Contraception: an update

Contraception: an update

There is a wide range of issues to consider when a woman requests contraception. These should include a discussion to find out if she has preferred method of contraception, her future plans for having children, whether she has any underlying health issues, what current medications (including contraception) she might be taking, and any contraindications to contraception.1,2

Once these have been established, general practice nurses should provide information on all contraceptive methods, to help her make an informed choice.

The information should be presented using language and formats that can be easily understood and accessed by the woman, and should at least include information about the efficacy of the methods and how they work, common adverse effects and any potential drug interactions.^1,2

GPNs should also anticipate questions and provide information on return to fertility, including timescales after discontinuing the methods.

Addition information on contraception is also available from the NHS Website (www.nhs.uk) and Sexwise, a website produced by the FPA (Family Planning Association) for the National Health Promotion Programme for Sexual Health and Reproductive Health (www.sexwise.org.uk).

ASSESSMENT FOR CONTRACEPTION

Once this information has been provided a fuller assessment should be undertaken.

Initially it is clearly important to exclude the possibility of pregnancy. Ask about the date of her last menstrual period. GPNs can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:³

• She has not had intercourse since her last normal menses.
• She has been correctly and consistently using a reliable method of contraception.
• She is within the first 7 days of the onset of a normal menstrual period.
• She is not breastfeeding and less than 4 weeks from giving birth.
• She is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
• She is within the first 7 days post-termination or miscarriage.
• A pregnancy test is performed no sooner than 3 weeks since the last episode of unprotected sexual intercourse (UPSI) and is negative.

In addition to the conditions mentioned above, also consider whether a woman is at risk of becoming pregnant as a result of UPSI within the last 7 days. If pregnancy cannot be reasonably excluded, assess the need for emergency contraception (EC) and prescribe this if necessary.³

If pregnancy cannot be reasonably excluded and the woman is likely to continue to be at risk of pregnancy or has expressed a preference to begin contraception as soon as possible then you should consider quick starting combined hormonal contraception (CHC [excluding co-cyprindiol]), the progestogen-only pill (POP), or the progestogen-only implant, provided there are no contraindications.⁴

In women where pregnancy has been excluded you should then move to an assessment of suitability for different contraceptive methods.⁴

Take a history and perform a clinical examination to identify factors that can affect the choice of contraception, such as comorbidities (for example hypertension and migraine), allergies, lifestyle factors (for example smoking), reproductive history (postpartum/breastfeeding), drug treatments (including liver enzyme-inducing drugs), and age (approaching menopause or under 18 years of age).⁴

If the woman is considering combined hormonal contraception, progestogen-only contraception, or intrauterine contraception, check the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) to ensure that the woman can safely use these methods.⁴

If the woman is considering barrier methods, sterilisation, or natural family planning, check the World Health Organization Medical Eligibility Criteria for Contraceptive Use, as these methods are no longer covered by the UKMEC.⁵

Assess her risk of sexually transmitted infections (STIs) and, when appropriate, advise testing, promote safer sex, and/or refer for sexual health counselling. Raise the subject sensitively as many STIs can be asymptomatic, but when symptoms are present the person may not link them to an STI. Take into consideration the local prevalence of STIs as well as the person's age and sexual activity.⁶

Ask about their current circumstances, including current and recent sexual partners, age of onset of sexual activity, type of sexual activity, and use of alcohol and other substances.⁷

Key groups at risk of STIs include:

• Young people under 25 years of age
• People who frequently change sexual partners
• Sex workers
• Men who have sex with men
• People who have come from, or who have visited, areas of high HIV prevalence and have been sexually active there.

