Section 1 Long-acting reversible contraception
NICE and the National Collaborating Centre for Women's and Children's Health have produced a guideline1 recommending that long-acting reversible contraception (LARC) should be offered to all women as part of their contraceptive choices.
The uptake of LARC is still low in the UK - only 10 per cent of women aged 16-49 were using LARC in 2005/6, compared with 24 per cent using the oral contraceptive pill and 21 per cent using condoms.
It is estimated that about 30 per cent of pregnancies are unplanned. The effectiveness of condoms and the oral contraceptive pill depends on their correct, consistent use. By contrast, being long-acting, the effectiveness of LARC methods is less susceptible to incorrect use.
NICE guidance on LARC states that service providers should be aware that increasing the uptake of LARC will reduce numbers of unplanned pregnancies and offer cost savings to the NHS.
All LARC methods are more cost-effective than the combined oral contraceptive pill because they reduce the likelihood of unplanned pregnancy.
Intrauterine methods and implants are more cost-effective than injectable contraceptives.
Information given to women should take account of individual needs and preferences, and should include:
- contraceptive efficacy
- duration of use
- risks and possible side-effects
- non-contraceptive benefits
- procedure for initiation and removal/discontinuation
- when to seek help while using the method.
Healthcare professionals advising women about contraceptive choices should be competent to help women consider and compare the risks and benefits of methods relevant to their needs, and to manage common side-effects and problems.
Contraceptive service providers who do not provide LARC within their own practice or service should have an agreed mechanism in place for referring women for LARC.
Healthcare professionals providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills required.
The guideline refers to the diploma of the Royal College of Obstetricians and Gynaecologists (RCOG) Faculty of Family Planning and Reproductive Health Care and letters of competence in intrauterine techniques and subdermal implants.
Section 2 Levonorgestrel, etonogestrel
The Mirena (levonorgestrel-releasing) intrauterine system releases 20 microgram of levonorgestrel per day and is licensed for five years.
Its mechanism of action is mainly related to atrophy of the endometrium and the majority of women will ovulate at least occasionally after the first year.
Mirena has a failure rate of about 0.2 per 100 women-years and, unlike its progesterone-releasing predecessor, is associated with a reduced risk of ectopic pregnancy.
In addition, its use results in a major reduction in menstrual flow and dysmenorrhoea, suggesting that it is a viable alternative to hysterectomy and endometrial ablation in women with menorrhagia.
Irregular, light bleeding also occurs, particularly in the first few months of use. Only about 10-15 per cent of women become amenorrhoeic. It does not appear to increase the risk of pelvic inflammatory disease.
The device is not licensed for postcoital use and there is evidence that it is unsuitable for such cases. However, it is already proving invaluable for perimenopausal women who need contraception, because it also provides the progestogen part of HRT.
A licence for use solely in HRT was obtained in 2004. It should be noted that this is for four years, rather than five, purely because of the length of follow-up available at the time of submission to the MHRA.
It has been suggested by NICE that if the device is fitted for contraception after the age of 45, there is no need to change it until the menopause. However, if being used as endometrial protection in HRT, it should be changed after four years.
There is some preliminary evidence suggesting that it may be of use in women with small fibroids2 and in those with endometriosis.3
Implanon (etonogestrel) consists of a single, semi-rigid rod, measuring 40mm x 2mm. It releases approximately 60-70 microgram of etonogestrel (per day at week 5-6) per day and 30-40 microgram per day by the end of the second year and lasts for three years.
This hormone level achieves complete inhibition of ovulation. In the worldwide phase III clinical trials, there has not been a single pregnancy.
The implant comes preloaded in a disposable inserter, which is about the same size as a blood transfusion needle.
Insertion is simple because it does not require a skin incision.It takes, on average, two minutes to insert the device.
Removal, using a 'pop-out' technique, is facilitated by the rigidity of the capsule and takes about three minutes.
Amenorrhoea is more common in etonogestrel users than it was with Norplant (21 per cent versus 10 per cent). However, there is no evidence that hypo-estrogenicity is a problem in etonogestrel users. Etonogestrel appears to inhibit LH but not FSH, so follicles and estradiol are still produced.
