Contraception — general principles

• Modern contraceptives help prevent, plan and space pregnancies
• Modern contraceptives are generally safer than being pregnant
• Some contraceptives help reduce period pain and bleeding problems
• Clinics and communities should promote effective contraception for all who need or want it
• At routine check ups and consultations
• Especially if being pregnant is risky for woman
• Consider what the woman wants from their contraception
  
• Reliable prevention of pregnancy
• Rapid return to fertility when stopped
• Easy to use
• Few side effects (problems), beneficial effects (eg improves acne), discrete, affordable
• Contraception is reversible. Sterilisation is permanent

Emergency contraceptive pill (ECP) 

• Offer ECP if woman
• Had unprotected sex in the last 4 days (96 hours)
• AND has no contraception
• OR her contraception is late or overdue

Always offer ECP straight away it is very safe

Routine contraception check is simple, be opportunistic

Include in — STI checks for women, STI checks for young people, Cervical cancer prevention and screening, Combined checks for chronic diseases, Adult Health Check

• Always do BP, BMI
• Re-check contraception risk
• Is their contraception appropriate, consider LARC
• Ask about worries, including period problems
• Check dates of contraceptive — when is it next due
• Offer ECP if woman
• Had unprotected sex in the last 4 days
• ex in the last 4 days (96 hours)
• AND has no contraception
• OR her contraception is late or overdue

How effective are contraceptives

Long-acting reversible contraception (LARC) is the most effective.

• Etonogestrel implant (ENG-implant)
• Intrauterine devices
• Copper IUD
• Levonorgestrel-releasing IUD (LNG-IUD)

• If 100 women used this method for 1 year, the percentage (%) number = how many don't get pregnant. This means that
• Using ENG-implant — only 1 out of 1000 women become pregnant each year
• Using contraceptive pills — 7 out of 100 women become pregnant each year

Be really safe — 'double-up' with contraceptive and condoms

• Using condoms properly can prevent STIs

Choosing a contraceptive method

Choosing the best contraceptive method may take time — explain that you may need to ask a lot of questions

Step 1 — talk about effectiveness

• Use Table 7.3 Comparing contraceptives
• Consider
• Risk of pregnancy occurring with a particular method compared with no contraception at all
• Risk of pregnancy itself, including woman's physical, emotional health, safety

Step 2 — talk with woman about what method is practical for her

• Has she used contraception before, was the method OK
• LARC ​are very convenient. Only need to visit clinic
• Every 3 months (12–14 weeks) for Depo-Provera
• Every 3 years for ENG-implant
• Every 5 years for LNG-IUD
• Every 5–10 years for copper IUD
• Would she mind feeling/seeing an implant in her arm
• Could she take a pill reliably (every day)

Step 3 — talk with woman about her bleeding patterns

• Many contraceptives change bleeding patterns (see individual methods)
• So can STIs (eg chlamydia), pregnancy, or abnormal cervix
• At suitable time in your consult, ask about
• Periods — timing, number days of bleeding
• Risk of STI — offer STI check — woman, young person
• Recent cervical screening

If abnormal vaginal bleeding

• Medical consult before starting contraception if woman
• Bleeds straight after sex
• Bleeds in-between her normal periods
• Has periods that aren't regular
• Has periods that are excessively heavy/painful
• See — ​Abnormal vaginal bleeding in non-pregnant women​

Step 4 — exclude pregnancy

• Can exclude pregnancy if
• No sex since last normal period
• Negative pregnancy test and no unprotected sex in last 3 weeks
• Day 1–5 of normal period
• Correct and consistent use of contraception (LARC, pills, condoms)
• Less than 21 days after birth of child
• Less than 5 days after miscarriage or abortion
• Urine pregnancy test — negative test only excludes pregnancy if more than 21 days since last unprotected sex
• If unprotected sex in last 5 days (120 hrs) 
• Offer ECP
• See — Quick Start
• If pregnant see — Unplanned pregnancy or Antenatal care

Step 5 — check woman's risk

• Always get help with working out and talking about risk
• Assessment includes
• Contraindications
• Risks associated with the contraception
• Drug interactions

• For young women 
• LARC usually first line due to high fertility and need for effective contraception
• Depo-Provera is second line due to possible impact on peak bone density
• The COC/ring may improve cycle regulation or improve acne (common in adolescence)
• POP can have higher failure rates in those younger than 25 compared to older users

