Various drug treatments for contraception are available: combined oral contraceptives (containing an oestrogen and a progestogen), progestogen-only oral contraceptives, a transdermal patch (containing an oestrogen and a progestogen), parenteral progestogen-only contraceptives, implants, intra-uterine devices (copper or progestogen-containing), caps, diaphragms and spermicides (nonoxinol-9). Emergency hormonal contraceptives are levonorgestrel and ulipristal - a progesterone receptor modulator.

Dosage regimen

•    Combined oral contraceptive: one tablet daily for 21 days (and repeated after a seven-day interval). Every day (ED) combined oral contraceptives: one tablet daily.

•    Progestogen-only contraceptive: one tablet daily. Emergency contraception with levonorgestrel: 1.5mg as a single dose as soon as possible after coitus (preferably within 12 hours but no later than 72 hours).

•    Combined contraceptive patch: one patch weekly for three weeks followed by a patch-free week.

•    Parenteral progestogen-only contraceptive: medroxyprogesterone acetate 150mg by deep intramuscular injection within the first five days of the cycle or within the first five days after parturition (delay until six weeks after parturition if breastfeeding); norethisterone enantate 200mg by deep intramuscular injection within the first five days of the cycle or immediately after parturition (duration eight weeks).

•    Etonogestrel implant 68mg by subdermal implantation during first five days of the cycle.

•    Ulipristal: 30mg as a single dose as soon as possible, but no later than 120 hours (five days) after coitus.

•    Intra-uterine system releasing levonorgestrel 20micrograms/24 hours. Usually inserted into uterine cavity within seven days of onset of menstruation.

•    Spermicides: To be used in conjunction with a barrier contraceptive.

Patient’s knowledge of the medicine’s use

•    Ensure patient is taking the combined oral contraceptive at the same time each day. If the tablet is delayed by 24 hours or more (12 hours or more for Qlaira), it is regarded as a ‘missed pill’.

•    If one pill missed: take an active pill as soon as remembered, then resume normal pill-taking.

•    If two or more pills missed: take an active pill as soon as remembered and, as the woman may not be protected, advise to use additional precautions (abstinence or barrier methods) for the next seven days. If these seven days run beyond the end of the packet, active tablets in the next packet should be started immediately.

•    If two or more combined oral contraceptives have been missed from the first seven in a packet and unprotected intercourse has occurred since finishing the last packet, advise emergency contraception.

•    Ensure patient is taking the progestogen-only oral contraceptive at the same time each day. Contraceptive protection may be lost if the tablet is delayed by three hours or more (12 hours for Cerazette), and it should be regarded as a ‘missed pill’.

•    If a woman forgets to take a progestogen-only pill, it should be taken as soon as she remembers, and the next one taken at the normal time. If the delay is three hours or longer (12 hours or longer for Cerazette) then she is not protected and should continue normal pill-taking and use additional precautions (abstinence or a barrier method) for the next two days. The Faculty of Sexual and Reproductive Healthcare recommends emergency contraception if one or more progestogen-only contraceptive tablets are missed or taken more than three hours late (12 hours for Cerazette) and unprotected intercourse has occurred before two further tablets have been taken correctly.

•    Intra-uterine progestogen-only system: releases levonorgestrel directly into the uterine cavity. Another indication besides contraception is for treating primary menorrhagia.

•    The transdermal patch should be applied on day one of the menstrual cycle then replaced on days eight and 15. On day 22, the patch should be removed and seven days allowed to elapse before a new patch is applied. If the woman forgets to apply a patch on day one, she should apply it as soon as she remembers but use additional contraceptive measures for seven days.


Is the medicine working?

•    Assess whether adequate contraception is being provided by the chosen method.

•    If a patch is being used, is the woman experiencing any problems with the patch detaching from the skin?

•    Advise the patient that vomiting or very severe diarrhoea within two hours of taking an oral contraceptive can interfere with its absorption. If there is vomiting within three hours of taking ulipristal, the dose should be repeated.

Side effects

•    Combined contraceptives: Nausea, vomiting, headache, changes in body weight, fluid retention and risk of thrombo-embolism.

•    Progestogen-only oral contraceptive: menstrual irregularities, nausea, vomiting, headache, breast discomfort, weight changes and risk of thrombo-embolism.

•    Parenteral medroxyprogesterone: delayed fertility and irregular cycles may occur after discontinuation. There is a rapid return to fertility after removal of an etonogestrel-releasing implant and intra-uterine progestogen-only system.

•    Intra-uterine progestogen-only system: abdominal pain, peripheral oedema, nervousness and pelvic pain.

•    Spermicides: local irritation. May also increase the chance of contracting sexually transmitted infections.

Monitoring

•    Oral and transdermal contraceptives: blood pressure and weight needs monitoring. If there is an increase in headache frequency or onset of focal symptoms, the tablets should be discontinued immediately and medical advice sought urgently.

•    Women using an implant, injection or IUS need to be seen by a GP only when the device requires replacing, or if they are experiencing any unusual or worrying symptoms.

•    The Committee on Safety of Medicines has advised that the benefits of medroxyprogesterone  acetate should be evaluated against the risks after two years, and other methods considered for women at risk of osteoporosis.

Lifestyle

•    Women may want advice on how quickly normal fertility levels will return if they stop using their contraceptive. This could happen immediately or take a few months with oral contraception (see also parenteral and IU system above). This is also a good opportunity to provide advice on losing weight, stopping smoking, taking folic acid, maintaining a balanced diet and taking regular exercise.

•    Women wanting to monitor their fertility more closely may wish to use a fertility thermometer or ovulation testing kits.

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