C H A P T E R 2 7 Contraception and sexual health in a global society

1. C H A P T E R 2 7 Contraception and sexual health in a global society

3. -CHAPTER CONTENTS • The role of the midwife • Hormonal contraceptive methods • The combined hormonal contraceptive pill • The combined hormone injectable (Lunelle) • The combined hormone patch • The combined hormone vaginal ring • The progestogen-only pills • Long acting reversible contraception (LARC) • Progestogen injections • Subdermal contraceptive implants • Intrauterine contraceptive device (IUCD) • Progestogen-releasing intrauterine system (IUS) • Barrier methods of contraception (male and female methods)

4. Male condom • Female condom • Diaphragm • Cervical and vault caps • Spermicidal products • Emergency contraception • Coitus interruptus • Fertility awareness (Natural Family Planning) • Fertility awareness methods • Symptothermal methods • Fertility monitoring device • Lactational amenorrhoea method (LAM) • Male and female sterilization • Female sterilization • Male sterilization (vasectomy) • The future of contraception and sexual health services

5. The role of the midwife • The midwife has a unique and pivotal role in discussing contraception and sexual health. • one of the activities of a midwife is to provide sound family planning information and advice . • Midwives are encouraged to take on a wider public health role and are in a key position to create and use opportunities to enable women to express their needs in respect of choice of contraception. • The most appropriate time to discuss sexual health, be dependent on the individual woman,with postnatal women, even soon after giving birth

7. contraception advice should be imparted within a week of the birth. Issues such as loss of libido, adjustment to motherhood, breastfeeding, discomfort of the perineum, vaginal dryness and body image may also influence choice and use of a particular method of contraception • The use of a leaflet can be helpful as such leaflets are clear to understand. • The midwife should be familiar with the contraception and sexual health services available in the area in which she practises and know the system of referral to these specialist services.

8. the efficacy rate is given as a percentage. This rate does not reflect the fact that fertility decreases with age and may be suppressed during lactation, or that the success of a method is partially dependent on motivation, experience of using the method and the teaching received on its use. It is recognized that if 100 sexually active women do not use any contraception, 80–90 of them will become pregnant within a year primigravidae that almost 60% of the women had not resumed

10. intercourse six weeks following the birth. Discussions need to take place well before this time to ensure no unintended pregnancies occur. Some women may even appreciate information on contraception in the antenatal period, to give them plenty of time to decide which contraceptive method would be right for them. Partnership working between the new mother and midwife is essential and conversations regarding contraception should take place in a quiet, relaxed setting, with the midwife having up-to-date knowledge on all methods available.

11. Hormonal contraceptive methods • The combined hormonal contraceptive pill • The combined oral contraceptive pill (COC or ‘the pill’) came as a breakthrough, in 1960 • proven to be both effective and safe. • Around 100 million women rely on the pill worldwide

12. The combined pill contains the synthetic steroid hormones oestrogen and progestogen. • All COCs contain ethinyl oestradiol, with the exception of Norinyl-l, which contains mestranol and Qlaira which contains estradiol valerate. • There are a variety of COCs available containing different progestogens. • differences in their biological effects • monophasic pills, which deliver a constant dose of steroids throughout the packet. ‘ • Everyday’ pills contain 28 pills in each packet, 21 of which are active monophasic pills while the seven remaining pills contain no hormone

13. Also available are biphasic and triphasic pills, in which the dose of steroids administered varies in two or three phases throughout the packet to mimic the natural fluctuations of the hormones during the menstrual cycle. These pills are less commonly used. • new pill, called Qlaira, it is a complex quadraphasic pill designed to give optimal cycle control. • It is taken every day but has two placebo tablets. • The first generation COC pills contained large doses of oestrogen and were associated with a high risk of deep vein thrombosis.

