Contraception

Emergency contraception

Combined oral contraceptives

Injectable contraceptives & implants

Intrauterine contraceptive device

Contraception services may be limited in Johannesburg public hospitals. Intrauterine contraceptive devices (IUCDs) may not be freely available at most public hospitals, but many are inserted privately or at primary care clinics. How to insert them should be known. Condoms use provides STI protection for all who is not in a permanent relationship. Careful counseling & information is mandatory; many patients have no idea how & why the combined pill may fail. Parental consent is not required for minors, however they should be advised to talk with parents, guardian or family.

Effectiveness of contraception is measured with the PEARL INDEX, the number of pregnancies per hundred women years(e.g. pregnancies in 25 women studied for 4 years or in 1000 women for 10 years divided by 100).

The choice of contraceptive is based on a patient’s medical history and preference.  Risks and benefits of individual contraceptive methods should be assessed using WHO Medical Eligibility Criteria.

EMERGENCY CONTRACEPTION

If a woman presents within 72 hours of unprotected intercourse:

1. Prescribe Ovral 2 tablets, followed by a further 2 tablets after 12 hours
2. OR levonorgestrel 0.75 mg (e.g. Norlevo) repeated after 12 hours or 1.5 mg stat are more effective but may not be available in public hospitals
3. Prescribe metoclopramide 10 mg orally three times daily for 2 days for nausea & vomiting if using Ovral or levonorgestrel
4. If a woman presents from 3 to 7 days after unprotected intercourse, consider inserting a copper-containing intrauterine contraceptive device, if available. Consider antibiotic cover. 

COMBINED ORAL CONTRACEPTIVES

General notes & contraindications

• Available preparations are Triphasil, Nordette and Ovral (avoid Ovral , if possible, as estrogen dose is high [except where an enzyme inducer is being taken]). There are many others to use instead
• There may be irregular spotting early on during use. This usually settles
• There may be nausea early on during use. This almost always settles
• There may be a small amount of weight gain, but this is not progressive
• Emphasize the need to take the pills on each day as instructed
• Advice on missed pills:
• One missed pill: If there is more than 12 hours delay after the usual time, take the missed pill as soon as it is remembered, & the next one at the usual time; use additional precautions, e.g. condoms or abstinence, for the next 7 days
• If the missed pill is within 7 days of the end of active pills in the pack, go straight into the next packet, without a pill free/dummy pill (different colour) interval, & use additional precautions for the next 7 days
• If more than one pill is missed, continue the packet, using additional precautions until a new packet is started after a withdrawal bleed
• If the missed pill or pills are in the first 7 days of active pills in the pack & coitus has occurred, use emergency contraception and restart the pills 24 hours later. Use additional precautions for the next 7 days
• Advise on vomiting after pill ingestion, & diarrhea, & use of antibiotics – continue pills and use additional precautions, e.g. condoms or abstinence for a week after

Contraindications

• Caution is advised in patients who smoke or have hypertension, diabetes, obesity or dyslipidaemias, history of depression
• Absolute contraindications: Current or previous history of VTE, Ischaemic heart disease, stroke, Migraine, APLS & certain antiepileptic agents.

INJECTABLE CONTRACEPTIVES & IMPLANTS

General notes & contraindications

• Available preparations are medroxyprogesterone acetate 150 mg (Depo-Provera) & norethisterone enanthate 200 mg (Nuristerate), & Implanon (Etonorgesterel – see below) effective for 3 years, & Norplant (Levonorgestrel) effective for 5 years
• There may be weight gain, but this is not progressive – many users discontinue for this side-effect
• There may be irregular spotting in the first few weeks. This will almost always settle
• Warn the user that amenorrhoea is to be expected after prolonged use & is not a reason for alarm
• Advise regular attendance for further injections for injectables,  2 monthly – Nuristerate, 3 monthly – Depo-Provera. Duration of effect for Implanon is 3 years, Norplant is 5 years (Norplant 2 consists of two implants)
• Injectables, Implants are relatively contraindicated in young teenagers because of a risk of hypoestrogenic osteoporosis
• Implanon (Etonorgestrel) is currently popular. Concurrent ARV use has been associated with a 12% pregnancy rate in one study. Levels of Norethisterone (Nuristerate) & Medroxy progesterone (Depo-provera) are seemingly less affected with ARVs/FDC

Contraindications

• Use with caution in patients with multiple risk factors for arterial cardiovascular disease 

INTRAUTERINE CONTRACEPTIVE DEVICE (IUCD CuT380A)

General notes & contraindications

• Explain how the IUCD works. Copper IUCDs are primarily spermicidal but cause an inflammatory endometrial reaction also (effective 10-12 years). This occurs with the Mirena (contains levonorgestrel) which also causes persistent decidualisation (effective 5 years)
• Irregular spotting is common in the beginning, but usually settles
• Pain with or without vaginal discharge may suggest infection or a complication of insertion
• Some users are surprised at how small an IUCD is. Explain this
• Explain the need to check the threads
• Advise that the IUCD can be easily removed at the clinic if the user wants to discontinue the method, for whatever reason

Contraindications

• Current pelvic TB/PID, Puerperal sepsis, Fibroid uterus with distortion of the cavity, Gestational trophoblastic disease
• Caution: Nulliparity, Advanced HIV, unexplained PV bleeding should first be investigated

Insertion of an IUCD

Ensure by history & discussion that the IUCD is appropriate & understood. An ultrasound should preferably be performed to assess uterine size & axis, and to exclude any coexistent pathology. The LMP must be known (post menstrual is a good time for insertion). A cervical smear must be normal, there must be no irregular bleeding, & no history of PID in the previous 5 years.

• Place patient in lithotomy
• Cleanse area with antiseptic solution
• Perform bimanual examination assessing uterine size & axis, & to exclude pathology
• Pass a speculum, assessing vagina & cervix
• Grasp the cervix with single-toothed vulsellum
• Sound uterus with sound provided in packet & place the moveable ring on the IUCD introducer at the appropriate point
• Gently pass IUCD in its applicator to the fundus, remove applicator, and cut threads to 2-3 cm

Give Doxycycline 100 mg orally twice daily & Metronidazole 400 mg orally twice daily for 5 days. Offer analgesia before insertion (Indomethacin 100 mg suppository). Advise the patient to return for a check-up in 2 weeks & to periodically check the threads to exclude expulsion.

The ‘Levonorgestrol-intrauterine system’ or ‘Mirena’ is much broader in the shaft and may require greater skill, force or analgesia for insertion.