Contraception and family planning
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Contraception and family planning
Table of content
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Introduction
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Methods of contraception
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Failure rate
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Natural family planning
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Barrier methods
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Combined hormonal method
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Progestogen-only oral contraception
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Injectable contraception
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Subdermal implants
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Intrauterine methods
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Long acting reversible contraception
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Postpartum contraception
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Contraception and breastfeeding
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References
Introduction
UK Medical Eligibility Criteria is a definitive reference guide concerning all methods of contraception, indicating which women can safely use which of the following methods:
Methods of contraception
- Natural family planning
- barrier methods
- combined hormonal methods
- progestogen-only oral contraception
- injectable contraception
- subdermal implants
- Intrauterine methods.
Failure rate
| Method | Failure rate (% pregnant at first year) | Failure rate (% pregnant at first year) |
| Perfect use | Typical use | |
| No method | 85 | 85 |
| Barrier (male) | 2 | 15 |
| Diaphragm | 6 | 16 |
| Combined oral contraceptive
Progestogen-only contraception |
0.3 | 8 |
| Progestogen-only injectable | 0.3 | 3 |
| Progestogen-only implant | 0.05 | 0.05 |
| Intrauterine device | 0.6 | 0.8 |
| Intrauterine system | 0.1 | 0.1 |
| Female sterilisation | 0.5 | 0.5 |
| Male sterilisation | 0.1 | 0.15 |
Natural family planning
- Involves avoidance of sexual intercourse during the fertile phase of menstrual cycle
- It includes
- the calendar method (rhythm method)
- Basal body temperature method
- Billings method (ovulatory mucus)
- Cervical palpation method.
- Lactational amenorrhea method –only possible after child birth
Mode of action
- The calendar (rhythm method) is based solely on the length of the menstrual cycle and the lifespan of sperm in the female genital tract (5 to 7 days). For women with a regular cycle length, ovulation date is calculated as 14 days prior to the onset of expected menstruation and intercourse avoided around this time.
- Other methods are based on biological indicators of ovulation and therefore more accurate
- Mobile phone apps e.g. Natural cycle O and fertility tracking devices e.g. PersonaO’ are also being used
Effectiveness
- The methods can be combined to increase effectiveness.
Advantages
- May be the only option for couples with certain religious or cultural beliefs
- Not medical, with no need for visits to clinics
- Makes women aware of their ovulation cycle and natural fertility
- Enhances communication and cooperation within a relationship.
Disadvantages
- Removes spontaneity. Intercourse needs to be restricted to occur on ‘safe days’ only
- There is variation in length of the follicular phase of the menstrual cycle which can introduce inaccuracies in ovulation prediction
- The reliability of fertility awareness methods is likely to be reduced during breastfeeding, when discontinuing hormonal methods or during the perimenopause.
Barrier method
Types
- Male condom
- Female condom (femidom)
- Diaphragm/cervical cap/sponge and spermicides.
Mode of action
- Inhibits fertilisation by preventing sperm reaching the female upper genital tract.
Effectiveness
- Depends on the quality and consistency of use. Failure rates range from four to 20 per 100 woman-years.
Indications
- Client choice
- Medical reasons to exclude hormonal methods
- Intermittent, infrequent or predictable intercourse
- Barriers are also indicated while a new method is taking effect
- As additional protection against STIs
- At times of relatively low fertility, such as the perimenopause.
Contraindications
- Latex allergy (latex-free condoms are available and the female condom is made of polyurethane)
- Recurrent urinary tract infections, uterine prolapse and an aversion to touching the genitals are all contraindications to diaphragm/cap use.
Advantages
- Male condoms are cheap and widely available, avoiding the need to visit a health professional
- Male and female condoms also offer protection against sexually transmitted infections – diaphragms and caps do not
- No systemic side effects
- No effect on lactation
- Spermicides provide lubrication
- Decreased risk of malignant and premalignant cervical disease through reduced HPV exposure.
