Key learning points
- The contraceptive methods available to women
- The risks and benefits of these methods
- The role of the community-based nurse
This article will provide an overview of the various contraceptive methods which are available to women, the risks and benefits derived from those methods and information for the community-based nurse seeking to improve or simply refresh their knowledge relating to contraceptive provision in the UK, and current best practice guidelines.
There is little doubt that the provision and reliability of contraception has changed since Marie Stopes opened the doors of the first contraception service in Featherstone Street, London in 1921, with the slogan ‘children by choice not chance.’ However, worldwide evidence suggests the lack of modern contraception provision to over 200 million women remains a significant problem.1
Nurses have the ability to provide information and advice regarding contraception in a variety of settings, not least in community contraceptive clinics, GP practices and sexual health walk-in clinics, and are ideally placed professionals to educate and inform women about their family planning choices, which are both evidence-based and patient-centred.
Robust family planning services bring together an abundance of health, social and economic benefits for women on an individual level, their families also benefit in terms of improved maternal and infant health.
The Fraser Guidelines, formerly known as Gillick Competence,2 are the recommended format when prescribing contraception for women under the age of 16 years. The UK Medical Eligibility Criteria for Contraception Use (UKMEC) (see Box 1) is published by the Faculty of Sexual and Reproductive Health. It is an aid for all healthcare professionals who routinely discuss contraception provision with women, as it categorises the risk of using contraceptive methods with pre-existing medical issues.
There is little argument that the use of barrier methods in the form of condoms, when used correctly, can prevent both pregnancy and sexually transmitted infections (STIs), and have the ability to be used both as a primary and additional method – in the short term, for example when hormonal contraception is started, and in the long-term to provide double protection against STIs and HIV. For the community practitioner carrying out contraceptive consultations it would be recommended for discussions to take place regarding the use of condoms in tandem with other forms of contraception.
Diaphragms and caps provide a physical barrier to sperm reaching the cervix. As only the cervix is covered by these methods, they do not prevent exposure of the vaginal mucosa to semen or exposure of the penis to cervico-vaginal secretions. In 2008/2009, a survey found that less than 1% of women reported using this contraceptive method. Contraceptive sponges and spermicidal pessaries are no longer available in the UK.
Dams, while not being part of the contraceptive family, certainly have their place in protecting individuals against STIs. A dam is a thin film of material that provides a barrier between the mouth and cervico-vaginal secretions during cunnilingus or between the mouth and anus during oral-anal contact.3
Combined oral contraceptive pill
The combined oral contraceptive pill (COCP) is one of the most widely-used forms of contraception in the UK, and when used properly provides over 99% efficacy. In real terms this represents less than 1 in 100 women using the combined pill correctly becoming pregnant. Correct use of the COCP means not missing any pills and taking extra precautions when necessary – for example when taking antibiotics. The advantages of the combined pill are outlined in Box 1.
The majority of women who take the combined pill will not develop side effects. However it is important to identify those women who are potentially at risk. Particular caution would be advised in women who are current migraine sufferers or who go onto develop migraine when using the combined pill. The importance and significance of migraine has been shown as an increased risk factor in ischaemic stroke and myocardial infarction in women using the combined pill, and those who have a history of smoking.
The progesterone-only pill
For the majority of women the progestogen-only contraceptive pill (POCP) is an effective method of contraception if used correctly. It is commonly used when the combined pill (which also contains oestrogen) is not suitable and has the advantage of being safe to use by breastfeeding mothers. A clinical history should identify any conditions that fall within the UK Medical Eligibility Criteria (UKMEC) categories 3 or 4 for use of a POCP. In summary, patients with a current diagnosis of breast cancer are considered a UKMEC 4 patient and therefore are contraindicated in the use of POCP.