14. replaced pills that had lower doses of oestrogen and progestogen. They were equally as effective as the earlier pills, being much safer and befer tolerated. • The progestogens in these second generation pills were norethisterone and levonorgestrel. • The third generation pills,which came along in the mid-1980s, contained a variety of new synthetic progestogens, that appeared to have befer effects on serum lipid profiles. • Among these were desogestrel and norgestimate, which were also less androgenic • gestodene, which was the most potent, achieving the best cycle control • cyproterone acetate, which was anti- androgenic but licensed only as a treatment for acne. • Drospirenone has been available from the late 1990s, with mild antimineralocorticoid activity to counteract oestrogen- induced water retention. It is also anti-androgenic

15. Mode of action • Combined oral contraceptives work primarily by preventing ovulation. • The first seven active pills in a packet inhibit ovulation and the remaining pills maintain anovulation • Oestrogen and progestogen suppress follicle stimulating hormone (FSH) and luteinizing hormone (LH) production causing the ovaries to go into a resting state • the ovarian follicles do not mature and ovulation does not normally take place. • Progestogen also causes the cervical mucus to thicken, making penetration by spermatozoa difficult. • The pill renders the endometrium unreceptive to implantation by the blastocyst. These actions provide additional contraception in the event of breakthrough ovulation occurring. • Efficacy • Provided that the pill is taken correctly and consistently, and that it is absorbed normally and interaction with other medication does not affect its metabolism, its reliability with consistent perfect use is almost 100%

17. Important considerations • The combined oral contraceptive pill is a reliable contraceptive, which is independent of sexual intercourse The combined oral contraceptive pill is a reliable contraceptive, which is independent of sexual intercourse and has many advantages. • benefits of taking the COC pill, in the short term, are • Regular • lighter • less painful periods • possible reduction in premenstrual symptoms • reduction in acne • protection against pelvic inflammatory disease (PID) (because of the thickened cervical mucus) • decreased incidence of ectopic pregnancy • and reduced risk of benign breast disease. • Taken long term, COC pills offer protection against ovarian and endometrial cancers • reduction in the incidence of ovarian cysts and benign ovarian tumours

19. Use of the COC pill may lead to side-effects such as : • irregular bleeding • headaches • nausea • breast tenderness • lifle evidence to support the association of weight increase depressionCOC use • These effects often diminish with continued use or may improve with a change of pill. • A basic knowledge of the side- effects attributable to the components of the COC pill is helpful when making decisions about changing pills.

20. Oestrogen dominance in a pill may cause: • water retention • resulting in breast tenderness, • mild headaches, • elevated blood pressure • and cyclical weight gain. • nausea and vomiting, • excessive vaginal secretion (leucorrhoea) • skin pigmentation similar to chloasma. • The progestogens • :may lower mood and libido • provoke acne • seborrhoea • cause mastalgia.

21. majority of women experience no adverse effects. • Every woman is unique in their biological response and also in their perception and tolerance of side-effects. • The metabolic effects of the COC pill can occasionally result in major side-effects. • The risks of venous thromboembolism (VTE) with the COC pill, in absolute terms, show a rarity of VTE in women of reproductive age • The risk of VTE is higher in women with a Body Mass Index (BMI) over 30, heavy smokers, those with a previous history of deep vein thrombosis or a family history of venous thrombosis and those who are immobile.

22. Table 27.1 • Risks of venous thromboembolism • Risk of VTE per 10 000 woman years

23. the risks of VTE when comparing all COCs appear to be unclear, but if there are differences they are likely to be very small and similar, therefore, any of the COCs may be considered for prescription if this method has been chosen for contraception. • Some women may develop a significantly high blood pressure, which could increase the potential for haemorrhagic stroke and myocardial infarction. Hypertension with a blood pressure (BP) between 141/91 mmHg • and 159/94 mmHg is considered to be at a level of risk that outweighs the benefits of using the COC. • Hypertension with BP of 160/95 mmHg or higher poses an unacceptable health risk with COC use

24. Cigarette smoking is known to potentiate most of the risks associated with COC pill use such as ischaemic and haemorrhagic stroke and myocardial infarction • the risk of developing breast cancer for COC users is largely contradictory, but it is widely acknowledged that there is a small increase in this risk • Any excess risk of breast cancer associated with COC use declines in the first ten years after discontinuing the pill.

