Contraception Advice/Request
Definition & DDx
Hormonal Contraception Emergency Hormonal Contraception
- Combined - Ulipristal (EllaOne)
o Pill e.g., Rigevidon, - Levonorgestrel (Levonelle)
Microgynon
o Patch e.g., Evra Non-hormonal Contraception
o Ring e.g., Nuvaring - Copper IUD (Can be emergency)
- Progestogen only - Barrier methods e.g., M/F condom,
o Pill e.g., Desogestrel, diaphragm/cervical cap
Cerelle, Cerazette - Surgical methods, e.g., tubal
o Subdermal implant e.g., ligation, vasectomy
Nexplanon - Lactational amenorrhoea
o Injection e.g., Depo - Fertility awareness methods
o Intrauterine system e.g.,
Mirena, Levosert
Combined Contraception
Anatomy & Risks
Combined Hormonal Contraception (CHC)
- Contains both oestrogen and progestogen
- Thickens cervical mucous to obstruct sperm entry
- Thins lining of endometrium / inhibits ovulation
- Most common = every-day pills
o 21 hormone pills, 7 hormone free pills
o Can do ‘tricycling’ with 9 weeks hormones and 7-day hormone free interval
o OR, continuous without HFI / used until bleeding occurs, then 4-day HFI
- Other types = each pill same hormone dose (monophasic); phasic (pills with different
amounts, must be taken in same order)
Contraindications of CHC
UKMEC4 (Absolute CI) UKMEC2 (Adv. outweigh disadv.) - CVD
- Known/suspected pregnancy - Initiating after Hx MI/stroke
- ≥35yo smoking ≥15/day - ≤3wks postpartum + VTE risk
- Obesity factors
- Breastfeeding ≤6wks postpartum - Cardiomyopathy/AF
- FHx VTE ≤45yo - BMI 30-34
- Breast cancer/hx recent cancer - BP ≥160sys/≥100dias
- BRCA genes - Vascular disease
UKMEC3 (Disadv. outweigh the adv.) - IHD
- Breastfeeding >6wks postpartum - Hx cerebrovascular accident/TIA
- Hx VTE/Heart disease/stroke - Hx VTE
- BMI ≥35 - Complex valve disease
- Migraines with aura - Antiphospholipid antibodies/
- Liver/gallbladder disease thrombogenic mutations
UKMEC1 = no limit on that choice of - Surgery with prolonged
contraception immobilisation
,Treatment/Management & Side effects
When to start combined: Missed pill during:
- 1st day natural period = pregnancy - Wk1: use emergency if UPSI
protection immediately - Wk2: no emergency
- Any other day = need to use other - Wk3: Take last pill missed, finish
precautions for 7 days current pack, skip pill-free period
- Postpartum = can start 21 days Side effects of combined:
after birth if not breastfeeding - Breast tenderness and
If vomiting within 3hrs taking = take enlargement
another one - Headaches
- May be breakthrough bleed similar - Mood and libido changes
to period during HFI - N&V
o Absence of this doesn’t - Irregular menstrual
indicate pregnancy bleeding/spotting/amenorrhoea
Pt with gastric sleeve/bypass/duodenal - Ovarian cysts
switch cannot have oral contraception - VTE
Copper IUD
- Recommended for women ≥40 – Unexpected bleeding/pain:
can stay in place until menopause - Displacement/expulsion of IUD
(~10yrs) - Uterine perforation
- Not recommended ≤28days - PID
postpartum - Pregnancy (including ectopic)
- Follow up 3-4wks after insertion
o Confirm no pregnancy Contraindications
o Discuss future - Postpartum/post-abortion sepsis
contraception - Cervical/endometrial cancer
o Establish if IUD for long - Chlamydia/gonorrhoea/cervicitis
term - PID/pelvic TB
- Regularly check position of device - Unexplained vaginal bleeding
- Can experience spotting/period-
like pains after insertion
Progesterone Only
- Reduced FSH to prevent follicular development in ovaries
- Inhibits LH surge
- Thickens cervical mucous
- Thins endometrium lining
Contraceptive Implant
- Works for 3yrs – most effective form
- No daily medication regimen (takes 7 days to work if not inserted on day 1)
- Periods can stop/become irregular/last longer – COCP given to manage these
- Acne may occur/worsen
- LA should be used to fit the device
- Can be tenderness, bruising and swelling at site of insertion
- CI: IHD; breast cancer; CVD; liver cirrhosis/cancer; unexplained vaginal bleeding
, IUS
- Works for 5yrs Can be used by smokers/
- Periods become lighter breastfeeding/etc.
