Intrauterine contraceptive devices

Overview

• This comprises both conventional copper intrauterine devices (IUDs) and

levonorgestrel-releasing intrauterine systems (IUS, Mirena) (This is also used
in the management of menorrhagia).

Effectiveness

• Both the IUD and IUS are considered more than 99% effective

Mode of action

• IUD
o The primary mode of action is the prevention of fertilisation by causing
decreased sperm motility and survival (this is possibly an effect of
copper ions)
• IUS
o Levonorgestrel prevents endometrial proliferation and thus causes
cervical mucus thickening

Counselling

• IUD is effective immediately after insertion

• IUS can be relied upon after 7 days

Potential problems and complications

• IUDs make periods heavier, longer and even more painful

• The IUS is linked with initial frequent uterine bleeding and spotting. And Later
women usually have intermittent light menses with less dysmenorrhoea and
some women become amenorrhoeic
• Uterine perforation:
o Up to 2 per 1000 insertions
• The proportion of pregnancies that are ectopic is increased but the absolute
number of ectopic pregnancies is reduced. This is in comparison to women
who are not using contraception
• Infection:
o There is a small increased risk of pelvic inflammatory disease in the
first 20 days after insertion but after this period the risk returns to that
of a standard population
• Expulsion:
o Risk is around 1 in 20 and that is most likely to occur in the first 3
months

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP

Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC 2. If no contraindications,
COCP PCP or implant may be more suitable as they would be UKMEC
1.
• Woman with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Progestogen-only pill
• It is important to counsel women who are considering taking the progestogen-
only pill (POP)

Potential adverse effects

• Irregular vaginal bleeding is the most common problem

Starting the POP

• If commenced up to and including day 5 of the cycle it provides immediate

protection, otherwise, additional contraceptive methods (for example
Condoms) should be used for the first 2 days
• If switching from a combined oral contraceptive (COC) it provides immediate
protection if continued directly from the end of a pill packet (means from Day
21)
Taking the POP

• Should be taken at the same time every day, without a pill-free break (that’s
unlike the COC)

Missed pills

• If < 3 hours late:

o Continue as normal
o For Cerazette (desogestrel) a 12 hour period is allowed
• If > 3 hours:
o Take the missed pill as soon as possible, continue with the rest of the
pack, extra precautions (example: Condoms) should be used until pill
taking has been re-established for 48 hours

Other potential problems

• If diarrhoea and vomiting:

o Continue taking POP but assume pills have been missed - refer above
• Antibiotics:
o These have no effect on the POP
o Unless the antibiotic alters the P450 enzyme system, for example,
Rifampicin
• Liver enzyme inducers may reduce the effectiveness

Other information

• Discussion on STIs

Missed pill POP

With regard to 'Traditional' POPs (Micronor, Noriday, Nogeston, Femulen)

• If less than 3 hours late

o No action required, continue as normal
• If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
o Action needed - refer below

Cerazette (desogestrel)

• If less than 12 hours late

o No action required, continue as normal
• If more than 12 hours late (i.e. more than 36 hours since the last pill was
taken)
o Action needed - refer below

Action required, if needed are:

• Take the missed pill as soon as possible.

 • If more than one pill has been missed just take one pill.
• Take the next pill at the usual time, which may mean taking two pills in one
day
• And then continue with the rest of the pack
• extra precautions (for example condoms) should be used until pill taking has
been re-established for 48 hours

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP

Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC [Link] no contraindications, COCP
PCP or implant may be more suitable as they would be UKMEC 1
• Woman with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Combined oral contraceptive pill

Counselling
Overview
It is important for women who are considering taking the combined oral contraceptive
pill (COC) to be counselled in a number of areas
Potential harms and benefits

• The COC is around > 99% effective if they are taken correctly
 • There is a small risk of blood clots
• There is also a very small risk of heart attacks and strokes
• Increased risk of breast cancer and cervical cancer

Advice on taking the pill

• If the combined oral contraceptive pill (COCP is started within the first 5 days
of the cycle, then there is no need for additional contraception.
• If it is started at any other point in the cycle then alternative contraception
should be used (for example, condoms) for the first 7 days
• This should be taken at the same time every day
• It is taken for 21 days then stopped for 7 days - similar uterine bleeding to
menstruation
• It should be advised that intercourse during the pill-free period is only safe if
the next pack is started on time

