Need to Know - Contraception

1. What are your thoughts about the risk of related cancer and the combined oral contraceptive (COC) after the recent BMJ study?

But it’s worth pointing out that the study enrolled women using mainly higher doses of ethinylestradiol than are currently prescribed. It also began before the start of the cervical screening programme, which has prevented 7% of cervical cancer cases per year. Confounding factors, such as reduction in condom use in women choosing the COC, may result in greater exposure to human papillomavirus. There was no association between use of COC and breast cancer risk.

Taken overall, cancer risks were decreased by 12% with use of the COC, and one can be reassuring about both the protective effects – which persist for 15 years after stopping the COC in the case of ovarian cancer – and the possible small risk for cervical cancer, ensuring the woman is aware of the need for cervical screening.

2. We all have women who insist they want to stay on the COC despite risk factors such as a BMI over 35, smoking over the age of 35, migraine with aura, or simple migraine over the age of 35. How do you approach these women – assuming they have just one risk factor?

To some degree this is a patient choice issue, but as their prescriber you have a duty to explain the risks of vascular events. There are many safer alternative methods but if the woman finds them unsuitable, changing would be doing her a disservice.

I would cautiously agree to continue to prescribe a COC and fully document the discussions but give a smaller number of packs to enable regular review.

The UK Medical Eligibility Criteria for Contraceptive Use are useful when helping a woman understand why you have concerns, and how possible modification of these factors would improve the risk/benefit ratio. A downloadable copy is available left

3. What is the evidence-based place of Yasmin? We are under a lot of pressure not to prescribe it but it’s being initiated elsewhere – in gynae clinics or abroad and so on – and women don’t want to stop.

There is some evidence for the use of Yasmin to control conditions with an androgen excess, such as polycystic ovaries, and anecdotally for endometriosis. But ordinary COCs may be equally beneficial.

If Yasmin was prescribed at another centre as a first-line COC there would be no reason to assume there have been problems with other brands. Continuation is partly determined by a woman’s experiences and expectations, but it may be worth explaining that she may be equally well suited to an older brand.

There have been claims of very modest weight loss with Yasmin compared with other brands and women may report improvement in mood swings or bloating. Acne may develop, worsen or improve with any brand of COC. The evidence base that Yasmin is significantly different from other brands in this respect is not strong.

Local therapeutics committees will have advised on prescribing after looking at the evidence base and cost-benefit analyses, but a case could be made for being able to offer the full range of contraception, as the alternative may be a risk of abandoning any method, as was seen after the Pill scare in the 1990s.

4. What are the figures for the failure of emergency contraception at different points in the cycle?

Progestogen-only emergency contraception (POEC) is quoted as preventing 85% of expected pregnancies which would have occurred without it, but therein lies the difficulty. Recall of when the period began, and the spacing between periods, is often not very accurate when comparing dates given with hormonal profiles. Recall of when the first unprotected event occurred in the current cycle may not be good, or not disclosed.

POEC given within 72 hours has a total success rate of 84%, and of 63% between 73 and 120 hours – although this use is unlicensed. The fact that it works best the earlier it is taken – certainly within the first 72 hours – suggests it delays or prevents ovulation, rather than preventing implantation.

In contrast, the emergency IUD, wherever it is inserted in the cycle, is more than 99% effective, when used up to five days after the first unprotected episode or up to five days after the earliest predicted ovulation. We should be giving information about this alternative method whenever emergency contraception is requested.

5. What is your experience of Cerazette now we have been using it for a while? How do you manage persistent bleeding – which seems quite prolonged in some patients?

Women using any progestogen-only method of contraception may experience a variety of bleeding patterns. Cerazette users are more likely to have unpredictable or troublesome bleeding than users of older-style POPs at least for the first year of use. In my experience this has led to similar rates of discontinuation.

There is little that can be done about this apart from perseverance or continuous use of NSAIDs or tranexamic acid if the bleeds are heavy. Increasing the progestogen intake – via a doubling of dose or addition of alternatives – has been tried.

There is some evidence that doxycycline may inhibit matrix metalloproteinase degradation and overcome troublesome bleeding while it is taken, even in the absence of chlamydia infection.

Once you have excluded infections, current or recent use of liver enzyme-inducing medication, and erratic pill taking as causes of changed bleeding patterns, a change of POP brand may result in an improvement.

Many women have now tried Cerazette as a first-line POP, and switching may help, as responses vary woman to woman.

As with any progestogen-only method, exploring how a woman might feel if she had bleeding problems before starting Cerazette may save some of the switching or abandoning of contraceptive use.

6. What is the current position on Depo Provera and bone health? Should women at either end of the reproductive age groups try something else?

Depo-Provera (medroxyprogesterone acetate) is known to lower circulating levels of oestrogens in some women and be associated with a reduction in bone mineral densities at some sites in the body. But there is no proven link with present or future bone fractures.

