11.5 Contraception

 

Contraceptive methods should be chosen based on the preference of the woman and potential medical contra-indications identified through clinical history and examination.

 

The essential clinical examinations are:

• For hormonal contraception: blood pressure. Oestroprogestogens, also called combined oral contraceptives (COCs), are contra-indicated in women with hypertension (≥ 140/90 mmHg). Progestogen-only injectables are contra-indicated in women with severe hypertension (≥ 160/100 mmHg).
• For an intrauterine device (IUD): speculum and digital vaginal examination. Placement of an IUD is contra-indicated in case of active genital infection. It is performed after the infection has been treated.

 

In all cases, exclude pregnancy (perform pregnancy test if in doubt).
No laboratory testing is required for prescribing contraceptives.

 

The effectiveness of contraceptives is measured by the number of unintended pregnancies for every 100 women within the first year of correct regular use of contraception.

 

Table 11.1 Contraceptive failure rates a Citation a. For more information see: Centres for Disease Control and Prevention. Effectiveness of Family Planning Methods. https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/Contraceptive_methods_508.pdf
This table shows the effectiveness of contraceptives from most to least effective with typical use.

 

Methods	Unintended pregnancies per 100 women
Progestogen implants Etonogestrel (ETG) or levonorgestrel (LNG)	0.05%
Levonorgestrel IUD (LNG-IUD)	0.2%
Copper IUD (Cu-IUD)	0.8%
Progestogen-only injectable Medroxyprogesterone (DMPA)	6%
Progestogen-only pills (POP) Levonorgestrel (LNG) or desogestrel	9%
COC Ethinylestradiol (EE) + levonorgestrel (LNG)	9%

 

To make a contraceptive choice, women should be advised and informed about the different methods available and their effectiveness.

 

11.5.1 Main contraceptive methods

Contraception can be started at any time (according to woman's wishes), as long as it is reasonably certain that she is not pregnant. The woman should be informed that the protection may take a few days and that condoms must be used during this period [1] Citation 1. World Health Organization. Family Planning - A global handbook for providers, 2018.
https://apps.who.int/iris/bitstream/handle/10665/260156/9780999203705-eng.pdf?sequence=1 .

 

Additional contraception (condoms) is not required if the method is started:

• With a Cu-IUD.
• Within 5 days of the start of her period if the woman uses a POP or a COC.
• Within 7 days of the start of her period if the woman uses a progestogen implant or a LNG-IUD or a progestogen-only injectable.
• Within 7 days of a first or second trimester abortion, for any method of contraception.
• Within 28 days postpartum, whether the woman is breastfeeding or not; for any method of contraception. 
• After 28 days up to 6 months postpartum if the conditions for lactational amenorrhoea (Section 11.5.2) are met, for any method of contraception.

 

Outside of these conditions, the delay in protection is 2 days for a POP and 7 days for a progestogen implant, a LNG-IUD, a progestogen-only injectable or a COC.

 

Contraceptives can be used immediately after childbirth (or abortion) and during breastfeeding, except for COCs which can be started at least 21 days after childbirth if the woman is not breastfeeding and at least 6 weeks after childbirth if the woman is breastfeeding.

 

All these methods are reversible. Return of fertility is prompt after stopping (or removing) contraception, with the exception of progestogen-only injectables.

Hormonal contraception

Progestogen implants
One (or two) rods inserted under the skin of the upper arm, under local anaesthesia.

• Protection: 3 years for ETG; 5 years for LNG. After this period the implant must be replaced if this method of contraception is still desired. It may be removed at anytime by a health professional if the contraception is no longer desired.
• Specifics to underline: effectiveness does not depend on compliance; bleeding may occur at any time (irregular) or there may be no monthly bleeding (amenorrhoea); the implant is discreet but palpable under the skin.

 

Progestogen-only injectable
One injection every 13 weeks. There are 2 forms: DMPA-IM administered by IM route by a health professional and DMPA-SC for self-injection by SC route.

• Protection: 3 months.
• Specifics to underline: no daily administration; discreet method (no evidence of contraception); self-administration possible (DMPA-SC); long delay in return to fertility (on average 5 months after stopping injections, sometimes up to 1 year [1] Citation 1. World Health Organization. Family Planning - A global handbook for providers, 2018.
  https://apps.who.int/iris/bitstream/handle/10665/260156/9780999203705-eng.pdf?sequence=1 ); bleeding may occur at any time (irregular) or there may be no monthly bleeding (amenorrhoea).

 

Oral contraceptives
POP
One tablet every day at the same time, without interruption, including during menstruation.

