Contraception

Question 1

Barrier methods

Answer 1

Barrier methods of contraceptions include:

• Condoms (male and female)
• Diaphragms and caps

These are often used with a spermicide. Barrier methods are useful for STI prevention.

Question 2

hormonal methods

Answer 2

There are many hormonal methods currently available to women wanting to use these forms of contraception. These include:

• Combined oral contraceptives (COCs)
• Progesterone oral contraceptives (POPs)
• Combined hormonal contraceptive Patches
• Combined hormonal contraceptive ring
• Levonorgestrel-releasing Intra-uterine system (IUS)
• Progestogen-only injections
• Progestogen-only subdermal implants

Injections, the IUS and implants are long acting reversible contraceptive (LARC) methods. The COC pill, patch and ring are combined hormonal methods containing both oestrogen and progesterone.

Question 3

Combined hormonal methods

Answer 3

Combined hormonal contraception methods are an effective method of fertility control and regulation of the menstrual cycle. However they are contraindicated in some women and can have both serious and less serious side effects. Examples of combined hormonal contraceptives include the combined oral contraceptive (COC) pill, the contraceptive ring and the contraceptive patch. All contain a combination of oestrogen and a progesterone in varying strengths.

There are currently several different types of COC pill available.

Combined hormonal contraceptives can interact with other medicines (including herbal).

Question 4

Progesterone only pill

Answer 4

Progesterone only pills inhibit fertility by changing cervical mucus to prevent sperm penetration, and/ or inhibit ovulation. There are different forms of progesterone used in different preparations

Question 5

Long acting reversible contraceptive (LARC) methods

Answer 5

There are four types of LARC:

Copper IUD
Levonorgestrel-releasing Intra-uterine system (IUS)
Progestogen-only injections
Progestogen-only subdermal implants

Many commissioners have upgraded their emergency contraception services to sexual health services. This means that along with the provision of emergency contraception pharmacists are required to provide advice on avoiding unwanted pregnancy and sexually transmitted infections via safer sex messages and advice on condom use, information about on-going contraception, including LARC methods, and signposting onto other services. In addition to this some community pharmacy LARC services have previously been commissioned.

In 2011 pharmacists in Newcastle-upon-Tyne were commissioned to run a LARC service from their Healthy Living Pharmacy1,2 . The service included insertion and removal of progesterone-only subdermal implants and initiation and follow-up of progesterone-injections.

Question 6

Fertility awareness methods

Answer 6

Fertility awareness methods of contraception (also known as natural family planning) track ovulation to prevent pregnancy.

Question 7

Surgical methods of contraception

Answer 7

Surgical methods of contraception or sterilisation are designed to be a permanent method of contraception. Male sterilisation is known as a vasectomy and female sterilisation as tubal occlusion.

Question 8

Emergency Contraception

Answer 8

There are currently three forms of emergency contraception:

• Levonorgestrel (Levonelle®) - emergency hormonal contraception, available on prescription, via PGD and over the counter
• Ulipristal acetate (ellaOne®) - emergency hormonal contraception available on prescription, via PGD and over the counter
• Copper-bearing Intra-uterine device (Cu-IUD) - available from specialist sexual health clinics and GPs

Question 9

Contraception advice for women with epilepsy

Answer 9

• Anti-epileptic drugs such as carbamazepine, phenytoin, and phenobarbital can reduce the efficacy of hormonal contraceptives.
• Consider long acting reversible contraceptives such as medroxyprogesterone acetate depo injection, copper intrauterine device, and levonorgestrel releasing intrauterine systems in patients on enzyme inducing anti-epileptic drugs.
• Sodium valproate is not recommended in women of childbearing age because of high teratogenicity.

