Chapter 99: Family planning

The classic family planning consultation is the presentation of a young woman for contraceptive advice. It is a very critical visit and provides an excellent opportunity to develop a good rapport with the patient and provide education on important health concerns, such as sexual health, fertility, pregnancy prevention, STI prevention, immunisation and cervical screening.

In counselling and treating patients, especially teenagers, confidentiality is of paramount importance. Keep in mind the Gillick test of competency for females aged under 16 (see CHAPTER 97). Contraceptive methods can be confusing, so careful education using charts and other aids is recommended to enhance the therapeutic relationship and ensure the patient understands the best options available to them.

FERTILITY CONTROL

The choice of contraceptive methodology will be determined not only by individual needs, personal preference and resources but also by its effectiveness, safety and incidence of side effects.

In developed countries of the Western world, the most widely used methods in order of preference are the male condom, combined oral contraceptive pill, intra-uterine device (IUD), female sterilisation and withdrawal.¹

The past decade has seen a wider availability of long-acting reversible contraception (LARC). LARC methods are defined as non-permanent contraception administered less frequently than once a month. They include implants, IUDs and injectables. LARC methods are the most effective reversible contraceptives, with failure rates for typical use virtually the same as for perfect use. For this reason, LARC plays an important public health role in reducing unintended pregnancies.² Approximately half the pregnancies in the US are unintended and occur because of non-use of contraception, failure of a specific method or discontinuation of contraception.³ While many women are satisfied with oral contraceptives or barrier methods, it is important to check their awareness of LARC proactively.⁴

A comparison of the failure rates of the various contraceptive methods is presented in TABLE 99.1.

It should be noted that condoms are the only contraception that protect against STIs. For women at risk of acquiring STIs, dual protection should be recommended. This involves use of condoms in addition to an effective form of contraception, offering both STI and pregnancy protection.⁶

SAFE PRESCRIBING⁴

Most women of reproductive age can safely use all contraceptive methods. However, there are some conditions, risk factors and concurrent medications that make a particular method unsuitable. Medical Eligibility Criteria (MEC) tables for contraceptive use are an internationally recognised system to guide clinicians in the safe provision of contraceptive methods. Conditions affecting eligibility are classified under one of four categories: MEC 1—no restrictions; MEC 2—the benefits generally outweigh the risks; MEC 3—the risks generally outweigh the benefits; MEC 4—an absolute contraindication. A full listing of the UK MEC is available at <http://ukmec.pagelizard.com/2016>; see also the WHO MEC at <www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/>.

HORMONAL CONTRACEPTION

Methods of hormonal contraception include:^7,8

• Progestogen-only contraceptives:

  • – etonogestrel implant (Implanon NXT)

  • – levonorgestrel-releasing IUD (Mirena)

  • – depot medroxyprogesterone acetate (DMPA)

  • – progestogen-only pill (POP or ‘mini-pill’)

• Combined hormonal contraceptives:

  • – combined oral contraceptive pill (COC or ‘the pill’)

  • – vaginal ring (NuvaRing)

• Emergency contraception:

  • – levonorgestrel emergency contraceptive pill (ECP)

  • – ulipristal acetate

Progestogen-only methods include the progestogen-only pill, implant, IUD and injection. These methods are safe in women who are breastfeeding or have a contraindication to taking oestrogen. Progestogen-only contraception is contraindicated in women with active breast cancer within the past 5 years (MEC 4), but has relatively few other contraindications. The harms outweigh the benefits in the following conditions (MEC 3): antiphospholipid antibodies with systemic lupus erythematosus, unexplained vaginal bleeding, ischaemic heart disease or stroke, severe cirrhosis or hepatocellular carcinoma.

Use of progestogen-only contraception is not associated with an increased risk of venous thromboembolism. Women taking liver enzyme-inducing drugs are not advised to use the POP or etonogestral implant due to reduced effectiveness. DMPA and the levonorgestrel IUD are appropriate for use with liver enzyme-inducing drugs. If emergency contraception is required, a double dose of the levonorgestrel-ECP is recommended.