Carry out a risk assessment for sexual abuse, rape, and non-consensual sex, particularly if the woman is considered to be vulnerable (that is, younger than 16 years of age; is from a disadvantaged background; is in, or is leaving, care; has low educational attainment).^8,9

The legal age of consent to sexual activity is 16 years in the UK. Sexual activity under the age of consent is an offence, even if consensual. Offences are considered more serious (statutory rape) when the person is younger than 13 years of age.^8,9

Consider other relevant legal and ethical issues, for example if a girl younger than 16 years of age requests contraception without parental consent, assess her competency to independently consent to treatment and document in her case notes whether she meets (or does not meet) the Fraser Criteria (see below). If the Fraser Criteria are not met, consider breaching confidentiality and seeking parental consent.^8,9

If a woman with learning and/or physical disabilities requests contraception you should support her to make her own decisions about contraception and assess her competence to consent to treatment by her ability to understand the information provided, weigh up the risks and benefits, and express her own wishes.^8,9

If the woman cannot understand or take responsibility for decisions about contraception, carers and other involved parties should meet to address issues around the woman's contraceptive need and to establish a care plan.^8,9

THE FRASER CRITERIA

In the UK, people 16 years of age and older are presumed to be competent to consent to medical treatment. In contrast, competence to consent to medical treatment must be demonstrated in children younger than 16 years of age.¹⁰

In England and Wales, it is lawful to provide contraceptive advice and treatment to young people without parental consent, provided that the practitioner is satisfied that the Fraser criteria for competence are met. The criteria are that:

• The young person understands the practitioner's advice.
• The young person cannot be persuaded to inform their parents, or will not allow the practitioner to inform the parents, that contraceptive advice has been sought.
• The young person is likely to begin or to continue having intercourse with or without contraceptive treatment.
• Unless he or she receives contraceptive advice or treatment, the young person's physical or mental health (or both) are likely to suffer.
• The young person's best interest requires the practitioner to give contraceptive advice or treatment (or both) without parental consent.

In Scotland, the Fraser guidelines do not apply; however, the Age of Legal Capacity Act 1991 applies similar criteria. Competence is demonstrated if the young person is able to:

• Understand the treatment, its purpose and nature, and why it is being proposed
• Understand its benefits, risks, and alternatives
• Understand in broader terms what the consequences of the treatment will be
• Retain the information for long enough to use it and weigh it up in order to arrive at a decision.

TYPES OF CONTRACEPTION

The following methods of contraception are available in the UK:

• Combined hormonal contraception (CHC) — combined oral contraception (COC) pill, combined transdermal patch, and combined vaginal ring.
• Progestogen-only contraception — progestogen-only pill (POP), progestogen-only implant, and progestogen-only injectable.
• Intrauterine contraception — copper intrauterine device (Cu-IUD) and levonorgestrel intrauterine system (LNG-IUS).
• Barrier methods — male condom, female condom, and diaphragm or cap (plus spermicide).
• Sterilisation methods — male sterilisation (vasectomy) and female sterilisation (tubal occlusion).
• Natural family planning methods — fertility awareness methods and the lactational amenorrhoea method.
• Long-acting reversible contraceptives (LARCs) are contraceptive methods that require administration less than once per cycle or month.

LARC methods, which include the progestogen-only injectable, progestogen-only implant, the Cu-IUD, and the LNG-IUS, are highly reliable because their effectiveness does not depend on daily concordance. We will discuss LARCs in a forthcoming issue of Practice Nurse.

Emergency contraception (EC) is an intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse or contraceptive failure. The methods of EC currently available in the UK are oral levonorgestrel, oral ulipristal acetate, and the Cu-IUD.

Bridging contraception can be offered if a woman’s choice of contraceptive method is not available or is not appropriate at the time of presentation. The methods of contraception that can be quick started as bridging contraception include CHC (excluding co-cyprindiol), the POP, the progestogen-only implant, and the progestogen-only injectable (if other methods are not appropriate or acceptable).

We will discuss some of these contraceptive options in more detail.

Combined hormonal methods

There are three types of combined hormonal contraceptives (CHCs): oral contraceptives, transdermal patch, and vaginal ring. CHCs act to inhibit ovulation by acting on the hypothalamo-pituitary axis to reduce production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). With no surge in LH and FSH to stimulate the ovaries, ovulation does not occur.

CHCs also have contraceptive effects on cervical mucus and the endometrium the oestrogen component causes the endometrium to proliferate and grow and the progestogen component prevents hyperplasia (excessive growth) of the endometrium by opposing the proliferative effects of oestrogen. The usual 7-day pill-, patch-, or ring-free interval causes oestrogen and progestogen concentrations to fall, which causes the oestrogen-primed endometrium to slough, mimicking menstruation.

