Contraception request/advice

Related Subjects: | Management of Unprotected Sex and Emergency Contraception (EC) | Contraception request/advice | Combined Oral contraceptive pill (COCP)

💡 Contraception is a vital aspect of reproductive healthcare. Choice should be tailored to individual needs, considering effectiveness, safety, contraindications, and patient preference. Always check pregnancy excluded before starting.

⏱️ Time Until Contraceptives Become Effective (if not started Day 1 of period)

• ⚡ Immediate: Copper IUD (emergency or routine use)
• ⏳ 2 days: POP (Progestogen-only pill)
• 📆 7 days: COC (Combined pill), injection, implant, LNG-IUS (hormonal coil)

🌀 Intrauterine Device (IUD – Copper Coil)

• Small T-shaped device releasing copper → toxic to sperm/ova, prevents fertilisation.
• 💯 >99% effective; lasts 5–10 years.
• ✅ Can be used as emergency contraception up to 5 days after unprotected sex.
• 👎 Side effects: heavier/longer periods initially, cramping, rare perforation or expulsion.
• 👍 Hormone-free, safe in breastfeeding, fertility returns immediately on removal.

💊 Combined Oral Contraceptive (COC – “the pill”)

• Contains oestrogen + progestogen → inhibits ovulation + thickens cervical mucus.
• ~99% effective if used correctly; typical use ~91%.
• 📅 Usually 21 days on + 7 pill-free days (or placebo pills).
• 🌸 Benefits: lighter, regular periods; reduced acne, PMS, ovarian & endometrial cancer risk.
• 💔 Risks: ↑ VTE, stroke, hypertension, small ↑ breast/cervical cancer risk.
• ❌ Avoid if: smoker >35, migraine with aura, VTE/stroke history, uncontrolled hypertension, liver disease, active cancer.

💊 Progestogen-Only Pill (POP – “mini pill”)

• Effective in theory 99% but ~91% typical use.
• Must be taken same time daily (traditional POP ±3h, desogestrel POP ±12h).
• 👍 Safe in smokers, >35 yrs, breastfeeding women, and those with contraindications to oestrogen.
• 👎 Irregular bleeding, acne, headaches, breast tenderness, functional ovarian cysts.

📍 Implant (etonogestrel)

• 💉 Flexible rod under skin of upper arm; lasts 3 years.
• Over 99% effective, “fit and forget” option.
• 👎 Side effects: irregular bleeding, weight change, mood disturbance, headaches.
• Fertility returns rapidly on removal.

💉 Contraceptive Injection (Depo-Provera, Sayana Press, Noristerat)

• Given every 8–13 weeks depending on preparation.
• Over 99% effective with correct use.
• 👍 Suitable for women who cannot take oestrogen.
• 👎 Side effects: irregular bleeding, weight gain, mood changes, reduced bone mineral density (use with caution in teenagers/long-term use).
• ⏳ Fertility may take several months to return after stopping.

🌀 Intrauterine System (IUS – Hormonal Coil, e.g. Mirena)

• Small T-shaped device releasing levonorgestrel.
• 💯 >99% effective; lasts 3–6 years depending on brand.
• 🌸 Benefits: lighter periods, many women become amenorrhoeic, less dysmenorrhoea.
• 👎 May cause irregular spotting initially; insertion risks (infection, perforation).
• ✅ Used in management of menorrhagia as well as contraception.

🛡️ Barrier Methods

• Condoms (male/female) = only method that protects against STIs.
• Effectiveness: 85–98% depending on consistency and correct use.
• 👎 Can split or slip; some couples find they reduce spontaneity.
• ✅ Cheap, widely available, hormone-free, used in combination with other methods.

👩‍👧 Contraception in Adolescents and Young Women

Young people (<18) often present with unique challenges: safeguarding, confidentiality, irregular cycles, and higher risk of unintended pregnancy and STIs. Doctors must balance autonomy with child protection responsibilities.

⚖️ Legal & Ethical Framework (UK – Fraser Guidelines)

• Under-16s may consent to contraception if they demonstrate competence (Gillick competence).
• Confidentiality must be respected unless there are safeguarding concerns (e.g. coercion, abuse).
• Discuss safe sex, STI protection, and encourage parental involvement if appropriate.