Disadvantages
- Completely user-dependent so high rates of failure with ‘typical use’
- Negotiating condom use may be problematic or impossible in some relationships
- Barriers can be messy, especially when spermicide is needed
- Diaphragms need fitting at a clinic and the woman needs to learn to fit them herself
- The size of diaphragm needs to be changed when there is a weight change of ± 4 kg or following childbirth.
Combined contraceptives (Estrogen and progestogen)
Types
- Pills – monophasic and bi-/tri-phasic
- Transdermal patch
- Vaginal ring
Mode of action
- Inhibit ovulation
- Alters cervical mucus to reduce sperm penetration
- Alters the endometrium, making it atrophic and unreceptive to implantation.
Effectiveness
- The failure rate of combined hormonal contraceptives is 0.2–8 pregnancies per 100 woman-years, depending on reliability of use.
Indications
- Combined hormonal contraceptives can provide reliable protection against pregnancy if consistently taken. They are generally administered on a 21:7 day basis, although continuous pill-taking regimes are becoming increasingly common and have been shown to be safe. The method is independent of intercourse. The combined oral contraceptive pill (COCP) is often used in the treatment of gynaecological conditions such as dysmenorrhoea and heavy menstrual bleeding.
Contraindications
The absolute and relative contraindications are given in the table. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2016 (link is external), published by the Faculty of Family Planning and Reproductive Health Care is a very comprehensive list of medical eligibility for all methods of contraception.
www.fsrh.org/documents/ukmec2016/fsrh-ukmec-full-book-2017.pdf
Advantages
- Reliable
- Reversible
- Independent of intercourse
- Benefit on menstrual and premenstrual symptoms
- Decreased risk of benign conditions in current users (e.g. benign breast disease, ovarian cysts, and endometriosis) and long-term reduction in carcinoma of the endometrium, ovary and bowel
- Allows manipulation of the time of menstruation e.g. bi or tricycling packs.
Disadvantages
- User-dependent – missed pills (> 24 hours late) can reduce efficacy of the method
- Minor hormonal side effects, e.g. nausea, fluid retention, weight gain, breast tenderness
- Increased risk of venous thromboembolism, secondary to the estrogen-induced effect on clotting factors
- Increased risk of arterial disease (in the presence of other risk factors)
- Interactions with some drugs causes reduction of efficacy
- Concomitant illness e.g. vomiting and diarrhoea can affect absorption and reduce efficacy.
Combined hormonal contraceptive pill contraindications
| Absolute contraindications to COCP use | Relative contraindications to COCP use |
| Ø Past or present cardiovascular disease | |
| Ø History of VTE or current VTE on anticoagulants
Ø Thrombogenic mutations
Ø Familial hypercholesterolaemia Ø Insulin-dependent diabetes with complications (e.g. retinopathy) Ø BP consistently >160/95 mmHg Ø Smokers >35 years Ø BMI ≥40 Ø Focal migraine with aura
Ø Stroke
Ø Major surgery with prolonged immobilisation |
Ø Family history (first-degree relative) of VTE aged under 45 years
Ø Systolic BP: 140–159 mmHg; diastolic BP: 90–94 mmHg Ø BMI 30–35 Ø Focal migraine with aura >5 years ago |
| Active liver disease
Porphyria |
|
| Medical condition affected by sex steroids e.g. chorea, pemphigoid gestationis | |
| Pregnancy | Some malabsorption conditions |
| Undiagnosed genital tract bleeding | Conditions requiring drug that may interact with COCP (some anti-retrovirals, some anticonvulsants, some anti-tubercular agents) |
| Estrogen-dependent tumours e.g. breast cancer |
Progestogen only contraception
Types
- Progestogen-only pill (POP)
- Injectables (DMPA – Intramuscular or subcutaneous)
- Subdermal implants (SDI)-e.g. nextplanon
- Intrauterine systems (IUS). E.g. Mirena, Levosert, Jaydess, Kyleena
Mode of action
- Alteration of the cervical mucus, making it thicker and less penetrable to sperm.
- DMPA also suppresses ovulation.
- The newer desogestrel-based pill Cerazette® prevents ovulation in 97% of cycles.
- The main effect of all intrauterine systems is through the progestogenic effect of endometrial thinning and prevention of implantation.