Progesterone is the hormone of the corpus luteum. Following the escape of the ovum from the ruptured follicle, the corpus luteum secretes progesterone which stimulates the growth and secretion of the endometrial glands of the uterus during the fourteen days before menstruation. In the event of a pregnancy, the secretion of progesterone continues until the birth. It works mainly by thickening the mucus made by the cervix, which forms a plug in the cervix. This stops sperm from getting through to the uterus and will also prevent the uterus from thickening making conception far less likely due to prevention of implantation. The POCP has been referred to in the past as the mini-pill as women have only a three–hour period in which to take the pill before it is considered a missed pill, with the exception of Cerazette®, which has a 12-hour window and which has stopped ovulation in 9 out of 10 women.4
Daily pill taking of POCPs will maintain contraceptive efficacy.5-8 Ideally a pill should be taken at or around the same time every day and there should be no pill-free interval. If taken consistently and correctly POCPs are more than 99% effective in preventing pregnancy.5 Failure rates for traditional POCPs vary (0.3 and 8.0 per 100 woman-years)9 but are lower for women aged over 40 years (0.3 per 100 woman-years) compared to younger women.10 Increasing parity is associated with an increase in efficacy but this may be linked to age.10 In the only comparative trial (desogestrel versus levonorgestrel-only pills) the overall failure rate for the desogestrel-only pill was 0.41 per 100 woman-years (95% CI 0.085–1.204) and for the traditional levonorgestrel containing pill was 1.55 per 100 woman-years (95% CI 0.422–3.96).11 Although the desogestrel-only pill is more effective at inhibiting ovulation than a traditional POP this study was not powered to detect differences in efficacy and the failure rates of the two POPs are not significantly different.
It has been suggested that the efficacy of traditional POPs may be reduced in women weighing >70 kg. However, a large observational study found no association between body weight and accidental pregnancy in POP users.12
Long-acting reversible contraceptives
In October 2005 the National Institute of Health and Care Excellence (NICE) published a clinical guideline recommending long-acting reversible contraceptives (LARC) to be offered to all women as part of their contraceptive choices. The document aimed to promote not only more control for women, but give them a broad set of choices when looking to use contraception.
LARC is defined in the NICE guidance as contraceptive methods that require administration less than once per cycle or month which includes the methods outlined in Box 2.
It is estimated that about 30% of pregnancies are unplanned. The effectiveness of the barrier method and oral contraceptive pills depends on their correct and consistent use. By contrast, the effectiveness of long-acting reversible contraceptive (LARC) methods does not depend on daily concordance. The uptake of LARC is low in Great Britain, at around 8% of women aged 16–49 in 2003–04, compared with 25% for the oral contraceptive pill and 23% for male condoms.
The intrauterine device (IUD) and intrauterine system (IUS) are two different types of LARC which are both inserted into the uterus. The main difference is that the IUD is a small plastic and copper device which works by preventing fertilisation and inhibiting implantation, while the IUS is a small plastic device which releases progesterone and works by preventing implantation and sometimes prevents fertilisation. Neither system will prevent a woman from becoming pregnant once removed.
The IUD may cause heavier more painful periods, however in the case of the IUS there may be irregular bleeding and spotting for up to 12 months, with some women becoming amenhorragic. The initial release of levonorgestrel is approximately 20 micrograms per day reducing to approximately 10 micrograms per day after five years in women using Mirena for contraception or treatment of menorrhagia. Mirena is effective for five years in the indications for contraception and idiopathic menorrhagia so should be removed after five years use. If the user wishes to continue using the same method, a new system can be inserted at the same time, in which case no additional protection is required.13
Side effects are mainly related to ectopic pregnancy. Overall however the risk is lower in women using IUD/IUS systems than in women using no contraception. Women should be advised relating to risk factors, and while reassurance should be given as part of the pre-insertion counselling, women who do become pregnant should be referred for an ultrasound scan to rule out ectopic pregnancy.
Depot medroxyprogesterone acetate (DMPA) – brand name Depo-Provera - is a long-term contraceptive agent suitable for use in women who have been appropriately counselled concerning the likelihood of menstrual disturbance and the potential for a delay in return to full fertility. Many women using injectable contraceptives find that their periods will stop, although some women will have irregular or persistent bleeding. The Nexplanon implant may cause periods to stop, become longer and more painful or become irregular, usually until the implant is removed. However period pain may be reduced.
Depo-Provera may also be used for short-term contraception for partners of men undergoing vasectomy, for protection until the vasectomy becomes effective; in women who are being immunised against rubella, to prevent pregnancy during the period of activity of the virus; and in women awaiting sterilisation.
