Many factors comes into consideration when we discuss the type of contraception that best suits the patient such as efficacy, safety, noncontraceptive benefits (for example regulating menses or reducing heavy menses), cost, side effects and personal medical history.
As we all know there are various form of hormonal contraceptions and routes of administration available. Therefore, choosing the most suitable one may require you a short visit to the doctors for a better discussion. In this article, I will concentrate on the hormonal contraceptives which are available in our clinics.Click here for our full range of Women’s Health Services
Hormonal contraception is a popular choice of contraception. It consist of either a combination of estrogen and progesterone, or progesterone alone which can be administered via oral, injection into the muscle, patch or inserted vaginally. The amount of estrogen and the type progesterone used determines the potential side effects.
Different brands of Contraceptive Pills
1) COMBINED CONTRACEPTION
Combined oral contraceptives are highly effective in preventing pregnancy. It works by preventing ovulation, and when taken correctly, efficacy is up to 99%. Failure rates are attributed to patient compliance (i.e. you gotta remember to take it everyday!).
If you missed 1 or more pills and you are unsure what you should do, do speak to a doctor for advice to ensure you are still protected from pregnancy.
– Makes menses more regular and predictable
– Reduces heavy menses
– Freedom to manipulate cycle to avoid menses during certain events (for example during holidays/vacations)
– Reduces risk of ovarian and uterine cancer up to 40%
– Helps improve skin condition such as acne ( anti androgenic effect)
– Common side effects include breast tenderness, nausea, headache, breakthrough bleeding
– Does not protect against STD
– Requires daily compliance
– Problems with missed dosage/pills
– Risk of clot formation in blood vessel ( DVT) in the first year of use – risk is much higher for patients who smoke, and obese ( BMI >25)
– May increase blood pressure up to 5%
The association of oral contraceptive use with cervical and breast cancer in young women is controversial and not proven. However, it is recommended for ladies on COCP to undergo annual pap smear.
The combined contraceptive patch is an alternative for ladies who do not like the idea of having to take the pills every day. Each box contains 3 patches. Each patch lasts for 7 days. Hence, the patch needs to be changed weekly for 3 weeks followed by a patch free week, during which your menses will occur. The best sites to apply the patch are: the lower abdomen, upper arm, buttock or upper chest (excluding the breast area). Avoid placing two consecutive patches over the exact same area. Efficacy is 99.1% if used correctly and consistently.
– Very convenient, only requires weekly change of the patch
– Better compliance
– Less nausea and vomiting
– Possible skin irritation
– May be removed unnoticed for example during shower
– Slightly higher estrogen exposure compared to COCP
It is important to note that rates of DVT with combined contraception are still significantly lower than DVT rates seen in pregnancy.
This is a monthly contraceptive vaginal ring that contains both estrogen and progesterone. It is relatively small and flexible and easy to insert vaginally, similar to a tampon. The difference is with Nuva Ring, you leave it inside for 3 weeks, thereafter you remove it then put in a new one 1 week later. Hence, it is a good choice for ladies who have problems with pill compliance.
The efficacy rate is similar to the combined pill when used correctly. Most women do not feel it once it is in place. Best positions to insert the Nuva ring include lying down, squatting or standing with one leg up.
2) PROGESTERONE ONLY PILL (POP, or ‘mini pill’ eg Micronor)
This choice of contraception will be suitable for women who are breastfeeding and women with contraindications to estrogen use for example those with history of deep venous thrombosis, high blood pressure or high sugar, known breast cancer; active liver disease or heart condition. Failure rates with typical use are estimated to be 5- 7% in the first year of use.
– Suitable for breast feeding mothers ( no adverse effect on breast milk)
– Also helps reduce heavy menses
– Occasional irregular bleeding and spotting even with correct Use
– POP requires the woman to take the pill at the same time every day ( if the pill is missed by > 3 hours, extra protection with condom is necessary for the next 7 days)
3 ) DEPO INJECTION
Some of you may have heard about this mode of contraception. It is actually synthetic progesterone that is injected into the muscle, usually over the upper arm (deltoid muscle). It acts by inhibiting ovulation.