However, there is no health benefit from having this hormone-free interval, and women can avoid monthly bleeding and associated symptoms by taking fewer, or no, hormone free intervals. It is important to note that the use of CHC in this way is off-label.⁴

All three methods have a similar efficacy when used perfectly (consistently and correctly), 0.3% of women will conceive within the first year of use due to method failure. When used typically, 9% of women will conceive within the first year of use due to method failure or user failure.

For the combined oral contraceptive pill, practice nurses should offer advice on how to manage missed pills and what to do if there is vomiting or diarrhoea.⁴

For the combined transdermal patch, advice should also be offered on how and where to apply the patch, what to do if the patch is not changed or the cycle is started late, or if the patch becomes detached.4

For the combined contraceptive vaginal ring, advice should also be offered on how and when to insert and remove the vaginal ring, how and when to check for the presence of the ring, what to do if the vaginal ring is not changed and the cycle is started late and what to do if the vaginal ring is expelled or broken.⁴

Progestogen-only methods

The progestogen-only methods of contraception include the progestogen-only pill (POP), the progestogen-only implant, and the progestogen-only injectable. The POPs currently available in the UK contain either levonorgestrel, norethisterone, or desogestrel.

The POP has several independent modes of action, including thickening cervical mucus thereby preventing sperm penetration, delaying ovum transport, inhibiting ovulation, and providing an endometrium hostile to implantation. It should be taken daily with no pill-free interval.⁴

When used perfectly (consistently and correctly), 0.3% of women will conceive within the first year of use due to method failure. When used typically, 9% of women will conceive within the first year of use due to method failure or user failure.⁴

Since July 2021, POPs containing desogesterol have been available for women to buy in pharmacies, without a prescription – but are still available free of charge on prescription.

Nexplanon® (etonogestrel 68 mg) is currently the only progestogen-only implant licensed for use in the UK. The implant prevents pregnancy by inhibiting ovulation. It also causes changes in cervical mucus that inhibit sperm. It needs to be replaced every 3 years. When used perfectly (consistently and correctly), 0.05% of women will conceive within the first year of use due to method failure.⁴

The progestogen-only injectables contain depot medroxyprogesterone acetate (Depo Provera® and Sayana Press®) or norethisterone enantate (Noristerat®). Progestogen-only injectables prevent pregnancy by inhibiting ovulation and thickening the cervical mucus, thereby presenting a barrier to sperm penetration. In addition, changes to the endometrium make it an unfavourable environment for implantation.⁴

Depo Provera® should be given by deep intramuscular (IM) injection every 12 weeks. Noristerat® should be given by deep IM every 8 weeks but is only used for short-term use (two injections).⁴ Sayana Press® should be given by subcutaneous injection every 13 weeks, but can also be self-administered by women at home, reducing the risk of missed appointments which can leave them at risk of unintended pregnancy.¹¹

When used perfectly (consistently and correctly), 0.2% of women will conceive within the first year of use due to method failure. When used typically, 6% of women will conceive within the first year of use due to method failure or user failure.⁴

Barrier

Barrier methods of contraception include male condoms, female condoms and diaphragms and caps. Male and female condoms prevent pregnancy by providing a barrier to the ejaculate, pre-ejaculate secretions, and cervicovaginal secretions. This prevents fertilisation and reduces the risk of sexually transmitted infections (STIs).5

Diaphragms and caps fit into the vagina to cover the cervix, thus excluding semen. They must be used in conjunction with a spermicide.5

Sterilisation

Sterilisation is considered a permanent method of contraception. Male sterilisation is by vasectomy. Female sterilisation is called tubal occlusion.

