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7.3 Contraceptives

FSRH Guidelines

NICE CG30 - Long-acting reversible Contraception October 2005

7.3.1 Combined Oral Contraceptives

Combined Oral Contraceptives BNF

For a woman receiving her first prescription of a combined oral contraceptive (COC), the recommended first-line option is a monophasic preparation containing 30 micrograms of ethinylestradiol (standard strength) with norethisterone or levonorgestrel (first-line progestogens)

   SPC Link  RIGEVIDON (150mcg levonorgestrel / 30mcg ethinylestradiol)  
   SPC Link  GEDAREL (30mcg ethinylestradiol / 150mcg desogestrel) 
   SPC Link  GEDAREL (20mcg ethinylestradiol / 150mcg desogestrel) 

Consider contra-indications and precautions for example, age, other co-existing conditions, weight, drug history, risk of venous thromboembolism, smoking status etc. MHRA Combined Hormonal Contraceptives

There is a lack of evidence supporting the use of biphasic and triphasic COCs, cycle control is not improved and they are more complicated to use.

Norethisterone- and levonorgestrel- containing COCs may have a lower risk of venous thromboembolism than COCs containing desogestrel and gestodene (NPC)

However, Gedarel 30/150 may be suitable for women who suffer side effects, e.g. acne, on COCs containing norethisterone or levonorgestrol.

Guidelines from the DOH state that, provided women are informed of the very small risks of venous thromboembolism associated with desogestrel and gestodene, the decision about which pill to use should be made jointly by the woman and her doctor or other family planning professional.

Microgynon ED should be used only if a pill free period may cause poor compliance.

Co-cyprindiol is not licensed for use solely as a contraceptive. It should only be used to treat severe acne and hirsutism for relatively short periods of time, owing to increased venous thromboembolism risk. See BNF Section 13.6.2 for warnings. Progestogen only contraceptives (POPs)  

 1st    NORETHISTERONE 350mcg 
 1st    LEVONORGESTROL 30mcg

POPs may offer a suitable alternative when oestrogens are contra-indicated, but failure rates are higher. The window for missed POPs is only 3 hours except for Cerazette (12 hours)

Cerazette is not recommended unless she can not tolerate oestrogen and is unreliable at taking medication at a regular time (although if this is the case a less user dependant method should be advised) Parenteral Progestogen-only contraceptives  

   SPC Link  ETONOGESTREL (Nexplanon)
2nd    DEPO-PROVERA (medroxyprogesterone acetate injection) 
2nd    SAYANA PRESS (medroxyprogesterone acetate)

If used for three years, Nexplanon is more cost effective then Depo-Provera and associated with an increase in bone mineral density (BMD)

CSM advises not to use Depo-Provera in adolescents unless other methods of contraception are inappropriate due to potential risk of reduced bone mineral density

Advise evaluation of risks if used beyond 2 years

If risk factors for osteoporosis then other methods would be advised Intra-uterine progestogen-only device  

 1st    MIRENA (Levonorgestrel 20mcg/24 hours)
     Mirena should be used in preference to an IUD only if heavy periods are a problem
 2nd    JAYDESS (Levonorgestrel 13.5mg IUD)

 7.3.3 Spermicidal contraceptives

     NONOXINOL "9" GEL (Gygel)

7.3.4 Intra-uterine contraceptive devices (IUD)

Long acting reversible contraceptive methods (copper intrauterine devices (IUD), levonorgestrel releasing intrauterine system (IUS), are more cost effective than COCs if used for the full permissible time.

The most cost effective is a copper containing IUD with 380 milligrams of copper.

 7.3.5 Emergency Contraception  

 FSRH Emergency Contraception Guidance   
 1st    LEVONELLE 1500 (levonorgestrel 1.5mg tablet)
     This can be taken as a single dose. Levonorgestrel is licensed for use within 72 hours of intercourse.
     Please see EllaOne prescribing Flowchart
     Ulipristal acetate can be used up to 5 days after intercourse

Consider use of an IUD as emergency contraception paticularly in women who present 3-5 days after unprotected intercourse, and in women on enzyme-inducing medication (see BNF for details)

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