The unwanted side-effects of using contraceptive injections include the possibility of weight gain (2-3kg over 12 months).15 Since loss of bone mineral density (BMD) may occur in females of all ages who use the Depo-Provera injection long-term, a risk/benefit assessment, which also takes into consideration the decrease in BMD that occurs during pregnancy and/or lactation, should be considered. This loss of BMD is of particular concern during adolescence and early adulthood, a critical period of bone accretion. It is unknown if use of Depo-Provera by younger women will reduce peak bone mass and increase the risk for fracture in later life.14
Significant risk factors for osteoporosis include:
1. Alcohol abuse and/or tobacco use.
2. Chronic use of drugs that can reduce bone mass, eg, anticonvulsants or corticosteroids.
3. Low body mass index or eating disorder, eg. anorexia nervosa or bulimia.
4. Previous low trauma fracture.
5. Family history of osteoporosis.15
Affording women the right information regarding their contraceptive choices will prevent unwanted pregnancy. As healthcare professionals, nurses are in an ideal position to discuss the variety of products on the market which will allow women to control not only their family size but also when the time is right to have a baby. Trust between the healthcare professional and our patients has been under the spotlight for a host of wrong reasons recently, and we owe it to ourselves in terms of professionalism to offer information which is evidence-based so that women (and their partners) can make a fully informed choice relating to contraception.
1. Foreman M, Spieler J. Contraceptive Evidence: Questions and Answers. Available at: www.prb.org/Publications/Reports/2013/contraceptive-evidence.aspx
2. Lopez LM, et al. Behavioral interventions for improving condom use for dual protection. Cochrane Database of Systematic Reviews 2013;10. Art.No.: CD010662. DOI: 10.1002/14651858.CD010662.pub2
3. Faculty of Sexual and Reproductive Healthcare. Progestogen-only Pills. London; 2009.
4. Summary of Product Characteristics (SPC) - Cerazette® 75 microgram film-coated tablet; Merck Sharp & Dohme Limited, Electronic Medicines Compendium. December 2011.
5. Schering Health Care Limited. Norgeston. Summary of Product Characteristics (SPCs). 2001. Available at: www.medicines.org.uk
6. Janssen-Cilag Ltd. Micronor Oral Contraceptive Tablets. Summary of Product Characteristics (SPCs). 2001. www.medicines.org.uk
7. Schering Health Care Limited. Neogest 75 Microgram Tablets.Summary of Product Characteristics (SPCs) 2000. Available at: www.medicines.org.uk
8. Pharmacia Limited. Femulen Tablets. Summary of Product Characteristics (SPCs). 2002. Available at: www.medicines.org.uk
9. Hatcher RA, et al. Contraceptive efficacy: In: Contraceptive Technology (19th revised edn). New York, NY: Ardent Media, 2007.
10. Vessey MP, et al. Findings in a large prospective study with special reference to effectiveness. Br J Fam Plann 1985;10:117–121.
11. Collaborative Study Group on the Desogestrel-containing Progestogen-only Pill. A double-blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75 micrograms/dayor levonorgestrel 30 micrograms/day. Collaborative Study Group on the Desogestrel-containing Progestogen-only Pill. Eur J Contracept Reprod Health Care 1998;3:169–78.
12. Vessey M. Oral contraceptive failures and body weight: findings in a large cohort study. J Fam Plann Reprod Health Care 2001;27:90–91. www.ncbi.nlm.nih.gov/pubmed/12457519.
13. Pharmacia Limited. Mirena. Summary of Product Characteristics (SPCs). 2003. Available at: www.medicines.org.uk.
14. Pharmacia Limited. Depo-Provera. Summary of Product Characteristics (SPCs). 2003. Available at: www.medicines.org.uk
15. NICE Guidance Long Acting Reversible Contraception. Available at: www.nice.org.uk/CG30
Practice Nurse, Brynderwen Surgery, St Mellons, Cardiff
Helen has a keen interest in women's health, wound care and travel health - she recently developed a travel pack for use in practice, which has been well received by both fellow nurse team members and patients alike. When not running around in practice, Helen runs around after her three daughters, which does not leave a great deal of "downtime" for her much enjoyed hobby of cross stitch!
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