Contraception Clinic

Introduction to Contraception

The normal menstrual cycle

During fertile years women are unique in having a more or less regular cycle of changes in their bodies. This cycle is caused by the ebb and flow in the bloodstream of various hormones or chemical messengers which are released into certain glands. The whole process is controlled by the brain. Some women who have a stressful emotional upset can cause periods to stop altogether for months. Parts of the brain involved are called the pre-optic area and the hypothalamus. Below the brain is the pituitary gland, sometimes called the leader of of the hormones because of its importance, which is the size of a large pea. The ovaries and uterus are also important as blood flows through them all connecting the whole system together. Any hormone released into the blood by one gland can therefore travel to all the others and can cause its own specific effects there or as appropriate anywhere in the body.

Contraception is considered a matter of personal decision, but health professionals have a responsibility to extend the knowledge and availability of contraception to anyone who requests it. Responsibilities include having appropriate training in family planning in order to give either single individuals or couples seeking contraception, concise, factual information about the different methods of contraception available. The doctor reviews the history and other recommendations which may effect the person's or couple's choice. The doctor will also validate the person's real understanding of the chosen method, and provide explanations and interpretations if necessary, and also discuss the pros and cons of each method. In addition, they need to aware of the emotional, social, and religious aspects of contraception.

There are numerous methods of contraception, most of which, seem to depend more on the woman than the man. Not only is there a difference in the way the methods work and are used, but there is significant difference in the protection each method provides.

A List of Contraceptive Methods with the Possibility of User failure:

  • The Combined Pill
  • The Progestogen only pill
  • Male Condom
  • Female Condom
  • Diaphragm or Cap
  • Natural Family Planning(NFP)

Contraceptive Methods which no user interaction:

  • Contraceptive Injection
  • Implant
  • Intrauterine System (IUS)
  • Intrauterine Device (IUD)
  • Female Sterilisation
  • Male Sterilisation (Vasectomy)

Contraception - The Pill

Emergency Contraception

If you have had unprotected sex, or you are worried that your contraception has failed, there are two methods of emergency contraception: Emergency pill (also known as the morning after pill), and the copper IUD (Intrauterine device).

Both methods are very effective if used soon after unprotected sex. The emergency pill can be taken up to three days after sex, and this prevents more than nine out of ten pregnancies if taken within 24 hours. However, the later the emergency pill is taken the lower the chance of success. The emergency pill is a single tablet that is effective within 72 hours of unprotected sex, it releases the hormone progestogen and works in three possible ways.

  • It can prevent ovulation (an egg being released in the womb)
  • Delay ovulation until a safe time
  • Prevent implanting (when a fertilised egg settles in the womb.

If vomiting occurs within two hours of taking the pill, it is very important to seek advice from the Doctor about getting a repeated dose, together with a medicine to stop the vomiting again, this should be done without delay.

Due to the way the emergency pill works, your period may be later or earlier than expected. If there are any concerns contact the doctor again. Although most women can use the emergency pill, women already taking other medication will need to discuss this with the doctor first, who will advise the best method of emergency contraception. The emergency contraception pill should not be taken if already pregnant, as the treatment will not work, although if it is taken when pregnant, there is no evidence to suggest it will harm the baby.

If a copper IUD is considered, it is important to have an examination to check for sexually transmitted infections prior to being fitted, and if an infection such as chlamydia has been diagnosed your doctor will delay fitting until the infection has been treated. A copper IUD will not be considered if there is a history of a previous ectopic pregnancy (when a fertilised egg settles in the fallopian tubes) or any other problems with the womb or cervix. The copper IUD can be fitted into the womb by the doctor within five days of having unprotected sex, or at the earliest time when ovulation took place, it has almost a 100% success rate.

The emergency pill should not be relied on as a regular method of contraception. The doctor will discuss the best option available following history taking of each case at consultation.

Oral Contraception (the pill)

Contraceptive pills are synthetic chemical hormones which resemble the female hormones of the ovary. In suppressing ovulation they mimic the action of pregnancy. Protection is established as soon as the woman begins taking the pill, if started on the 1st day of the menstrual cycle. The pills are divided into two types, the combined pill and progestogen pill. The combined pill contains synthetic oestrogen and progesterone hormones in each pill. The progestogen or ( Mini-Pill) contains a progestational agent and no oestrogen.

