Published: 28 July 2021
The following questions can be used as discussion points for
peer groups or self-reflection of practice. The questions for this
peer group discussion relate to the contraception article series.
It is strongly recommended that the linked articles are read before considering the questions.
Prescribing contraception is a core part of primary care
practice. A patient’s co-morbidities and concurrent
medicines can influence the balance of risks and benefits
and therefore the choice of contraceptive. Publication of
New Zealand Aotearoa’s guidance on contraception by the
Ministry of Health (Dec, 2020) is likely to have an increasing
impact on the contraceptive choices made by both clinicians
and patients.
Condoms are an effective method of contraception
provided they are used correctly on every occasion of
sexual intercourse. Condoms are also effective at preventing
transmission of most sexually transmitted infections (STIs),
including HIV, gonorrhoea, chlamydia and hepatitis B. They
can also provide some protection from dermal or oral
transmission of STIs, although this risk is not eliminated as
they may not cover all infectious areas. Condoms should
therefore be offered in addition to other contraceptive
regimens for anyone at increased risk of STIs, i.e. unless
the person is in a monogamous relationship where both
partners do not have any STIs. Condoms should be routinely
and widely offered in primary care to ensure equitable access.
Long-acting reversible contraceptive methods, such as
the levonorgestrel implant or intrauterine contraceptives
(IUCs), are now recommended as a first-line choice for people
of all ages, including adolescents. These methods have the
highest rates of effectiveness of the available contraceptive
options and are recommended particularly for patients who
want a “fit and forget” approach to contraception and who
do not wish to become pregnant for a number of years.
Clinicians require training for insertion of both the implants
and IUCs.
Levonorgestrel implants are the most effective form of
reversible contraception and can provide protection for
a period of up to four or five years (depending on body
weight). Levonorgestrel implants are inserted sub-dermally
under local anaesthetic in the inside of the upper arm. They
are generally well tolerated but can have variable effects on
bleeding patterns.
Copper intrauterine devices (IUDs) may initially cause heavier
bleeding, whereas levonorgestrel intrauterine systems
(IUSs), e.g. Mirena, reduce bleeding and are now funded
for contraception. If heavier and more painful menstrual
bleeding occurs with a copper IUD, advice should be given
that this typically improves after the first three months and
most people report being satisfied with this contraceptive
method. Although not listed as a contraindication in most
guidelines, the use of a copper IUD may not be ideal in
patients who already have heavy, painful menstrual bleeding.
Levonorgestrel IUSs reduce menstrual bleeding and one-half
to two-thirds of patients report lighter and less frequent
bleeding within three months of use.
New Zealand guidance recommends that use of some
IUCs can be extended in some patients, without affecting
contraceptive efficacy. Patients who have a Mirena inserted
for contraception or heavy bleeding at age 45 years or
older can extend use for seven years or until menopause*
if amenorrhoeic. Patients who have a copper IUD inserted
after age 40 years may continue to use the same device
until menopause; the device should be removed when
contraception is no longer required. Extended use of IUCs in
younger people is not specifically endorsed by the Faculty of
Sexual and Reproductive Healthcare, United Kingdom (basis
of New Zealand contraception guidance).
* In general, natural loss of fertility can be assumed at age 55 years;
spontaneous conception after this age is extremely rare even in those
who still have menstrual bleeding
Oral contraceptive pills are a safe and effective
contraceptive method widely used in New Zealand. They are
available in two formulations, a combined ethinylestradiol/progestogen pill and a progestogen-only pill (POP).
Combined oral contraceptives (COCs) are generally the first-line choice for those who wish to use an oral contraceptive,
unless oestrogen use is contraindicated. This is because COCs
require less strict adherence to regular dosing times than
POPs and provide additional non-contraceptive benefits.
A reasonable option for a first-time COC user is 30 – 35
micrograms ethinylestradiol with either 150 micrograms
levonorgestrel or 500 micrograms norethisterone. A lower
dose of ethinylestradiol is recommended for older patients,
e.g. aged > 40 years. The choice of oral contraceptive may
also be influenced by whether the patient seeks non-contraceptive benefits from the medicine, e.g. a formulation
containing cyproterone may be appropriate for a patient
with acne or polycystic ovary syndrome, however, the
benefits should be weighed against the higher VTE risk.
