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Female doctor in Durban

Dr H Ganesen( MBCHB, MMed Fam Med) 

Contraception

 

  • Contraception allows women to choose when to have children. There are many different options available.
  • There are a few important factors to consider when choosing a contraceptive method:
    • How effective is the method?
    • What are the side effects of the method?
    • Is it convenient to use?
    • What is the cost of the method
    • What is its reversibility ie: how soon after discontinuing that chosen method can I fall pregnant?
    • Are there any medical reasons why I cannot use a particular method ( we call these medical contraindications)

 

Oral contraception

These pills usually contain two hormones, referred to as combined oral contraceptives (COC).  I included a long description on these two hormones.  Once you understand these hormones, you will understand what makes each pill different.

 

 

  • Oestrogen
    • Oestrogen in the pill prevents pregnancy by inhibiting ovulation and preventing follicle maturation. All the COC’s in SA contain a synthetic oestrogen called ethinyl oestradiol, except in Qlaira which contains Oestradiol valerate. The dose of oestrogen in the pill ranges from 15-50ug. 
  • Progestogen
    • Progestogen thins the lining of the uterus and thickens the cervical mucus to prevent pregnancy.
      • Norethisterone (NET) This is a low-potency progestogen, and fairly nonandrogenic.  Menstruation is very light, sometimes even absent. In some women it causes breast tenderness, bloating and nausea because of the relative oestrogenicity.
      • Levonorgestrel (LNG) A more potent progestogen and more androgenic (can cause acne and weight gain) than norethisterone. Cycle control is usually good.
      • Desogestrel (DSG) This progestogen is more oestrogenic and there is a slightly higher risk of thrombo-embolism in users of pills containing this hormone. Fewer androgenic side effects experienced ie: irritability, weight gain and acne.
      • Gestodene (GSD) Same as DSG. It also has excellent cycle control.
      • Cyproterone acetate An anti-androgenic progestogen, this is an effective drug against acne and hirsutism, as well as an effective contraceptive.
      • Norgestimate A prodrug, which is rapidly absorbed and metabolised and converted to norgesterol.
      • Drospirenone Antiandrogenic and an analogue of spirinolactone, it has a mild diuretic effect, which is useful in patients who experienced fluid retention on other COC’s. It provides safe prevention against pregnancy. Drospirenone also has an anti-mineralocorticoid activity that reduces PMS and related symptoms. The anti-androgenic activity reduces acne.

 

  • There are two types of oral contraception (COC and POP)
    • Combined oral contraceptive pill (COC)
      • These pills can be
        • Monophasic: has a constant dose of oestrogen and progesterone throughout the cycle.
        • Biphasic: there are two changes in the dose, the last 10 pills contain a higher progesterone dose
        •  Triphasic: the dose changes three times in the cycle and it imitate the normal menstrual cycle.
        • Quadriphasic: Currently the only quadriphasic pill available in SA is Qlaira. There are 4 different, active, low dose birth control pills in a pack of Qlaira. A higher dose of oestrogen is delivered at the start of your cycle, finishing with the lowest dose delivered at the end. The progestin dose is also varied during the cycle.
      • Most COC’s contain
        • 21 active pills and 7 placebos (21/7 regimen)
        • 24 active pills and 4 placebos (24/4 regimen): found in lower dose ethinyloestradiol pills to reduce the risk of escape ovulation and to prevent hormonal fluctuations associated with the longer hormone-free interval of the 21/7 packs.
    • Progesterone only pill (POP -mini pill).
      • These pills contain progesterone only.
      • There are no gaps between the pills ( i.e.: no placebos)
      • You may experience light irregular bleeds while on this pill
      • Ovulation may occur while on this pill
      • It must be taken the same time every day to be effective.
      • It is usually used in
        •  Women who cannot use the COC
        • Post pregnancy in the woman who is breastfeeding

Table 1: Oral Contraceptives available in SA

Phase

Name of Pill

Type of oestrogen

Dose

Type of Progestogen

Dose

Monophasic

Ovral

EE

50µg

NGS

500µg

 

Nordette

EE

30µ

LNG

150µg

 

Femodene ED, Minulette

EE

30µg

GSD

75µg

 

Loette

EE

20µg

GSD

75µg

 

Melodene

EE

20µg

GSD

75µg

 

Marvelon

EE

30µg

DSG

150µg

 

Mercilon

EE

20µg

DSG

150µg

 

Mirelle, Minesse

EE

15µg

GSD

60µg

 

