Gynaecology 5th class DR.

Hanaa Al-Heidery

Contraception
Combined oral contraceptive pill:

COCP provides reliable, effective contraception, with a failure rate of

0.2–0.3 per 100 woman-years. Modern COCPs all contain
ethinylestradiol (20–35 micrograms) and are classified by type of
progestagen they contain.

Type of progestagen in the COCP

• 2nd generation:
• n orethisterone
• levonorgestrel.
• 3rd generation:
• gestodene (less androgenic)
• norgestimate (metabolized to levonorgestrel).
• Yasmin® : contains drospirenone (antiandrogenic and weak
antidiuretic properties).
• Co-cyprindiol:
• contains cyproterone acetate (antiandrogenic)
useful in the treatment of hirsutism and acne.

Mode of action
• Ovulation inhibition (–ve feedback on hypothalamus + pituitary).
• Thickened cervical mucus preventing sperm penetration.

• Thin endometrium preventing implantation.

Side effects
• Breakthrough bleeding: may occur especially in the first 3mths. Missed
pills, STIs, and pregnancy should all be considered.
• Headache: change of progestagen.
• Weight gain: no evidence of additional weight gain due to COCP.

Contraindications to the COCP

• Pregnancy.
• Personal history of thromboembolic disease.
• Undiagnosed genital tract bleeding.
• Cardiovascular disorders.
• Migraine with aura.
• Oestrogen dependent tumours.
• Active hepatobiliary disease or liver tumours.

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Gynaecology 5th class DR. Hanaa Al-Heidery

• Hypertension and diabetes.

• 35yrs old who smoke (may use 1yr after cessation).
• BMI ≥ 35.

Advantages and disadvantages of the COCP

Advantages
•Decrease menstrual blood loss and pain.
• Menstrual cycle can be regulated and controlled.
• Decrease risks of benign ovarian tumours.
• Decrease incidence of PID.
• Improvement in skin condition in acne vulgaris.
• Possible decrease symptoms:
- premenstrual syndrome.
- endometriosis.
• Decrease risks of colorectal cancer.
• Decrease ovarian cancer risk ≥ 50% during use and for >15yrs after.

Disadvantages
• Increase risks (although absolute risk is very low)
• VTE
• stroke
• Cardiovascular disease.
• Small increase risk of breast cancer: returns to the background risk
10yrs after stopping.
• Very small association with i risk of cervical cancer.
The pill and VTE
The absolute risk of VTE is:
• Background risk: 5:100 000 women/yr.
• 2 nd generation COCP: 10–15:100 000 women/yr.
• 3rd generation COCP: 25:100 000 women/yr.
• Pregnancy: 60:100 000 women/yr
.
Advice regarding the COCP and VTE
As long as women are well informed of the small increased risk of
thrombosis associated with 3rd generation pills, and do not have any
medical contraindications, it should be a matter of user preference and
clinical judgement on which COCP is to be prescribed. Combined
hormonal contraception is contraindicated where there is a personal
history of VTE or a known thrombogenic gene mutation.

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Gynaecology 5th class DR. Hanaa Al-Heidery

Combined oral contraceptive pill:

regimes
‘Pill-teach’
• Contraception is immediate if the woman starts the pill between days
1 and 5 of her cycle.
• If her fi rst pill is after day 5, other contraception is needed for 7 days.
• Take the pill the same time every day.
• One pill daily for 21 days followed by 7 pill-free days. Some
formulations have 7 ‘dummy pills’, rather than the pill-free interval.
• If vomiting or diarrhoea use extra contraception from the onset of
illness and continue it for the next 7 days.
Special circumstances
• Post-partum (not breast-feeding): start day 21 after delivery.
• Post-termination: within 7 days of termination.
• Switching from other oral hormonal contraception: start immediately if
using other contraception reliably.
• Switching from implant or injectable progestagens: start at any time up
to removal of implant or when injection is due.
Drug interactions
• No additional contraception is needed if taking antibiotics unless
associated with diarrhoea/vomiting.
• COCP should not be prescribed to lamotrigine users as it decreases
the serum drug concentration and therefore increases seizure
frequency.
• Patients taking enzyme-inducing medication should be offered
alternative contraceptive method due to d effi cacy. If it is decided
to continue the COCP, the ethinyloestradiol should be increased to
50 micrograms, or the pill-free interval reduced to 4 days.
Missed pills
Missed pills may lead to failed contraception. The risk of pregnancy is
greatest at the beginning and the end of the pack.

