Contraception and what you need to know.
Contraception is divided into hormonal contraception and non-hormonal contraception.
Hormonal contraception contains the synthetic version of natural oestrogen and progesterone, or progesterone only. There are seven different methods of hormonal contraception currently available in the UK. These are divided into two main groups: combined hormonal contraceptives and progestogen-only contraceptives. Combined hormonal contraceptives include the combined oral contraceptive pill, transdermal patch and vaginal ring. Progestogen-only contraceptives include the progestogen-only pill, contraceptive injection, intrauterine system and contraceptive implant.
The non-hormonal contraceptive methods include the copper intrauterine device and barrier methods such as condoms (both external and internal), cervical cap, diaphragm, sponge and vaginal spermicides.
How do they work?
The dominant mechanism of action of all hormonal contraceptive methods is to prevent ovulation (the process in which a mature egg is released from the ovary). Hormonal contraceptives also thicken the cervical mucus to prevent the sperm reaching the egg and thin the lining of the womb to prevent implantation.
The only exception is the intrauterine system, where the primary mode of action is to thicken the cervical mucus to prevent the sperm reaching the egg and to thin the lining of the womb to impede implantation. Some women who have intrauterine systems will continue to ovulate; however, for some, the progestin may impact ovulation.
Non-hormonal contraception works by preventing a man’s sperm from joining a woman’s egg. Barrier methods also have the obvious advantage of protection from sexually transmitted infections.
How effective are they?
In ‘perfect’ use’ hormonal contraception is highly effective, and provides virtually 100 per cent protection from unwanted pregnancy. Non-hormonal contraception is less effective than hormonal contraceptive methods, and there is much more risk for women to get pregnant. It can be good practice to use a combination of both to protect from pregnancy and also STIs.
There is new advice that has improved the effectiveness of taking a combined contraceptive pill. No longer is the advice to take a combined pill for 21 days and then take 7 days off, but it is to take just a 4 day gap after 21 days or to run several packs together until you have a break through bleed and then take a 4 day break. This takes into account how some women have shorter cycles and how this could lead to the combined pill being less effective.
Long term contraceptives information.
We would often like to have a contraception that is longer lasting than a pill but the procedure to have them inserted puts us off. The insertion of an intrauterine device is uncomfortable but is similar to the discomfort of having a smear test and is over quickly. The doctor can give you something to make it less painful. It will need a longer appointment with a doctor trained in insertion or many sexual health clinics and private GP clinics offer an insertion service. Often you need to have a pregnancy test before insertion and sometimes a follow up appointment to check the strings of the coil are the right length. Intrauterine devices last between 3 and 10 years depending on the type and how old you are.
An implant is inserted under the skin in your upper arm using a local anaesthetic to numb the area first. Although it is relatively quick and easy it will need a longer appointment with a trained insertor or appointment in a sexual health clinic or private GP clinic. It is effective for up to 3 years.
The contraceptive injection or depo is given as an injection into your buttock or thigh every 12 weeks. It is very quick and easy to do and often your practice nurse can give it in a routine appointment.
Possible side effects: Combined hormonal contraceptives
(combined oral contraceptive pill, contraceptive patch, vaginal ring)
Breakthrough bleeding or spotting
Some women react unpredictably to hormonal contraception. Breakthrough bleeding or spotting between periods can occur, especially during the first few months of use. This happens because a woman’s body can take time to adjust to the hormones in the hormonal contraception. The breakthrough bleeding is more likely to happen when a woman misses a pill (or forgets to apply contraceptive patch or insert contraceptive ring) starts a new medication, such as certain antibiotics, or is physically unwell.
Breast pain and tenderness are common amongst women using combined hormonal contraceptives that contain both oestrogen and progestin, instead of only progestin. Naturally occurring oestrogen and progesterone can cause breast tenderness that is experienced 5 to 10 days leading up to the start of a period. Combined hormonal contraceptives alter the level of natural oestrogen and progesterone, causing some women more breast pain and tenderness. If the breast pain and discomfort persist it is advisable to switch to progestogen-only contraceptives.
