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Contraception Counselling

The COCP

How to take the COCP

 

The first pill is taken on the first day of the patient's period for immediate contraceptive effect. If started on any other day, additional barrier contraception must be used for 7 days. One pill is taken at the same time every day for 21 consecutive days, then 7 pill-free days are taken during which a withdrawal bleed will occur. A new pack is started the next day.

 

Missed pills: One pill can be missed (more than 24 hours late) anywhere in the pack without reducing the contraceptive efficacy. If two pills are missed, take the most recently missed pill and the rest of the pack as normal BUT use barrier contraception for next 7 days (emergency contraception may be needed if patient has had unprotected sex in the last few days). If more than one pill is missed and there are less than 7 pills remaining in pack, avoid the pill-free break and start the next pack the day after finishing the last.

 

Other instructions: Follow missed pill instructions for each day of a diarrhoeal illness and if vomiting occurs within 2 hours of taking the pill. If taking certain antibiotics (penicillin, ampicillin, tetracycline, cephalosporins) use additional barrier contraception during the course and for 7 days after the course finishes.

 

Contraindications

  • Migraine
  • History of DVT
  • History of stroke, ischaemic heart disease or severe hypertension
  • BMI over 40
  • Smokers older than 35 years
  • History of breast or endometrial cancer
  • History of liver disease
  • Diabetes with complications or for longer than 20 years
  • Pregnancy or first 6 months of breastfeeding

 

Additional advice

 

Regular blood pressure reviews are needed (every 6 months) and smokers must be advised to stop smoking. Patients must see a doctor urgently if any of the following symptoms occur: SOB, chest pain, painful leg swelling, haemoptysis, weakness or numbness in arms or legs, or unusual headaches.

 

The POP

How to take the Progesterone only Pill

 

The POP is taken on the first day of the menstrual cycle for immediate contraceptive effect. One pill is taken at the same time every day until the pack is finished, subsequently starting a new pack. It is important to stress to the patient that they will be taking the pill everyday; there is no break for a withdrawal bleed as with the COCP (which most patients are more familiar with). The traditional POP must be taken within a 3 hour window. However, newer preparations of the POP such as Cerazette, have an extended window allowing the patient to take the pill within 12 hours. If pills are missed, patients are encouraged to take one as soon as possible and use additional barrier contraception for 2 days. They can then resume taking the pill as normal. If vomiting or diarrhoeal illnesses occur within 2 hours of taking the pill, patients must take another, and then continue the rest of the pack as normal. They must follow missed pill instructions for each day of diarrhoeal illness.

 

Contraindications

  • Pregnancy
  • History of heart disease or stroke
  • History of breast cancer
  • Liver disease
  • SLE

 

    The Contraceptive Implant (Implanon)

    How the implant is used

    The implant is a small flexible tube inserted into the upper arm underneath the skin. Local anaesthetic is given before insertion.

    If inserted within the first 5 days of the cycle, contraceptive effect is immediate. If inserted on any other day additional barrier protection must be used for 7 days.

    The implant is replaced after 3 years but can be easily removed at any time by a doctor or nurse.

     

    Contraindications

    • Pregnancy
    • Unexplained vaginal bleeding

     

      The Contraceptive Injection

      How is the contraceptive injection used?

       

      The contraceptive injection is given every eight (noristerat) or twelve (depo-provera) weeks.

      The injection is given into a muscular area (usually the buttock, but sometimes the leg or arm). 

      The primary mechanism of action is to prevent ovulation but it also thickens cervical mucus and prevents build up of endometrium.

       

      Contraindications

      • Pregnancy
      • Want return to fertility within a year
      • Thrombosis, heart or circulatory disease
      • Active liver disease
      • History of breast cancer
      • Migraine with aura
      • Diabetes with complications or have had diabetes for more than 20 years
      • Concurrent risk factors for osteoporosis

       

        Barrier Contraception

         How barrier contraception is used

        • Male condom fits onto erect penis
        • Female condom fits inside vagina
        • Diaphragm is dome-shaped with a stiffened rim, fitting between pubic bone and posterior fornix of vagina to cover cervix (patient needs to be measured first)
        • Cervical cap fits over cervix
        • Diaphragm and cervical cap fitted before intercourse and must remain in place for minimum of 6 hours after intercourse
        • Used in conjunction with a spermicide

         

        Advantages

        • Protection against STIs
        • Safe

         

         

        Disadvantages

        • High failure rate depending on technique (2-15 per 100 for condom and 5 per 100 for diaphragm and cap)
        • High user motivation required
        • Interference with intercourse

         

          Intrauterine System (IUS) e.g. Mirena

           

          How the IUS is used

          The IUS is a small, plastic T-shaped device inserted into the uterus during first half of the cycle by a doctor or nurse. It can also be inserted immediately after or 6 weeks post-delivery, or at TOP. If the IUS is fitted in the first 7 days of the cycle, contraceptive effect is immediate. If inserted at any other time additional barrier contraception must be used for 7 days.

          An internal examination is carried out first by a doctor or nurse to check the position and size of the uterus. It is then inserted using a tube passed through the vagina into the uterus. Patients must be advised to check for the strings after each period.

          The IUS is replaced after 5 years but can be removed at any time by a doctor or nurse.

          Contraindications

          • STIs / multiple sexual partners
          • PID
          • Previous ectopic pregnancy
          • Pregnancy

           

            Emergency Contraception

            The morning-after pill (Levonelle)

            The morning-after pill is ideally taken within 24h (95% success rate) and no later than 72h (58% success rate) after unprotected intercourse. It DOES NOT provide contraception for the remainder of the cycle. The IUD may be necessary if vomiting occurs within a few hours of taking the pill.

            Side effects include headache, nausea, vomiting, abdominal pain, and menstrual disturbance in next cycle.

             

            The IUD

            The IUD can be used as emergency contraception if inserted within 5 days after intercourse, OR up to 5 days after ovulation. See risks and side effects of Mirena coil (above).

             

            Counselling points

            • Discuss future contraception and explain that emergency contracpetion is not as effective as regular contraception
            • Consider need for STI screening
            • Advise pregnancy test if period delayed
            • Advise to see a doctor urgently if sudden or unusual abdominal pain (ectopic)
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