The concern with young people who have not yet acquired peak bone mass – and older women whose oestrogen levels are falling – is that this extra insult may be (but is not proved to be) clinically significant.

Since the Committee on Safety of Drugs statement in 2004, and Faculty of Sexual and Reproductive Healthcare guidance2, most clinicians will be following the recommendation that women under the age of 18 may consider the use of Depo-Provera if other methods are not suitable. The guidance stresses that regular review after each two years of use at any age should inform the decision about continuation, based on age and personal and family history in regard to higher risk of acquiring osteoporosis.

There is no national recommendation to supplement the woman’s diet with vitamin D or calcium while using Depo-Provera.

If an alternative hormonal long-acting method is required, Implanon would be suitable, as it has no effect on bones.

7. If a CuT380 or the equivalent is fitted in the late 30s can it be left in longer than eight years? Sometimes women aren’t keen on removal and may not be keen on an IUS if they have no menstrual problems.

Standard-length banded copper T380 devices like TT380S or TSafe380 are currently licensed for 10 years – even though when fitted some may only have been licensed for eight years. There is also evidence of effectiveness up to 12 years of use at any age. Any copper device fitted after age 40 is considered effective until the menopause but as an unlicensed use, and should be discussed with the woman, with clear documentation and an audit trail.

A cut-off age of 40 is the guideline for extended use, but I would include women nearing their 40th birthday. It is worth remembering that at each change of device, there are risks that infection – if present in the cervix – may be carried to the upper genital tract, and risks of perforation.

8. How do you manage recurrent bacterial vaginosis – or actinomycoses on a smear – in women with an IUD?

Bacterial vaginosis arises when the vaginal pH is raised above its usual acid levels. Women using IUDs or the IUS may have more bleeding days, which creates a more alkaline environment. But not all women with increased bleeding complain of symptoms of bacterial vaginosis.

Condoms will prevent alkaline semen entering the vagina, and avoiding perfumed soaps and shower gels and douching may also prevent pH changes. Stopping smoking may prevent recurrence, as might metronidazole or clindamycin cream after an episode of bleeding.

Actinomyces-like organisms (ALOs) are found as a vaginal commensal in women regardless of IUD use. The report of ALOs on a smear does not indicate infection with actinomyces but you should ask about symptoms – discharge, dysuria, dyspareunia, abdominal pain – which may require treatment. If symptomatic, swabs should also be taken for other STIs.

If there are no symptoms, the IUD may be left in place and the smear only needs repeating at the routine screening interval. The woman should be advised to return for further evaluation if symptoms occur.

9. How useful have contraceptive patches been?

Patches can be useful for women who prefer a regime of weekly rather than daily action but restarting after the patch-free week is just as likely to be forgotten as after a pill-free week. This is the danger time for contraceptive failure. There have been cases where discontinuation of the patch is more likely than with the oral versions because of skin reactions and there is also inconvenience if they fall off.

In terms of side-effects there is no reason why one would expect any difference, but they can be useful – though expensive – for women who cannot swallow tablets or have ongoing severe gastrointestinal problems that may prevent absorption of the pill.

Drug interactions are basically the same as for the COC with the exception that tetracycline has been researched and does not seem to lower efficacy.

10. How do you assess a woman in her late 40s or older who is using hormonal contraception but wants to know if she can stop or has had the menopause?

One cannot rely at all on bleeding patterns to indicate ovarian changes in women using hormonal contraception and FSH levels cannot be interpreted in women using a COC. It is best to use barrier methods for a couple of months before sampling. If natural cycles have returned, the blood should be taken between days two and six, otherwise on any day.

For users of other hormonal contraception, FSH can be measured at any time. Two readings separated by two to three months are required, and if both are above 30iu/l, these are considered indicative of ovarian failure. But the perimenopause is a fluid time, and contraception should not be stopped for two years from the last reading if this was taken below the age of 50, or one year if over 50.

Pragmatically, contraception is often considered superfluous after the age of 55. But only 96% of women at this age will be incapable of ovulation, and an unplanned pregnancy could well be fraught with health and social problems.

11. Are there any developments likely to become widely available soon?

We have been waiting for the arrival in the UK of the combined vaginal ring Nuvaring, which may go through the UK licensing process soon. This will be used for three weeks and removed for one week to give a withdrawal bleed.

Continuous use of the COC for up to a year has been licensed abroad with Anya or for 84 days with Seasonale and both regimes may be licensed here. But women for years have been ‘disobeying the rules’ and choosing when or whether to have a withdrawal bleed.

Male hormonal methods still seem quite a long way off, but developments have been in active research for around 30 years.

To provide more holistic sexual health protection, microbicides are being trialled abroad which act as a ‘chemical condom’. This will give women more autonomy in situations when male partners do not use traditional barriers.

Dr Alyson Elliman is a consultant in sexual and reproductive healthcare at Croydon PCT

Competing interests Educational sponsorship has been received from Durbin Sales, Organon, Schering Healthcare and Wyeth