Mood related issues (anxiety/depression)
The literature regarding the effects of combined hormonal contraceptives on mood related issues is complex, confusing, and often contradictory. It is difficult to conclude whether particular combined hormonal contraceptive method causes mood related issues or if other factors play a part. The literature to date shows that a minority of combined hormonal contraceptive users may experience anxiety, depressive symptoms or mood swing. The best advice is if you feel your pill is causing mood related changes to ask to change to another. Often a change in the progestogen form within the pill can make a difference.
Recent literature suggests that women who use combined hormonal contraceptive methods may have a small increased risk of breast cancer, but the overall risk remains very low. This risk disappears after 10 years of stopping use.
Venous thromboembolism (VTE)
VTE refers to blood clots that can form in veins. It is a serious, yet preventable medical condition. The risk of VTE is higher in women using combined hormonal contraceptives than in women not using combined hormonal contraceptives. The risk of VTE appears to be higher in combined oral contraceptive pills containing high doses of estrogen or newer progestins, such as desogestrel, gestodene, and drospirenone. It is worth pointing out that the risk of VTE is higher if you are a smoker, are overweight, have any kind of surgery that means you are less mobile, have a family history, take long haul flights. It is rarely just about the pill so it is worth weighing up your own risk factors or discussing this with your doctor. If you ever notice swelling in one of your legs then seek emergency medical advice.
Cervical cancer is caused by certain types of Human Papillomavirus, which is transmitted sexually. Women using combined hormonal contraceptives for 5 years or more are at a small increased risk of cervical cancer. This risk disappears after 10 years of stopping use.
Possible side effects: Progestogen-only contraceptives
(progestogen-only pill, contraceptive injection, intrauterine system and contraceptive implant)
Progestogen-only contraceptives can be used by women who cannot or should not take the hormone oestrogen such as women with a history of migraine with aura or those with a higher risk of a Venous Thromboembolism. Progestogen-only contraceptives such as contraceptive injection, intrauterine system and contraceptive implants are long acting, and work well to prevent pregnancy. Every woman’s body is different, and progestogen-only contraceptives affect every woman a little differently.
Possible side Effects
The main side effect of progestogen-only contraceptives is irregular, sometimes prolonged bleeding and/or spotting. The bleeding may occur between periods for several months after starting progestogen-only contraceptives. The irregular bleeding pattern can be inconvenient, however, it is not a health risk. It usually goes away on its own after few months of using progestogen-only contraceptives. If it is continuous though you may want to talk to your doctor about changing to a different form of progestogen-only contraception.
Also, some women may develop amenorrhoea (the absence of menstruation for 3 months in a row or more). This is a result of anovulation, and it actually indicates a very high efficacy of progestogen-only contraceptives. The absence of menstruation may be seen as an advantage for many women, without evidence of harm.
Delayed return to fertility
The contraceptive injection can cause a delay of around 8 months in fertility after cessation of use.
Mood related issues (anxiety/depression)
Similar to the combined hormonal contraception, the literature regarding the effects of progestogen-only contraception on mood related issues is complex and confusing. Nevertheless, it shows that some women using progestogen-only contraceptive methods may experience depression/anxiety symptoms or mood swings.
Reduced bone density
Many women are concern about their bone health during progestogen-only contraceptive use. Recent data shows that the contraceptive injection can cause temporary bone loss, however this is reversible following cessation of contraception. Other progestogen-only contraceptive methods such as contraceptive implants, progestogen-only pill, and intrauterine system do not have an impact on bone mineral density or fracture risk.
Progestogen-only contraceptives, and especially contraceptive injection, contraceptive implant and intrauterine system may cause weight gain in some women but this does not happen to every woman. Existing data shows that women using progestogen-only contraceptives gain on average less than 2 kg (4.4 lb) at 6 or 12 months of use which is similar to women using combined hormonal contraceptives. The only group of women that is more susceptible to considerably more weight gain are those women with a BMI of more than 30 who decide to use contraceptive injection. Overall, the literature to date show no consistent proof that the weight gain is solely a result of using progestogen-only contraceptives.
Other minor common side effects of all contraceptives include abdominal pain or cramping, bloating, dizziness, drowsiness, mild headaches, pain or irritation at place of injection/implant site. These usually clear up within few weeks after the body get used to the hormones.