The questions for this peer group discussion relate to contraception which was one of the topics within the recent “Sexual Health” theme.
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. Recent changes in local and international guidance are likely to have an increasing impact on the
contraceptive choices made by both clinicians and patients.
Condoms are an effective method of contraceptive 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
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
A reasonable option for a first-time COC user is 30 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.
Long-acting contraceptive methods, such as the levonorgestrel implant or intrauterine contraceptive devices (IUDs),
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 IUDs.
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
Copper IUDs may initially cause heavier bleeding, whereas levonorgestrel IUDs reduce bleeding, however, they are not
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 IUDs reduce menstrual bleeding and one-half to two-thirds
of patients report lighter and less frequent bleeding within three months of use. Some patients may choose to use this
form of contraception unsubsidised.
International clinical guideline groups recommend that use of some IUDs can be extended, without affecting contraceptive
efficacy. This recommendation does not apply at present to nulliparous patients aged <25 years as this patient group
was generally not included in studies. 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.
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?
- 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
- The change in advice regarding when a COC can be started post-partum may be new for many clinicians. Were you aware
of this change in guidance? If not, after reading this article will this change your practice?
- Do you routinely offer patients information about long-acting contraceptive methods, i.e. implants and IUDs? Would
you be more likely now to consider use of an IUD 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 IUDs or implants? If not, do you think this should be considered
now that the long-acting options are increasingly recommended first-line?
- International guidance now recommends that some IUDs can remain in situ for extended durations, e.g. some copper
IUDs for up to 12 years and the current subsidised brand of levonorgestrel IUD for up to seven years. In
your experience are most patients comfortable with leaving an IUD in place for an extended time? Given that the possible
extended durations vary with the brand of IUD, do you have effective documentation and recalls in place on your practice
management system to ensure that IUDs are removed at the correct time?