Missed pill rules

If 1 pill is missed
• Take the missed pill as soon as possible.
• Continue the rest of the pack as usual.
• No additional contraception is required.
If 2 or more pills are missed
• Take the most recent missed pill as soon as possible.
• Continue the rest of the pack as normal.
• A dditional contraceptive cover is required until 7 consecutive pills
have been taken.

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Gynaecology 5th class DR. Hanaa Al-Heidery

• If the missed pills are in day 1–7: emergency contraception should be

considered.
• If the missed pills are in day 8–14: emergency contraception not
needed.
• If the missed pills are in day 15–21: omit the pill free interval.

Other combined hormonal contraceptives

Vaginal ring
• Ethinylestradiol with etonogestrel.
• Remains in situ for 21 days, then removed for 7 days to induce
awithdrawal bleed.
Transdermal patch
• Ethinylestradiol with norelgestromin.
• Replaced weekly for 21 days, then 7 patch-free days to induce
awithdrawal bleed.
. Efficacy and side effect profile as for COCP.

Progestagen-only pill
POPs currently marketed contain either levonorgestrel, norethisterone,
or etynodiol acetate. The failure rate ranges from 0.3 to 4.0% per 100
woman-years and decreases with age.
•Cerazette ® , a POP (75 micrograms desogestrel), reliably blocks
ovulation,increasing efficacy.
To be reliable, a POP must be taken at the same time every day.
Mode of action
• Thickened cervical mucus (4h after dose).
• Thin endometrium preventing implantation.
• Inhibition of ovulation (60% old POP, 97% desogestrel).
Indications
Useful in conditions where COCP is contraindicated:
• During lactation—has no effect on quality or quantity of milk.
• Sickle cell disease.
• SLE and other autoimmune diseases.
Side effects
• Menstrual disturbance—regular (40%), irregular (40%), or
amenorrhoea (20%).
• Headaches, nausea, mood swings, abdominal bloating, and breast
tenderness—usually subside after a few months.
Drug interactions
• Broad spectrum antibiotics do not affect the effi cacy of POP.
• Rifampicin and other enzyme-inducing drugs increase the metabolism
of POP, leading to a reduction in efficacy.

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Gynaecology 5th class DR. Hanaa Al-Heidery

Contraindications to the POP

• Pregnancy.
• Undiagnosed genital tract bleeding.
• Severe arterial disease.
• Active hepatic disease.
• History of recurrent follicular cysts.

How to take the POP

• Take the pill daily, at the same hour.
• If started on day 1 of the cycle no extra contraception is required.
• if started after day 5, extra contraception should be used for 48h.
• After miscarriage or TOP: start on the day of the miscarriage or TOP.
• After delivery: start on day 21 (whether breast-feeding or not). From
COCP to POP: if the first POP is taken the day after the last activeCOCP,
no other contraception is needed.
Missed POP rules
• If >3h late or 27h since last dose:
• take missed pill as soon as possible
• take subsequent pill at the usual time
• use extra contraception for the next 48h.
• If vomit within 2h of ingestion:
• take another pill now
• use extra contraception for the next 48h.
For Cerazette ® same rules apply if missed pill is >12h late.

Other forms of contraception

Injectable progestagen
Depo-Provera ® (MDPA) (given 12-weekly)
• Useful for women who are unable or unwilling to take a pill.
• Contains 150mg of medroxyprogesterone.
• Very effective (failure rate <1 per 100 woman-years).

Side effects
• Menstrual disturbance (regular, irregular, or even amenorrhoea).
• Delayed conception (fertility may not return for 6–12mths).
• Weight gain (probably due to progestagen i appetite).
• Bone loss (small risk of d bone density with prolonged use).

Progestagen-only subdermal implant

Nexplanon® (has replaced Implanon® in the UK):
• Contains etonogestrel.
• Insertion and removal involves a small procedure under local

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Gynaecology 5th class DR. Hanaa Al-Heidery

anaesthetic (inserted into the arm).

• It lasts for 3yrs.
• Is radio-opaque.
• Specially designed applicator to minimize incorrect insertion.
Highly effective (failure rate reported as <0.1 per 100 woman-years).

Side effects
Menstrual disturbance—20% amenorrhoea, 50% erratic bleeding.

Copper-bearing IUCD
• Provides long-term reversible contraception.
• Insertion is usually easy.
• May be retained beyond the menopause.
Very effective (failure rate of 0.6–0.8 per 100 woman-years).

Mode of action
• Foreign body reaction in the endometrium prevents implantation.
• Copper content may inhibit spermatozoa motility.