The incidence of acne appears to be slightly lower than with levonorgestrel implants. However, irregular bleeding can be a problem.
Section 3 Longer-acting combined hormonal methods
The Evra patch and the Nuva-Ring are combined estrogen-progestogen preparations that avoid the GI tract and first pass effect in the liver. This allows a lower hormone dose and removes the necessity for additional precautions with broad spectrum antibiotics, although these are still necessary with enzyme-inducing drugs.
Evra, a contraceptive patch releasing 20 microgram of ethinylestradiol and 150 microgram of norelgestromin per day, was launched in the UK in 2003.
A recent observation, which necessitated a change in the product labelling in the US, revealed that users are exposed to about 60 per cent more of the estrogen component than they would be from a 35 microgram combined oral contraceptive pill.4
Each patch is left in place for a week and can be worn on the buttocks, abdomen, back, or upper arm. Showering, bathing and swimming do not appear to affect adherence.
In clinical trials, approximately 20 per cent of women experienced mild to moderate application site reactions, although only 2 per cent discontinued for this reason.
Efficacy was high, with a failure rate of only 0.7-1.2 per 100 women-years.5,6 Cycle control was good and comparable to that of 20 microgram ethinylestradiol plus 150 microgram desogestrel (about 10-15 per cent of users reported spotting or bleeding in the third cycle).
The main side-effect was transient breast tenderness in the first couple of months, experienced by 18 per cent of users.
Compliance has been shown to be better than with an oral contraceptive pill, particularly in young women.
Only 68 per cent of women under 20 took their oral contraceptive pills correctly, compared with 88 per cent of those using a patch.7 So the patch is likely to be a useful alternative for those who find it difficult to remember a daily oral contraceptive pill.
NuvaRing is a vaginal ring releasing 15 microgram of ethinylestradiol and 120 microgram of etonorgestrel a day.
The ring is flexible and transparent; it is made of ethylene vinylacetate copolymers, with an outer diameter of 54mm and a cross-sectional diameter of 4mm.
Each ring is used for three weeks, followed by a one-week ring-free interval.
NuvaRing has been available in Europe and the USA for several years and was launched in the UK in January 2009.
Like Evra, NuvaRing can be inserted and removed by the woman. It can be removed for up to three hours if desired, e.g. for sexual intercourse.
In a large multicentre trial the method failure was 0.77 per 100 women-years, and the user failure rate was 1.18 per 100 women-years.8
NuvaRing has very good cycle control (comparable to a 30 microgram ethinyl estradiol pill) considering its low dose and is well tolerated.9 Although it is supposed to be used for 21 days, it can be used for 28 days without the need for extra precautions.
Vaginal preparations such as spermicides and antifungals do not affect efficacy.
A practical consideration is the need for refrigeration: once the cold chain is broken, a NuvaRing has a shelf life of four months.
NuvaRing has proved popular in other countries, including the USA, and studies suggest that there are no obvious demographic characteristics which would predict satisfaction.
Clinicians have found that it is useful to have the woman put a ring in while actually at the clinic, to allay any fears about insertion and removal.
Section 4 IUDs, barrier methods, sterilisation
IUDs alter the migration of sperm, inhibiting fertilisation, and generate a foreign body reaction in the endometrium, preventing implantation.
The most effective IUDs contain approximately 380mm2 of copper.
The T-Safe 380A QL is licensed for 10 years (cumulative pregnancy rate 2.2 per 100 women-years). The Multiload Cu-375 has a 10-year cumulative pregnancy rate of 5.4. The Nova T380 is licensed for five years, with a cumulative pregnancy rate of 2.0.
The majority of complications associated with IUD use, such as perforation, infection, or expulsion, are related to the insertion procedure.
Screening for chlamydia should be carried out before fitting an IUD or the Mirena Intrauterine system. In women at low risk of STI, the risk of pelvic inflammatory disease is as low as 1 in 1,000.
The most common problems with copper IUDs relate to heavier, more painful periods.
