Contraception Treatments

Contraceptive methods can be quite confusing as there are so many available. This guide is intended to help you make an informed decision. Common questions asked in my clinic are:

“Where can I get contraception?”

“Which method of contraception suits me?”

“Is it 100% effective?”

“Does it have any side effects?”

Whatever questions you may have, we at The Family Chemist can help.

The following methods of contraception are available in the UK:

• Combined oral contraception (COC) – These come in pill, patch, and vaginal ring form. We at The Family Chemist only sell the pill and patch form. You may recognise the COC pill as “the pill”. It contains artificial estrogen and progesterone, which are produced naturally by the ovaries.
• Progesterone-only contraception – These come in a pill, implant, and injectable form. We at The Family Chemist only sell the pill form. Progesterone-only pills (POP) thicken the mucus in the cervix to stop sperm from reaching the egg and can also stop ovulation.
• Intrauterine contraception – These come in a copper intrauterine device (Cu-IUD) and levonorgestrel intrauterine system (LNG-IUS). Often referred to as a “coil”. These are available from your GP or GUM clinic. More information can be found here.
• Barrier methods – Male condom, female condom, and diaphragm or cap (plus spermicide). These methods form a physical cover to prevent sperm from entering the womb.
• Sterilisation methods – Male sterilisation (vasectomy) and female sterilisation (tubal occlusion). These are surgical procedures and are carried out by specialist services across the UK.
• Natural family planning – Fertility awareness methods and lactational amenorrhea methods.

I know what’s next…” give me the best contraceptive pill”. Unfortunately, the selection process is much more complex. There are many things to consider when selecting your most suitable contraceptive method. Your needs and personal circumstances are important as some contraceptive pills can do more for your health than just prevent pregnancy. These include:

• Whether you would like regular periods or no periods.
• Whether you want liighter/less painful periods
• Whether you want less acne
• Whether you want less premenstrual symptoms such as bloating, breast pain, and mood swings before your period is due?
• Whether you want something that is less effort to remember
• Whether you want a method without hormones
• Your future plans for having children
• Personal beliefs and views about contraception
• Attitudes of your partner and family towards contraception.

By answering the question accurately, The Family Chemist clinician can make this process easier. An excellent website which I use can help narrow down your choice: Contraceptionchoices.org

How does a combined oral contraceptive pill work?

The mechanism of action is to primarily stop the release of an egg from the ovaries (ovulation). Ovulation is inhibited by the actions of oestrogen and progesterone. The two hormones reduce the production of luteinizing hormone and follicle-stimulating hormone. With no surge in LH and FSH to stimulate the ovaries, ovulation does not occur. COC also 1. thicken the mucus in the neck of the womb, so it is harder for the sperm to penetrate the womb and reach an egg. 2. Thins the lining of the womb so there is less chance of an egg implanting in the womb and growing.

There are three different types of COC:

• Monophasic 21-day pills: This is the most common type used. Each pill contains the same amount of estrogen and progesterone. You take the pill at the same time each day for 21 days then have a 7-day break where you will get a bleed. You start the pack on the 8^th day whether you are bleeding or not. Common examples include Microgynon, Marvelon, and Yasmin.
• Phasic 21-day pills: These contain 2-3 sections of different colour pills in a pack and contain different strengths of estrogen and progesterone. You take the pills for 21 days with a 7-day break however the order of pill taking must be followed correctly. These are great for women who may find some side effects of monophasic pills unmanageable. A common example of this type is called Logynon.
• Every day (ED) pills: These contain 28 pills, with 7 of them being dummy pills. The seven inactive pills contain no hormones in it. They need to be taken in the correct order and help patients remember to take the medication correctly. A common example of this type is Microgynon ED.

Doses or strengths of oestrogen can vary. Standard strengths include 30-35 micrograms of ethinylestradiol in monophasic COCs and 30-40 micrograms of ethinylestradiol in phased preparations. Low-strength COCs are also available.

Advantages

• COCs are more effective at preventing pregnancy than barrier methods.
• Menstrual bleeding is usually regular, lighter, and less painful.
• Reduced risk of ovarian and endometrial cancer.
• Reduced risk of colorectal cancer and functional ovarian cysts and benign ovarian tumours.
• Reduced severity of acne in some women
• Normal fertility returns almost immediately after stopping COC.

Disadvantages

• Some women may experience temporary adverse effects when starting COCs: headaches, nausea, mood changes and breast tenderness.
• It does not protect you against STIs.
• It may increase your risk of breast and cervical cancer.
• It may increase the risk of deep vein thrombosis (DVT) and other blood clots.
• Less effective than long-acting reversible methods such as Cu-IUD or LNG-IUS.
• It can increase your blood pressure.
• Breakthrough bleeding and spotting are common in the first few months of using the pill.
• It can interact with certain medicines.