COCs are typically taken in a regimen of 21 “active” hormone
pills followed by a hormone-free interval of seven days,
during which withdrawal bleeding occurs. However, there
is no evidence to support any health benefits from having
a monthly withdrawal bleed and lengthening the hormone-free interval can increase the risk of pregnancy. Many women
already run up to three packs together (“tricycling”) to avoid
withdrawal bleeds or oestrogen withdrawal symptoms.
Recent guidelines have now extended this concept to
continuous use, i.e. the hormone-free interval is omitted
and active hormone pills are taken continuously. There is
no evidence that this is unsafe. There is an increased risk of
breakthrough bleeding when pills are taken continuously,
but this declines with time. If breakthrough bleeding persists
for three to four days when taking pills continuously, the pills
should be stopped for four days and then resumed. If patients
do not wish to omit the hormone-free interval completely,
another option is to shorten this period from seven to four
days. This reduces the chance of return to ovarian activity
and therefore may decrease the risk of contraceptive failure,
e.g. if pills are missed.
A further recent change in advice concerns post-partum
use of COCs. Traditionally COCs have not been prescribed
until six months post-partum. Guidelines now advise that
they can be started from six weeks post-partum provided
breastfeeding is well established and there are no concerns
with the infant’s growth. Mothers who are not breastfeeding
can start a COC from three weeks post-partum provided
there are no other risk factors for VTE (e.g. caesarean delivery,
haemorrhage or transfusion at delivery, smoking, BMI ≥30
kg/m2). If any of these additional risk factors are present, the
COC should not be started until six weeks post-partum.
Depot medroxyprogesterone acetate (DMPA) injections
are a highly effective form of contraception and are usually
well-tolerated. In approximately 50% of women they result
in amenorrhoea, however, some report problems with
irregular or prolonged bleeding and weight gain. Despite
these risks and the potential for a delayed return to fertility
when stopped, DMPA injections are a preferred method of
contraception for many people as they do not rely on daily
adherence or require an insertion procedure. Due to an
association with a reduction in bone mineral density, they
are not recommended as a first-line contraceptive method in
those aged under 18 years or in any woman with risk factors
for osteoporosis. New Zealand guidelines recommend a
dosing interval of 13 weeks; this is an evidence-based change
from the previously recommended 12 week dosing interval.
Questions for discussion
- Ensuring consistent and correct use are the most
important considerations when providing patients
with condoms. Do you have a range of condoms in
the practice to provide to patients (obtained on a
Practitioner’s supply Order)? When prescribing condoms,
do you ask patients about their previous experience with
size or fit? Do you tend to specify a particular brand or
size on the prescription or leave this up to the pharmacist
to discuss?
- Do you routinely offer patients information about long-acting contraceptive methods, i.e. implants and IUCs?
Would you be more likely now to consider use of an IUC
in young nulliparous women given that traditionally they
were not widely used in this group? Do you find that
women are satisfied with these forms of contraception?
What are some of the issues you have encountered with
their use?
- Do you (or someone at your practice) regularly insert
IUCs or implants? If not, do you think this should be
considered now that the long-acting options are
recommended first-line? Is insertion training available in
your area?
- National and international guidance now recommend
that some IUCs can remain in situ for extended durations,
e.g. some copper IUDs for up to 12 years and the current
funded brand of levonorgestrel IUS for up to seven years.
In your experience are most patients comfortable with
leaving an IUC in place for an extended time? Given that
the possible extended durations vary with the brand of
IUC, do you have effective documentation and recalls in
place on your practice management system to ensure
that IUCs are removed at the correct time?
- Were you aware of the changes in guidance regarding
continuous use of COCs? Have you found patients
receptive to the idea? Do you think there are still
concerns among both patients and clinicians about the
safety of this practice?
- The change in advice regarding when a COC can be
started post-partum may also be new for many clinicians.
Were you aware of this change in guidance? If not, after
reading this article will this change your practice?
- Our new national contraceptive guidelines now
recommend a 13 week dosing interval for DMPA
injections rather than 12 weeks as in previous guidance.
Were you aware of this evidence-based change in
practice prior to reading the articles? Have you found
patients to be accepting of the change in timing or to be
concerned about effectiveness?
