Contraception

Key Points

  • While fertility declines with age, women are at risk of an unintended pregnancy until 12 months after the last menstrual period if over 50 years (24 months if below 50 years)
  • Women should be provided with evidence-based information about all contraceptive options in order to support informed decision making
  • Oestrogen containing methods (combined oral contraception and the vaginal ring) and the contraceptive injection are generally not recommended after 50 years as the cardiovascular risks outweigh the benefits
  • The LNG-IUD provides effective management of heavy menstrual bleeding as well as contraception and it can be used as part of an HRT regimen
  • Women in a new relationship should be advised about the use of condoms to prevent STIs
  • Women should be informed about the availability of the Emergency Contraceptive Pill without a prescription at pharmacies and its effectiveness up to 96 hours after unprotected intercourse

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Contraceptive methods can be conveniently categorised by their duration of use

Permanent methods

Female and male sterilisation must be viewed as being permanent as successful reversal cannot be guaranteed. 

Tubal ligation (4)

Tubal ligation is carried out under general anaesthetic either laparoscopically or via a laparotomy. 

Advantages:

Disadvantages:

Hysteroscopic transcervical occlusion(4)

Tiny metallic coils are inserted into the fallopian tubes (Essure®) resulting in tubal scarring and blockage. Contraception is required until tubal occlusion is confirmed radiologically three months after device placement.

Advantages:

Disadvantages:

Vasectomy(4)

Vasectomy involves interruption or occlusion of the vas deferens to prevent the presence of sperm in the ejaculate. While reversal is technically possible through microsurgical techniques, the success rate falls with time.

Advantages:

Disadvantages:

Long acting reversible contraception (LARC) methods

LARC methods are administered less frequently than once per month and are associated with a very low failure rate compared with shorter acting methods (6, 7).

The contraceptive implant(7)

Advantages:

Disadvantages:

Levonorgestrel Intra-Uterine Device (LNG-IUD)(7,10)

The LNG- IUD (Mirena®) is inserted into the uterus by a trained provider. It releases LNG over a five year period and primarily works by thinning the lining of the uterus, toxicity to the sperm gametes and thickening the cervical mucus. It may prevent ovulation in some women in the early months of use (7).

Advantages:

Disadvantages:

Copper-bearing IUD(7)

A copper-bearing IUD is inserted into the uterus by a trained provider. Depending on the type, they last for up to five or ten years. It primarily works by being toxic to the gametes but may also have an effect on implantation.

Advantages:

Disadvantages:

Depomedroxyprogesterone acetate (DMPA) injections(7)

DMPA is a progestogen-only injection administered into the gluteal or deltoid muscle every 12 weeks. It works by preventing ovulation and is not recommended for women over the age of 50 due to its effects on bone density and cardiovascular risk (2).

Advantages:

Disadvantages:

Medium-acting contraception

Vaginal ring (5)

The vaginal ring is a soft silastic ring (NuvaRing®) containing a low dose of oestrogen and progestogen hormones, which the woman inserts into her vagina. The ring is left in place for 3 weeks then removed for a week prior to inserting a new ring. It primarily works by preventing ovulation but also thickens cervical mucus and thins the endometrium (5).

Advantages:

Disadvantages:

Short-acting contraception

Combined oral contraception

The combined hormonal contraceptive pill contains a low dose of oestrogen and progestogen hormones. It primarily works by preventing ovulation but also thickens cervical mucus and thins the endometrium. While there are many different pill formulations available, it is generally recommended to use the lowest possible dose of hormones (i.e. pills containing 35mcg ethinyl estradiol or less)(5).

Advantages :

Disadvantages:

Progestogen-only pill – the ‘mini-pill’

The progestogen only pill contains a very small dose of progestogen and primarily works by thickening cervical mucus. In some women in some cycles it may prevent ovulation.

Advantages:

Disadvantages:

Coitally-dependent barrier methods

The barrier methods require ‘action’ with every act of intercourse, which results in them being less effective than the longer acting methods. Condoms, both male and female, are the only method of contraception that prevent STIs(4).

Contraceptive diaphragms

The diaphragm is a barrier method which the woman inserts herself to cover the cervix to prevent sperm reaching the uterus. It must be left in place for a minimum of 6 hours after intercourse to allow sperm to be killed off by the vaginal acidity. A single size silicone contoured diaphragm called Caya® has been introduced into Australia in 2015 replacing the multi-size Ortho® All-Flex®. The single size diaphragm has a life-span of two years; the manufacturer recommends the use of a lactic acid buffer gel with the diaphragm (note that spermicide is unavailable in Australia).