Complications
• Irregular PV bleeding, especially first 3–6mths.
• Risk of infection: screen for Chlamydia prior to insertion.
• IUCD expulsion: most common in the fi rst 3mths after insertion.
• Perforation: poor insertion technique or <4wks post-partum.
• Dysmenorrhoea.
• Missing threads. ‘Missing’ threads may indicate pregnancy,
expulsion or perforation. However, it is often the case that the threads are
merely sitting in the cervical canal or uterus. A pregnancy test should be
performed and emergency contraception/alternative contraception
provided until the IUD can be confirmed to be in situ, either by
visualization of the threads on speculum examination or an ultrasound
confirming presence of the IUD within the uterus.

Timing of IUCD insertion

• Insert any time during cycle (as long as pregnancy excluded).
• Post-partum: safe to insert IUCD from 4wks after delivery.
• Following TOP: insert within fi rst 48h after termination.
• Switching from other contraception: any time as long as not pregnant.

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Contraindications to copper-bearing IUCD

• Pregnancy.
• Undiagnosed genital tract bleeding.
• Active genital tract infection or PID.
• Uterine anomalies or fi broids distorting cavity.
• Copper allergy.

Levonorgestrel-releasing system (Mirena® IUS)

The LNG-releasing system has a T-shaped rod containing 52mg LNG
(20 micrograms released daily). It is a reversible, highly effective
contraceptive with a failure rate of 0.18 per 100 woman-years.
Due to its progestagenic content, menstrual blood loss is decreased
by >90%, and it is as effective as endometrial ablation in the management
of menorrhagia at 1yr.

Mode of action
• It acts on the endometrium, leading to endometrial atrophy and
preventing implantation.
• Thickened cervical mucus inhibits sperm penetration.
• It is particularly useful when oestrogen is contraindicated.
• May be used in patients with a history of breast cancer: no disease for
5yrs and after consultation with breast surgeon.
• Breast-feeding: can be inserted 4 or more weeks post-partum.
Side effects
• Irregular PV bleeding is common in the fi rst 3–4mths: amenorrhoea in
up to 30% by 1yr.
• Hormonal symptoms: nausea, headache, breast tenderness, bloating.

Barrier contraception
Condoms
Male condoms are cheap and widely available. They protect against STIs
including HIV. They are the only reversible male method. Typical failure
rates are in the region of 24% since they rely on the user to put it on it
correctly, before penetration and before every act of sex. The female
condom is a lubricated polyurethane condom that is inserted into the
vagina. It also protects against STIs.

Diaphragm and cap

These are latex or non-latex devices that are inserted into the vagina to
prevent passage of sperm to the cervix. They can be inserted in advance
of sex. Caps fit over the cervix whereas diaphragms form a hammock
between the post-fornix and the symphysis pubis. Caps and diaphragms

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are often used in conjunction with a spermicide. Disadvantages are that

women need to be taught how to insert and remove the device and typical
failure rates in the region of 18% are reported. In some women their use
may be associated with increased vaginal discharge and urinary tract
infections.

Spermicides
Spermicide alone is not recommended for prevention of pregnancy as it is
of low effectiveness.
Nonoxynol 9 (N-9) is a spermicidal product sold as a gel, cream, foam,
sponge or pessary for use with diaphragms or caps. Some data have
suggested that frequent use of N-9 might increase the risk of HIV
transmission. It is therefore no longer recommended for women who are
at high risk of HIV infection.

Emergency contraception
Emergency contraception (EC) is licensed for use to protect women from
unwanted pregnancy following UPSI or contraceptive failure.
The two main forms are:
• Oral EC—LNG or ulipristal (ellaOne® ).
• Copper IUCD EC.
Levonogestrel (LNG EC)
• Consists of a single oral dose of 1.5mg of LNG.
• If taken within 72h of unprotected coitus it is estimated to prevent 85%
of expected pregnancies.
• It may be used up to 120h after, but effi cacy is uncertain and it is not
licensed for use after 72h.
• It may also be used more than once in a cycle if clinically indicated.
• It does not provide contraceptive cover for the remainder of the cycle,
another method of contraception must be used.
Side effects
• Nausea is common after ingestion.
• Vomiting only affects 1%.
• If a woman vomits within 2h of ingestion, she should take a further
dose as soon as possible.
• Erratic PV bleeding is common in the fi rst 7 days following treatment.
Ulipristal
• Progesterone receptor modulator.
• Licensed for use within 120h of UPSI.
• Can only be used once per cycle.
• Due to mode of action may impair the effectiveness of progestagen
containing contraceptives for the remainder of the cycle and so alternative
contraceptive methods are advised.