Effectiveness
- Older first-generation progestogen-only pills do not prevent ovulation and have to be taken within 3 hours of the same time every day.
- The newer desogestrel-only pill (Cerazette® or Cerelle®) is anovulant with superior efficacy and a longer window for administration (12 hours).
Failure rates per 100 women-years
- POP: 0.3 (ideal use)
- DMPA: 0.3 (ideal use)
- IUS: 0.2
- Implant: 0.05 (most effective method available
Indications
- Long-acting reversible contraception (LARC; such as implant, IUS or injectable) should be discussed with all women in view of their superior efficacy over user-dependent methods
- Women with unacceptable side effects from estrogen or contraindications to its use e.g. smokers over the age of 35, migraine with aura sufferers
- DMPA can be used short term to give reliable protection from pregnancy while awaiting interval sterilisation or a vasectomy to be effective
- Safe during lactation
- DMPA and IUS have high rates of amenorrhoea and are regularly used in the management of gynaecological conditions such as heavy menstrual bleeding, dysmenorrhoea and endometriosis.
Contraindications
- Sensitivity or side effects to progestogens
- Pregnancy
- Undiagnosed vaginal bleeding
- Breast cancer.
Advantages
- Long-acting reversible contraception methods are significantly more reliable than user-dependent methods
- DMPA and IUS reduce risk of endometrial cancer
- Lighter, shorter, less painful periods (and amenorrhoea) are achieved with some progestogen-only methods (IUS and injectables).
Disadvantages
- Irregular bleeding and changes in the bleeding pattern are the major side-effects of these methods
- There can be a delayed return of fertility after discontinuing DMPA – up to 12 months
- DMPA use is linked to weight gain
- DMPA is associated with a small reversible reduction in bone mineral density as a result of hypoestrogenism with long-term treatment – caution should be used with long-term use in those with additional risk factors for osteoporosis and at the extremes of reproductive age before attainment of peak bone mineral density, and during perimenopausal decline
- Implants and IUS need to be inserted and removed by a healthcare practitioner, with the associated procedural risks.
Long acting reversible contraception
Types
Copper intrauterine device
Progestogen only intrauterine systems
Progestogen only injectable contraceptives
Progestogen only subdermal implant
- They also provide superior cost-effectiveness due to their low failure rate and long-term continuation.
- Check guideline for the use of long acting contraception. https://www.nice.org.uk/guidance/cg30
Postpartum Contraception
- Ovulation can resume as early as 3-4 weeks after childbirth in non-breastfeeding women.
- 50% of couples will resume sexual activity by six weeks postpartum.
- Rapid repeat pregnancy is associated with an increase in a number of obstetric and neonatal complications including preterm birth, fetal growth restriction, stillbirth and increased neonatal mortality.
- World Health Organisation recommends an inter-pregnancy interval of at least 12 months
- Where contraception is initiated within the first 3 weeks postpartum the method will be immediately effective.
- If the method is commenced after this, additional precautions e.g. condoms, abstinence should be used until the method becomes effective (7 days for LNG-IUS/DMPA/IMP; 2 days for POP)
Overview of methods in the postpartum period
- Cu -copper intrauterine device;
- LNG-LUS – levonorgestrel intrauterine system;
- IMP – progestogen-only implant;
- DMPA – progestogen-only injectable;
- POP – progestogen-only pill;
- CHC – combined hormonal contraception.
- No restriction for use of method
- Advantages of using generally outweighs risk
- Risks generally outweigh advantages of using; provision requires expert judgment or referral
- Unacceptable health risk if used
Postpartum intrauterine contraception
| Insertion Method | Timing |
| Immediate postpartum | Within 48 hours of childbirth |
| Post-placental | Within 10 minutes of placental delivery |
| Interval postpartum | Beyond first 48 hours after childbirth (usually 4-6 weeks |
Exclusion criteria
| Pregnancy Specific exclusions | General contraindications to IUD |
| Signs of intrapartum/postpartum sepsis | Active tubal infection/PID |
| Prolonged rupture of membranes | Unexplained abnormal vaginal bleeding |
| Unresolved post-partum haemorrhage | Abnormal uterine anatomy |
- At caesarean section, the device is placed manually at the fundus either manually or using an instrument.