The combined pill contains two hormones which inhibit the release of hormones which stimulate the final development and release of ova (eggs) from the ovary.

The combined pill is convenient and over 99 per cent effective when taken correctly, and has many advantages ( including protection against cancer of the womb and the ovary). Like all drugs, there health risks associated with its use. A very small number of women will develop a blood clot which can be life-threatening. Women who take the pill are also more at risk of being diagnosed with breast cancer or cervical cancer. However, for the vast majority of women the advantages of taking the pill greatly outweigh the risks.

How it works

Contains two hormones, oestrogen and progestogen, which stop ovulation.

Pros

Can reduce PMS, period pain and bleeding. Protects against cancer of the womb and ovary.

Cons

Increased risk of breast and cervical cancer, increased risk of thrombosis (blood clots).

Remarks

Smokers over 35 should not use it (risk of thrombosis).

Effectiveness

Over 99%

The combined pill must be prescribed by a doctor or prescribing nurse, and blood pressure should be checked regularly, as it can be associated with a very slightly increased risk of breast cancer and thrombosis (blood clot), it should not be prescribed for women with migraine or have had a previous blood clot.

The progestogen-only pill contains only one hormone and stops sperm from getting to the egg by maintaining the natural plug of mucus in the neck of the womb. It also makes the lining of the womb thinner. It is highly effective (99 per cent) and it is particularly useful for women who cannot use the combined pill. It has however, to be taken regularly at the same time each day, and can have the disadvantage of causing irregular bleeding.

How it works

Contains the hormone progestogen, which thickens the cervical mucus, and stops sperm getting near the egg.

Pros

Can be used when breast-feeding. More suitable for older smokers than the combined pill.

Cons

May reduce irregular periods with bleeding in between. May be less effective in women weighing over 70 kg (11 stone).

Remarks

Must be taken at the same time each day (to within three hours).

Effectiveness

99%

Fertility declines after the age of 35 because of the reduced quality of the females egg's. At the stage of the perimenopause (the time around the menopause), fertility is low though not zero. Pregnancies over the age of 50 are rare but the oldest woman to have conceived naturally and given birth was aged 57 years. Increased risks of complications such as miscarriage, chromosomal disorders ( e.g. Down's syndrome), hypertension and gestational diabetes ( diabetes developing during pregnancy) are possible.

The types of contraception available for older women are the same as those available for younger women, and because of the reduced fertility, many of the methods are more effective in the perimenopausal years. No contraceptive method is contraindicated by age alone, though if you smoke, the combined oral contraceptive pill is not recommended after the age of 35. A low dose contraceptive can be used at this stage if you are a non-smoker, not overweight, and generally healthy. It would suppress the irregular hormone production from the ovaries and lead to a more regular withdrawal bleed. Some women continue on the oral contraceptive pill up until the age of 50. Once known to be menopausal, HRT (Hormone Replacement Therapy) is a better option because the hormones used are natural and will be in a lower dose.

Contraception - Other Methods

Intrauterine Contraceptive system (IUS)

These small plastic T shaped devices containing the hormone progestogen. It is inserted into the womb by GPs, at the surgery, or by nurses at family planning clinics. The IUS prevents pregnancy in the same way as the progesterone-only pill, is over 99 per cent effective, can be left in place for up to five years, and can be used by women both before and after having children. Initial side-effects can include irregular bleeding, but periods then tend to become lighter and shorter, or stop altogether; period pain is also reduced. Like the IUD, the IUS is removed easily by a doctor or nurse, and does not alter sensation during intercourse following its removal.

Intrauterine Device (IUD)

The IUD is a rigid T shaped contraceptive device made from plastic and copper that fits inside the womb (Uterus). It used to be called a coil or a loop. It prevents pregnancy by stopping sperm and egg meeting, and it also makes the lining of the womb unsuitable for implantation should fertilisation occur.

The device has one or two very fine threads that come through the cervix opening and rest on the top of the vagina.

Fitting should be done by a trained doctor or nurse. It can be done at the Capio private clinic, GP surgery, local family planning clinic, or sexual health clinic (GUM).

An IUD is usually fitted during your menstrual period, or some fit on the 5th day of a period. From the moment the IUD is fitted until the time it is taken out, you are protected against pregnancy.

The IUD is between 98-99% effective with newer, more efficient models presenting even lower risks of failure. These contain more copper and provide an even higher success rate.