Discussion on situations here efficacy may be possibly reduced

• If they vomit within 2 hours of taking the COC pill

• If they are taking liver enzyme-inducing drugs

Other information to discuss

• Discussion on STIs

Concurrent antibiotic use

• For many years doctors in the UK have advised that the concurrent use of
antibiotics may possibly interfere with the enterohepatic circulation of
oestrogen and as a result make the combined oral contraceptive pill
ineffective.
o 'Extra-precautions' were advised for the duration of antibiotic treatment
and for 7 days afterwards
• But it is also important to note that no such precautions are taken in the US or
the majority of mainland Europe
• In 2011 the Faculty of Sexual & Reproductive Healthcare produced new
guidelines abandoning this approach. The latest edition of the BNF has been
updated in line with this guidance.
• However, precautions should still be taken with enzyme-inducing antibiotics
such as rifampicin.

Contraindications
Overview
The decision of whether to start a woman on COCP is now guided by the UK
Medical Eligibility Criteria (UKMEC).
This scale categorises the potential cautions and contraindications according
to a four-point scale

• UKMEC 1
o A condition for which there is no restriction for the use of the
contraceptive method
• UKMEC 2
o Advantages generally outweigh the disadvantages
• UKMEC 3
o Disadvantages generally outweigh the advantages
• UKMEC 4
o Represents an unacceptable health risk

Examples of UKMEC 3 conditions

• More than 35 years old and also those who smoke less than 15 cigarettes/day
• BMI > 35 kg/m^2
• If there is a family history of thromboembolic disease in first-degree relatives <
45 years
• Controlled hypertension
• Immobility
o For example wheelchair use
• Carrier of known gene mutations associated with breast cancer (for example
BRCA1/BRCA2)

Examples of UKMEC 4 conditions

• Migraine with aura

• Breastfeeding <6 weeks post-partum
• Age 35 or over who smokes 15 or more cigarettes/day
• Systolic 160mmHg or diastolic 95mmHg
• Vascular disease
• History of VTE
• Current VTE (on anticoagulants)
• Major surgery with prolonged immobilisation
• Known thrombogenic mutations
• Current and history of ischaemic heart disease
• Stroke (including TIA)
• Complicated valvular and congenital heart disease
• Current breast cancer
• Nephropathy/retinopathy/neuropathy
• Other vascular diseases
• Severe (decompensated) cirrhosis
 • Hepatocellular adenoma
• Hepatoma
• Raynaud's disease with lupus anticoagulant
• Positive antiphospholipid antibodies

NOTE: Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or

4 depending on the severity
Changes that were made in 2016

• Breastfeeding 6 weeks - 6 months postpartum was changed from UKMEC 3

→2

Missed pill criteria

The recommendations mentioned below are for those who take combined oral
contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (I.E. at any time in the cycle)

• Take the last pill even, even if it means taking two pills in one day and then
continue taking pills daily, one each day.
• Note that no additional contraceptive protection is needed

If 2 or more pills missed

• Take the last pill even if it means taking two pills in one day, and then leave
any earlier missed pills and then continue taking pills daily, one each day.
• The women should be advised to use condoms or abstain from sex until she
has taken pills for 7 days in a row. FSRH has stated this: 'This advice may be
overcautious in the second and third weeks, but the advice is a backup in the
event that further pills are missed'.
• In case the pills are missed in week 1 (Days 1-7):
o Then emergency contraception should be considered if she had
unprotected sex in the pill-free interval or in week 1
• If pills are missed in week 2 (Days 8-14):
o After the individual has taken the COC pill for seven consecutive days,
there is no need for emergency contraception
▪ Also note that theoretically women would be protected if they
took the COC in a pattern of 7 days on, 7 days off
• If pills are missed in week 3 (Days 15-21):
o She should finish the pills in her current pack and start a new pack the
next day; this means that she should omit the pill-free interval.

