BNF for Children (BNFC) 2018-2019

(singke) #1
Hormonal emergency contraception interactions
The effectiveness of levonorgestrel and ulipristal acetate
p. 507 is reduced in women taking enzyme-inducing drugs or
griseofulvin (and for at least^4 weeks after stopping).gA
copper intra-uterine device can be offered instead. If the
copper intra-uterine device is declined or unsuitable, the
dose of levonorgestrel should be increased (SeeDose
adjustments due to interactionsunder levonorgestrel). There
is no need to increase the dose for emergency contraception
if the patient is taking antibacterials that are not enzyme
inducers.h
The effectiveness of ulipristal acetate for emergency
contraception in women using drugs that increase gastric pH
has not been studied.gLevonorgestrel or a copper intra-
uterine device should be considered as alternatives.
Hormonal contraception should not be newly initiated in
a patient untilfive days after administration of ulipristal
acetate as emergency hormonal contraception—the
contraceptive effect of ulipristal acetate will be reduced.
Consistent and careful use of condoms is recommended.
Ulipristal acetate can be used as emergency hormonal
contraception more than once in the same cycle.h
Conversely, manufacturer advises that use of levonorgestrel
as emergency contraception more than once in the same
cycle is not advisable due to increased risk of side-effects
(such as menstrual irregularities).
gLevonorgestrel should not be used (as emergency
hormonal contraception) within 5 days of administration of
ulipristal acetate (as emergency hormonal contraception), as
the contraceptive effect of ulipristal acetate may be reduced
by progestogens.
Ulipristal acetate is not recommend for use in women who
have severe asthma treated by oral corticosteroids, due to
the antiglucocorticoid effect of ulipristal acetate.h

Useful Resources
Drug interactions with hormonal contraception. The Faculty
of Sexual and Reproductive Healthcare. Clinical guidance.
January 2018.
http://www.fsrh.org/standards-and-guidance/current-clinical-guidance/
drug-interactions

3.1 Contraception, combined


OESTROGENS COMBINED WITH
PROGESTOGENS

Combined hormonal f


contraceptives
lCONTRA-INDICATIONSAcute porphyrias p. 603 .gallstones
.heart disease associated with pulmonary hypertension or
risk of embolus.history during pregnancy of cholestatic
jaundice.history during pregnancy of chorea.history
during pregnancy of pemphigoid gestationis.history
during pregnancy of pruritus.history of breast cancer (but
can be used after 5 years if no evidence of disease and non-
hormonal methods unacceptable).history of haemolytic
uraemic syndrome.migraine with aura.personal history
of venous or arterial thrombosis.sclerosing treatment for
varicose veins.severe or multiple risk factors for arterial
disease.severe or multiple risk factors for venous
thromboembolism.systemic lupus erythematosus.
transient cerebral ischaemic attacks without headaches.
undiagnosed vaginal bleeding
lCAUTIONSActive trophoblastic disease (until return to
normal of urine- and plasma-gonadotrophin
concentration)—seek specialist advice.Crohn’s disease.
gene mutations associated with breast cancer (e.g. BRCA
1).history of severe depression especially if induced by

hormonal contraceptive.hyperprolactinaemia (seek
specialist advice).inflammatory bowel disease.migraine.
personal or family history of hypertriglyceridaemia
(increased risk of pancreatitis).risk factors for arterial
disease.risk factors for venous thromboembolism.sickle-
cell disease.undiagnosed breast mass
CAUTIONS, FURTHER INFORMATION
▶Risk of venous thromboembolismThere is an increased risk of
venous thromboembolic disease in users of combined
hormonal contraceptives particularly during thefirst year
and possibly after restarting combined hormonal
contraceptives following a break of four weeks or more.
This risk is considerably smaller than that associated with
pregnancy (about 60 cases of venous thromboembolic
disease per100 000pregnancies). In all cases the risk of
venous thromboembolism increases with age and in the
presence of other risk factors, such as obesity. The risk also
varies depending on the type of progestogen.
Provided that women are informed of the relative risks
of venous thromboembolism and accept them, the choice
of oral contraceptive is for the woman together with the
prescriber jointly to make in light of her individual medical
history and any contra-indications.
Combined hormonal contraceptives also slightly
increase the risk ofarterialthromboembolism; however,
there is no evidence to suggest that this risk varies
between different preparations.
▶Risk factors for venous thromboembolismUse withcautionif
any of following factors present butavoidif two or more
factors present:
.family history of venous thromboembolisminfirst-degree
relative aged under 45 years (avoid contraceptive
containing desogestrel or gestodene,oravoid if known
prothrombotic coagulation abnormality e.g. factor V
Leiden or antiphospholipid antibodies (including lupus
anticoagulant));
.obesity; body mass index 30 kg/m

2
(avoid if body mass
index 35 kg/m^2 unless no suitable alternative); (in
adolescents, caution if obese according to BMI (adjusted
for age and gender); in those who are markedly obese,
avoid unless no suitable alternative);
.long-term immobilisatione.g. in a wheelchair (avoid if
confined to bed or leg in plaster cast);
.history of superficial thrombophlebitis;
.ageover 35 years (avoid if over 50 years);
.smoking.

Combined Hormonal Contraception and Risk of
Venous Thromboembolism

Progestogen in Combined
Hormonal Contraceptive

Estimated incidence per 10000
women per year of use
Non-pregnant, not using
combined hormonal
contraception

2

Levonorgesterol^15 – 7
Norgestimate^15 – 7
Norethisterone^15 – 7
Etonogestrel^16 – 12
Norelgestromin^16 – 12
Gestodene^19 – 12
Desogestrel^19 – 12
Drospirenone^19 – 12
Dienogest^2 Not known—insufficient data
Nomegestrol^2 Not known—insufficient data
1
Combined with ethinylestradiol

2
Combined with estradiol

498 Contraception BNFC 2018 – 2019


Genito-urinary system

7

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