preparations) are appropriate for standard use. Phased
preparations are generally reserved for women whoeither
do not have withdrawal bleeding or who have
breakthrough bleeding with monophasic products.
The progestogens ethinylestradiol with desogestrel p. 500 ,
ethinylestradiol with drospirenone p. 501 , and
ethinylestradiol with gestodene p. 502 may be considered for
women who have side-effects (such as acne, headache,
depression, breast symptoms, and breakthrough bleeding)
with other progestogens. Drospirenone, a derivative of
spironolactone, has anti-androgenic and anti-
mineralocorticoid activity; it should be used with care if an
increased plasma-potassium concentration might be
hazardous.
Dienogest with estradiol valerate p. 500 is in the combined
oral contraceptiveQlaira®. Nomegestrol is the progestogen
contained in the combined oral contraceptiveZoely®,in
combination with estradiol.
The progestogen norelgestromin is combined with
ethinylestradiol in a transdermal patch (Evra®). The vaginal
contraceptive ring contains the progestogen etonogestrel
combined with ethinylestradiol (NuvaRing®).
Surgery
Oestrogen-containing contraceptives should preferably be
discontinued (and adequate alternative contraceptive
arrangements made) 4 weeks before major elective surgery
and all surgery to the legs or surgery which involves
prolonged immobilisation of a lower limb; they should
normally be recommenced at thefirst menses occurring at
least 2 weeks after full mobilisation. A progestogen-only
contraceptive may be offered as an alternative and the
oestrogen-containing contraceptive restarted after
mobilisation. When discontinuation of an oestrogen-
containing contraceptive is not possible, e.g. after trauma or
if a patient admitted for an elective procedure is still on an
oestrogen- containing contraceptive, thromboprophylaxis
(with unfractionated or low molecular weight heparin and
graduated compression hosiery) is advised. These
recommendations do not apply to minor surgery with short
duration of anaesthesia, e.g. laparoscopic sterilisation or
tooth extraction, or to women using oestrogen-free
hormonal contraceptives.
Reason to stop immediately
Combined hormonal contraceptives or hormone
replacement therapy (HRT) should be stopped (pending
investigation and treatment), if any of the following occur:
.sudden severe chest pain (even if not radiating to left
arm);
.sudden breathlessness (or cough with blood-stained
sputum);
.unexplained swelling or severe pain in calf of one leg;
.severe stomach pain;
.serious neurological effects including unusual severe,
prolonged headache especially iffirst time or getting
progressively worseorsudden partialorcomplete loss of
visionorsudden disturbance of hearing or other
perceptual disordersordysphasiaorbad fainting attack or
collapseorfirst unexplained epileptic seizureorweakness,
motor disturbances, very marked numbness suddenly
affecting one side or one part of body;
.hepatitis, jaundice, liver enlargement;
.blood pressure above systolic 160 mmHg or diastolic
95 mmHg; (in adolescents stop if blood pressure very
high);
.prolonged immobility after surgery or leg injury;
.detection of a risk factor which contra-indicates
treatment.
Progestogen-only contraceptives
Oral progestogen-only contraceptives
Oral progestogen-only preparations alter cervical mucus to
prevent sperm penetration and may inhibit ovulation in
some women; oral desogestrel-only preparations
consistently inhibit ovulation and this is their primary
mechanism of action. There is insufficient clinical trial
evidence to compare the efficacy of oral progestogen-only
contraceptives with each other or with combined hormonal
contraceptives. Progestogen-only contraceptives offer a
suitable alternative to combined hormonal contraceptives
when oestrogens are contra-indicated (including those with
venous thrombosis or a past history or predisposition to
venous thrombosis, heavy smokers, those with hypertension
above systolic 160 mmHg or diastolic 95 mmHg, valvular
heart disease, diabetes mellitus with complications, and
migraine with aura).Parenteral progestogen-only contraceptives
Medroxyprogesterone acetate p. 512 (Depo-Provera®,
SAYANA PRESS®) is a long-acting progestogen given by
injection; it is at least as effective as the combined oral
preparations but because of its prolonged action it should
never be given withoutfull counselling backed by the patient
information leaflet. It may be used as a short-term or long-
term contraceptive for women who have been counselled
about the likelihood of menstrual disturbance and the
potential for a delay in return to full fertility. Delayed return
of fertility and irregular cycles may occur after
discontinuation of treatment but there is no evidence of
permanent infertility. Troublesome bleeding has been
reported in patients given medroxyprogesterone acetate in
the immediate puerperium; delaying thefirst injection until
6 weeks after birth may minimise bleeding problems. If the
woman is not breast-feeding, thefirst injection may be given
within 5 days postpartum (she should be warned that the risk
of troublesome bleeding may be increased).
.In adolescents, medroxyprogesterone acetate (Depo-
Provera®,SAYANA PRESS®) should be used only when
other methods of contraception are inappropriate;
.in all women, the benefits of using medroxyprogesterone
acetate beyond 2 years should be evaluated against the
risks;
.in women with risk factors for osteoporosis, a method of
contraception other than medroxyprogesterone acetate
should be considered.
Norethisterone enantate(Noristerat®) is a long-acting
progestogen given as an oily injection which provides
contraception for 8 weeks; it is used as short-term interim
contraception e.g. before vasectomy becomes effective.
Anetonogestrel-releasing implant(Nexplanon®) is also
available. It is a highly effective long-acting contraceptive,
consisting of a singleflexible rod that is inserted
subdermally into the lower surface of the upper arm and
provides contraception for up to 3 years. The manufacturer
advises that in heavier women, blood-etonogestrel
concentrations are lower and therefore the implant may not
provide effective contraception during the third year; they
advise that earlier replacement may be considered in such
patients—however, evidence to support this
recommendation is lacking. Local reactions such as bruising
and itching can occur at the insertion site. The contraceptive
effect of etonogestrel is rapidly reversed on removal of the
implant.
Intra-uterine progestogen-only device
The progestogen-only intra-uterine systemsMirena®,
Jaydess®andLevosert®release levonorgestrel p. 508 directly
into the uterine cavity.Mirena®is licensed for use as a
contraceptive, for the treatment of primary menorrhagia and
for the prevention of endometrial hyperplasia during
oestrogen replacement therapy.Jaydess®andLevosert®are
licensed for contraception, andLevosert®is additionallyBNFC 2018 – 2019 Contraception 495
Genito-urinary system7