- The threads are left long and directed towards the internal cervical os, although not directly pushed through the cervical canal as this may cause injury or increase the risk of infection.
- Following insertion, the threads will remain in the cervical canal or appear in the vagina during uterine involution or resumption of menses.
- At this stage, the woman may need to attend to have the threads trimmed.
- There is an observed increase in the expulsion rate following vaginal Postpartum intrauterine contraception insertion compared to delayed insertion (approximately 1 in 7 compared to 1 in 20). This is reduced with high fundal placement of the device and increasing inserter experience.
Hormonal method
Progestogen only methods
- Progestogen-based methods can be initiated immediately postpartum including the pill, injectable and implant.
- The duration of use, side effects and cautions for use remain unchanged.
- Women can be reassured that they are no more likely to experience irregular bleeding if these methods are started immediately after childbirth
- All methods are safe for use while breastfeeding.
Combined hormonal contraception
- Immediate postpartum initiation is not recommended due to increased risk of Pulmonary embolism and Deep Vein Thrombosis
- Coagulation factors mostly normalise by three weeks postpartum, therefore CHC can be initiated at this time in otherwise low-risk non-breastfeeding women.
- Wait for 6 weeks postpartum if there is risk of pulmonary embolism or deep vein thrombosis e.g. smoking, preeclampsia, BMI>30, immobility, caesarean delivery, postpartum haemorrhage, transfusion, some medical disorders in pregnancy
Non-hormonal methods
Sterilisation
- Provides a permanent option for couples who have completed their family.
- There is an increased risk of regret when the procedure is performed in close proximity to pregnancy.
- Women considering sterilisation during planned caesarean section should be counselled at least two weeks in advance of the procedure.
- Discussion should include information about risks, failure rate and available alternatives.
- Tubal occlusion using Filshie clips and salpingectomy are suitable options for intra-caesarean sterilisation.
- Salpingectomy offers a slightly lower failure rate, but operating time and blood loss may be higher.
- Female sterilisation is rarely performed immediately after a vaginal birth, therefore an interim contraceptive method should be advised for women considering this option in the longer term.
Barrier methods
- Condoms can be initiated any time postpartum.
- Women should delay use of female barrier methods such as the diaphragm and cervical cap until at least six weeks after childbirth (when uterine involution is complete).
- If used prior to pregnancy, a reassessment for size of the device required should be arranged prior to recommencing.
Fertility Awareness Methods (FAM)
- These methods rely on physiological indicators of ovulation (e.g. menstrual pattern, basal temperature, cervical mucus) to identify fertile times of the cycle.
- Mobile applications e.g. Natural Cyclesâ are also available to support users in identifying their fertile days following a period of individual calibration. Many of these indicators are unreliable during the postpartum period therefore use of this method for contraception should be delayed until regular menstruation resumes.
Contraception and breastfeeding
- Breastfeeding may be contraceptive if the criteria for the Lactational Amenorrhoea Method (LAM) are met:
- Exclusive breastfeeding,
- Amenorrhoea
- Within six months postpartum.
- Exclusive breastfeeding should include regular feeds throughout the day and night, with the avoidance of pacifiers and top-ups.
- High levels of prolactin inhibit oestrogen secretion and ovulation at the level of the hypothalamic-pituitary axis and LAM is 98% effective if all criteria are met.
- Efficacy may be reduced if breastfeeding frequency declines or bleeding resumes.
- Transition to another method should be ensured by six months if other contraception has not been used alongside.
- All progestogen-only contraceptives are safe for use by breastfeeding women as there is no evidence to suggest a detrimental effect on milk production or infant outcomes.
- Combined-hormonal contraceptives should be avoided in breastfeeding women for the first six weeks postpartum due to theoretical concerns on breastfeeding at this time.
- Both oral methods of emergency contraception (levonorgestrel, ulipristal acetate) are safe for use in the postpartum period.
- Breastfeeding women should be advised to discontinue and express milk for one week following administration of ulipristal acetate, due to a lack of safety data on its presence and effect in breast milk