25. a small increase in the relative risk of cervical cancer, which is associated with a long duration of use. • the effects of confounding factors such as sexually transmitted infections (STI), non-use of barrier methods and a high number of sexual partners may distort an accurate understanding of the influence of the COC pill. • Contraindications to COC pill use are : • Pregnancy • undiagnosed abnormal vaginal bleeding • , history of arterial or venous thrombosis (or predisposing factors such as immobility), • hypertension, • focal migraines,

28. current liver disease, • trophoblastic disease (until serum human chorionic gonadotrophin [hCG] is no longer detectable) • , smoking (if the woman's age is over 35 years) and a BMI over 39. • This is not an exhaustive list. As the pill is not suitable for everyone, women wishing to consider using this form of contraception should have a full history recorded and be fully informed and counselled regarding possible side-effects.

29. Using the COC pill • first pill is usually taken on the first day of the menstrual period (for postpartum use, see later). • Starting on any day up to the fifth day is just as effective, provided the first seven pills are taken correctly. • If a 21-day pill has been prescribed, the contraceptive effect is immediate, provided that the remainder of pills in the packet are taken correctly. • If the pill is initially commenced on any day beyond the fifth day of the cycle, additional contraception (such as a condom) should be used in conjunction with the pill for the first seven days. • It is recommended that Qlaira is taken on the first day of the menstrual cycle, and if taken on any other day, additional contraception should be used for nine days. • One pill is taken every day for 21 days, then no pills for the next seven days. Vaginal bleeding usually occurs within the seven day break, before the next packet of pills is commenced

30. When commencing the ‘Everyday’ (ED) COC pill, the active pills are taken first. One pill is taken daily, with care to take the pills in the correct order. • Vaginal bleeding will usually occur when the inactive pills are taken, which are usually denoted by a different coloured section on the pill packet. • If two or more pills have been missed, or the next pack of pills is two or more days late, the advice given in should be followed. • If a pill is forgotten from the beginning or end of a packet, the pill-free interval is lengthened and ovulation may be more likely to occur • If a woman is concerned about a missed or late pill, she can contact the local contraception clinic or General Practitioner (GP) for reassurance or advice, as emergency contraception may be indicated

31. Other factors that may render the pill less effective include: • interaction with other medication • vomiting within 2 hours of taking a pill • severe diarrhoea. • Medications that may hinder the effectiveness of the pill include liver-enzyme-inducing drugs such as rifampicin, • some anticonvulsants and some herbal remedies, • for example St John's wort. • after absorption, synthetic oestrogen and progestogen are transported to the liver via the portal vein. • Liver-enzyme-inducing drugs reduce the efficacy of the pill by increasing the metabolism, and subsequent elimination of oestrogen and progestogen in the bile. • Some newer antiepileptics are not enzyme inducers but the COC pill may reduce seizure control with lamotrigine.

32. Please note that additional precautions are no longer required when taking antibiotics (non-enzyme inducing) • The advice to be given in cases of an illness with severe vomiting and diarrhoea is to follow the missed pill rules. • It is important that women are made aware of possible drug interactions and inform their medical practitioner/GP

34. Preconception considerations • It is useful to wait for one natural period after discontinuing the pill before trying to conceive as dating the pregnancy can be more accurate and pre-pregnancy care can begin. • Postpartum considerations • The combined oral contraceptive pill reduces milk supply, particularly if lactation is not well established, and is therefore not recommended for use in the early months in lactating women. If the mother is bottle-feeding her baby, the COC pill may be commenced 21 days postpartum. • This allows the high oestrogen levels of pregnancy to decrease before introducing the pill • thus reducing the risk of thromboembolism, but allowing the contraceptive effect to be initiated before ovulation resumes. • Women who have experienced pregnancy-induced hypertension should be assessed on an individual basis with regard to recommencing COC use

36. The COC pill can be commenced immediately following spontaneous miscarriage or therapeutic termination of pregnancy. • Due to the risk of thromboembolism, the COC pill should be discontinued 4 weeks before major surgery and a progestogen-only method of contraception used. • If this is not possible, then thromboprophylaxis and compression hosiery are advised. • Women who have minor surgery do not need to discontinue taking the pill. • Appropriate follow-up, including blood pressure assessments, should be conducted. • Following the first prescription, follow-up is usually at 3 months postpartum and thereafter it may be annually.