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Copper IUCD
• IUCD acts as an emergency contraceptive by inhibiting fertilization by
direct toxicity.
• Affects implantation by inducing an infl ammatory reaction in the
endometrium.
• The copper content may also inhibit sperm transport.
• IUCD EC can be inserted within 120h following UPSI.
• Failure rates are less than 1%.
The risks and complications for IUCD EC are similar to IUCD use in
general. It can be removed after the next menstruation provided that
no unprotected coitus has occurred since menstruation, or retained for
ongoing contraception.

Female sterilization: preoperative

considerations
Sterilization has become increasingly popular since the late 1960s and it
is now the most commonly used method of contraception in women over
40yrs of age.
History and examination
• This includes reasons for sterilization, menstrual history, current
contraception, obstetric history, previous abdominal surgery, chronic
medical conditions, and drug history.
• The patient’s BMI should be noted and abdominal examination
performed to look for scars from previous surgery or pelvic masses
(previous surgery, endometriosis, PID, or fi broids may make the
procedure technically difficult).

Counselling
It is important to establish that the woman is taking the decision of her
own free will.
• Alternatives to procedure must be discussed, including long-acting
reversible contraceptives (LARCs) and vasectomy.
• Must use effective contraception until her fi rst period following
sterilization. The commonest reason for failure is already being
pregnant when the procedure is performed or in the same cycle!
• Reassure that there is no increased risk of heavier periods in
women >30yrs of age. There is a small association with increased
hysterectomy rates, but the reason is unclear.
• Laparoscopy and tubal occlusion with Filshie clips is usually the
method of choice and must be explained, including the operative risks.
• Counselling must be supported by printed information leafl ets.

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Consent for female sterilization

• Written informed consent must be taken from patient prior to
procedure: in case of doubt regarding mental capacity, case should
be referred to court for judgement.
• Patient must fully understand that the procedure is intended to be
permanent: success rates with reversal procedures are very small
and rarely provided by the NHS.
• Lifetime risk of failure with tubal occlusion is 1:200:
• pregnancies can occur several years after procedure
• longest follow-up data available for Filshie clips suggest failure
rate after 10yrs of 2–3 per 1000 procedures.
• In case of failure: i risk of ectopic pregnancy: advise women to seek
medical attention if pregnant/have abnormal pain and bleeding.
There is a risk of injury to the blood vessels, bowel, and bladder with
laparoscopic surgery: women must be warned about the possibility of a
laparotomy, particularly if they have had previous abdominal surgery.

Women at higher risk of regret

Care must be taken when considering sterilization for women from the
following groups, as they are more likely to have regret and present
requesting reversal:
• Under the age of 30yrs: current RCOG recommendation to avoid.
• Who do not have children.
• Who decide during pregnancy.
• Who have had recent relationship loss.

Female sterilization: the procedure

Preoperative—mandatory checklist
• Document LMP.
• Check current contraception has been used to date.
• Pregnancy test must be performed (a negative test does not exclude
the possibility of a luteal phase pregnancy).
• f any doubt exists about certainty of wishes or risk of pregnancy, the
procedure should be abandoned.
Intraoperative
• Day case laparoscopic procedure is associated with quicker recovery
rates and less morbidity than mini-laparotomy.
• Usually general anaesthesia, but local anaesthesia is an acceptable
alternative.
• Laparascopic mechanical occlusion of the tubes by either Filshie clips
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Gynaecology 5th class DR. Hanaa Al-Heidery

or rings: diathermy i the risk of ectopic pregnancies and is less easy to

reverse.
• When a mini-laparotomy is used, any effective surgical or mechanical
method of tubal occlusion can be used (a modifi ed Pomeroy procedure
may be preferable for post-partum sterilization or at the time of CS due to
lower failure rates).
Postoperative
• The patient must be informed about the method of occlusion used and
any procedural complications.
• She must be advised to use effective contraception till her next
menstrual period.
Special circumstances
• Tubal occlusion should ideally be performed after an appropriate
interval following pregnancy.
• Sterilization post-partum or post-abortion carries a higher risk of
regret and possibly increased failure rates.
• In cases of sterilization at the time of CS, counselling and consent
should be taken at least 1wk before the procedure.
Other techniques
Hysteroscopic methods for sterilization Essure is the only form of
hysteroscopic tubal occlusion licensed for use in the UK at present. It
involves placing a metal micro-insert in the fallopian tubes under
hysteroscopic guidance. This causes tubal blockage by subsequent fi
brosis. A hysterosalpingogram is usually done 3mths after the operation
to confirm tubal blockage.

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