- SE: irregular bleeding/spotting in
first 6mths Injection/Depo
- Small infection risk during first - Given every 13wks
20days - Can be associated weight gain
- If pt ≥40 – can stay in place until - Only contraceptive where it may
menopause take time to regain fertility (6-
- Useful for women with 12mths)
heavy/painful periods
SE: Postpartum
- Breast tenderness/enlargement - Contraception not required first
- Headache 3wks postpartum
- Changes to mood/libido - IUD/IUS can be inserted
- N&V immediately after delivery up to
- Irregular menstrual bleeding, 48hrs
spotting, amenorrhoea o If >48hrs, then need to wait
- Ovarian cysts 28 days
- Progestogen only = any time
Epilepsy: recommended IUD/IUS/depo
Emergency Contraception
Copper IUD
- Gold standard
- Up to 120hrs UPSI/within 120hrs earliest expected date of ovulation
- Anti-implantation effect if fertilisation occurs
Ulipristal
- Suppressing LH surge
- Delays ovulation for ≥5 days (until sperm from UPSI no longer viable)
- Can be used within 120hrs of UPSI
- Wait 5 days before starting ongoing hormonal contraception
- Only used once per cycle
- CI: severe asthma on oral steroids; severe liver disease
- Avoid breast feeding ≥1wk after taking
- SE: headache, nausea, dysmenorrhoea
- Repeat dose if vomiting within 3hrs taking
Levonorgestrel
- Within 72hrs UPSI
- Delays ovulation for ≥5 days (until sperm from UPSI no longer viable)
- Thickens cervical mucous
- Ineffective after LH surge
- Can take more than once in same cycle
- Can ‘kick start’ hormonal contraception
- Can be less effective in BMI≥26/≥70kg
o Unlicensed ‘double dose’ may be used
Definition & DDx
Hormonal Contraception Emergency Hormonal Contraception
- Combined - Ulipristal (EllaOne)
o Pill e.g., Rigevidon, - Levonorgestrel (Levonelle)
Microgynon
o Patch e.g., Evra Non-hormonal Contraception
o Ring e.g., Nuvaring - Copper IUD (Can be emergency)
- Progestogen only - Barrier methods e.g., M/F condom,
o Pill e.g., Desogestrel, diaphragm/cervical cap
Cerelle, Cerazette - Surgical methods, e.g., tubal
o Subdermal implant e.g., ligation, vasectomy
Nexplanon - Lactational amenorrhoea
o Injection e.g., Depo - Fertility awareness methods
o Intrauterine system e.g.,
Mirena, Levosert
Combined Contraception
Anatomy & Risks
Combined Hormonal Contraception (CHC)
- Contains both oestrogen and progestogen
- Thickens cervical mucous to obstruct sperm entry
- Thins lining of endometrium / inhibits ovulation
- Most common = every-day pills
o 21 hormone pills, 7 hormone free pills
o Can do ‘tricycling’ with 9 weeks hormones and 7-day hormone free interval
o OR, continuous without HFI / used until bleeding occurs, then 4-day HFI
- Other types = each pill same hormone dose (monophasic); phasic (pills with different
amounts, must be taken in same order)
Contraindications of CHC
UKMEC4 (Absolute CI) UKMEC2 (Adv. outweigh disadv.) - CVD
- Known/suspected pregnancy - Initiating after Hx MI/stroke
- ≥35yo smoking ≥15/day - ≤3wks postpartum + VTE risk
- Obesity factors
- Breastfeeding ≤6wks postpartum - Cardiomyopathy/AF
- FHx VTE ≤45yo - BMI 30-34
- Breast cancer/hx recent cancer - BP ≥160sys/≥100dias
- BRCA genes - Vascular disease
UKMEC3 (Disadv. outweigh the adv.) - IHD
- Breastfeeding >6wks postpartum - Hx cerebrovascular accident/TIA
- Hx VTE/Heart disease/stroke - Hx VTE
- BMI ≥35 - Complex valve disease
- Migraines with aura - Antiphospholipid antibodies/
- Liver/gallbladder disease thrombogenic mutations
UKMEC1 = no limit on that choice of - Surgery with prolonged
contraception immobilisation
,Treatment/Management & Side effects
When to start combined: Missed pill during:
- 1st day natural period = pregnancy - Wk1: use emergency if UPSI
protection immediately - Wk2: no emergency
- Any other day = need to use other - Wk3: Take last pill missed, finish
precautions for 7 days current pack, skip pill-free period
- Postpartum = can start 21 days Side effects of combined:
after birth if not breastfeeding - Breast tenderness and
If vomiting within 3hrs taking = take enlargement
another one - Headaches
- May be breakthrough bleed similar - Mood and libido changes
to period during HFI - N&V
o Absence of this doesn’t - Irregular menstrual
indicate pregnancy bleeding/spotting/amenorrhoea
Pt with gastric sleeve/bypass/duodenal - Ovarian cysts
switch cannot have oral contraception - VTE
Copper IUD
- Recommended for women ≥40 – Unexpected bleeding/pain:
can stay in place until menopause - Displacement/expulsion of IUD
(~10yrs) - Uterine perforation
- Not recommended ≤28days - PID
postpartum - Pregnancy (including ectopic)
- Follow up 3-4wks after insertion
o Confirm no pregnancy Contraindications
o Discuss future - Postpartum/post-abortion sepsis
contraception - Cervical/endometrial cancer
o Establish if IUD for long - Chlamydia/gonorrhoea/cervicitis
term - PID/pelvic TB
- Regularly check position of device - Unexplained vaginal bleeding
- Can experience spotting/period-
like pains after insertion
Progesterone Only
- Reduced FSH to prevent follicular development in ovaries
- Inhibits LH surge
- Thickens cervical mucous
- Thins endometrium lining
Contraceptive Implant
- Works for 3yrs – most effective form
- No daily medication regimen (takes 7 days to work if not inserted on day 1)
- Periods can stop/become irregular/last longer – COCP given to manage these
- Acne may occur/worsen
- LA should be used to fit the device
- Can be tenderness, bruising and swelling at site of insertion
- CI: IHD; breast cancer; CVD; liver cirrhosis/cancer; unexplained vaginal bleeding
, IUS
- Works for 5yrs Can be used by smokers/
- Periods become lighter breastfeeding/etc.
- SE: irregular bleeding/spotting in
first 6mths Injection/Depo
- Small infection risk during first - Given every 13wks
20days - Can be associated weight gain
- If pt ≥40 – can stay in place until - Only contraceptive where it may
menopause take time to regain fertility (6-
- Useful for women with 12mths)
heavy/painful periods
SE: Postpartum
- Breast tenderness/enlargement - Contraception not required first
- Headache 3wks postpartum
- Changes to mood/libido - IUD/IUS can be inserted
- N&V immediately after delivery up to
- Irregular menstrual bleeding, 48hrs
spotting, amenorrhoea o If >48hrs, then need to wait
- Ovarian cysts 28 days
- Progestogen only = any time
Epilepsy: recommended IUD/IUS/depo
Emergency Contraception
Copper IUD
- Gold standard
- Up to 120hrs UPSI/within 120hrs earliest expected date of ovulation
- Anti-implantation effect if fertilisation occurs
Ulipristal
- Suppressing LH surge
- Delays ovulation for ≥5 days (until sperm from UPSI no longer viable)
- Can be used within 120hrs of UPSI
- Wait 5 days before starting ongoing hormonal contraception
- Only used once per cycle
- CI: severe asthma on oral steroids; severe liver disease
- Avoid breast feeding ≥1wk after taking
- SE: headache, nausea, dysmenorrhoea
- Repeat dose if vomiting within 3hrs taking
Levonorgestrel
- Within 72hrs UPSI
- Delays ovulation for ≥5 days (until sperm from UPSI no longer viable)
- Thickens cervical mucous
- Ineffective after LH surge
- Can take more than once in same cycle
- Can ‘kick start’ hormonal contraception
- Can be less effective in BMI≥26/≥70kg
o Unlicensed ‘double dose’ may be used