Question 10

Types of spermicides

Answer 10

Gygel® vaginal cream, which contains 2% nonoxinol-9, is the only licensed spermicide available in the UK.
Nonoxinol-9 is a surfactant that disrupts sperm cell membranes

Question 11

How to use spermicides

Answer 11

Advise that:

• Spermicides should always be used in conjunction with a diaphragm or cervical cap.
• Spermicides are not recommended for use in conjunction with condoms.
• Douching is not recommended, but if desired it should be deferred for at least six hours after sexual intercourse.

Question 12

Advantages, disadvantages, and risks of spermicides

Answer 12

Advantages

• They are easy to use.
• They are easy to obtain, and can be bought from pharmacies without a prescription.

Disadvantages

• They are not as effective as other methods, so should not be used alone.
• They lose effectiveness after about 1 hour.
• Some people find them messy to use.
• They may irritate the genital mucosa.
• They do not protect against sexually transmitted infections (STIs).
• They should not be used by women at increased risk of STIs, as spermicides can increase the risk of HIV transmission.

Question 13

Advantages and disadvantages — male condom

Answer 13

Advantages Male condoms:

• Are easy to obtain and use.
• Are effective in preventing pregnancy if used correctly.
• Provide significant protection against some sexually transmitted infections (STIs), including HIV.
• May protect against cervical cancer.
• Adverse effects are rare.

Disadvantages Male condoms require:

• Forward planning and may interrupt sex.
• The participation and commitment of both partners.
• Motivation at each act of intercourse.
• Careful disposal.
• Are less effective at preventing pregnancy compared to hormonal and intrauterine methods.
• Can break or slip off.
• Loss of sensitivity during intercourse may occur.
• Men who sometimes lose their erection during sex may find it difficult to use a male condom correctly.
• Allergy to latex can occur (rare).

Question 14

Advantages and disadvantages — female condom

Answer 14

Advantages Female condoms may:
- Reduce the risk of some sexually transmitted infections, including HIV.
- Protect against cervical cancer.
- Used with oil-based lubricants because they are made of polyurethane.
- Used if either partner is allergic to latex.
Inserted up to 8 hours before sex.
- Female condoms are less likely to tear than the latex male condom.
- Some men prefer the freer sensations during the penetrative phase of intercourse.
- There are no known adverse effects.

Disadvantages Female condoms:

• Require careful insertion.
• Require motivation at each act of intercourse.
• Can be dislodged, or the penis can be inserted between the vaginal wall and the female condom.
• Can be noisy during intercourse.
• May cause discomfort during sex due to the inner ring.
• Are not as effective at preventing pregnancy as hormonal and intrauterine methods.

Question 15

Types of diaphragm and cap

Answer 15

Diaphragms

• Two types of diaphragm are available on prescription:
• Silicone-based
• Coiled spring diaphragm; type B. Sizes range from 60-90 mm in increments of 5 mm.
• Arcing spring diaphragm; type C. Sizes range from 60-90 mm in increments of 5 mm. They are useful for women with poor vaginal muscular support, or those in whom the length or position of the cervix makes fitting a coil spring diaphragm more difficult.

Cervical caps
- These are smaller than diaphragms and are a useful alternative for women who do not want to (or cannot) use a diaphragm. They are available in sizes 22, 26, and 30 mm.

Question 16

How diaphragms and cervical caps work

Answer 16

Diaphragms consist of a thin, soft dome (made of latex/rubber or silicone) with an encased flexible steel ring around its edge.
They are designed to fit between the posterior fornix of the vagina and the pubic bone. The diaphragm is held in place by the vaginal muscles, the tension of the ring, and the pubic bone.
Cervical caps fit directly over the cervix and are held in place by suction and by support from the vaginal wall.
When inserted correctly, the diaphragm and cap fit into the vagina to cover the cervix, thus excluding semen.
They are used in conjunction with a spermicide, which further reduces the likelihood of fertilization.

Question 17

Types of progestogen-only pill

Answer 17

Norgeston® (levonorgestrel 30 micrograms).

Noriday®, Micronor® (norethisterone 350 micrograms).