This is a subdermal contraceptive implant; it is a 3-year system consisting of a single rod containing the progestogen etonogestrel. It inhibits ovulation and has an anti-cervical mucus effect. Irregular bleeding is the most common side effect, with one in 5 women experiencing frequent or prolonged bleeding episodes. Twenty-two per cent of women are amenorrhoeic within 12 months. Several treatments (e.g. cyclical use of a COCP; mefenamic acid; tranexamic acid) are safe to use to reduce troublesome bleeding in the short term. Approximately 20–25% of women request the implant to be removed within 12 months and it is important to provide information about expected bleeding patterns prior to insertion. It requires a minor surgical procedure to insert it and also to remove it. The pregnancy rate is the lowest of all contraceptives at <1:1000 over 3 years of use.

IUDs are highly effective LARCs that are increasingly used worldwide by women of all reproductive ages, including young and nulliparous women. They are made of an inert material to which may be added a bioactive substance such as copper (e.g. Multiload Cu375) or a progestogen (e.g. Mirena). All IUDs prevent pregnancy by inhibiting sperm migration and ovum transport and preventing implantation. The levonorgestrel IUD also causes endometrial suppression and cervical mucus thickening and may prevent or delay ovulation.

Efficacy:

• copper IUDs: 99.4% perfect use; 99.2% typical use

• levonorgestrel IUDs: 99.8% perfect and typical use

Absolute contraindications include active PID, undiagnosed abnormal genital tract bleeding and current or past history of breast cancer for those considering levonorgestrel IUD (MEC 4).

Recommended use time: copper IUD 5–10 years depending on brand, Mirena 5 years.

Side effects and complications of IUD use

The biggest difference between copper and hormonal IUDs is the effect on bleeding patterns and pain. Women with a copper IUD will have their usual menstrual periods, usually with an increase in menstrual loss and dysmenorrhoea. Spotting, heavier and prolonged bleeding are common in the first 3–6 months but usually decrease with time.

The levonorgestrel IUD results in a reduction of blood loss. Sixty-five per cent of women are amenorrhoeic or have light bleeding only after the first year of use. For this reason, the hormonal IUD is particularly suitable for women with heavy menstrual bleeding. Persistent light vaginal bleeding and/or spotting are common initially for the first 3–5 months.

Menstrual bleeding and pain are the most common reason for IUD discontinuation. Discontinuation rates for both IUDs are similar.

Pregnancy/ectopic pregnancy

If pregnancy occurs there is an increased risk of abortion and intra-uterine sepsis during the second trimester. Early removal of the IUD is essential. Since the IUD prevents intra-uterine rather than tubal pregnancies, the proportion of ectopic pregnancy is higher in the case of IUD failure, although the absolute risk is low compared to the risk for women using no contraception.

Pelvic inflammatory disease

There is a small increased risk of PID in the first 20 days post-insertion. Subsequent risk of PID reverts to baseline and is related to the risk of STIs.

Extrusion, perforation of uterus and translocation

Spontaneous extrusion occurs in about 5% with the highest risk within the first year. Perforation of the uterus occurs in up to 2.3 in 1000 insertions.⁷ Factors that increase risk of perforation include breastfeeding, first 6 months postpartum and previous caesarean section. If translocation of the IUD outside the uterus is proved by X-ray and pelvic ultrasound, referral for removal is mandatory. The woman should attend for a follow-up visit between 3–6 weeks after insertion specifically to exclude infection, perforation or expulsion.

Depot medroxyprogesterone acetate

Depot medroxyprogesterone acetate (DMPA) is the only injectable intramuscular contraceptive available in Australia. It is very effective for up to 14 weeks. Although DMPA is technically a LARC, it is not immediately reversible and is less effective than implants and IUDs due to the need for repeated injections.

• Dose: 150 mg by deep IM injection in first 5 days of the menstrual cycle. The same dose is given every 12 weeks ± 2 weeks to maintain contraception.

• Effectiveness: perfect use 99.8%; typical use 94%.

Side effects include a disrupted menstrual cycle (amenorrhoea rate 50–70% by 12 months), weight gain (average 2–6%), breast tenderness, mood changes and a delay in return of fertility (mean time 8 months).⁷ Long-term use is associated with accelerated bone loss, but this is not clinically significant and does not translate into fracture risk. However, for this reason it is not recommended as a first-line contraceptive for women less than 18 and more than 45 years.