Cilest

EE

35µg

NGS

250µg

 

Diane-35,

Diva-35

Ginette, Minerva

EE

35µg

CA

2mg

 

Yasmin

EE

30µg

D

3mg

 

Yaz

EE

20µg

D

3mg

Biphasic

Biphasil

EE

50µg

LNG

50/125µg

Triphasic

Triphasil

Logynon Ed

EE

30/40/30µg

LNG

50/75/125µg

 

Triodene

Tri-minulet

EE

30/40/30µg

GSD

50/70/100µg

 

Trinovum

EE

 

 

 

Quadriphasic

Qlaira

EV

3/2/1mg

Dienogest

2mg/3mg

Abbreviations: EE: ethinyloestradiol; GSD: gestodene; LNG:Levonorgesterol; NET: Norethisterone; NGS: Norgestimate; D: Drospirenone; CA: Cyproterone acetate.

Compiled by Dr H Ganesen (December 2015)

 

 

  • Am I allowed to use oral contraception?         

The following are situations where the oral contraceptive is not advised:

  1. Breastfeeding : Not to use contraception in the first six weeks following delivery.
  2. Smokers: Women older than 35 years and smoking more than 15 cigarettes per day.
  3. Obesity: Females with a BMI greater than 40
  4. Cardiovascular disease: Females with multiple risk factors for arterial cardiovascular disease
  5. High Blood pressure: Systolic BP >160 or diastolic BP > 95 or vascular disease
  6. Venous thromboembolism: Past or current history ( on anticoagulants)
  7. Major surgery recently with prolonged immobilisation
  8. Genetic abnormality which predisposes you to thrombosis
  9. Ischaemic heart disease: Current or past history
  10. Previous stroke
  11. Valvular heart disease or congenital heart disease: With pulmonary hypertension, atrial fibrillation or endocarditis
  12. Migraines with an aura
  13. Gestational trophoblastic disease with elevated HCG levels
  14. Breast cancer
  15. Diabetes: With vascular complications ie: neuropathy, retinopathy or nephropathy
  16. Liver disease: viral hepatitis, cirrhosis, liver tumors
  17. Raynauds disease: if associated with SLE.
  • How do I initiate the oral contraceptive?

 

  • First day method
    • Start the pill on the first day of your period.
    • This will provide immediate protection.
    • No protection will be provided if the first OC is taken after the 5th day of the cycle.
  • Quick start method
    • This is the method where you cannot wait until the next period to start the OC.
    • Sunday start method
      • Start the active pill in the pack on the first Sunday after the menses starts. If menses starts on a Sunday, start taking the pill on that day.
      • Use back up contraception for the first 7 days
      • Advantage: You will not have a period over a weekend
    • Thursday Start Method
      • When using the 24/4 OC pills regimen, this will also result in not having a period over the weekend.

How to postpone the next menstrual period?           

  • Omit the last seven placebo pills in the pack.  A new pack is started after the last active pill of the previous pack
  • Do not do this for consecutive cycles without discussing it with your doctor.

 

Emergency Contraception

  • This is often referred to as the ‘morning after pill’.
  • It is used by women who had recent unprotected sex as an emergency intervention to prevent pregnancy.
  • It does not protect you against HIV.  For protection from possible HIV infection following unprotected sex, please see your doctor for post exposure prophylaxis.
  • It must be taken with 72 hours of unprotected sex.
  • The following options are available in SA:
    1. Ovral®
      • Take two tablets immediately.  Take another 2 tablets 12 hours later
      • It is cheapest option
      • Side effects: Nausea, vomiting, dizziness and headache
      • Patients with thromboembolic disease, migraines and arterial disease should not use this medication.
    2. Egen C®
      • It has the same ingredients as Ovral® but is packaged as four tablets.
    3. Norlevo®
      • It contains 0,75mg levonorgestrel in each tablet.
      • There are two ways to use this medicine as emergency contraception. Take 1 tablet immediately and 1 tablet 12 hours later or take 2 tablets immediately as a single dose.
    4. Escapelle®
      • Contains 1,50mg levonorgestrel.
      • Take 1 tablet within 72 hours after intercourse.
      • The effectiveness of the tablet is dependent on how many hours have passed since intercourse.  (24 hours -95% effective; 25-48 hours 85% effective; 49-72 hours 58% effective).
    5. Microval®
      • Take 25 tablets at a time 12 hours apart.
    6. Nordette®
      • Take 4 tablets immediately after unprotected sex and another 4 tablets 12 hours later.