Advantages and disadvantages of Combined oral contraceptive pill

Advantages of the combined oral contraceptive pill

• Highly effective (there is a failure rate < 1 per 100 woman years)
• This does not interfere with sex
• Contraceptive effects are reversible upon stopping
• Typically makes periods
o Regular, lighter and less painful
• Reduced risk of the following
o Ovarian
o Endometrial
o Colorectal cancer
• It may also possibly protect against pelvic inflammatory disease
• This may reduce the following
o Ovarian cysts
o Benign breast disease
o Acne vulgaris

Disadvantages of the combined oral contraceptive pill

• Many people may forget to take it

• This offers no protection against sexually transmitted infections
• It also increases the risk of venous thromboembolic disease
• Increased risk of breast and cervical cancer
• It also may increase the risk of stroke and ischaemic heart disease (and that’s
especially in smokers)
• Temporary side-effects are
o Headache
o Nausea
o Breast tenderness may be seen

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP

Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It is vital to note that these questions will also mention possible
contraindications for COCP
 oIf a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC [Link] no contraindications, COCP
PCP or implant may be more suitable as they would be UKMEC 1.
• Women with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Infertility
Overview

• This affects around 1 in 7 couples.

• Approximately around 84% of couples who have regular sex will conceive
within 1 year, and 92% within 2 years

Causes

• Male factor 30%

• Unexplained 20%
• Ovulation failure 20%
• Tubal damage 15%
• Other causes 15%

Basic investigations

• Semen analysis
• Serum progesterone that should be done 7 days prior to expected next period

Interpretation of serum progestogen

• < 16 nmol/l
o Repeat, if consistently low refer to a specialist.
• 16 - 30 nmol/l
o Repeat
• >30 nmol/l
o Indicates ovulation

Key counselling points

• Advise regular sexual intercourse every 2 to 3 days

• Advice to quit smoking or drinking
• Folic acid
• Aim for BMI 20-25
P450 enzyme system
Inducers of the P450 system include (CRAP GPS)

• Carbamazepine
• Rifampicin
• Alcohol (chronic)
• Phenytoin
• Griseofulvin
• Phenobarbitone
• St John's Wort / Sulfonylureas / Smoking (this affects CYP1A2, this is why
smokers require more aminophylline)

Inhibitors of the P450 system are ([Link])

• Sodium valproate
• Isoniazid
• Cimetidine
• Ketoconazole
• Fluconazole
• Acute alcohol intake
• Chloramphenicol
• Erythromycin
• Sulfonamides
• Ciprofloxacin
• Omeprazole
• Metronidazole

A few others for extra knowledge

• Quinupristin
• Amiodarone
• Allopurinol
• SSRIs:
o Fluoxetine
o Sertraline
• Ritonavir

Contraceptive choices for young people

Overview

• The notes below are mainly based on The Faculty of Sexual and
Reproductive Health (FRSH). Please refer to the link for more details.
Legal and ethical issues

• Note that the age of consent for sexual activity in the UK is 16 years.
• Practitioners may however provide advice and contraception if they feel that
the young person is 'competent'. This is typically assessed using the Fraser
guidelines (refer below)
• Children under the age of 13 years are considered unable to consent for
sexual intercourse and hence consultations regarding this age group should
automatically trigger child protection measures

The Fraser Guidelines have stated that all the following

requirements should be fulfilled:

• The young person understands the professional's advice

• The young person cannot be persuaded to inform their parents
• The young person is likely to begin, or to continue having, sexual intercourse
with or without contraceptive treatment
• Unless the young person receives contraceptive treatment, their physical or
mental health, or both, are likely to suffer
• The young person's best interests require them to receive contraceptive
advice or treatment with or without parental consent

Sexual Transmitted Infections (STIs)

• It is important to advise young people to have STI tests 2 and 12 weeks after
an incident of unprotected sexual intercourse (UPSI)

Choice of contraceptive

• Clearly, long-acting reversible contraceptive methods (LARCs) have

advantages in young people, because this age group may often be less
reliable in remembering to take medication
• However, there are some concerns about the effect of progesterone-only
injections (Depo-Provera) on bone mineral density and the UKMEC category
of the IUS and IUD is 2 for women under the age of 20 years, as a result, they
may not be the best choice
• The progesterone-only implant (Nexplanon) is, therefore, the LARC of choice
is young people

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP
Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC 2. If no contraindications,
COCP PCP or implant may be more suitable as they would be UKMEC
1.
• Woman with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Contraceptive choices for young people

Overview

• The notes below are mainly based on The Faculty of Sexual and
Reproductive Health (FRSH). Please refer to the link for more details.