The POP (mini-pill) is most commonly prescribed for breastfeeding women for whom an oestrogen contraceptive would potentially suppress milk supply. It is safe from 6 weeks postpartum.

The two common formulations are:

• levonorgestrel 30 mcg/day

• norethisterone 35 mcg/day

The primary mechanism of action is cervical mucus thickening, preventing sperm penetration. In addition, POPs prevent ovulation in up to 60% of cycles.⁸

Efficacy is 99.7% in perfect use and 91% in typical use.⁷ The failure rate is lower in women >40 years compared to younger women. The POP is considered to have a more vulnerable efficacy, and it is important that the woman strictly adheres to taking the pill within a daily 3-hour timeframe for maximum efficacy. The POP is effective after 3 tablets have been taken.⁴

Compliance can be a problem because of cycle irregularity. Twenty per cent of women will be amenorrhoeic on the POP, 40% will have regular bleeding and 40% will have irregular bleeding.⁷

Combined hormonal contraceptives contain an oestrogen and progestogen, and their main mode of action is inhibition of hypothalamic and pituitary function leading to anovulation. They are available as a combined oral contraceptive pill (COC) and the vaginal ring. COCs and vaginal rings work in the same way and are treated similarly in terms of contraindications, complications, side effects and drug interactions.

Combined oral contraception (COC)

COCs in Australia contain ethinyloestradiol (EE), oestradiol valerate (EV), oestradiol (E2) or mestranol and one of a range of progestogens. Efficacy is 99.7% with perfect use, 91% with typical use.

Which oestrogen to use⁷

EE is the most commonly used oestrogen. The active oestrogen in the newer E2 and EV pills is structurally identical to the E2 produced by the ovaries. They have a theoretical but unproven benefit in terms of venous thromboembolism (VTE) risk, and it will be some years before there is any evidence of VTE rates in women using these pill preparations. Both E2 and EV are associated with a moderately high rate of amenorrhoea during the hormone-free break.

It is recommended to use a dose of 35 mcg EE or less. There is some association between increasing EE dose and risk of venous thromboembolism (VTE). Formulations containing 50 mcg EE are no longer recommended because there is no known additional benefit from their use and they are associated with an increased risk of VTE. Women starting on a 20 mcg EE pill are likely to have fewer hormonally related side effects such as headaches or mood swings, but have a higher chance of discontinuation due to breakthrough bleeding.

Which progestogen to use⁷

The early progestogens include levonorgestrel and norethisterone. Newer progestogens have been developed over recent decades to reduce androgenic side effects and to minimise the effect EE has on lipids. Nomogestrol acetate, gestodene, desogestrel and etonogestrel are less androgenic, while cyproterone acetate, drospirenone and dienogest are anti-androgenic. Drospirenone is an analogue of spironolactone and has a mild diuretic effect. There is insufficient data to initially prescribe newer progestogens in preference to older versions.

Various COC preparations available in Australia are listed in TABLE 99.2.

Starting the pill: which COC to use⁷

The past menstrual and medical history of the woman should be documented and contraindications excluded.

A suitable first choice is a monophasic pill containing 30 mcg or 35 mcg ethinyloestradiol (EE) with levonorgestrel or norethisterone (e.g. Nordette, Microgynon 30, Monofeme, Levlen ED, Brevinor).

Education and counselling are very important for the woman starting the pill. Suitable patient education should be given. Pill swatches produced by manufacturers are a useful aid. Cover starts immediately if a hormone (active) pill is commenced on day 1–5 of the menstrual cycle (except the quadriphasic pill Qlaira—refer to product information).

Note: A ‘quick-start’ technique, described by Westhoff, can be used to start the COC on the day of the consultation. If commenced at any time other than day 1–5 of the menstrual cycle, abstinence/condoms are required for the first 7 days after the start.⁹

Specific patient groups^4,7

Adolescents. There is no lower age limit if the young woman has started menstruating.

Acne and hirsuitism. The oestrogen in any CHC may improve acne and hirsuitism via increased sex hormone binding globulin (SHBG) levels and reduction of free testosterone. COCs containing an anti-androgenic progestogen have a theoretical advantage for women who request management of androgenic symptoms. Any beneficial effect may take up to 6 months.

