Gynaecology

Contraception

If you are not planning to start a family and are sexually active, a suitable contraceptive method is an important consideration. Here are some of the options to choose from, which are divided into short-term and long-term methods.

Short-term

Barrier methods

Common barrier methods includes condoms. Condom is a latex sheath worn on the erect penis before intercourse. It collects semen and prevents sperm from entering the vagina. (1)

Effectiveness:

This method is user-dependent and have a high typical failure rate as demonstrated below. (1)

Method Perfect use % Typical use %
Male condom 98 82

Advantages:

These methods are cheap, immediately available, come in various sizes and have no effect on your hormones.

A positive aspect of a barrier method is that if offers protection against Sexually Transmitted Diseases (STDs). (1)

Disadvantages:

Users of condoms report decreased sensation and dislike the interruption pause when putting it on.

There is a high chance of a condom break if not placed correctly.  Latex allergic individuals need to use non-latex condoms or opt for an alternative method of contraception. (1)

Hormonal Methods

Combined oral contraceptive pill (COCP)

COCP is a tablet containing both estrogen and progesterone.

It works by inhibiting ovulation, reduce ability of endometrial implantation, as well as thicken the cervical mucus, and hence forming a sperm barrier. (1) (4)

Effectiveness:

COCP is highly effective if used correctly.

Table 2: Effectiveness (1)

Method Perfect use % Typical use %
COCP 99.7 91

Advantages:

This method is readily accessible, reversible and can help manage menstrual problems such as heavy bleeding, pelvic pain and acne. (1)

Another benefit of COCP is cycle control, where you can manipulate when to have or even skip your withdrawal bleed. (3)

Additionally, there are a number of non-contraceptive benefits associated with taking the pill. These include decreased risk of:

  • Ovarian cancer
  • Endometrial cancer
  • Benign breast disease
  • Iron-deficiency anemia
  • Ovarian fibroids and cysts  (3)

Disadvantages:

Since the pill needs to be taken at the same time everyday, within a 12 hours window, its efficacy relies with the user.

Some of the common side effects include: nausea, breast tenderness, reduced libido and weight gain. (1)

COCP has some contraindications to its use such as history of blood clots, high blood pressure and migraines with aura.

COCP offers no protection against STDs.

Progestogen-only pills (POP)

POP main action is to prevent sperm penetration by thickening the cervical mucus.

Efficacy is similar to COCP, but the window to take a tablet is reduced from 12 hours to 3 hours. 

Advantage with POP is that to get the contraceptive cover back on patient would have to take 3 active pills instead of 7 as with combined preparation.

Disadvantage of POP is side effects of irregular bleeding pattern and spotting.

POP is a good option for women who experience nausea and breast tenderness with estrogen.  Additionally, the presence of migraines and family history of hypertension are not a concern with POP. It is also an oral contraceptive of choice during breastfeeding. (1)

Combined vaginal contraceptive ring

Vaginal ring is a soft plastic ring that contains both estrogen and progesterone. The brand that is available in Australia is NuvaRing®.  The ring is inserted vaginally for 3 weeks every month, and it works in a similar way to the COCP to prevent pregnancy.

Another similarity with COCP is the benefit of cycle control, where a woman can skip her withdrawal bleed. (3)

It is highly effective if used correctly, but effectiveness is dependent on the user.

Method Perfect use % Typical use %
Vaginal ring 99 93

It can be a good option for women who find it difficult to remember to take a pill every day and who do not feel comfortable with long-term methods of contraception.

It does not protect against STDs.

Long-term methods

Intra Uterine Devices (IUDs)

IUDs are small devices inserted into the uterus cavity and are one of the most effective reversible methods of contraception.

In Australia it is available in two types: hormonal based (MirenaÆ) and non-hormonal (Multiload-Cu375Æ).  (1)

Effectiveness: Both types are 99% effective and are not user-dependent. (1)

Advantages: 

Both IUDs can be removed at any time when the patient would like to get pregnant. Return to fertility post-IUD is immediate.