For ladies who have problems with daily pill compliance, this is definitely a suitable choice for you. First injection is given on day 1-5 of menses and is repeated every 3 months. It is an extremely effective contraceptive option with only a failure rate of 0.3%. It is not affected by any concurrent use of other medications for example antibiotics.
– No adverse effects of estrogen as mentioned above, hence suitable for ladies who cannot take estrogen products
– Helps reduce painful periods
– Reduces risk of ovarian and uterine cancer
– Safe for breastfeeding mothers
– Up to 40% of women reported disruption in menstrual cycle and irregular bleeding
– May cause delay in return to fertilty
– Few have reported weight gain and mood swings
– Reversible bone density loss (long term use basis)
Implanon is a small single-rod implant that contains both hormone estrogen and progesterone to prevent pregnancy.
The rod is inserted usually into the inner aspect of upper arm, near the axilla. Before the injection, we will numb the area with local anaesthetic injection or numbing cream. Once inserted, it lasts for 3 years and protection begins within 24 hours of insertion if inserted during the first 5 days of menses. The efficacy of implanon is comparable to that of surgical sterilization with efficacy of 99.8%.
– Lasts for 3 years, good for ladies who have difficulties with compliance
– Prompt return to fertility state once removed
– No adverse effect on breast milk production
– Requires a simple removal under local anaesthesia
– Some side effects include : Irregular bleeding, headache, mood swings, and occasionally acne
5) INTRAUTERINE DEVICE/ SYSTEM (IUD/IUS)
Intrauterine device is another highly effective method of contraception. The IUDs available are copper or progesterone relasing form (Mirena).
Mirena consists of a small T-shaped frame that contains levonorgestrel, a progesterone. It is inserted through the neck of the womb (cervix) into the womb cavity. Once inserted, the contraceptive effect lasts for as long as 5 years. Efficacy is up to 99.9%.
Advantages of mirena :
– Reduces heavy menses, resulting in lighter periods
– Helps with painful periods
– Up 50% of women experience little or no menses ( amenorrhea)
Disadvantages of mirena :
– Does not protect against STD
– Possibility of being expelled unnoticed : rare
– Possible injury to womb cavity during insertion : rare
For ladies who prefer non hormonal contraception, the copper IUD is a good and extremely effective alternative. It is a T shaped frame that is wrapped with a copper wire. It is approved for contraception up to 10 years, after which the device must be removed and replaced with a new one if patient wishes to continue this method. Copper IUD is also effective as an emergency contraception if inserted within 5 days of unprotected intercourse.
Both mirena and copper IUD are as effective as female sterilization in preventing pregnancy. They are best used only for women who have had children. Ideally IUD should be inserted day 4-5 of menses. This is to ascertain that patient is not newly pregnant. A urine pregnancy test may be required prior to insertion. It is common to have some mild pain during insertion. Up to 30% may experience some cramping days to weeks after insertion. It is advisable for you to consult the doctor to have a prior discussion before the day of insertion.
There is insufficient evidence that IUD increases risk of pelvic infection or pregnancy outside the womb (ectopic pregnancy). However, it is definitely not recommended for ladies who have a history of ectopic pregnancy, active pelvic infection or previous history of pelvic infection, undiagnosed vaginal bleeding, and known cancer of the womb and cervix.
Last but not least, for ladies who are not keen on hormonal contraception or IUD, the alternative is using mechanical barrier such as male and female condoms. It is important to bear in mind that even with consistent and correct use, the failure rate of male condoms is estimated to be approximately up to 10%.. This can be due to several reasons such as failure to use condoms at every act of intercourse, poor withdrawal technique causing condoms slippage, incorrect placement of condom on the penis and improper use of lubricant. The use of female condoms is very rare because it is difficult to place in the vagina. It may also cause discomfort and increases risk of urinary tract infection. Risk of failure is up to 15%.
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