotting especially in the first 3 months
Effective and reversible Rare complications at insertion: uterus perforation
Does not interfere with intercourse Rare complications following insertion: infection and expulsion
Reduces menstrual blood loss and cramps (many women have no periods) Does not protect against STIs
Swift return to fertility upon removal  
Suitable for women over the age of 35 who smoke  
May be suitable for breastfeeding women  

 

How to use the IUS
A specially trained Healthcare provider must insert the IUS into the uterus through the cervix.  This can be achieved at any time during the menstrual cycle (as long as pregnancy is ruled out) but is best at the end of the menses.  Removal and replacement of the IUS can take place during the same appointment.

 

Local anaesthetic is applied to the cervix and/ or oral analgesia, as the procedure can be uncomfortable or painful.  Averagely insertion takes approximately 15 minutes.  Cramping period like pains are not unusual for a day or so following insertion.  The IUS strings should be checked from time to time to ensure the IUS is still in place.  This is achieved by inserting the finger into the vagina and feeling for the strings near the cervix.

 

Myths and Facts

MYTH FACT
The IUS cannot be used if a lady has not delivered a child naturally Completely untrue!
The IUS increases the risk of infertility Untrue.  Women who have their IUS taken out will get pregnant at the same rate as women who have never used an IUS.
IUSs increase the long-term risk of infection (pelvic inflammatory disease). After the first month, the risk of infection is not significantly higher than in women without IUSs.
The IUS increases the risk of having an ectopic pregnancy (a pregnancy in the fallopian tubes) The IUS does not increase the risk of ectopic pregnancy.

 

Who should use it?
Women who want to decrease the amount of bleeding and cramping during their periods, do not desire a pregnancy for an extended period of time and want the convenience of not having to do anything on an ongoing basis.

 

The Implant (Nexplanon®)

 

What is it?

The implant is a single matchstick-sized rod with progesterone.  It is placed underneath the skin in the upper arm by a healthcare provider. Once inserted, a small amount of progesterone is slowly and continuously released which stops the release of the egg from the ovary and also thickens the cervical mucus making it more difficult for sperm to reach the egg.

 

Nexplanon® is significantly more than 99% effective at preventing pregnancy.

 

Advantages and Disadvantages

 

ADVANTAGES DISADVANTAGES
Lasts 3 years May cause irregular bleeding or spotting especially in the first 3 months
Effective and reversible Rare complications at insertion site: infection or pain in the arm
Does not interfere with intercourse Small scar at insertion/ removal site
Usually reduces menstrual blood loss and cramps (many women have no periods).  However, some have longer periods. Does not protect against STIs
Swift return to fertility upon removal  
May be suitable for women over the age of 35 who smoke  
May be suitable for breastfeeding women  

 

How to use the implant

A specially trained healthcare provider inserts the implant under the skin using a large bore needle, full aseptic technique and local anaesthetic. The procedure takes approximately 5 minutes.

The implant can be removed at any time.

Removal must also be by a specially trained healthcare provider and again involves local anaesthetic and aseptic technique.  This time, a small cut is made in the skin to allow removal.  The procedure usually takes approximately 15 minutes.

Another implant can be re-inserted at the same appointment if desired.

 

If the implant is inserted during the first 5 days of the period, contraception is immediate.  However, insertion at any other time requires additional protection for 7 days.

 

Who should use it?
Nexplanon® is a good choice for women who want a long-term contraception that is hidden and effective for a longer period of time. This method may be a good choice for women who are sensitive to or cannot use oestrogen containing hormonal methods.

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