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Contraception - new developments and practice

Catriona Sutherland
RN
Member of Royal College of Nursing Sexual Health Forum
Practice Nurse and Nurse Specialist in Family Planning and Women's Health
Paxton Green Group Practice London

Practice nurses are in an excellent position to provide patients with information on contraceptive methods. The least every practice should have is a comprehensive supply of up-to-date information leaflets. If the nurse is planning to do more than provide leaflets, she must be trained in family planning. Some practices are able to provide a comprehensive contraceptive service. Many others are able only to offer a more restricted range of methods. In these circumstances the practice nurse needs to know how patients can access more specialist services.
Historically, contraceptive services have been undervalued. Family planning nurses were thought to just take weights and blood pressures, or carry out "pill checks". However, since the "pill scares", the Crown report,(1) the introduction of Patient Group Directions and professional accountability, nurses must be aware that recognised training (that is regularly updated) is essential to provide patients with the safe and appropriate care they deserve. Patients must be made aware of the benefits and risks of their chosen contraceptive method, and be willing to accept them.

New developments in contraception

Progestogen methods
Progestogen-only pill (POP): This method of contraception has reduced efficacy in women over 70kg, and they should be advised to take two POP tablets daily.(2)
Cerazette (desogestrel; NV Organon) is a new POP. Additional contraception is needed only if a pill is taken 12 hours late.(2) It is to be launched soon.
Injection
: Depo Provera (medroxyprogesterone acetate; Pharmacia & Upjohn) is administered by intramuscular injection every 12 weeks. It is licensed both for long-term use and as a first-line contraceptive.(3) It is important to discuss advantages and side-effects such as amenorrhoea with the patient - patients are more likely to continue with the method if counselled appropriately.
Implants
: Implanon (etonogestrel; Organon) is currently the only marketed implant. A single rod is inserted subdermally into the medial upper arm. The implant contains progestogen in a slow-release carrier that lasts for 3 years.(3) Counselling for irregular bleeding is essential. Some nurses are now training to fit the implants.

Emergency contraception
There are many different reasons why a woman requests emergency contraception,(4) such as:

  • Unprotected sex.
  • Barrier method failure.
  • Missed or late pills (combined pill or POP).
  • Potential intrauterine device (IUD) failure (complete or partial expulsion of an IUD).
  • Recent use of suspected teratogens (eg, cytotoxic drugs or live vaccines).
  • Drugs that interact with combined pill or POP (eg, enzyme inducers, antibiotics).

Hormonal emergency contraception is now best provided as progestogen-only emergency contraception (POEC) in the form of levonorgestrel, and is marketed as Levonelle-2 (Schering Health Care). This formulation is more effective than the previously available combined hormonal formulation and has far fewer side-effects, especially vomiting. POEC is more effective the earlier it is taken (see Table 1).(5)

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With this information, there is an obligation on all of us to make it easy for our patients to access emergency contraception as early as possible.
A new Family Planning Association (FPA) leaflet, "Emergency contraception", indicates that a dose should be repeated if vomiting occurs within two hours.
POEC is considered so safe and effective that it has been made available in pharmacies over the counter (OTC) for a fee, although not to under-16s. Schemes have been set up, largely in areas with high teenage pregnancy rates, to provide POEC free of charge from designated pharmacies, while still free from clinics and on FP10.
Intrauterine emergency contraception is highly effective. A copper-containing IUD is used that can be inserted up to 5 days following unprotected sex. It can also be fitted up to 5 days after the calculated earliest day of ovulation (ie, up to day 19 of a 28-day cycle). However, the risk of chlamydia and other sexually transmitted infections should be considered. Some contraindications may not be relevant (such as menorrhagia) if the woman only wants the IUD for short-term use, as it can be removed with menses.