Risks with contraception

Absolute risks for hormonal contraception

• Abnormal vaginal bleeding
• Past or current breast cancer
• Liver tumour

Women with absolute risks cannot use hormonal contraception — need non-hormonal method — medical consult

High risks for combined hormonal contraceptives (COC and vaginal ring)

• Contraceptives containing oestrogen (including COC and vaginal ring) increase the risk of clots compared to other methods
• Blood clots are uncommon but can cause severe problems
• Rural and remote women generally have increased risk factors for clots and hormonal contraception may add to these. The more risk factors the higher the risk with hormonal contraception
• Women with risk factors for clots still need contraception — medical consult

Risk factors for clots

• Do not use contraceptives containing oestrogen (COC, vaginal ring) if woman has risk factors for clots 

• Moderate or high cardiovascular risk or multiple CVD risk factors
• Previous stroke, heart attack, angina, AF
• Vascular disease (eg peripheral vascular disease)
• Mechanical heart valve or complicated valvular/congenital heart disease
• Cardiomyopathy with impaired heart function
• Anticoagulant use
• Diabetes and any of — poor control (HbA1c more than 84mmol/mol [9.8%]), nerve pain (neuropathy), eye damage, kidney disease, vascular disease
• Chronic kidney disease — stage 2 or worse
• High BP
• Obesity — BMI more than 30
• Migraine with aura
• Smoker aged 35 years or over
• Previous venous thromboembolism (VTE)  or family history of VTE — first degree relative under 45 years
• Thrombogenic mutation (eg Factor V Leiden)
• SLE (antiphospholipid positive)
• Over 49 years old
• Breastfeeding — less than 6 weeks after delivery (if not breastfeeding can start after 3 weeks if no risk factors for VTE)
• Organ transplant — with complications
• Immobility (eg surgery, wheelchair use)
• Current gallbladder disease (or medically treated)

Other risks with individual methods

• LARC
• Depo-Provera
• COC
• ECP
• Barrier contraception
• Permanent sterilisation

Quick Start — hormonal contraception

We used to wait until a period before starting contraception (day 1–5) — but some women got pregnant while waiting for their contraception

• If a woman has her usual period (day 1–5) — she is not pregnant and any type of contraception may be started and is immediately effective
• Some women do experience an implantation bleed 10-14 days after conception and confuse this with their usual period

• Quick Start supports starting a hormonal contraceptive method straight away. This means
• Better chance of woman starting and understanding method
• Less unplanned pregnancies
• Very early pregnancy can't always be excluded
• No known problems for foetus or pregnancy from LARC, COC, POP
• Not recommended for quick start, IUDs or COC containing cyproterone acetate due to risk of harm to the foetus
• Must do repeat urine pregnancy test in 4 weeks — high priority recall

Quick Start — only 3 steps

Step 1 — exclude pregnancy

Can be confident not pregnant if

• No sex since last normal period
• Negative pregnancy test and no unprotected sex in last 3 weeks
• Negative urine pregnancy test only excludes pregnancy if more than 21 days since last unprotected sex
• Day 1–5 of normal period
• Correct and consistent use of contraception (LARC, pills, condoms)
• Less than 21 days after birth of child
• Less than 5 days after miscarriage or abortion

Step 2 — start contraceptive method

• Always check BP, BMI when starting contraception — see Check woman’s risk
• If pregnancy can be excluded, contraception can be started immediately
• Explain that hormonal methods take 7 days to work so use condoms or avoid sex during this time
• If pregnancy cannot be excluded offer contraception today and explain that 
• The pregnancy test today is negative but very early pregnancy is possible 
• No known adverse outcomes on foetus or pregnancy from hormonal contraceptives 
• Hormonal methods take 7 days to work so use condoms or avoid sex during this time
• If first choice method not available on the day — consider other effective contraceptive methods for short-term cover — Table 7.3

Step 3 — follow-up

• Must do repeat urine pregnancy test in 4 weeks — high priority medical follow up
• If woman pregnant at follow-up
  
• Stop contraception — medical consult 
• See Unplanned pregnancy 
• Repeat BP, BMI 

Stopping contraception

Ask why they stopped or want to stop

• If woman wants another type of contraception — Table 7.3
• If woman declining contraception or not using current method properly — tell her that risk of pregnancy is high
• ​Fertility returns very quickly when stopping modern contraception — except for Depo-Provera
• Offer pre-pregnancy counselling
• Advise woman to consider continuing contraception until after pre-pregnancy counselling is complete