The effectiveness depends on the type of contraception you use and whether you use it correctly. You must follow the instructions from your clinician and patient information leaflet. No contraceptive is 100% effective. When taken correctly at the same time each day, the pill is over 99% effective. This means 1 in 100 women will become pregnant each year. However, realistically we can all agree there is a high chance you will either forget to take a pill, take it at the wrong time, be sick or have diarrhoea, etc. In these cases, the pill is 91% effective, which means 9 in 100 women each year will become pregnant.

The risk of side effects is the same no matter what brand you use however, the severity of side effects varies from person to person. The most common side effects are nausea and abdominal pain, headache, breast pain and/or tenderness, breakthrough bleeding or spotting. Less common side effects include high blood pressure and changes in cholesterol.

The risks are low, but it is important you take an informed decision about your care.

• High blood pressure, heart attack and stroke – greatest in patients with pre-existing diseases such as CVD, diabetes, BMI>35kg/m2, migraines with aura or immediate family history.
• Venous thromboembolism (VTE): The risk is very low: 5-12 per 10,000 women. The risk of VTE is influenced by the progesterone component. COC containing levonorgestrel, norethisterone, or norgestimate have the lowest risk (5–7 per 10,000 women-years). These include levest, microgynon, rigevidon and ovranette. Those containing drospirenone, desogestrel, or gestodene have the highest risk (9–12 per 10,000 women-years). These include Yasmin.
• Breast and Cervical cancers: A small risk, but it is important to attend the routine cervical screening to rule out any risk.
• Mood changes: Speak to your doctor immediately if it develops into depression.

Generally, you would start the combined oral contraceptive on day 1 of your menstrual cycle if you are not using regular contraception or barrier methods such as condoms, you will be protected from pregnancy immediately. You will not need additional contraception. If you start your COC at any other time, it is essential that you use additional contraceptive measures such as condoms for the first seven days (9 days for Qlaira). If pregnancy cannot be excluded, take the COC immediately with 7-9 days of additional barrier methods and take a pregnancy test no sooner than three weeks after the last unprotected sexual intercourse.

When can I start a COC after taking oral emergency contraception?

For levonorgestrel (Levonelle), you would start the COC immediately and take additional barrier methods such as condoms for the first 7-9 days.

For Ellaone, you would start the COC 5 days after taking Ellaone and use additional barrier methods such as condoms for the first 7-9 days.

The 20mcg/30mcg/35mcg pill refers to the amount of oestrogen (ethinylestradiol) in one pill. All strengths provide the same contraceptive effect. However, the 20mcg pill has a lower incidence of side effects and a better safety profile than the higher strengths. An example of a 20mcg pill is Loestrin 20.  I have noted some advantages and disadvantages of taking the 20mcg pill over the 30mcg pill. However, it is important to note that both strengths still carry the same risks and benefits.

Advantages

• The 20mcg pills do have less effect on clotting factors, but the risk of blood clots is still similar to 30mcg pills.
• Lower incidence of nausea and vomiting
• Non-smoking, fit, and healthy women with a BMI<30 may find a 20mcg dose acceptable as a lower oestrogen strength may reduce cardiovascular/stroke risk.

Disadvantages

• Increased risk of breakthrough bleeding due to lower strength of oestrogen.
• Not as beneficial for Acne

Progesterone-only pills, also known as “mini pill” don’t contain oestrogen and can prevent pregnancy by thickening the mucus in the cervix to stop sperm from reaching the egg. This change is quick but short-lived and returns to normal if the pill isn’t taken correctly. The desogestrel pill can stop ovulation by preventing luteinising or follicle-stimulating hormone peaks. Other modes of action include slowing down the passage of the egg from the ovaries to the reproductive tract and preventing implantation of the egg. POP is more than 99% effective if taken correctly. These need to be taken daily with no break between packs of pills. They are ideal for patients who cannot use the more common contraception: combined only pills. They are more tolerable than the COC as they have fewer side effects. The POP is a bit trickier as it must be taken simultaneously each day. As you take the pill daily, you may notice that your periods become lighter, irregular, more frequent or stop completely.

The POPs currently available in the UK contain:

Norethisterone 350mcg (Noriday)

Levonorgestrel 30 micrograms (Norgeston)

Desogestrel 75 micrograms (Cerazette, Cerelle, Zelleta and others): Most common type.