Legal and ethical issues

• Note that the age of consent for sexual activity in the UK is 16 years.
• Practitioners may however provide advice and contraception if they feel that
the young person is 'competent'. This is typically assessed using the Fraser
guidelines (refer below)
• Children under the age of 13 years are considered unable to consent for
sexual intercourse and hence consultations regarding this age group should
automatically trigger child protection measures

The Fraser Guidelines have stated that all the following

requirements should be fulfilled:

• The young person understands the professional's advice

• The young person cannot be persuaded to inform their parents
• The young person is likely to begin, or to continue having, sexual intercourse
with or without contraceptive treatment
• Unless the young person receives contraceptive treatment, their physical or
mental health, or both, are likely to suffer
• The young person's best interests require them to receive contraceptive
advice or treatment with or without parental consent
Sexual Transmitted Infections (STIs)

• It is important to advise young people to have STI tests 2 and 12 weeks after
an incident of unprotected sexual intercourse (UPSI)

Choice of contraceptive

• Clearly, long-acting reversible contraceptive methods (LARCs) have

advantages in young people, because this age group may often be less
reliable in remembering to take medication
• However, there are some concerns about the effect of progesterone-only
injections (Depo-Provera) on bone mineral density and the UKMEC category
of the IUS and IUD is 2 for women under the age of 20 years, as a result, they
may not be the best choice
• The progesterone-only implant (Nexplanon) is, therefore, the LARC of choice
is young people

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP

Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC 2. If no contraindications,
COCP PCP or implant may be more suitable as they would be UKMEC
1.
• Woman with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Post-partum contraception
Overview

• Usually after giving birth women require contraception after day 21.

Progestogen-only pill (POP)

• FSRH have advised the following

o 'Postpartum women (breastfeeding and non-breastfeeding) can start
the POP at any time postpartum.'
• Note that after day 21 additional contraception should be used for the first 2
days
• Also a small amount of progestogen enters breast milk but this is not harmful
to the infant

Combined oral contraceptive pill (COC)

• This is an absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks

post-partum
• UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum
o This changed from UKMEC 3 in 2016
• The Combined oral contraceptive pill may reduce breast milk production in
lactating mothers
• This may be started from day 21 - this will provide immediate contraception
• After day 21 additional contraception should be used for the first 7 days

Lactational amenorrhoea method (LAM)

• Is 98% effective providing the woman is fully breast-feeding (no

supplementary feeds), amenorrhoeic and < 6 months post-partum

Implantable contraceptives
Overview

• Implanon was the original non-biodegradable subdermal contraceptive

implant which is now been replaced by Nexplanon. From a pharmacological
perspective, Nexplanon is the same as Implanon. The two main differences
are:
o The applicator has been redesigned to try and prevent 'deep' insertions
(example subcutaneous/intramuscular)
o It is radiopaque and therefore easier to locate if impalpable
• Both versions slowly release the progestogen hormone etonogestrel
• They are usually inserted in the proximal non-dominant arm, just overlying the
tricep. The main mechanism of action is preventing ovulation.
• They also work by thickening the cervical mucus

Key points
 • Highly effective
o Failure rate 0.07/100 women-years
• Long-acting
o Lasts 3 years
• Does not contain oestrogen so can be used if even if the patient has a past
history of thromboembolism, migraine etc.
• This can be inserted immediately following a termination of pregnancy

Disadvantages

• There is a need for a trained professional to insert and remove the device
• Additional contraceptive methods are needed for the first 7 days if not inserted
on day 1 to 5 of a woman's menstrual cycle

Adverse effects

• Irregular or heavy bleeding is the main problem

• 'Progestogen effects'
o Headache
o Nausea
o Breast pain

Interactions

• Enzyme-inducing drugs such as the following may reduce the efficacy of

Nexplanon
o Certain antiepileptic and rifampicin
• FSRH has advised that women should be advised to switch to a method
unaffected by enzyme-inducing drugs or to use additional contraception until
28 days after stopping the treatment

Contraindications

• UKMEC 3
o Ischaemic heart disease or stroke (for continuation, if initiation then
UKMEC 2)
o Unexplained & suspicious vaginal bleeding
o Past breast cancer
o Severe liver cirrhosis
o Liver cancer
• UKMEC 4
o Current breast cancer

Note that UKMEC 3 category means that the proven risks generally outweigh the
advantages and UKMEC 4 is a condition that represents an unacceptable risk if the
contraceptive method is used.