IUD expulsion is slightly higher in women who have not given birth but is not contraindicated in this group. (1)

 It is an extremely cost–effective long-term contraceptive method and both types last for 5 years.

One of the additional benefits of Mirena is that it decreases menstrual flow and the associated period pelvic pain. (1)

 Disadvantages:

Copper IUDs may increase menstrual bleeding and have higher chance of spotting particularly in the first 6 month of use.

There is a slight risk of infection associated with insertion of an IUD.

There is no protection from STDs. (1)

Progesterone only contraceptives

Progesterone Implant

Progesterone implant (ImplanonÆ) is a small piece of flexible plastic implanted under the skin of the upper arm. (1)

Implanon slowly releases progesterone into the body, which keeps the sperm from joining with an egg by thickening the cervical mucus. (1)

It is 99.9% effective. (1)

Advantages:

It is very long lasting and approved for 3 years use.

Not user dependant.

Return to fertility is immediate upon the removal.

Very few contraindications and could be an option for women who experience estrogen related side effects. (1)

Disadvantages:

Device insertion and removal involves a minor surgical procedure. Not many General Practitioners (GPs) are trained in this technique hence a referral may be required to a Gynecologist.

Irregular bleeding pattern during the first 6 to 12 month is common.

Other uncommon side effects include: headache, acne, weight change, breast pain, hirsutism, mood changes, and loss of libido.

No protection against STDs. (1)

Progesterone Depot

Progesterone depot (DepoProvera®) is an oily Intra-Muscular injection that slowly releases the hormone into the body. (1)

Released progesterone, thickens the cervical mucus, thins the endometrial lining and prevents ovulation. (1)

It is 94-99% effective and is not user -dependent. (1)

Advantages:

The effect is long lasting and injection needs to be repeated every 3 month.

It has similar profile to Implanon with a slightly lower efficacy and a less advantageous side effect profile. (1)

Disadvantages:

More common side effects include: bleeding pattern change (irregular and heavier), weight gain, breast tenderness and depression.

Returning to the baseline fertility is cannot be reversed immediately. (1)

Taking into the account that our patient is a frequent traveler, depot injection every 3-month may be inconvenient. Also side effects profile is less superior to Mirena and on par with Implanon. (1)

Permanent methods

TUBAL LIGATION (Female)

If a woman feels that her family is complete, she may opt for a permanent option of contraception. Using laparoscopy (keyhole) surgery, clips are inserted on the fallopian tubes to block the sperm and egg from meeting.

This is a very effective permanent form of contraception, but this option does not give protection to STIs.

VASECTOMY (Male)

Similarly, if a man does not wish to father children, he may opt for a permanent contraceptive option – Vasectomy. This is a minor surgical operation where the tubes that carry the sperm form the testes are cut. After this procedure there will be no sperm present in the ejaculate.

Vasectomy is 99% effective at preventing pregnancy, but this option does not give protection to STIs.

Majority of contraceptive options may be available from your GP. However, some of the longer lasting and permanent options can only be done by a specialist. Dr Polyakov can not only assist you in your choice of the most suitable contraceptive method but is also able to arrange an insertion or a procedure for all the options available.

References:

  1. Contraception: an Australian clinical practice handbook. Family Planning NSW, Family Planning Queensland and Family Planning Victoria 2013. [cited 2014 May 11].
  2. Guillebaud J, MacGregor A. Contraception: your questions answered. 6th ed. Churchill Livingstone Elsevier; 2013.
  3. Fraser IS, Kovacs GT. The efficacy of non-contraceptive uses for hormonal contraceptives. Medical Journal of Australia 2003 June; Vol 178: p621-623.
  4. Australian Medicines Handbook. Australian Medicines Handbook Pty ltd 2014. [cited 2014 May 11] Chapter: Drugs for contraception. Available here.

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