Advantages

• It can be used in women who can’t take oestrogen or a combined oral contraceptive.
• Suitable for breastfeeding women, women with high blood pressure, smokers over 35, those experiencing migraines, and having a family history of blood clots.
• It can be used on patients with a high chance of forgetting to restart the pill after a 7-day pill-free break.
• It can help with post-menopausal symptoms and painful or heavy periods.

Disadvantages

• The mini pill must be taken simultaneously daily with no pill-free intervals. (Within 3-12 hours of your usual time every day)
• Side effects may occur such as breakthrough bleeding and breast tenderness.
• Your periods may stop, become irregular or develop heavier periods.
• Does not improve acne.

All medications have the risk of side effects which differ from person to person. Just like the combined pill, the POP also carries a higher risk of side effects in the first few months. These tend to wear off after a couple of months. These include menstrual irregularities, breast tenderness, low sex drive, mood changes, headache, and weight changes. If you suffer from depression, panic attacks, migraines, cysts on your ovaries, or symptoms lasting longer than three months, you should see your doctor.

The pill should be taken daily with no pill-free intervals and simultaneously each day to ensure maximal efficacy. If the pill is taken more than 3 hours late (or 12 hours late for a desogestrel pill) you should follow the missed pill guidance. You can start the progesterone-only pill at any time in your menstrual cycle.

What time of day should I take the progesterone-only pill?

Take the progesterone-only pill at the time of day that best suits you to help with compliance. You can start the progesterone-only pill at any time in your menstrual cycle. The mini pill will be effective immediately if you start the pill on the first five days of your period. If you have a short menstrual cycle you will need to take the pill for 2 days before the tablet starts working. Taking additional contraception in the first two days, such as condoms. If you start any other day, you will need additional contraception (condoms) until you’ve taken the pill for 2 days.

Starting the mini pill after having a baby?

You can start the progesterone-only pill on day 21 after giving birth. If you start after 21 days, then you will need additional contraception (condoms) until you have been taking the mini pill for two days.

If you vomit within 3 hours of taking a combined oral contraceptive, you should take another pill as soon as possible. If vomiting or diarrhoea persists for more than 24 hours, follow the instructions for missed pills, counting each vomiting and/or diarrhoea as a missed pill. Don’t forget to use additional barrier methods such as a condom during illness and 7 days after.  The advice differs for patients taking Qlaira or Zoely.

If you are sick within 2 hours of taking the pill, take another one, as it may not have fully absorbed into your bloodstream. Take it straight away and take your next one at the usual time.

If you do not take another one within 3 or 12 hours (desogestrel) of your normal time, use additional contraception (condoms) for two days or seven days with desogestrel.

If you continue to be sick, use additional contraception whilst you are ill and take two days of reliably taking the POP.

Very severe diarrhoea (6-8 watery poos in 24 hours): take additional contraception (condoms) during illness plus two or seven days if taking desogestrel.

Women over 50 years with no menstrual bleeding before the age of 55 years should get their follicle-stimulating hormone levels checked by the GP. After analysing the blood results, the GP may decide you should stop taking the tablet.

Women over 55 should stop contraception even if they are still experiencing menstrual bleeding. However, this should be discussed with your GP following an FSH blood test.

Yes. It is usual for some contraceptives not to suit the patient, and others may do. If you are switching from another contraceptive, then it is important to highlight this on the questionnaire so The Family Chemist clinician, as the start dates may differ or discuss it with your doctor.

Yes, however, if you take the pill perfectly, the chances are very small (less than 1%). If you miss a period, take a pregnancy test immediately or consult your GP. There is no evidence of harm to the baby or the mother if pregnancy occurs whilst using the COC.

Although some women may report weight gain whilst taking the pill, there is little or no evidence that weight gain occurs whilst taking the pill.

You can use the pill up until confirmed menopause. However, the advice changes depending on the type being used. It is recommended that you switch over to a different method of contraception if you are still using a combined oral contraceptive at 50 years of age. Consult your Family Chemist Clinician for more advice.

What you need to do next all depends on a couple of important points:

• The number of pills you have missed. A missed pill is someone who has not taken a pill or vomited/diarrhoea for more than 24 hours.
• When have you missed the pill, particularly where you are in your contraceptive pack?
• The type and brand of contraceptive pill you are using.
• When did you last have unprotected sex?

The advice below differs for patients taking daylette, eloine, qlaria and zoely.

https://www.sexwise.org.uk/

https://www.contraceptionchoices.org/

https://www.nhs.uk/conditions/contraception/