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP

Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC [Link] no contraindications, COCP
PCP or implant may be more suitable as they would be UKMEC 1
• Woman with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Contraception for women aged > 40 years

Overview

• Whilst fertility has typically significantly declined by the age of 40 years

women still require effective contraception until menopause.

Specific methods

• No method of contraception is contraindicated based on age alone.

• All methods are UKMEC1 except for the combined oral contraceptive pill
(UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women >
45 years). The guidance issued by the FSRH contains a number of points that
should be considered about each method, few points are mentioned below,
please refer link for more information.

Combined oral contraceptive pill (COCP)

• Combined oral contraceptive pill use in the perimenopausal period may help
to maintain bone mineral density
• Combined oral contraceptive pill use may help reduce menopausal symptoms
 • A pill containing < 30 µg ethinylestradiol may be more suitable for women >
40 years

Depo-Provera

• Women should be advised that there may be a delay in the return of fertility of
up to 1 year for women > 40 years
• Use is linked with a small loss in bone mineral density which is typically
recovered after discontinuation

Stopping contraception
The FSRH produced a table detailing how the different methods may be stopped.
Please refer to the link for the full table.

Hormone Replacement Therapy and Contraception

• As we know hormone replacement therapy (HRT) cannot be relied upon for

contraception so a separate method of contraception should be needed.
• The FSRH advises that the POP may be used in conjunction with hormone
replacement therapy as long as the hormone replacement therapy has a
progestogen component (means that the POP cannot be relied upon to
'protect' the endometrium).
 • In agreement, the IUS is licensed to provide the progestogen component of
HRT.

Emergency contraception
Emergency hormonal contraception

• There are now two methods of emergency hormonal contraception

('emergency pill', also known as 'morning-after pill')
o Levonorgestrel and ulipristal, a progesterone receptor modulator.

Levonorgestrel

• Should be taken as soon as possible

o Efficacy decreases with time
• Must be taken within 72 hrs of unprotected sexual intercourse
o It May be offered after this period as long as the client is aware of
reduced effectiveness and unlicensed indication
• Single dose of levonorgestrel 1.5mg (its a progesterone)
• Mode of action not fully understood
o Acts both to stop ovulation and inhibit implantation
• It is 84% effective is used within 72 hours of unprotected sexual intercourse
• Levonorgestrel is safe and well-tolerated.
• Disturbance of the current menstrual cycle is seen in a significant minority of
women. Vomiting does occur in approximately around 1% of the cases.
• If vomiting does occur within 2 hours then the dose should be repeated
• Can be used more than once in a menstrual cycle if clinically indicated

Ulipristal

• A progesterone receptor modulator currently marketed as EllaOne.

• The primary mode of action is thought to be inhibition of ovulation
• 30mg oral dose taken as soon as possible, no later than 120 hours after
intercourse
• Concomitant use with levonorgestrel is not recommended in practice
• Ulipristal may reduce the effectiveness of hormonal contraception.
Contraception with the pill, patch or ring should be started, or restarted, 5
days after having Ulipristal. And it is advised to use barrier methods during
this period
• Caution should be exercised in patients with severe asthma
• Repeated dosing within the same menstrual cycle was previously not
recommended - however, note that this has now changed and ulipristal can
be used more than once in the same cycle
• Breastfeeding should be delayed for one week after taking ulipristal. However,
there are no such restrictions on the use of levonorgestrel.