Intrauterine contraception
The mode of action of IUDs and IUSs is the sterile "foreign body" response that leads to an increased concentration of white cells, prostaglandins and enzymes.(6) The greatest risk of infection occurs during the first 20 days after insertion. This is most probably because of pre-existing infection.(6)
If a patient is considering using an IUD it is essential to take an accurate sexual history, as screening for sexually transmitted infections may be indicated. Any copper IUD fitted in a woman in her 40s can stay in until the menopause.(6)
The IUD of choice is the CuT 380 (Pregna), which is now licensed for use for 10 years. GyneFix (FPS) is a frameless IUD with six copper beads on a thread that is imbedded into the fundus of the uterus, and is licensed for 5 years. It is designed to cause less dysmenorrhoea and menorrhagia, and reduced expulsion. It can be difficult to position accurately, so training is essential.

Levonorgestrel-releasing intrauterine system (IUS)
Mirena (Schering Health Care) is a highly effective method, now licensed for 5 years. Irregular uterine bleeding is common in the first months following insertion, after which amenorrhoea may be the norm, or light menses. Good preinsertion counselling should pre-empt early discontinuation.
IUS is not licensed for emergency contraception but is now licensed as a treatment for menorrhagia. Ideally a scan should be carried out to identify the location of suspected fibroids to enable accurate placement of the device. Studies are continuing on its use for hormone replacement therapy.

Combined methods
It is always essential to take an accurate history to identify possible contraindications, and to counsel the patient of the benefits and risks. Personal and family history, which should be regularly updated, will give an indication as to which type of pill (second or third generation) may be more suitable.
There is ongoing research into a combined monthly injection.

Barrier methods(7)
These are more suitable for those who are breastfeeding, spacing children or who do not require a highly effective method.

Oves cap: This can stay in for 72 hours and is disposable. A fitting pack of three sizes is available from chemists for £9.99, but it has to be taken to a family planning trained nurse who can assess the correct size and teach the woman how to use it; the fitting technique is the same as the cervical cap. Initial research on efficacy is limited.(8)

Femcap: Ongoing research looks promising on this method of contraception.

Protectaid: This is a new contraceptive sponge containing spermicide. It claims 90% efficacy and must be left in situ for 12 hours. It is possible that it may dislodge and result in pregnancy.

Conclusion
As research on current contraception and new methods are being developed, practice nurses need to keep up to date with changes. This may be achieved through their professional bodies.

References

  1. Crown J. Review of prescribing, supply and administration of medicines. A report on the supply and administration of medicines under group protocols. London: NHS Executive; 1998.
  2. Everett S. Handbook of contraception and family planning. London: Baillière Tindall; 1998.
  3. Guillebaud J. Contraception today. 4th edn. London: Martin Dunitz; 2000.
  4. Kubba A, Guillebaud J. Emergency contraception. In: Kubba A, Sanfilippo J, Hampton N, editors. Contraception and office gynecology. London: Saunders; 1999.
  5. Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:428-33.
  6. Rowlands S, Hampton N. Intrauterine contraception. In: Kubba A, Sanfilippo J, Hampton N, editors. Contraception and office gynecology. London: Saunders; 1999.
  7. Schwartz JL, Creinin MD. Male and female barriers. In: Kubba A, Sanfilippo J, Hampton N, editors. Contraception and office gynecology. London: Saunders; 1999.
  8. Veos UK Limited. Oves: The new contraceptive cap. London: Veos UK Ltd; 2001.

Resources
Family Planning Association UK
2-12 Pentonville Rd
London N1 9FP
T:020 7837 4044
W:www.fpa.org.uk

Royal College of Nursing
20 Cavendish Square
London W1G 0RN
T:020 7409 3333
W:www.rcn.org.uk

NANCSH
c/o 9 Church Close
Drayton Bassett
Tamworth
Staffs B78 3UJ
T:01827 260117
W:www.nancsh.org.uk

Further reading
Sutherland C. Women's health: a handbook for nurses. Edinburgh: Churchill Livingstone; 2001.

Andrews G, editor. Women's sexual health. 2nd edn. London: Baillière Tindall; 2001