Advantages:

Disadvantage:

Male condom(4)

The male condom is a fine latex or polyurethane sheath, worn on the erect penis. They can be used with a water-based lubricant which may be useful for women experiencing perimenopausal vaginal dryness.

Advantages:

Disadvantages:

Female condom(4)

The female condom is a polyurethane sheath inserted into the vagina prior to intercourse. It has an inner and an outer ring which are used to anchor the condom in place and to ensure that the penis is guided into the sheath.

Advantages:

Disadvantages:

Emergency contraceptive methods:

Emergency contraception (previously known as “the morning after pill”) is used to prevent pregnancy after unprotected intercourse or contraceptive failure. A new emergency contraceptive pill, ulipristal acetate (UPA), has recently become available in Australia.

  1. Single 1.5mg levonorgestrel emergency contraceptive (LNG-EC) tablet; licensed for use up to 72 hours after unprotected intercourse; it should be taken as early as possible but has some effectiveness if taken up to 96 hours after unprotected intercourse; available over the counter without the need for a prescription; acts by preventing or delaying ovulation; can be used by breastfeeding women; can be used multiple times in a cycle if needed(12).
  2. Single 30mg ulipristal acetate (UPA) tablet marketed as EllaOne; licensed for use up to 120 hours after unprotected intercourse with superior efficacy to LNG-EC if taken within 24, 72 and 120 hours of intercourse (most effective if taken within 24 hours)(13);
  3. UPA is a selective progesterone receptor modulator (SPRM) which works to prevent or delay ovulation even when the LH surge has begun. Breastfeeding women are advised to express and discard breastmilk for one week after taking UPA. Women using progestogen containing contraception should seek medical advice on when to start or re-start the method after taking UPA.UPA and the LNG-EC should not be used together in the same cycle.
  4. A Copper IUD inserted within five days of unprotected intercourse; provides highly effective ongoing long-term contraception; can be difficult to access within the appropriate time frame.

Advantages of oral EC:

Disadvantages of oral EC

Note that women over the age of 50 years using a progestogen-only method of contraception (LNG-IUS, implant or POP) who are amenorrhoeic for 12 months may have two x FSH tests six weeks apart and if both are over 30IU then it can be advised that contraception is only required for a further 12 months.

May 2016

Further reading

References

  1. Bateson D, McNamee K, Harvey C, Stewart M. Contraception for women aged over 40 An important but neglected area. Medicine Today 2012;13(8):27-36.
  2. Royal College of Obstetricians and Gynaecologists. Contraception for Women Aged Over 40 Years. In: Faculty of Sexual & Reproductive Healthcare Clinical Guidance, editor. 2010.
  3. World Health Orgainzation. Medical eligibility criteria for contraceptive use. 4th ed. Geneva:2009.
  4. Stewart M, McNamee K, Harvey C. A practical guide to contraception. Part 3: Traditional methods, sterilisation and emergency contraception. Medicine Today 2013; 14(9): . 2013;14(9):55-65.
  5. McNamee K, Harvey C, Bateson D. A practical guide to contraception. Part 1: Contraceptive pills and vaginal rings. 2013.
  6. Stoddard A, McNicholas C, Peipert JF. Efficacy and safety of long-acting reversible contraception. Drugs. 2011;71(8):969-80.
  7. Harvey C, McNamee K, Stewart M. A practical guide to contraception. Part 2: Long-acting reversible method. Medicine Today 2013;14(8):39-51.
  8. MIMS/myDr Implanon. 2013.
  9. New Zealand Consumer Medicine Information. Jadelle. 2014.
  10. MIMS. Mirena. 2014.
  11. FPNSW Factsheet: Contraceptive Diaphragm – single-size contraceptive barrier device. https://www.fpnsw.org.au/health-information/contraception/contraceptive-diaphragm-%E2%80%93-single-size-contraceptive-barrier-device
  12. Pharmacy Council of New Zealand, Pharmaceuical Society of New Zealand Inc. BEST PRACTICE GUIDELINES FOR THE SUPPLY BY PHARMACISTS OF THE EMERGENCY CONTRACEPTIVE PILL (ECP). 2013.
  13. Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011 Oct;84(4):363-7.

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Content Updated May 2016

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