BNF for Children (BNFC) 2018-2019

licensed for the treatment of menorrhagia. These may

therefore be a contraceptive method of choice for women

who have excessively heavy menses.

The effects of the progestogen-only intra-uterine system

are mainly local and hormonal including prevention of

endometrial proliferation, thickening of cervical mucus, and

suppression of ovulation in some women (in some cycles). In

addition to the progestogenic activity, the intra-uterine

system itself may contribute slightly to the contraceptive

effect. Return of fertility after removal is rapid and appears

to be complete.

Advantages of the progestogen-only intra-uterine system

over copper intra-uterine devices are that there may be an

improvement in any dysmenorrhoea and a reduction in

blood loss; there is also evidence that the frequency of pelvic

inflammatory disease may be reduced (particularly in the

youngest age groups who are most at risk).

In primary menorrhagia, menstrual bleeding is reduced

significantly within 3 – 6 months of inserting the

progestogen-only intra-uterine system, probably because it

prevents endometrial proliferation. Another treatment

should be considered if menorrhagia does not improve

within this time.

Surgery

All progestogen-only contraceptives (including those given

by injection) are suitable for use as an alternative to

combined hormonal contraceptives before major elective

surgery, before all surgery to the legs, or before surgery

which involves prolonged immobilisation of a lower limb.

Contraceptives, non-hormonal

Spermicidal contraceptives

Spermicidal contraceptives are useful additional safeguards

but donotgive adequate protection if used alone unless

fertility is already significantly diminished. They have two

components: a spermicide and a vehicle which itself may

have some inhibiting effect on sperm activity. They are

suitable for use with barrier methods, such as diaphragms or

caps; however, spermicidal contraceptives are not generally

recommended for use with condoms, as there is no evidence

of any additional protection compared with non-spermicidal

lubricants.

Spermicidal contraceptives are not suitable for use in

those with or at high risk of sexually transmitted infections

(including HIV); high frequency use of the spermicide

nonoxinol‘ 9 ’p. 513 has been associated with genital lesions,

which may increase the risk of acquiring these infections.

Contraceptive devices

Intra-uterine devices

The intra-uterine device (IUD) is a suitable contraceptive for

young women irrespective of parity; however, it is less

appropriate for those with an increased risk of pelvic

inflammatory disease e.g. women under 25 years.

The most effective intra-uterine devices have at least

380 mm^2 of copper and have banded copper on the arms.

Smaller devices have been introduced to minimise side-

effects; these consist of a plastic carrier wound with copper

wire orfitted with copper bands; some also have a central

core of silver to prevent fragmentation of the copper.

A frameless, copper-bearing intra-uterine device (Gyne

Fix®) is also available. It consists of a knotted, polypropylene

thread with 6 copper sleeves; the device is anchored in the

uterus by inserting the knot into the uterine fundus.

Caution with oil-based lubricants

Products such as petroleum jelly (Vaseline®), baby oil and

oil-based vaginal and rectal preparations are likely to

damage condoms and contraceptive diaphragms made from

latex rubber, and may render them less effective as a barrier

method of contraception and as a protection from sexually

transmitted infections (including HIV).

Emergency contraception 01-Sep-2017

Overview

gEmergency contraception is intended for occasional

use, to reduce the risk of pregnancy after unprotected sexual

intercourse. It does not replace effective regular

contraception.

Women who do not wish to conceive should be offered

emergency contraception after unprotected sexual

intercourse that has taken place on any day of a natural

menstrual cycle. Emergency contraception should also be

offered after unprotected intercourse from day 21 after

childbirth (unless the criteria for lactational amenorrhoea

are met), and from day 5 after abortion, miscarriage, ectopic

pregnancy or uterine evacuation for gestational

trophoblastic disease.

Emergency contraception should also be offered to

women if their regular contraception has been compromised

or has been used incorrectly.h

Emergency contraceptive methods

Copper intra–uterine devices

gInsertion of a copper intra-uterine device (see intra-

uterine contraceptive devices (copper) p. 505 ) is the most

effective form of emergency contraception and should be

offered (if appropriate) to all women who have had

unprotected sexual intercourse and do not want to conceive.

A copper intra-uterine contraceptive device can be inserted

up to 120 hours ( 5 days) after unprotected intercourse or up

to 5 days after the earliest likely calculated ovulation (i.e.

within the minimum period before implantation), regardless

of the number of episodes of unprotected intercourse earlier

in the cycle. Antibacterial cover should be considered for

copper intra-uterine contraceptive device insertion if there

is a significant risk of sexually transmitted infection that

could be associated with ascending pelvic infection.

A copper intra-uterine device is not known to be affected

by body mass index (BMI) or body-weight or by other drugs.

h

Hormonal methods

gHormonal emergency contraceptives (includes

levonorgestrel p. 508 and ulipristal acetate p. 507 ) should be

offered as soon as possible after unprotected intercourse if a

copper intra-uterine device is not appropriate or is not

acceptable to the patient; either drug should be taken as

soon as possible after unprotected intercourse to increase

efficacy. Hormonal emergency contraception administered

after ovulation is ineffective.

Levonorgestrel is effective if taken within 72 hours

( 3 days) of unprotected intercourse and may also be used

between 72 and 96 hours after unprotected intercourse

[unlicensed use], but efficacy decreases with time. Ulipristal

acetate is effective if taken within 120 hours ( 5 days) of

unprotected intercourse. Ulipristal acetate has been

demonstrated to be more effective than levonorgestrel for

emergency contraception.

It is possible that a higher body-weight or BMI could

reduce the effectiveness of oral emergency contraception,

particularly levonorgestrel; if BMI is greater than 26 kg/m^2 or

body-weight is greater than 70 kg, it is recommended that

either ulipristal acetate or a double dose of levonorgestrel

[unlicensed indication] (seeEmergency contraceptionunder

levonorgestrel) is given. It is unknown which is more

effective.

Ulipristal acetate should be considered as thefirst-line

hormonal emergency contraceptive for a woman who has

496 Contraception BNFC 2018 – 2019

Genito-urinary system

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