Purpose of Contraception

Purpose of Contraception

Contraception is primarily used to prevent pregnancy. There are eight different types of contraceptive methods available.

Types of Contraceptive Methods

1. Combined hormonal contraceptives: pill, patch, and ring
2. Progestogen-only: pill, injectable, or implant
3. Intrauterine devices: copper IUD or LNG IUD (levonorgestrel type)
4. Barrier methods: male and female condoms, diaphragms, and cups with spermicides
5. Sterilisation: vasectomy and tubal occlusion
6. Natural family planning: fertility awareness methods and lactational amenorrhoea method (LAM)
7. Emergency contraception: oral levonorgestrel, ulipristal acetate, and copper IUD
8. Bridging methods: all combined hormonal contraceptives (except co-cyprindiol), progestogen-only pill, implant, and injectable

The progestogen-only implant is the most effective method for preventing unintended pregnancy in the first year.

Long-Acting Reversible Contraceptives (LARCs)

• Intrauterine devices (copper and LNG)
• Implant
• Injectable

Assessment for Prescribing Contraception

1. Rule out pregnancy:
   • No intercourse
   • More than 21 days with HCG >20 IU
   • Using contraception correctly within the first 5 days of a normal period o Less than 21 days postpartum (not breastfeeding)
   • Less than 6 months postpartum (fully breastfeeding and amenorrhoeic) o Less than 5 days after a miscarriage or abortion
2. If pregnancy cannot be excluded:
   • Consider emergency contraception
   • If high risk of pregnancy and express contraceptive interest, offer progestogen-only pill or implant & CHC
3. Identify risk factors using UKMEC criteria 1-4:
   • UKMEC 4: Absolutely contraindicated o UKMEC 3: Advised to avoid (risks outweigh benefits) o       UKMEC 2: Benefits outweigh risks o            UKMEC 1: Safe to use
4. Identify those at risk of STIs:
   • Age <25
   • Multiple sexual partners o Male-to-male sexual intercourse o     Frequent partner changes
   • People who have come from/visited high-prevalence HIV areas & have been sexually active

5. Assess for suspected rape or abuse Consent considerations:
   • Age 16+ can give consent
   • Under 16 years: use Fraser guidelines to assess competence o Under 13 years: illegal  Comorbidities and Contraception Choices
6. Idiopathic menorrhagia:
   • First-line: LNG IUD o Second-line: COCP o Third-line: POP and injectable
7. Abnormal vaginal bleeding:
   • Consider IUD
   • Avoid progestogen-only implants or injectables o All other hormonal methods
8. Ectopic pregnancies, history of PID, fibroids: All methods okay 4. Distortion of uterine cavity: UKMEC 3 for IUDs 5. PID:
   • Past infection or no STI risk factors: All methods okay o Current PID or symptomatic STIs: UKMEC 4 for IUDs o     IUD already in place: UKMEC 2

6. Vaginitis, bacterial vaginosis, trichomoniasis: All methods okay 7. Diabetes:

• No vascular disease: All methods okay
• Macro/microvascular complications: CHCs are UKMEC 3 o Gestational DM : All methods okay

8. Migraines:
   • Non-migraine headaches: All methods okay
   • Migraine without aura: CHCs okay, but UKMEC 3 if it develops o Migraine with aura: CHCs contraindicated (UKMEC 4)
   • History of migraine with aura >5 years: CHCs UKMEC 3, all others ok
9. Cardiovascular disease:
   • Risk factors: Avoid progestogen injectables and CHCs
   • BMI 30-35: All methods okay o BMI >35: CHCs become UKMEC 3
   • Hypertension without vascular disease: Avoid CHCs (UKMEC 3-4) o Hypertension with vascular disease: CHCs UKMEC 4, progestogen injectable UKMEC 3
10. VTE or risk factors:
    • CHCs UKMEC 3 or 4 o Other methods okay
11. Smoking:
    • Age >35, >15/day: CHCs UKMEC 4
    • Age >35, <15/day or quit <1 year ago: CHCs UKMEC 3
12. Postpartum and breastfeeding:
    • IUDs: Use within 48 hours or after 4 weeks o CHCs: UKMEC 4 if <6 weeks postpartum
13. Postpartum without breastfeeding:
    • IUDs: Similar to breastfeeding

CHCs: UKMEC 3-4 if <3 weeks, UKMEC 3 if 3-6 weeks with VTE risk factors

14. Teratogenic medications:
    • Use LARCs as the most effective o CHCs or POPs require additional contraception
15. Liver enzyme-inducing drugs:
    • Use IUDs or progestogen injectables
    • Avoid CHCs with lamotrigine (decreases seizure threshold) 16. Perimenopause: All methods are okay if no contraindications 17. Age <18:
    • All methods okay
    • Avoid depot unless others are inappropriate or have failed o STI check at 2 and 12 weeks if sexually active.

Specific Contraception Information

1. Progestogen-only pills:

• Ensure cervical screening
• Drospirenone is contraindicated in renal insufficiency, AKI, or high potassium. Baseline U&E and BP if significant CKD risk or age >50 2. Implant: Ensure cervical screening 3. Injectable:
• Ensure cervical screening o Assess osteoporosis risk o      Review every 2 years

4. IUDs (LNG and copper):
   • Perform a pelvic examination o Do not insert with unexplained bleeding o             LNG IUD can be inserted for idiopathic menorrhagia
5. Natural family planning:
   • LAM is suitable for complete amenorrhoea, full breastfeeding, and <6 months postpartum

Contraception Reference