🔑 Key Considerations

• High rates of inconsistent use and discontinuation → need methods that are easy to remember or “fit and forget”.
• STI risk is high → always advise on condom use even if another method chosen.
• Safeguarding concerns (sexual exploitation, coercion, abuse) must always be considered.

💡 Recommended Methods

• Long-Acting Reversible Contraception (LARC): – Implants (etonogestrel) 💉 and IUS/IUD 🌀 are highly effective, don’t rely on daily adherence, and are recommended by NICE/FSRH as first-line for young people. – Need careful explanation and reassurance about insertion.
• Combined Oral Contraceptive (COC): – Popular choice for cycle regulation and acne 🌸. – Requires good adherence; missed pills are common in teenagers.
• Progestogen-Only Pill (POP): – Good option if oestrogen contraindicated; but needs strict daily compliance ⏱️.
• Condoms: – Essential for STI protection 🛡️, always advised alongside other contraception.

🚫 Methods to be cautious with

• Depot injection (Depo-Provera): Can reduce bone mineral density 🦴, a concern in adolescents; should not be first-line unless no alternatives are suitable.

🌸 Wider Support & Health Promotion

• STI screening (Chlamydia, Gonorrhoea) should be offered routinely.
• HPV vaccination 💉 is crucial in prevention of cervical cancer.
• Discuss healthy relationships, consent, and sexual wellbeing as part of holistic care.
• Encourage follow-up and ongoing support, as adherence can be challenging.

🧪 Emergency Contraception

• ⚡ Copper IUD: Most effective, can be fitted up to 5 days after unprotected sex.
• 💊 Levonorgestrel pill: Within 72h; effectiveness decreases with time.
• 💊 Ulipristal acetate (ellaOne): Up to 120h after sex, more effective than levonorgestrel after 72h; avoid if on hormonal contraception (requires 5-day gap).

✨ Key Exam Tips

• 🌡️ IUD = immediate protection + emergency contraception.
• ⏱️ POP = 2 days; everything else (except copper coil) = 7 days if not started day 1 of period.
• 💔 COC → avoid in smokers >35 & migraine with aura.
• 🌸 POP safe in smokers & breastfeeding women.
• 🛡️ Condoms = only STI protection.

📚 References

• NHS Contraception Guide
• Faculty of Sexual & Reproductive Healthcare (FSRH) Guidelines
• NICE CKS: Contraception

Clinical cases

• 💊 Case 1 – Age 19 (Combined Pill): University student requested contraception for the first time. Regular cycles, BMI 22, non-smoker, no migraines or family history of thrombosis. Choice: Combined oral contraceptive pill (ethinylestradiol + levonorgestrel). Advice: Take at the same time daily; 21 days on, 7 days off. Discussed benefits (cycle control, acne improvement) and risks (VTE, hypertension). Teaching point: The combined pill is first-line for young, healthy, non-smoking women - ensure BP and BMI are checked before prescribing.
• 🚭 Case 2 – Age 36 (Progestogen-Only Pill): Smoker (10/day) seeking contraception. Combined pill contraindicated due to age and smoking. Choice: Desogestrel-containing progestogen-only pill (POP). Advice: Take at the same time daily (within 12-hour window); may cause irregular bleeding. Teaching point: POP is safe in smokers and those with cardiovascular risk factors - acts mainly by cervical mucus thickening and endometrial suppression.
• 🩺 Case 3 – Age 28 (LARC): Woman with chaotic lifestyle and difficulty remembering tablets requested a low-maintenance option. Choice: Levonorgestrel intrauterine system (Mirena). Advice: Provides 5 years’ protection, lightens or stops periods, and is rapidly reversible. Counselling given on insertion discomfort and infection risk. Teaching point: Long-acting reversible contraception (LARC) is highly effective and suitable for those seeking “fit and forget” options.
• 🤱 Case 4 – Age 32 (Postpartum): Six weeks after delivery, breastfeeding and undecided about more children. Choice: Progestogen-only implant (etonogestrel, Nexplanon). Advice: Safe while breastfeeding; effective for 3 years; may cause irregular bleeding. Discussed timing of insertion and fertility return after removal. Teaching point: Oestrogen-containing methods are avoided in the first 6 weeks postpartum due to VTE risk - progestogen-only options are preferred for lactating women.