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Current issues and changes in contraception

Catriona Sutherland
RGN
Practice Nurse
Clinical Nurse Specialist in Contraception and Women's Health
London

If a general practice provides an incomplete service or if a patient needs referral for specialist advice, then the practice nurse needs to know how the patient can access these other services. Leaflets and other resources are available from local health promotion units, and there are accredited courses for nurses.

The extension to nurse prescribing is the most innovative and far-reaching development for nurses working in the field of reproductive and sexual health.(2) The extended formulary includes almost every method of contraception. This year sees the first courses being run by a number of universities, as a result of which we will see the first batch of independent nurse prescribers in the field of contraception and reproductive health.

Sexual health consultations
Sexual health and teenage pregnancy are issues high on the political and health agenda, consequently providing more opportunities for development within the primary healthcare setting.(1) Some practices have had a very positive response from providing a dedicated "Young People's" clinic where a full range of health concerns relevant to young people can be discussed (eg, acne, weight, body image, risk taking and emotional issues, as well as sexual health and contraception).

Every consultation with any woman or man, regardless of age, is an opportunity to raise the issue of sexual health. Many women consult with the expectation that they will be given the opportunity to discuss and obtain information on a wide range of sexual health issues. The consultation is also always an opportunity for general health promotion.

There are stages in a woman's life when she will need to take special consideration of her contraceptive needs, such as after having a baby or at the menopause.

When discussing contraception with any woman, the importance of taking an accurate personal, family and sexual history cannot be emphasised too strongly. This is to identify any areas for concern or caution and any possible contraindications to her chosen method, and to counsel her on the risk and benefits. All information must be regularly updated to be meaningful.

Emergency contraception (EC)
There are important messages about EC, including the importance of maintaining public awareness of the effectiveness and availability. As with counselling for any method of contraception, a nonjudgmental approach is essential. There are many different reasons why a woman may need EC, such as:(3)

  • Unprotected sex (possibly as a result of assault).
  • Barrier method failure.
  • Missed or late pills.
  • 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 the combined pill or progestogen-only pill (POP) (eg, enzyme inducers, antibiotics).

Progestogen-only emergency contraception (POEC), marketed as Levonelle-2, is now the hormonal method of choice. It is more effective the earlier it is taken (see Table 1), and women must be encouraged to ask for it at the earliest opportunity.(4)

[[NIP07_table1_43]]

Intrauterine emergency contraception is even more effective. A copper-containing IUD is used, and can be inserted up to five days following unprotected sex. It can also be fitted up to five days after the calculated earliest ovulation (ie, up to day 19 of a 28-day cycle). However, the risk of chlamydia and other sexually transmitted infections (STIs) should be considered. Some contraindications may not be relevant (such as menorrhagia) if the woman wants the IUD for short-term use only, as it can be removed with menses.

Progestogen methods
The progestogen-only pill (POP) may be less effective in women who weigh more than 70kg. The advice is that these women take two progestogen-only pills daily, usually at the same time.(5)

The levonestrel-releasing intrauterine system (IUS), tradename Mirena, is licensed for use for five years before it needs replacing and can also now be used as a treatment for menorrhagia. 

Depo-Provera (DMPA) is the only injectable currently licensed for long-term use, and is highly effective. Excessive bleeding can usually be treated successfully with additional oestrogen.(6) There is concern that prolonged hypo-oestrogenism may increase the risk of osteoporosis and arterial disease, particularly in the DMPA user who is amenorrhoeic.(6) There is not sufficient data at present.

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.(7) The greatest risk of infection occurs during the first 20 days after insertion. This is most probably because of pre-existing infection.(7) If a woman is considering using an IUD it is essential to take an accurate sexual history, as screening for sexual infections may be indicated. Any copper IUD fitted in a woman in her 40s can stay in until the menopause.

GyneFix is a frameless IUD with six copper beads on a thread that is imbedded into the fundus of the uterus, and licensed for five years. It is designed to cause less dysmenorrhoea and menorrhagia, and to reduce the risk of expulsion.

Barrier methods
Lea's Shield, Oves cap and FemCap are all types of cervical cap made from silicone. Early research looks promising, but larger scale studies are needed. 

New developments in hormonal contraception
In this time of pill scares and litigation, it is easy to forget that the pill has many health benefits.(8) These include: fewer menstrual problems (particularly dysmenorrhoea and anaemia); protection against pelvic inflammatory disease, probably from the thickening of the cervical mucus; considerable protection against ovarian and endometrial cancer, due to the reduction in ovulations in a lifetime; reduced likelihood of developing fibroids; relief of the symptoms of endometriosis and premenstrual syndrome; prevention of ovarian cysts and benign breunched in the UK in April 2002. The 30mg pill (Yasmin)ast disease.

A combined pill with a unique profile was la contains a new progestogen, drospirenone, derived from spirolactone, and is thought to reduce fluid retention.

A new progestogen-only pill, Cerazette (desogestrel) has still not been made available in the UK, although it is available in Europe. It is highly effective and has low androgenic activity. It had been hoped that a licence will be approved for a "12-hour rule" for missed pills. This will be a considerable advantage over the current "3-hour rule" for missed pills with existing POPs.
A further study is underway. 

Current research
There is continuing research into progestogen-releasing vaginal rings and also combined rings releasing oestrogen and progestogen.

Progestogen-releasing biodegradable implants that will not need to be removed, only replaced at the end of its lifespan, have been studied, but progress is slow - the author of this piece took part in a research trial for this method 20 years ago.

Patches releasing oestrogen and progestogen are in development. The technology is already in use and highly acceptable for hormone replacement therapy. Patches would probably have to be changed weekly.

Injectable contraception is possible if a woman could give herself the monthly injections of oestrogen and progestogen. 

Mifepristone (formerly RU486) may be more effective as emergency contraception than that currently in use.
Development continues for barrier methods, including new male and female condoms, caps and diaphragms, and new types of spermicide.

References

  1. Social Exclusion Unit. Teenage pregnancy. London: The Stationery Office; 1999.
  2. Crown J. Review of Prescribing, Supply & Administration of Medicines Final Report - March 1999. London: DoH; 1999.
  3. Kubba A, Guillebaud J. Emergency contraception. In: Kubba A, Sanfilippo J, Hampton N, editors. Contraception and office gynecology. London: Saunders; 1999.
  4. Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonogestrel versus Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:428-33.
  5. Guillebaud J. Progestogen-only pills (POPs) and body weight. J Fam Plann Reprod Health Care 2001;27(4):239.
  6. Guillebaud J. Contraception Today. London: Martin Dunitz; 2000.
  7. Rowlands S, Hampton N. Intrauterine contraception. In: Kubba A, Sanfilippo J, Hampton N, editors. Contraception and office gynecology. London: Saunders; 1999.
  8. Szarewski A, Guillebaud J. Contraception: Your Questions Answered. Oxford: Oxford University Press; 2002.

Resources
fpa (formerly the Family Planning Association)
T:0845 310334
W:www.fpa.org.uk
Brook
T:0800 0185023
W:www.brook.org.uk
National Association of Nurses for Contraception and Sexual Health
W:www.nancsh.org.uk
Margaret Pyke Trust
W:www.margaretpyke.org
Marie Stopes
W:www.mariestopes.org.uk

Further reading
Andrews G, editor. Women's Sexual Health. London: Baillière Tindall; 2001
Belfield T. fpa
Contraceptive Handbook. London: fpa; 1999
Everett S. Handbook of contraception and family planning. London: Bailliere Tindall; 1998
Sutherland C. Women's Health: A Handbook for Nurses. Edinburgh: Churchill Livingstone; 2001