The IUD can be used by women both before and after having children. The IUD is not recommended for women who are at risk of acquiring a sexually transmitted infection. It is recommended that screening for infections are carried out prior to insertion of the IUD. The IUD can be removed easily by a doctor or nurse who is family planning trained.

There are several different types and sizes of (IUD) The doctor will decide suitability during examination.

Hormone Implant (for women)

One small rod containing progestogen is inserted under the skin in the arm, usually using a local anaesthetic. It works like the progesterone-only pill and lasts for three years. The main disadvantage is that it can cause irregular bleeding for several months. It is over 99 per cent effective and is easily removed in a minute or two.

Other Combined pill-type methods: other routes of delivery for hormones.

EVRA skin patch: the transdermal route. This is a skin patch delivering hormones through the skin. Each patch is worn for seven days for three consecutive weeks followed by a patch free week.

Hormone Injection (for women)

The hormone progestogen is given as an injection every 8 or 12 weeks, depending on the type used. It is over 99 per cent effective and works by stopping the ovaries producing eggs. It shares many of the advantages of the combined pill, but can cause irregular bleeding and weight gain. Once the injections stop it can take a year or more for periods to return to normal.

Contraception - Barrier

The Male Condom

Society is increasingly accepting the condom as one of the normal requirements of modern life. This has led to their wider availability and condoms can now readily be obtained - in supermarkets, from garages, by mail order, through slot machines, as well as in pharmacies. They are free from all family planning clinics and genito-urinary medicine clinics. Colours, flavours and new materials, like plastic, make interesting options. Condoms now come in different shapes and sizes, and it is often necessary to try different types before the right one is found. If used correctly condoms are 98 per cent effective at preventing pregnancy and the additional advantage of providing good protection against many sexually transmitted infections. Hermetically sealed, the modern condom will remain usable for a long time, though always check the expiry date. Good quality condoms will also have the CE mark and the Kitemark. Once the seals broken they should be used quite soon as the rubber will perish on exposure to the air and the lubricant will dry, making it difficult to put on.

Further Information on the Male Condom

Using a condom correctly is essential for it to be effective. It should be put on before any contact between the penis and the vagina or the genital area, and rolled on the correct way round. Air should be excluded from the end of the condom as it can cause it to burst or slip off. Sharp finger nails, rings and teeth are a hazard. Only finger pulps should be used to unroll the condom unto the penis. If extra lubrication is needed then only a water based one should be used with rubber condoms. There is a need to withdraw and remove the condom while the penis is still erect to avoid semen leaking out as the penis shrinks in size.

How it works

Barrier method. The condom covers the penis and stops sperm entering the vagina.

pros

Wide choice and good availability. Provides some protection against sexually transmitted infections. Under male control.

Cons

Need to stop to put it on. Can split or come off if not used correctly. Need to withdraw while still erect.

Remarks

Do not re-use. Must be put on before genital contact occurs. Do not use oil based lubricants on latex condoms.

Effectiveness

98%

The Female Condom

The condom for women is relatively new, but there are regular users reports that they find them favourable as do many men. Made of plastic it is larger in diameter than the male condom and has a flexible ring at each end. The smaller ring fits inside the vagina, while the outer, larger, ring remains on the outside of the vagina. After ejaculation this outer ring should be twisted to prevent escape of the sperm and the condom gently withdrawn. Female condoms are 95 per cent effective, and also have the advantage of providing protection against many sexually transmitted infections.

How it works

Barrier method. The condom lines the vagina and stops sperm entering.

Pros

Can be put in before sex. Provides some protection against sexually transmitted infections.

Cons

If not inserted in advance, need to stop to put it in. Need to make sure that the penis enters correctly.

Remarks

Do not re-use. Must be put in before genital contact occurs. Expensive to buy, but can be obtained free at some family planning clinics, and genito-urinary medicine clinics.

Effectiveness

95%

The Diaphragm or Cap

How it works

A Barrier Method. A rubber or silicone cap covers the cervix to keep sperm out of the womb. Used with spermicidal cream or jelly.

Pros

Can be put in before sex. Provides some protection against sexually transmitted infections.

Cons

If not inserted in advance, need to stop to put it in. Can provoke cystitis in some users.