Cerazette®, Cerelle®, Feanolla®, Aizea® (desogestrel 75 micrograms).

A generic desogestrel 75 micrograms.

Question 18

Lactational amenorrhea method adv and disadv

Answer 18

Advantages

Lactational amenorrhoea can be effective for up to 6 months.
It encourages exclusive breastfeeding up to 6 months.
It can be used immediately after childbirth.
There is no need to do anything at the time of sexual intercourse.
There is no direct cost, as it requires no supplies or procedures.
It has no hormonal adverse effects.
Counselling for the method encourages starting a follow-on method at the proper time.
It does not involve abstinence from sexual intercourse.

Disadvantages

The lactational amenorrhoea method does not protect against sexually transmitted infections, including HIV.
It becomes unreliable after 6 months and when other foods (including infant milk formula) are introduced into the baby’s diet.
Frequent breastfeeding is inconvenient or difficult for some women.

Question 19

Advantages, disadvantages, and risks of tubal occlusion

Answer 19

Advantages

Tubal occlusion is very effective in preventing pregnancy.
It has a lifetime failure rate of about 1 in 200 women.
If a Filshie clip is used (the most common method used in the UK) the failure rate 10 years after the procedure may be lower (1 in 333-500 women).
It is permanent.
Sex need not be interrupted to use contraception.

Disadvantages

Tubal occlusion requires a surgical procedure.
People may regret having had the procedure:
The assessment process is designed to ensure that people at risk of regret are identified and fully informed about alternative long-acting reversible contraceptive methods.
It cannot easily be reversed, and the NHS does not routinely offer reversal procedures.
It does not protect against sexually transmitted infections.
It can fail, but this is uncommon.

Risks

Tubal occlusion is performed using laparoscopy (or laparotomy). The risk of a major complication with laparoscopy (injury to bowel, bladder, or blood vessels requiring laparotomy or leading to death) is about 2 per 1000 procedures. The risk of death with a laparoscopy is 1 in 12,000 procedures.
The risk of complications and need for laparotomy are increased by previous abdominal or pelvic surgery, previous pelvic inflammatory disease, and obesity.
If tubal occlusion fails, the resulting pregnancy may be ectopic.
Women should be reassured that tubal occlusion is not associated with an increased risk of heavier or irregular periods when performed after 30 years of age.
There is little information on the effect on menstruation when tubal occlusion is performed for women less than 30 years of age.
The procedure requires a general anaesthetic.

Question 20

Advantages, disadvantages and risks of vasectomy

Answer 20

Advantages

Very effective in preventing pregnancy.
Permanent.
Sex need not be interrupted to use contraception.

Disadvantages

It requires a minor surgical procedure that carries a small risk of haematoma and infection.
There is a post-operative period for vasectomy to be confirmed as effective.
Effective contraception is required until azoospermia is confirmed - 12 weeks is the optimal time to schedule a post-vasectomy semen analysis.
People may regret having had the procedure:
The assessment process is designed to ensure that people at risk for regret are identified and fully informed about alternative long-acting reversible contraceptive methods.
Vasectomy cannot easily be reversed, and the NHS does not routinely offer reversal procedures.
Vasectomy does not protect against sexually transmitted infections.
Rarely, the procedure fails after clearance has been given that there are no spermatozoa in the ejaculate.
Late failure is defined as the presence of sperm after confirmation of sterility (azoospermia or special clearance at post vasectomy semen analysis [PVSA]).
The rate of late failure due is reported to be between 0.03% and 1.2%.

Risks

There is a small risk of testicular or scrotal chronic post vasectomy pain (CPVP), which may develop months or years after the procedure.
The incidence of CPVP ranges from 1-14%.
The risk of pain adversely affecting quality of life has not been well quantified by controlled trials.
An unpublished cohort study reported that 1 in 300 men previously asymptomatic, experienced pain which was severe enough to require medical attention and/or to affect quality of life