CONTRACEPTION

There are a number of contraceptive methods available. Each person may be suited to a different form of contraception and there is no method that is universal in its application and individual selection is most important.

A decision on the appropriate form of contraception can be made on the effectiveness of the method, specific factors which preclude the use of certain methods, patient reliability and individual patient’s preference.

The following are some of the most commonly used methods for contraception and I would be happy to provide additional information on each one of them if it is necessary.

1. ORAL CONTRACEPTIVE:

“The Pill” - is made up of synthetic Oestrogens and Progestogens of various types and in differing dosages and potencies. The pill exerts its action by mainly the suppression of ovulation. One can get “oestrogenic” or progestogenic” type pills. One can also get high and low dose combined oral contraceptive pills. Each one of these may be suited to different patients.

The standard contraceptive pack consists of 21 hormone pills with 1 pill free week during the withdrawal bleed time.

The second type of pack is a 28 day pack which again consists of 21 hormone tablets with 7 placebo tablets. It is during this placebo pill time, that the withdrawal bleed occurs.

The pill is the most commonly used contraceptive in younger women although there are some relative contra-indications. These include hormone dependent cancers, some cardio-vascular diseases, uncontrolled diabetes and hyperlipidaemia. Certain liver conditions, epilepsy and fibroids may be relative contra-indications.

Certain drugs may decrease the efficacy of the oral contraceptive. Some anti-convulsants, anti-migraine tablets and antibiotics are well known to reduce the effect of an oral contraceptive. One should therefore talk to your local doctor or myself in this regard.

Side Effects:

Generally the effects may be attributed to any one of the following.

a. Oestrogen deficiency. These features would include irritability, hot flushes, midcycle breakthrough bleeding and low menstrual flow.
b. Oestrogen excess. Symptoms from oestrogen excess would include nausea, breast tenderness, weight gain and headaches. An increased vaginal discharge and heavy bleeding may also be attributed to this factor.
c. Progesterone excess. When the progresterone level is a little high, then depression, loss of libido, tiredness, increased appetite and weight gain may be present. Vaginal dryness and dyspareunia with acne and an oily scalp may be attributed to this factor.
d. Progestogen deficiency. Heavy menstrual flow and clots with late breakthrough bleeding are common side effects of a low progesterone pill.

It is sometimes difficult to get a “balanced” pill and this may be achieved by trial and error. One should always take a pill for at least 3 months before changing to a different type of pill.

2. MINI PILL (Progesterone only pill):

This is a low dose progesterone pill which is taken on a daily basis. All the pills are the same and there are no breaks between packs.

Its main use is during breast feeding. It does not interfere with lactation or the content of the milk. This type of pill may also be used when the combined oral contraceptive pill is contra-indicated. In such conditions as high blood pressure, varicose veins and previous clots.

The advantages that there is no Oestrogen component and therefore has no oestrogenic side effects. However, the disadvantages that there may be poor cycle control and there is often irregular spotting and bleeding. It also can have some of the progestogenic side effects.

It takes 6 to 8 hours to become effective and it is therefore recommended that is should be taken at a regular time either in the afternoon or early evening.

3. DEPO PROVERA:

This is also a Progesterone only form of contraception. A single 150 mgm injection is given every 3 months. It is absorbed slowly and prevents ovulation.

It is generally recommended in women who have completed their families and in patients who are unable to use various forms of other contraception. Failed other methods or psychiatric patients would be good examples.

It is also very good when used during breast feeding and can be used in patients who have had previous history of thrombosis.

Side effects:

The most common side effect is disruption of the menstrual cycle with irregular spotting or bleeding.

It may cause weight gain and high blood pressure. One often gets headaches with abdominal cramps. There may be loss of libido and depression. If used in young women there may be a long interval before menstruation returns. It can be up to 2 years.

4. IMPLANON:

This is also a Progesterone only contraceptive. It comes as a small rod which is inserted under the skin and lasts for 3 years. Its action is very similar to the Mini pill and Depo Provera. The side effects are that of a progesterone as can be seen above in Depo Provera. However, the effects are much less pronounced and if necessary this implant can be easily removed and the effects are therefore quickly reversible.

It is ideal for long term use and in breast feeding mothers. It is high effective as a contraceptive.

5. NUVARING:

This is a new form of contraceptive that principle of action is the same as the combined oral contraceptive. The ring contains both oestrogen and progesterone and releases the hormone slowly into the vagina over the 3 weeks that it is held in the vagina.