According to NICE guidance, any copper IUD fitted in a patient over the age of 40 does not need to be changed until after the menopause.1
Results of several studies on the effects of the spermicide nonoxynol-9 have led to a reassessment of the policy and recommendations about spermicide-coated condoms in family planning and HIV prevention programmes.10
Nonoxynol-9 coated condoms are no longer recommended - unless there is no alternative condom available - because nonoxynol-9 does not provide additional protection against pregnancy or STIs.
It addition, it could perhaps be harmful, by causing epithelial disruption on frequent exposure, resulting in an increased risk of STI and HIV infection.
Sterilisation is viewed traditionally as the final and most effective form of contraception. However, this may no longer be the case.
The US Collaborative Review of Sterilization followed up more than 10,000 sterilised women for nearly 15 years and showed that after 10 years, the cumulative failure rates of some techniques were much higher than expected, particularly in women who had been sterilised while young (under 27 years).
However, in the UK, it should be noted that the Filshie clip was not included in this review.11
Another worrying finding was that one-third of the pregnancies were ectopic, presenting a significant risk to health.
During the past 10 years, effective reversible methods have become available and sterilisation may no longer be the most sensible, or even the most effective, option for many women.
Studies suggest that with improved counselling, at least one-third of women referred for sterilisation will choose other methods, particularly LARC.12,13
1. NICE. Long-Acting Reversible Contraception. Clinical Guideline 30. October 2005. www.nice.org.uk/nicemedia/pdf/CG030fullguideline.pdf
2. Grigorieva V, Chen-Mok M, Tarasova M, Mikhailov A. Use of a levonorgestrel-releasing intrauterine system to treat bleeding related to uterine leiomyomas. Fertil Steril 2003; 79: 1,194-8.
3. Lockhat F B, Emembolu J O, Konje J C. The evaluation of the effectiveness of an intrauterine-administered progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease. Hum Reprod 2004; 19: 179-84.
4. Weisberg E. Ortho Evra contraceptive patch. International Planned Parenthood Federation Medical Bulletin 2006; 40(1): 3-4.
5. Smallwood G H, Meador M, Lenihan J et al. Efficacy and safety of a transdermal contraceptive system. Obstet Gynecol 2001; 98: 799-805.
6. Audet M, Moreau M, Koltun W D et al. Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive. JAMA 2001; 285: 2,347-54.
7. Archer D F, Bigrigg A, Smallwood G H et al. Assessment of compliance with a weekly contraceptive patch (Ortho Evra/Evra) among North American women. Fertil Steril 2002; 77(2): S27-31.
8. Dieben T O M, Roumen F J M, Apter D. Efficacy, cycle control and user acceptability of a novel combined contraceptive vaginal ring. Hum Reprod 2002; 100 (3): 585-93.
9. Shimoni N, Westhoff C. Review of the vaginal contraceptive ring (NuvaRing) J Fam Plann Reprod Health Care 2008; 34(4): 247-50.
10. IMAP recommendations on nonoxynol-9. International Planned Parenthood Federation Medical Bulletin 2003; 37(1): 2.
11. O'Brien S, Gupta J, Najia S, Yehia M. Update on female sterilisation: report from an international symposium on considerations for assessing long-term failure rates. J Fam Plann Reprod Health Care 2008; 34(1): 13-8.
12. Mattinson A, Mansour D. Female sterilisation: is it what women really want or are alternative contraceptive methods acceptable? J Fam Plann Reprod Health Care 2006; 32(3): 167-9.
13. Smith R A, Martindale E A. Outcomes of women referred for sterilisation. J Fam Plann Reprod Health Care 2006; 32(3): 171-2.
- Szarewski A, Guillebaud J. Contraception: a user's handbook. Third edition. OUP, Oxford, 2002.
- Szarewski A. Contraceptive Dilemmas. Altman Publishing, 2006. www.altmanpublishing.com/photo_58270.html
- Guillebaud J. Contraception: Your Questions Answered. Fifth edition. Churchill Livingstone, Oxford, 2008.