Intrauterine device (IUD)

 • This must be inserted within 5 days of unprotected sexual intercourse, or if a
woman presents after more than 5 days then an IUD may be fitted up to 5
days after the likely ovulation date
• This may inhibit fertilisation or implantation
• Prophylactic antibiotics may be possible given if the patient is considered to
be at high risk of sexually transmitted infection
• This is 99% effective regardless of where it is used in the cycle
• May be left in-situ to provide long-term contraception.
• If the client wishes for the IUD to be removed it should be at least kept in until
the next period

Contraception summary
Young woman, not sexually active

• Only menorrhagia
• Tranexamic acid
• Menorrhagia with dysmenorrhoea
• Mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses)
• COCP

Sexually active woman (those who require contraception)

• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC [Link] no contraindications, COCP
PCP or implant may be more suitable as they would be UKMEC 1
• Woman with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

• Within 72 hours of unprotected sex - Levonelle pill

• Within 120 hours of unprotected sex - IUCD or ellaOne pill

Epilepsy: Contraception
There are a number of factors to consider for women who present
with epilepsy:

• The effect of the contraceptive on the effectiveness of the anti-epileptic

medication
• The effect of the anti-epileptic on the effectiveness of the contraceptive
 • The potential teratogenic effects of the anti-epileptic if the woman becomes
pregnant

Given the points above, the Faculty of Sexual & Reproductive Healthcare (FSRH)
recommend the consistent use of condoms, in addition to other forms of
contraception.

For women who are on the following drugs

• Phenytoin
• Carbamazepine
• Barbiturates
• Primidone
• Topiramate
• Oxcarbazepine

The following is the category they fall into

• UKMEC 3: the COCP and POP

• UKMEC 2: implant
• UKMEC 1: Depo-Provera, IUD, IUS

For lamotrigine

• UKMEC 3: the COCP

• UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

NOTE: If a COCP is chosen then it should contain a minimum of 30 µg of

ethinylestradiol.

Combined contraceptive patch

Overview

• The Evra patch is the only combined contraceptive patch licensed for use in
the UK. The patch cycle does last for 4 weeks.
• For the first 3 weeks, the patch is worn every day and it needs to be changed
after each week.
• During the 4th week, the patch is not worn and during this time there will be a
withdrawal bleed.
• For delays in changing the patch, different rules apply depending on what
week of the patch cycle the woman is in.
• If the patch change is delayed at the end of week 1 or week 2:
o If the delay in changing the patch and that is less than 48 hours, it
should be changed immediately and no further precautions are
needed.
 o If the delay is more than 48 hours, then the patch should be changed
immediately and a barrier method of contraception used for the next 7
days.
o In case the woman has had sexual intercourse during this extended
patch-free interval or if unprotected sexual intercourse has occurred in
the last 5 days, then it is advised to consider emergency contraception.
• If the patch removal is delayed at the end of week 3:
o The patch should be removed as soon as possible and the new patch
applied on the usual cycle start day for the next cycle, even if
withdrawal bleeding is occurring. Note that no additional contraception
is needed.
o If patch application is delayed at the end of a patch-free week,
additional barrier contraception should be used for 7 days following any
delay at the start of a new patch cycle.

For further information please refer to the NICE Clinical Knowledge Summary on
combined hormonal methods of contraception

Injectable contraceptives
Overview

• Depo Provera is the main injectable contraceptive used in the UK.

• It contains medroxyprogesterone acetate 150mg.
• It is given via an intramuscular injection every 12 weeks.
• It can however be given up to 14 weeks after the last dose without the need
for extra precautions.
o BNF has given different advice. They say that a pregnancy test should
be done if the interval is greater than 12 weeks and 5 days - This is
however not commonly adhered to in the family planning community.
• The method of action is by inhibiting ovulation.
• Secondary effects
o Cervical mucus thickening and endometrial thinning.
• Disadvantages are the fact that the injection cannot be reversed once given.
• There is also a potential delayed return to fertility (that may be up to 12
months)

Adverse effects

• Irregular bleeding
• Weight gain
• This may potentially increase the risk of osteoporosis
o Should only be used in adolescents if no other method of contraception
is suitable
• Not quickly reversible and fertility may return after a varying time
NOTE: Noristerat, the other injectable contraceptive licensed in the UK, is rarely
used in clinical practice. It is given every 8 weeks.