The action is therefore identical to the combined oral contraceptive pill but the total dose of oestrogen and progesterone is significantly lower than that of the pill and therefore has less of the side effects of the pill. It also has the benefit of not requiring a pill on a daily basis. It acts by suppressing ovulation.

It is inserted once a month into the vagina and removed after 3 weeks. During the 1 week where the ring is not in the vagina, the menstrual withdrawal bleed will occur.

Side effects:

The side effects are those of the oral contraceptive pill but to a lesser degree. The other disadvantage is that one has to insert and remove the ring oneself. The manufacturers have an easy SMS reminder system for patients to have it removed and re-inserted at the appropriate time.

6. INTRA-UTERINE CONTRACEPTIVE DEVICE (IUCD): 

This type of device fits into the endometrial cavity to prevent pregnancy. There are various shapes and sizes that used to be used but currently the two most commonly used IUCD’s are the Multiload-375 and the Mirena device.

Both can remain in use for 5 years but obviously can be removed at any time before that. They can be replaced with another device after 5 years if one wants to continue using that form of contraception.

a. Copper containing device

The most commonly used copper containing device in Australia is the Multiload-375. There is a slow release from the device which creates an unfavourable medium in the uterus for implantation. The copper is accumulated and copper irons will destroy sperm.

It is ideally suited for poor patient motivation when they are unable to remember to take tablets on a daily basis. It is also suggested where the pill is contra-indicated for various reasons as described above. It is also commonly used in patient’s with mental retardation or are neglectful.

It has recently been used where unprotected midcycle intercourse has occurred and the IUCD may be inserted to prevent implantation.

Caution should be exercised when using this device in certain cardiac conditions where there is a risk of infection. Also where there has been heavy bleeding. Fibroids and uterine abnormalities would cause side effects from this device. If there is a history of pelvic inflammatory disease then one would have to be very cautious in using this device. The same would apply with a previous ectopic pregnancy.

Complications:

As any other form of contraception there are numerous potential side effects. The most common is that of expulsion which occurs in about 7% or 8% of cases. There is also an increased risk of ectopic pregnancy.

Heavy bleeding or menorrhagia is one of the most common side effects of this device. This may be associated with painful periods and is also very common. Both these last side effects may be controlled with various other forms of medication.

Perforation and pelvic inflammatory disease are now less commonly associated with this device.

The device is ideally inserted within the first few days after a menstrual period. It is usually done in the consulting rooms either with or without a small local anaesthetic and the strings are usually cut at about 2 cms and can be felt throughout the cycle.

b. The Mirena device

This is an IUCD that is impregnated with a progestogen. It releases a very low dose of this drug into the endometrial cavity on a daily basis. It causes the glands to atrophy and there is minimal absorption into the general circulation. It otherwise has most of the other effects of an IUCD.

Side effects:

The most common side effect is irregular spotting or bleeding which can occur during the first 6 to 9 months after the device is inserted. These side effects should slowly decrease over time and ultimately one may have a reduction in the menstrual periods. In some patients the bleeding will be reduced completely so that there is absolutely no bleeding.

It is therefore ideally used to control heavy bleeding but in addition as a significant role as a contraceptive.

The side effects are similar to those of the Multiload as described above.

7. DIAPHRAGM: 

This is made of a soft rubber ring which has a dome across it. It acts as a mechanical barrier and prevents sperm reaching the cervix.

It is always recommended that spermicidal cream be used at the edges of this ring to prevent the odd sperm sneaking around the barrier.

It is usually used in women who cannot use contraceptive methods such as oestrogen or the IUCD. The patient needs to be very well motivated.

It is difficult to use where one has an allergy to rubber and where one has poor vaginal muscle tone.

There are virtually no side effects except that one has to insert it every time one has intercourse. It should be removed 8 hours later. There is also a higher failure rate compared to other forms of contraception.

If one uses the device then I would be happy to instruct you on exactly how to use it but there is also a patient information brochure that comes with the diaphragm.

8. TUBAL LIGATION:

This is an operative and permanent form of contraception.

Under general anaesthetic one would perform a laparoscopy and apply Filshe clips to the Fallopian tubes.

This is regarded as “a permanent” form of contraception and is known to have a 1 in 500 failure rate.

The side effects are generally those of the surgery itself but there are no other long term side effects except for the fact that it is permanent.

It is ideally suited to patients who have completed their families and in those who cannot have children for various surgical or medical reasons.