This article, written by a senior medical expert, offers advice to people who are trying to decide what form of contraception may be best for them and introduces new products both for ongoing protection and emergency contraception.
- What should I expect from a contraceptive consultation?
- Two more recent contraceptive products
- Different ways of using the combined oral contraceptive
- Further information
There are many methods of contraception. The ideal contraceptive which is 100% effective, 100% safe and 100% acceptable, however, does not exist. Many factors influence contraceptive choice but all methods need to be used correctly and consistently to be effective. This is of course, directly related to the acceptability of the method of contraception to the user. Obtaining expert advice and individual tailored care enables you to find the method that suits you best.
In this article I will explain what you should expect from a comprehensive consultation on contraception, give a brief overview of two valuable newer methods, and explore important recent information on different ways of using the Combined Oral Contraceptive (COC) pill.
It is important that you feel at ease throughout any discussion about contraception. A detailed clinical history is needed so that all medical factors that influence contraceptive choice can be brought to light. This includes contraceptive, gynaecological, medical, sexual, and family history, as well as a review of lifestyle factors such as smoking. Whilst height, weight (and therefore BMI) and blood pressure measurements are needed, further examination is not always necessary although this is a good opportunity for a breast assessment and cervical smear to take place.
Having listened carefully to all that you have said it is likely that together with the doctor you will have identified the methods that could suit you. For each of these your doctor should explain to you how each method works, how to use it, what benefits there are (some additionally help with gynaecological problems) and any possible side effects. Where possible you should be able to see examples of the method (e.g. a subdermal implant), and as always, there should be the opportunity to ask questions. The male condom is the only method to be shown to offer a degree of protection against sexually transmitted infection and it is now commonplace to use this and another method of contraception together.
Often it is possible to decide on a method there and then, however, there is a lot to consider and if you want more time to reflect and to return on a later date this is very reasonable. If you have chosen a method, then before you leave your consultation you should be told when your follow-up appointment will be required, this is usually three months later.
Research into contraceptive methods continues at a fast pace and of the more recent arrivals I would like to highlight two in particular. In the UK the NuvaRing® is now available. This is a flexible transparent ring that is 4mm thick and 54mm in diameter containing oestrogen and progesterone. It is inserted into the vagina for three weeks and then a new ring is inserted after a seven day “ring free” break. It remains in place during sex and is rarely felt by either partner. The effectiveness is comparable to the combined oral contraceptive pill (COC). As the hormones are not taken by mouth, the method is not affected by gastrointestinal problems and the overall exposure to oestrogen is about half of that from the COC (1). It is easy to use and has a low incidence of side-effects, especially breakthrough bleeding, and is very popular in other countries. The rings should be stored at room temperature and used within four months.
The ellaOne® is an additional product for emergency contraception (2). It is licensed within the EU to be used up to 120 hours after unprotected sex and it may be more effective at 24 and 72 hours than progesterone-only emergency contraception. Currently progesterone-only emergency contraception is licensed for use for only up to 72 hours. Insertion of a copper intrauterine device within 120 hours is perhaps most effective, but this is more invasive and therefore ellaOne® provides a licenced oral alternative.
Along with new contraceptive methods, further research continues into well-established methods. For the COC, new national guidance has been published for “missed pills”, starting regimens and extended taking. In May 2011 the Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Healthcare (FSRH) produced new guidance for missed pills (3). This harmonised advice has provided much greater clarity and the “rules” are now the same for the majority of COCs.
The rules for starting different contraceptive methods have been reviewed (4), particularly with reference to starting in conjunction with emergency contraception. Not all methods (e.g. progesterone–only injectable) are best suited to this “quick start”, in which case another option, usually the COC or progesterone-only pill (POP), are used as a “bridging method” until such time as the preferred choice can be started. These provide much more flexibility in getting effective contraception on board in a timely way. “Quick starting “and use of “bridging methods” can be complex, and again expert advice is very valuable here.
A review of “tailor made” extended COC pill taking instructions has led to the production of more national guidance for most COCs (5). This has the advantage of postponing withdrawal bleeds and in some cases reduces the number of bleeds to four times a year. Not surprisingly these new regulations are popular but unfortunately are not suitable for all women, or COCs.
There are a multitude of available information sources on contraception and I think the following are very helpful:
- Faculty of Sexual & Reproductive Healthcare
- FPA - the sexual health charity
- Brook - help and advice for under 25s
- Combined Vaginal Ring (NuvaRing®). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit at www.fsrh.org
- Ulipristal Acetate (ellaOne®). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit at www.fsrh.org
- Missed Pill Recommendations. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit at www.fsrh.org
- Quick Starting Contraception. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit at www.fsrh.org
- Combined Hormonal Contraception. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit at www.fsrh.org