First-time requests for contraception

Contributed by Dr Anne Szarewski, clinical consultant and honorary senior lecturer at the Cancer Research UK Centre for Epidermiology, Mathematics and Statistics, London

1. Assessment
Patients of any age can present for the first time for contraception. Most will be women between the ages of 16 and 19, but for those under 16, the Fraser guidelines must be observed.

Although the most common request is for the Pill, it is a good idea to mention the other options.

Counselling about the risk of STIs and the use of condoms is important.

History
It is important to establish if there is a history of any serious past or ongoing medical condition, any current medication, allergies, cardiovascular disease, venous thromboembolism, liver disease, migraine and smoking.

A family history of venous or arterial disease in a first-degree relative under 45 and breast cancer are especially relevant.

The sexual and menstrual history should be recorded.

Any symptoms of STIs and any history of abnormal smears (the cervical screening programme now starts at 25 years, but local policies vary) should be recorded.

Examination
BP and BMI should be recorded during examination.

There is no need for breast or vaginal examinations before prescribing contraception, unless indicated from the history of the patient. 

The Fraser guidelines
The medical professional should be satisfied that:

  • The patient will understand the professional’s advice.
  • The patient cannot be persuaded to inform their parents.
  • The patient is likely to begin, or to continue having sexual intercourse with or without contraceptives.
  • Unless the patient receives contraception, their physical or mental health, or both, are likely to suffer.
  • The patient’s best interests require them to receive contraceptive advice with or without parental consent. 

2. Hormonal contraception
Combined oral contraceptives

The easiest way to explain to patients the action of a combined oral contraceptive Pill (COC) is that it induces a state of ‘pseudo-pregnancy’.

The failure rate is 0.5–3.0 per 100 woman years, mostly due to poor compliance.

The incidence of serious health risks attributable to the COC in otherwise healthy women is very small. Hypertension, age and smoking are the biggest independent risk factors for MI and stroke, with risks multiplied up to 10 times in COC users.

Smokers over age 35 should not use the COC. Users who have migraine with focal aura have an increased risk of ischaemic stroke.

Progestogen-only Pills
Progestogen-only Pills (POPs) do not completely inhibit ovulation, but reduce sperm penetration of cervical mucus and cause endometrial atrophy.

The efficacy of POPs is more user- and age-dependent than COCs, with failure rates ranging from 0.5 to 4 per 100 woman years, and higher failure rates in young women. POPs are associated with irregular cycles, although this tends to settle with time.

Users should be advised about probable menstrual disturbance so they can understand that bleeding irregularities and amenorrhoea are not harmful.

POPs do not increase risks of cardiovascular disease or cancer.

Non-oral routes
Non-oral routes are unaffected by GI problems and are suitable for women who suffer nausea on COCs. They are also unaffected by broad-spectrum antibiotics. Avoiding first-pass metabolism in the liver means lower dosages can be given, resulting in fewer side-effects, and steadier blood levels can contribute to improved cycle control.

The Evra patch works in the same way as the COC. Compliance is improved by the non-oral route, with perfect use failure rates of around 0.7 per 100 woman years, and user failure rates of around 1.2 per 100 woman years. Contraindications are the same as for the COC.

The Evra patch is worn for a week, and unaffected by showering, bathing and swimming. Mild application site reactions occur in about 17 per cent of users, but lead to discontinuation in only 2 per cent. The main side-effect is transient breast tenderness.

Injectable preparations
Injectables are given every eight or 12 weeks. With prolonged use, most women become amenorrhoeic, and a return of fertility may be delayed by six to 12 months.

Depo-Provera may be used in adolescents first line after other methods have been considered unsuitable or unacceptable.

In women of all ages, careful re-evaluation of the risks and benefits should be carried out if treatment goes beyond two years. Women with significant lifestyle or medical risk factors for osteoporosis should consider other methods.

The Faculty of Family Planning suggest that no laboratory tests or imaging procedures are currently required routinely.

Implanon
Implanon is a low-dose systemic progestogen that does not inhibit FSH and ovulation is inhibited through prevention of the LH surge. It is a single rod implant that releases 30–40µg of etonogestrel daily and lasts for three years. It reliably inhibits ovulation and comes preloaded in a disposable inserter.

Insertion and removal are easy, and the effect is reversible within a month. Irregular bleeding can be a problem, and some 20 per cent of women become amenorrhoeic.

Mirena
Mirena is a levonorgestrel-releasing intrauterine system that releases 20µg of levonorgestrel daily and can be used for five years.

Irregular but light bleeding occurs at first and there is a significant reduction in menstrual flow.

About 75 per cent of women continue to ovulate, and only 10–15 per cent become amenorrhoeic. It does not appear to increase the risk of pelvic inflammatory disease.

3. Non-hormonals
Copper IUDs

Copper IUDs act primarily through the direct toxic effect of copper ions on sperm and ova, and decrease sperm motility. The overall failure rate is 1.2–2.0 per 100 woman years, lowest if there is more than 300mm2 of copper.

Menstrual abnormalities are common in the first three months, but usually settle with time.

The IUD does not cause pelvic infection, but is related to any pre-existing infection, so a pre-insertion sexual history and chlamydia screening are important.

The expulsion rate is 2–10 per 100 woman years, mostly in the first three months and is related to the skill of the inserter and the age, parity and uterine shape of the woman.

The ectopic rate is between one in five to one in 10 pregnancies with an IUD in situ, compared with one in 100 pregnancies in women using no contraception. Previous ectopic pregnancy is not an absolute contraindication.

For medico-legal reasons GPs should hold a Letter of Competence for intra-uterine techniques and be able to provide evidence of the quality of the service they provide.

Barrier and natural methods
Some first-time users are interested in diaphragms or cervical caps, but many are unaware that all barrier and natural methods have high failure rates between 10 and 20 per 100 woman years. Young people, in particular, may be embarrassed and inexperienced in their use. However, condoms should be encouraged as protection against STIs.

Contraception after birth
In a non-breastfeeding woman, ovulation might occur as early as 25 days after delivery, but in breastfeeding women it is almost impossible to predict.

Oestrogen-containing contraceptives should not be used in the first three weeks, even in non-breast feeding women, as there is an increased risk of venous thromboembolism post-partum. They should also be avoided by lactating women because they may reduce milk volume and have a detrimental effect on milk composition.

All progestogen-only methods are suitable, but bleeding irregularities can occur. It is generally suggested that progestogen-only methods should be started around six weeks post-partum to minimise bleeding problems, but they can be started earlier if desired.

Intrauterine devices or systems can be fitted between four and six weeks after delivery.

Contraceptive Awareness week runs from 12–18 February 2007. For more information see www.fpa.org.uk

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