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nMRCGP hot topics - contraception

Dr Sue Ford gives a round-up of the latest thinking on another key subject area

Dr Sue Ford gives a round-up of the latest thinking on another key subject area

This is something that will affect nearly every woman at some point in her life, and even with nurse triage it is a common reason for a GP consultation.

The range of contraception options is increasing all the time and new guidelines have recently been developed, making it an important hot topic.

Contraception choices

Hormonal contraception includes:

  • Combined oral contraceptive (COC) pill
  • Evra – combined contraception in the form of weekly skin patches worn for three weeks. Helps improve compliance
  • Progestogen-only pills or mini pill
  • Cerazette – newer progestogen-only pill has a 12-hour window period to take the pill within, often helpful for teenagers. Also works to suppress ovulation. More effective than the older pills

Long-acting reversible contraception includes:

  • Depo-Provera – IM injection every 12 weeks. Highly effective. Often results in amenorrhea and can affect bone density, see below
  • Implanon – matchstick-size subdermal implant that delivers constant levels of progestogen. Lasts three years. Easy to fit and remove but may affect bleeding pattern
  • intrauterine device (IUCD) copper coil – non hormonal, also effective as emergency contraception. Lasts five to 10 years
  • intrauterine system (IUS) Mirena – releases progestogen locally. Useful in treating menorrhagia as well as the progestogen part of HRT. Lasts five years

Other methods are:

  • condoms – the only method that helps to prevent STIs
  • diaphragm, spermicides, natural methods

New guidelines and developments

NICE guidelines October 2005: long-acting reversible contraception is:

  • more effective than other methods
  • more cost-effective than COC
  • safe

NICE suggests we give women information on these different methods to dispel any fears and increase their options.

CSM and NICE guidance (Nov 2004) on Depo-Provera:

  • Depo-Provera can decrease bone density, so don't use first line if patient is under 19 years unless other methods are unsuitable. If used, try alternative after two years. No need for DEXA scan at this point.

New rules for missed pills from the Faculty of Family Planning and Reproductive Healthcare (FFPRHC), April 2005:

  • if a woman misses a pill they should take the missed pill immediately and continue their normal schedule
  • if the pill is missed in week three they should take the pill immediately and miss the pill-free interval
  • if two or more 20µg pills or three or more 30µg pills have been missed, the patient should use barrier methods for seven days

FFPRHC guidelines on levonogestrel emergency contraception November 2005:

  • 1.5mg single dose as opposed to 0.75mg 12 hours apart
  • if taking enzyme inducers another 1.5mg is needed 12 hours later
  • it is licensed for up to 72 hours after unprotected intercourse, although it has been shown to be effective up to 120 hours. However, it should only be used after 72 hours if the IUCD is not suitable and the woman is counselled that it is outside the licence

The key message is to tailor the method to each individual, aiming for safe, effective, acceptable contraception.

Dr Sue Ford passed the MRCGP last year and is currently a maternity locum in Cambridge

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