Remarks

Must be correctly fitted, the doctor or nurse will provide the correct size, this will involve an internal examination to ensure the cap fits correctly over the cervix, a practice diaphragm is sometimes given to familiarize inserting at home, as some women find the cap difficult to insert.

The device must be checked every 12 months, check expiry date, check cap size again with the doctor if there is a significant weight loss, or weight gain. Must be inserted before genital contact occurs.

Effectiveness

92% to 96%

Contraception - Sterilisation

Female Sterilisation

This is a permanent method of contraception in which the fallopian tubes are either cut, sealed, or blocked so that eggs cannot pass down them to the uterus (womb). It has a failure rate of 1 in 200, making it 99.5 per cent effective - as good as other long term reversible methods. Should it fail, it carries a greater risk of the egg implanting in the fallopian tube (ectopic pregnancy). As a general anaesthetic is required and the operation is more invasive it is a more complicated and risky procedure than a vasectomy. It is possible to reverse the operation but with very limited success, together with an increased risk of an ectopic pregnancy.

Vasectomy (Male Sterilisation)

Vasectomy is a simple and permanent method of contraception. You don't need permission from your partner but it makes good sense to discuss with your partner. There is no recorded effect on enjoying sex. The testicles continue to produce sperm but rather than being ejaculated with the semen the sperm are reabsorbed in each testicle. Sperm therefore doesn't build up inside the testicles. As with any surgical procedure you will have to sign a consent form.

When it should be done

Although there is no lower age limit for vasectomy, young, childless men need to consider this method carefully to avoid later regret. It should therefore only be chosen by men who, for whatever reason, are sure that they do not want children in the future. Counselling is recommended so that other contraception options can be discussed and the procedure fully understood. A vasectomy immediately following a birth, miscarriage, abortion, or family or relationship crisis is usually not recommended. For further information on how the procedure is preformed, recovery, effectiveness, and future prospects about reversal operations can be discussed with the doctor at appointment.

Contraception - Natural Methods

Natural Method of family planning

It is only possible for your partner to conceive within 24 hours of ovulation. However, sperm can live for several days, sex that happens up to seven days before ovulation can result in pregnancy (this sex can even be during a period). It is possible to estimate the fertile period by noting certain changes in the body. Using a fertility thermometer and a chart it is possible to detect the sudden rise in temperature of around 0.02 degrees Celsius which occurs at ovulation.

Monitoring changes in the cervical mucus help identify the time before and after ovulation. The mucus becomes thin, watery and clearer before ovulation, and afterwards returns to being thicker, sticker and whiter. When practised according to instruction, natural family planning is 98 per cent effective, although it does take a while to learn it as a method and requires commitment from both partners.

How it works

Fertile and infertile times in the menstrual cycle are identified.

Pros

Freedom from side-effects, awareness of fertile times can be used for planning pregnancies as well as avoiding them.

Cons

Method must be taught by a qualified Professional. Users must abstain from sex, or use a barrier method, during the fertile period.

Remarks

There are various different methods of indicating fertility. Effectiveness is highest when using several indicators

Effectiveness

Up to 98%

Coitus Interruptus

This method consists of the male withdrawing his penis from the vagina before ejaculation occurs and ejaculates outside the vagina. Coitus interruptus, or withdrawal, is better than no attempt at preventing a pregnancy but it is very unreliable. Care must be taken not to ejaculate on or near the vulva, as sperm may make their way into the vagina and pregnancy can result.

The method requires the man to have advance awareness of ejaculation. This control and knowledge may be difficult to establish and may require more sexual experience than the man or couple possesses. Also, some sperm may escape before ejaculation occurs. The method has also been criticised for possible psychological effects. These have associated with frustration as a result of unresolved sexual tensions on the part of one or both partners. But if the method is accepted by both partners and orgasm and ejaculation do occur, the resulting psychological stresses are probable minimal.

Contraception - Summary

If the pill does no suit, or if for some reason the pill needs to be avoided, remember there are other reversible choices available which include the patch or ring, an injectable or an implant, the IUD or IUS. A lot of time in family planning, we, and for the most part women have to make the decisions, with the methods available. When deciding to take the pill, and currently this is the most effective personally controlled reversible method, make sure it is an informed decision, and discussed with your doctor. Remember condoms for safer sex, and consider the risk of sexually transmitted diseases like chlamydia and (HIV)

Dr Prabhat Sood

Consultant Physician
Genitourinary and HIV Medicine

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