• Protection: ceases as soon as the contraceptive is stopped.
• Specifics to underline: effectiveness depends on compliance (risk of forgetting the pill); respect of precise time pill should be taken (no more than 3 hours late for LNG and 12 hours for desogestrel); bleeding may occur at any time (irregular) or there may be no monthly bleeding (amenorrhoea).

COC
One tablet every day, preferably at the same time, without interruption, including during menstruation (for 28-day pack with 21 active tablets of EE + LNG and 7 inactive tablets of iron salts) b Citation b. If using 21-day pack:
 one tablet daily for 21 days, followed by a tablet-free interval of 7 days.  .

• Protection: ceases as soon as the contraceptive is stopped.
• Specifics to underline: effectiveness depends on compliance (risk of forgetting the pill).

 

For more information on hormonal contraceptives, including contra-indications, drug interactions, precautions, refer to the guide Essential drugs, MSF. 

Intrauterine device

Device inserted in the uterus within 48 hours after childbirth. If not inserted within 48 hours, delay insertion for 4 weeks [1] Citation 1. World Health Organization. Family Planning - A global handbook for providers, 2018.
https://apps.who.int/iris/bitstream/handle/10665/260156/9780999203705-eng.pdf?sequence=1 .
Can be used by women who have not had children.
There are 2 types available: hormonal IUDs that release levonorgestrel and copper IUDs.

• Protection: 5 years for a LNG-IUD; 10 years for a Cu-IUD.
• After this period the IUD should be changed if this method of contraception is still desired. It can be removed at any time by a health professional if this contraception is no longer desired.
• Specifics to underline: effectiveness does not depend on compliance; bleeding may occur at any time (irregular) or there may be no monthly bleeding (amenorrhoea) with LNG-IUD; prolonged bleeding and cramping particularly in the first few months with Cu-IUDs; IUD strings may be felt by the partner.

11.5.2 Other methods

Condoms

Condoms (male and female) are used for protection against sexually transmitted infections and also as a temporary method of contraception. They are sometimes used simultaneously with another type of contraception. Their effectiveness depends on consistent correct use with each act of intercourse. The contraceptive failure rate is high (18% for male condoms and 21% for female condoms).

Lactional amenorrhea method

Breastfeeding is an effective (98%) temporary method of contraception but only if all 3 following conditions are met: 1) the mother’s bleeding has not returned, 2) exclusive breastfeeding day and night, 3) infant is under 6 months old.

Sterilisation

Tubal ligation is an irreversible surgical procedure. It is performed in certain cases (e.g. if a subsequent pregnancy carries life-threatening risks for the woman and she desires permanent contraception) during a surgical procedure or caesarean section. Written patient consent is required before performing the intervention.

11.5.3 Special situations

HIV infection

Condom use helps prevent HIV transmission to a partner, reinfection by other strains of the HIV virus if the partner is HIV-positive, and transmission of other sexually transmitted infections. HIV-positive patients should systematically use condoms.

 

To prevent an unintended pregnancy, another effective method of contraception must also be used.

Treatment with liver enzyme inducers

Liver enzyme inducers reduce the effectiveness of implants and oral contraceptives [2] Citation 2. FSRH. Clinical Guidance: Drug Interactions with Hormonal Contraception, 2018.
https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-drug-interactions-with-hormonal/ . For women taking liver enzyme inducers (rifampicin, rifabutin, efavirenz, nevirapine, lopinavir, ritonavir, phenobarbital, phenytoin, carbamazepine, griseofulvin, etc.): recommend an IUD or a progestogen-only injectable.

Emergency contraception

Every woman should be informed about and have access to emergency contraception. 
It should be used as soon as possible within 5 days or 120 hours after unprotected or inadequately protected sex (forgotten pill or condom breaking, etc.).
There are three possible options:
levonorgestrel PO: 1.5 mg single dose (3 mg single dose in women taking an enzyme inducer [2] Citation 2. FSRH. Clinical Guidance: Drug Interactions with Hormonal Contraception, 2018.
https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-drug-interactions-with-hormonal/ )
or ulipristal acetate PO: 30 mg single dose 
or a Cu-IUD

 

Notes:

• There is no contra-indication for oral emergency contraceptives.
• For women taking liver enzyme inducer(s), use levonorgestrel (3 mg) or a Cu-IUD.
• Placement of the IUD is contra-indicated in case of active genital infection c Citation c. For more information see: World Health Organization. Medical eligibility criteria for contraceptive use, fifth edition 2015.
  https://apps.who.int/iris/bitstream/handle/10665/181468/9789241549158_eng.pdf?sequence=1 .