Women over 35 years. CHC use is safe for healthy non-smoking women until 50 years (MEC 2 for women over 40). CHC is not recommended if a woman is over 35 years and has multiple cardiovascular risk factors, including obesity, smoking, diabetes and hypertension (MEC 3/4).

Women taking liver enzyme-inducing drugs. Alternative contraception is strongly advised. The only hormonal contraceptives not affected by liver enzyme-inducing drugs are DMPA and IUDs. Current evidence suggests that most antibiotics do not interact with combined hormonal contraceptives. The only exceptions are liver enzyme-inducing rifabutin and rifampicin. Other liver enzyme-inducing drugs include many of the older anti-epileptics (e.g. phenytoin, carbamazapine), St John’s wort and protease inhibitors. For women who still request the use of COC, an extended or tricycling regime of a higher dose pill (e.g. containing at least 50 mcg EE) may be effective. Further guidance on drug interactions is provided by the UK Faculty of Sexual Health & Reproductive Healthcare at <https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-drug-interactions-with-hormonal/>.

Contraindications to CHC usage are shown in TABLE 99.3.

Non-contraceptive advantages of CHCs⁷

A number of significant beneficial effects arising from the use of COCs have now been documented:

• Reduction in most menstrual cycle disorders, including dysmenorrhoea, symptoms of endometriosis and heavy menstrual bleeding

• Reduction in the incidence of functional ovarian cysts and benign ovarian tumours

• Reduced incidence of ovarian and endometrial cancer

• Can reduce acne

• Can be useful in managing symptoms of polycystic ovarian syndrome

• Can assist with perimenopausal symptoms

• Can be used to manage premenstrual syndrome (PMS) and its more severe form (PMDD) in some women

• Can reduce the risk of bowel cancer

Serious side effects of CHCs

The most serious side effects to be considered are the effects of COCs on the circulatory system and the incidence of cancer.

The following circulatory disorders have been linked with pill usage.

• Venous deep vein thrombosis, pulmonary embolism, rarely: mesenteric, hepatic and kidney thrombosis

• Arterial myocardial infarction, thrombotic stroke, haemorrhagic stroke, rarely: retinal and mesenteric thrombosis

The risk of circulatory disease has not been related to duration of use and there is no increased risk in perpetual users.

The oestrogen content of the pill is considered to be the aetiological factor and the problem is increased in women taking high oestrogen-content COCs, but now that the oestrogen content of each pill has been reduced to 35 mcg EE or less, these risks of morbidity and mortality have been reduced.

The progestogen effect on lipid metabolism is not considered significant in the aetiology of circulatory disease. Circulatory diseases have now been recognised as occurring predominantly in certain high-risk groups—the ‘at-risk female’, particularly the smoker over 35 years of age.

Other at-risk groups include those with thrombophilia, hyperlipidaemia, diabetes, hyper-stension and a family history of cardiovascular disease or immobilisation.

Venous thromboembolism⁸

Venous thromboembolism (VTE) risk is increased 2–3 times in users of CHCs compared to non-users, with an increase of between one and three extra cases per 10 000 women in a year. The risk is highest in the first 4 months of use and gradually decreases with duration of use. Studies have shown that COCs containing cyproterone, desogestrel, drospirenone or gestodene have a higher risk of VTE than COCs containing levonorgestrel or other progestogens. However, the absolute risk of VTE in users of any CHC is very low and much lower than the risk associated with pregnancy and the postpartum period. Women who are eligible for an oestrogen-containing method of contraception can safely use any pill on the market with 35 mcg EE or less.

CHC and cancer⁷

Women who have used CHC have an overall lower risk of cancer compared to women who have not.

• Possible very small increased risk:

  • – cervix (benefits of use outweigh the risk with a low- or high-grade squamous intra-epithelial lesion)

  • – breast

• Protective effect:

  • – endometrial

  • – epithelial ovarian

  • – bowel

Common side effects

The relatively minor side effects listed in TABLE 99.4 may discourage women from persisting with oral contraception in the absence of appropriate explanation and reassurance. Management of these side effects is listed in the same table. It is useful in practice to have this list available as a ready reference for manipulating the COC if necessary. A common nuisance side effect is breakthrough bleeding in the first 2 months.

Important advice for the patient

• Diarrhoea and vomiting may reduce the effectiveness of the pill. If a woman vomits within 2 hours of taking an active pill, she should take an additional active pill.