37. The combined hormone injectable (Lunelle) • Lunelle contains 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. • Lunelle is commenced on the first day or within five days of a menstrual period, and given every 28–33 days. • It is both effective and reversible. Side-effects include breakthrough bleeding and weight gain. • The efficacy is comparable with perfect use of the COC pill. • Cyclofem and Mesigyna are similar monthly injections also available to women

40. The combined hormone patch • The combined hormone patch (EVRA) • One patch is used weekly for three weeks followed by one week patch-free. • It is particularly suitable for women who are unable to tolerate oral medications and those with malabsorption syndrome. • It releases 20 mg of ethinyl oestradiol and 150 mg of norelgestromin every 24 hours. • Compliance and cycle control may be improved. • The efficacy of the combined hormone patch is comparable with the COC pill. The patch may be worn on most places on the body except the breasts. • It is extremely sticky and should stay on during showering or swimming. • it may be used from day 21 in the postnatal period. However, if the mother is breastfeeding her baby, the patch should not be recommended as it will reduce breast milk production.

42. The combined hormone vaginal ring • The combined hormone vaginal ring (NuvaRing) is inserted into the vagina on the first day of the menstrual cycle. If inserted at any other time additional contraception such as condoms should be used for seven days. • It is then used continuously for three weeks followed by one week free of its use. • It releases 15 mg of ethinyl oestradiol and 120 µg of etonogestrel per 24 hours. • The NuvaRing appears to be acceptable to many women and well tolerated, with studies finding that compliance and cycle control are also remarkably good

44. The progestogen-only pills • Progestogen-only pills (POP) were introduced partly to avoid the side-effects of oestrogen in the combined pill, as discussed earlier. They also offer increased choice for women. Currently available in the UK are the older preparations, which contain norethisterone (Noriday, Micronor), etynodiol diacetate (Femulen) and levonorgestrel (Norgeston) and the new anovulant progestogen-only pills containing desogestrel (Cerazette). All have lower doses of progestogen compared with the COC pill.

46. Mode of action • The POP exerts its contraceptive effects at different levels. • The cervical mucus is viscid, making it impenetrable to spermatozoa and the endometrium is modified to prevent implantation. • The older POPs have been shown to suppress ovulation in up to 60% of women. • The new POP Cerazefe is anovulant and also suppresses FSH and LH consistently such that it is effective in about 97% of women • Limitations to POP use include menstrual disturbances, encompassing unpredictable and quite often prolonged bleeding, oligomenorrhoea or amenorrhoea

47. . Little is understood about the mechanism of erratic uterine bleeding, which most women experience to some degree. • The menstrual disruption is the most common reason for discontinuation of progestogen-only methods. • This indicates the need for careful explanation of the limitations to potential users. • An increased prevalence of functional ovarian cysts has been demonstrated in women using progestogen-only pills. • These may settle with continuation of use and will resolve if the POP is discontinued.

48. Contraindications to the use of progestogen-only-pills are: • pregnancy • undiagnosed abnormal vaginal bleeding • severe arterial disease • hydatidiform mole (until serum hCG is no longer detectable). • The rate of ectopic pregnancy in women using the progestogen-only pill is no higher than in women using no contraception; • the POP prevents uterine pregnancy more effectively than tubal pregnancy. • This is not a problem with the anovulant POP Cerazette. • Antibiotics do not adversely affect progestogen-only methods of contraception but women should be advised to consult the doctor/GP regarding possible interactions if any other medications (especially enzyme inducers such as rifampicin) are prescribed.

49. Preconception considerations • There is no evidence of a teratogenic effect with the POP. • Postpartum considerations • Progestogen-only-pills may be commenced 21 days postpartum for contraception. • These pills have no adverse effect on lactation. • Secretion of the hormone in breast milk and absorption by the neonate is minimal and does not affect the short-term growth and development of infants. • The POP can be used immediately following spontaneous miscarriage or therapeutic termination of pregnancy.

50. Using the POP • The POP is taken every day as there are no pill-free days and thus tablets are taken throughout the menstrual period. • If the first tablet is taken on the first to fifth day of the menstrual cycle, the contraceptive effect is immediate. • If the POP is started on any other day of the cycle then additional contraception, such as a condom, should be used for the first two days • If a pill is forgotten, the woman has only 3 hours in which to remember to take it.