If a person is considering sterilisation, the GPN should undertake an assessment of the person's level of understanding of the procedure, in addition to their mental capacity to make the decision, and the risk of later regret. The partner's suitability for sterilisation should also be assessed, as the couple's clinical history, present symptoms, and/or examination findings may influence which partner goes forward to have sterilisation.⁵

Verbal and written information on the procedure should be provided, including information on the efficacy, advantages, disadvantages, and possible risks.⁵

Emergency

Emergency contraception (EC) is an intervention aimed at preventing unintended pregnancy after UPSI or contraceptive failure. EC should be considered if a woman does not wish to conceive and has had UPSI:⁶

• On any day of a natural menstrual cycle
• After regular hormonal contraception has been compromised or used incorrectly
• From day 21 after childbirth, unless all the lactational amenorrhea method (LAM) criteria are met
• From day 5 after miscarriage, abortion, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.

Three methods of EC are currently available in the UK: the copper intrauterine device (Cu-IUD), oral ulipristal acetate 30 mg (single dose) tablet, and oral levonorgestrel 1.5 mg (single dose) tablet (6). The two oral methods are available without prescription from pharmacies.

The Cu-IUD inhibits fertilisation by its toxic effect on sperm and ova. If fertilisation does occur, the Cu-IUD has an anti-implantation effect. Ulipristal acetate acts by delaying ovulation for at least 5 days, until sperm from the UPSI for which it was taken are no longer viable. It delays ovulation even after the start of the luteinising hormone (LH) surge.

Levonorgestrel acts by inhibiting ovulation. If taken prior to the start of the LH surge, levonorgestrel inhibits ovulation for the next 5 days, until sperm from the UPSI for which it was taken are no longer viable. In the late follicular phase, however, levonorgestrel becomes ineffective (unlike ulipristal acetate).⁶

Oral EC should be taken as soon as possible after UPSI to maximise efficacy. Oral EC taken after ovulation is ineffective. The Cu-IUD is the most effective method of EC and should be offered to all women requiring EC, provided the criteria for insertion are met and the method is acceptable to the woman. The Cu-IUD can be inserted for EC within 5 days after the first UPSI in a cycle or within 5 days of the earliest estimated date of ovulation.⁶

If the Cu-IUD is unsuitable or not acceptable to the woman, oral EC should be considered. Ulipristal acetate is licensed for use within 5 days (120 hours) after UPSI or contraceptive failure. Levonorgestrel is licensed for use within 72 hours after UPSI or contraceptive failure.⁶

CONCLUSION

Consultations to discuss contraception are common in primary care. It is key that general practice nurses have an understanding of the range of options available to women who need advice on this subject. It is clearly important to align the needs of the women with the contraceptive method offered to ensure that it is both safe and effective. Providing this advice is of enormous benefit to patients and can be a very rewarding element of the GPN’s work.

References

1. NICE CG30. Long-acting reversible contraception; 2005, updated 2019. https://www.nice.org.uk/guidance/cg30

2. World Health Organization. Decision-making tool for family planning clients and providers; 2005. https://www.who.int/publications/i/item/9241593229

3. FSRH. Quick starting contraception; 2017. https://www.fsrh.org/standards-and-guidance/documents/fsrh-clinical-guidance-quick-starting-contraception-april-2017/

4. FSRH. UK Medical Eligibility Criteria For Contraceptive Use: UKMEC 2016 (amended September 2019). https://www.fsrh.org/ukmec/

5. WHO. Medical Eligibility Criteria for Contraceptive Use; 2015. https://www.who.int/publications/i/item/9789241549158

6. FSRH. FSRH Guideline: Emergency contraception; 2017, updated 2020. https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-emergency-contraception-march-2017/

7. NICE PH3. Sexually transmitted infections and under-18 conceptions: prevention; 2007. https://www.nice.org.uk/guidance/ph3

8. FSRH. Contraceptive choices for young people; 2010, updated 2019. https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-people-mar-2010/

9. NICE CG89. Child maltreatment: when to suspect maltreatment in under 18s; 2009, updated 2017. https://www.nice.org.uk/guidance/cg89

10. NICE. Clinical Knowledge Summaries, Contraception Assessment; 2021. https://cks.nice.org.uk/topics/contraception-assessment/

11. FSRH. CEU statement on self-administration of Sayana Press®; September 2015. https://www.fsrh.org/documents/ceustatementsayanaselfadmin/