• Withdrawal bleeds can be skipped for a woman’s convenience, by going straight from the last active pill in the cycle to the first active pill in the next cycle. Running packs of multiphasic pills together can result in unpredictable bleeding as a result of the fluctuating dose of hormones.¹⁰ A Cochrane Review did not demonstrate any additional safety concerns for women taking CHCs continuously without placebo breaks for up to 12 months.¹¹ An extended-regimen pill with 84 active pills plus 7 inactive pills is now available.

Missed pills

A missed pill is defined as one that is taken more than 24 hours late (>48 hours since last pill was taken). The advice is to take the missed pill as soon as possible, even if it means taking two pills in one day. Any previously missed pills should be discarded and the usual pill-taking schedule resumed. Condoms or abstinence should be used for 7 days (the ‘Seven-day rule’). This advice does not apply to the quadriphasic pill Qlaira and the product information should be consulted. Refer to FIGURE 99.1.

If the pill is missed with <7 pills left before the next placebo break, skip placebos and continue active pills.

If <7 active pills were taken before the missed pill, consider emergency contraception if unprotected sex took place in the past 5 days. If ulipristal acetate emergency contraception is used, the woman needs to wait 5 days before restarting the pill.

Causes of oral contraceptive failure include errors in administration, decreased absorption, missed pills and use of liver enzyme-inducing drugs. If the woman prefers to use a CHC, tricycling the COC or vaginal ring packs and having a shorter placebo break should be considered.

The first available contraceptive vaginal ring is NuvaRing®, a flexible polymer ring with 15 mcg EE and 120 mcg etonogestrel being released per 24 hours. Metabolic effects and side effects are virtually the same as for the COC. It is immediately protective when inserted on days 1–5 of the menstrual cycle. It is then removed after 21 days with a break of 7 days or can be used ‘back-to-back’. The cycle control is good, with a reduced incidence of irregular bleeding. This method may be useful for women who prefer the COC but are prone to missing pills, or women with inflammatory bowel disease or other malabsorption syndromes. It is recommended that the vaginal ring is not removed for intercourse.

• Ulipristal acetate 30 mg orally as a single dose within 5 days

• Levonorgestrel 1.5 mg as a single dose

• 25 levonorgestrel POPs (25 × 30 mcg) as an initial dose, repeating the same dose 12 hours later

• Yuzpe method: a large initial dose of COC, which is repeated 12 hours later, with each dose containing at least 100 mcg of EE and 500 mcg of levonorgestrel (example: 4 tablets of either Microgynon 30 or 5 tablets of Microgynon 20)

• Copper IUD inserted within 5 days

Uliprisital acetate is a selective progesterone receptor modulator that acts by preventing or delaying ovulation. It does this more effectively than the levonorgestrel emergency contraceptive pill (LNG-ECP), which is licensed for use only up to 72 hours after intercourse. Effectiveness for both is improved the earlier they are taken.

The Yuzpe method has an efficacy of 57–74% and is reserved only for when levonorgestrel is unavailable. The copper IUD is highly effective at 99% and can provide very reliable ongoing contraception. It may be appropriate to advise the woman seeking postcoital contraception to return for pregnancy testing in 3–4 weeks, depending on her risk. STI screening and the need for ongoing contraception need to be considered.

Barrier methods include male and female condoms and vaginal diaphragms. If used correctly, male condoms are very effective contraceptives with an efficacy of 98% with perfect use and 82% with typical use.

Condoms are also very effective in preventing the spread of STIs, including HIV infection. The main disadvantage is that they are mainly reliant on the cooperation of the user.

Diaphragms are inserted at any convenient time before intercourse and removed after 6 hours have elapsed since the last act of intercourse. Their presence on the Australian market in the future remains uncertain.

These methods require high motivation and some require regular menstrual cycles.

Basal body temperature method

Coitus should occur only after there has been a rise in basal body temperature of 0.2°C for 3 days (72 hours) above the basal body temperature measurement during the preceding 6 days, until the onset of the next menstrual period.

Calendar or rhythm method

The woman reviews and records six cycle lengths and then selects the shortest and longest cycles. She then subtracts 21 from the shortest cycle and 10 from the longest cycle to work out fertile and safe days (i.e. for a 26 to 30-day cycle: fertile days 5–20; for regular 28-day cycle: fertile days 7–18).

Billings ovulation method^7,12

This method is based on keeping a daily record of the sensation at the vulva and the appearance of the mucus, so that ovulation can be recognised and intercourse, in the pre-ovulatory time, can be confined to when the record shows an unchanging pattern, signalling unchanging hormones and thus infertility. The fertile phase commences when there is a change in the sensation or mucus, correlating with a rise in oestrogen. This sensation at the vulva will become progressively more lubricative and will be followed by a definite change to being no longer slippery (caused by rising progesterone). The peak day of fertility is the last day of the slippery sensation, with or without the visual presence of mucus. The postovulatory infertile phase begins on the fourth day after the peak day. Regular cycles are not required for successful use of the Billings ovulation method.

Withdrawal method or coitus interruptus

Male withdrawal before ejaculation is still a widely used method of contraception and will continue to have a definite place in contraceptive practice.

Lactational amenorrhoea method (LAM)⁸

LAM is as reliable as hormonal methods of contraception if the baby is younger than 6 months, is exclusively breastfed with no long intervals between feeds (no more than 4 hours during the day or 6 hours at night) and the woman remains amenorrhoeic postpartum. Lactation is not a reliable contraceptive method once any of these criteria is not met—if the mother is still breastfeeding, a progestogen-only method is advised. Since some women may ovulate prior to the onset of menses, an additional method of contraception should be advised to reduce the risk of another pregnancy.

Ceasing contraception and menopause¹³

Women using non-hormonal contraception (i.e. barrier, copper IUD, rhythm) can be advised that contraception is no longer required once they have been amenorrhoeic for 12 months over the age of 50 years and after two years before the age of 50.

Oestrogen-containing contraception and DPMA injections are not recommended after 50 years. After this age, women should switch to an alternative progestogen-only or non-hormonal method.

Women over the age of 50 who are amenorrhoeic while using progestogen-only contraception are advised to continue the method for a further 12 months UNTIL they have two follicle stimulating hormone levels of 30 IU/L or above taken 6 weeks apart. Contraception is not required beyond the age of 55 years.

Vasectomy¹⁴

A vasectomy involves interruption or occlusion of the vas deferens, preventing the passage of sperm from the testes to the penis. The procedure is generally performed in an outpatient setting under local anaesthesia. It is important to confirm the absence of spermatozoa in the ejaculate 2–3 months after the operation, before ceasing other contraceptive methods. It takes about 12–15 ejaculations to clear the remaining sperm from the semen.

For the average man undergoing vasectomy reversal, pregnancy rates range between 50 and 70%. This rate decreases as the interval between vasectomy and its reversal increases.

Tubal ligation

Female sterilisation is usually performed by mini-laparotomy or laparoscopy, at which time clips are applied to each fallopian tube. This is a potentially reversible method of contraception with 50% of women achieving pregnancy after reversal. Efficacy is >99.5%.⁷

Hysteroscopic transcervical occlusive sterilisation

This procedure—Essure—involves the placement of a flexible titanium micro-insert into each fallopian tube. The insert expands and over time reactive tissue growth occludes the tubes.

This irreversible method requires alternative contraception until complete tubal occlusion is confirmed radiologically at 12 weeks.

Up to 51% of Australian women have experienced an unplanned pregnancy.¹⁵ It is estimated that 1 in 4 pregnancies in Australia end in termination, and adoption is now an unusual outcome. It is important not to make assumptions about the ‘wantedness’ of a pregnancy.

Termination of pregnancy is lawful under certain circumstances; however, the law is different in every state and territory. The main methods used are the traditional surgical methods such as suction curettage and medical abortion. Surgical abortions can be performed from 6–7 weeks. There is an increased risk of continuing pregnancy if performed before 6 weeks. Medical abortions are usually performed before 9 weeks using mifepristone, an anti-progesterone, and then the prostaglandin analogue misoprostol 36–48 hours later. Bleeding and cramping usually occur within 4–6 hours and a check-up visit is required in two weeks.

Ideally, unintended pregnancies should be prevented through appropriate community education and contraception counselling. LARC methods are considered to play a vital role.