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The sincere spread is to a theory of the team whereas natural form is the information of modes or banks. Efficacy is also much greater during full lactation, approaching that of COCs. Table 8 Available progestogen-only pills. Pending more data, and given the great medical safety of the method, at the MPC we now usually offer 2 POPs a day to women over 70 kg irrespective of height , especially if they are young.
This is not of course necessary during established breastfeeding or in older women, particularly above age In the remainder there is reliance mainly on progestogenic interference with mucus penetrability, backed by some anti-nidatory activity at the endometrium. The starting routines are summarized in Table 9. Table 9 Starting routines for progestogen-only pills. See page 43, final footnote to Table 7. This is very cautious but is consistent with the advice for the COCs and may be logical with regard to the antiovulatory effect, which occurs in over half of POP users.
During full lactation, the efficacy is so much greater that extra precautions need only be advised if a pill is missed for more than 12 hours. Even this is probably over-cautious during the first 6 months postpartum if there is also amenorrhoea. But because breastfeeding varies in its intensity, it is usual to advise additional precautions during the next 7 tablet-taking days.
In young and highly fertile women it is advisable to recommend switching back to the COC for greater effectiveness as soon as the infant starts to be weaned, ideally no later than the first bleeding episode. Broad-spectrum antibiotics do not interfere with the effectiveness of POPs.
Another contraceptive method would 63 normally be advised during use of enzyme inducers such as rifampicin and griseofulvin. For long-term treatments with enzyme inducers, increasing the dose is an option: usually to two POPs daily, after consideration of other factors such as weight and age. As the POP is thought not to affect blood-clotting mechanisms it may be used by women with a definite history of venous thromboembolism VTE —and a whole range of disorders predisposing to arterial or venous disease pp. See also p. The quantity is the equivalent of only one POP in 2 years, considerably less than the progesterone level found in formula feeds.
These allow better preservation of the precious remaining fallopian tube, especially in nulliparae. The increased frequency of symptomatic cysts with POPs may lead to problems in the differential diagnosis from ectopic pregnancy among POP users with abdominal pains. Indeed, if it does not do so the woman most probably has essential hypertension. Apart from the complaint of breast tenderness, which is usually transient but may be recurrent and can sometimes be overcome by changing from one POP to another, the main side effect is menstrual irregularity.
With advance warning this is usually well tolerated. It is helpful to chart a bleeding record in early months, because this highlights the type of problem and usually demonstrates improvement. More than half the women will have a cycle between 25 and 35 days. Even when cycles are short, complaints are rare provided that the bleeding is not heavy. A few women experience prolonged or heavy bleeding, and if this is not relieved by changing the POP another method should be selected perhaps an implant or the IUS.
Except during full lactation, prolonged spells of amenorrhoea occur most often in older women. Once pregnancy is excluded, the amenorrhoea must be the result of anovulation and so signifies very high efficacy. The method can be continued unless there is evidence of hypo-oestrogenism see below. This is probably true in most POP-users even if they develop complete amenorrhoea, but it may not be true in all, raising as with DMPA concerns about hypo-oestrogenism, arterial disease or osteoporosis.
Pending more data, at the MPC hypo-oestrogenism is assessed regularly at follow-up, and then routinely after about 5 years of amenorrhoea. The assessment is primarily clinical dry vagina, loss of libido, vasomotor symptoms.
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But the fuller DMPA protocol p. Establishing ovarian failure at the menopause is less important than with the COC p. Two high values 6 weeks apart, especially if there are vasomotor symptoms, would make the likelihood of a later ovulation very low. While irregular bleeding is still a common problem, it has a relatively high incidence of amenorrhoea compared with all previously marketed POPs.
Nevertheless, Cerazette generally permits the ovary to supply adequate follicular phase oestradiol levels. A most useful feature is that extra contraception need only be advised if a pill is taken 12 hours late. It is expected to be therapeutic for many women with menstrual disorders, especially dysmenorrhoea and menorrhagia, and possibly also functional cysts, ovulation pain and PMS.
It will also be a good option if there is a history of ectopic pregnancy. It has been repeatedly endorsed by the expert committees of prestigious bodies, such as the International Planned Parenthood Federation and WHO. Anxiety about this method was generated by animal research of very doubtful relevance to humans. The latest WHO data imply that DMPA users have a reduced risk of cancer, with no overall increased risk of cancers of the breast, ovary or cervix, and a fivefold reduction in the risk of carcinoma of the endometrium RR 0.
There is still the possibility of a weak co-factor effect on breast cancer in young women similar to that with COCs see pp. However, this is unproven and the apparent association may be due to surveillance bias in early years of use by the younger women. Administration, mechanism of action and effectiveness There are two injectable agents available: Depo-Provera mg every 12 weeks, and Noristerat norethisterone oenanthate mg every 8 weeks, both given by deep 68 intramuscular injection in the first 5 days of the menstrual cycle.
The injection sites should not be massaged. If enzyme inducers are being taken long term, the injection interval is usually shortened to 10 weeks, and to 8 weeks for rifabutins. The effectiveness of DMPA is extremely high among reversible methods 0—1 failure per woman-years , primarily because it functions by causing anovulation, backed by similar effects on the mucus and endometrium to the COC. For overdue injections see p. The effects, whether wanted contraceptive or unwanted, are not reversible for the duration of the injection and this fact, unique among current contraceptives, must be explained to prospective users.
They must also be warned that after the last dose conception is commonly delayed: a median delay of 9 months, which is of course only 6 months after cessation of the method. Postpartum bleeding is thereby minimized—but much earlier use is sometimes clinically justified. All progestogen-only injectables may be used in spite of a past history of thrombosis see earlier comments for the POP , and they are ideal for many women who require effective contraception while waiting for major or leg surgery.
Injectables are positively beneficial in endometriosis, in sickle cell anaemia, for women at risk of PID, and in epilepsy, in which it often reduces the frequency of seizures. Main unwanted effects The most significant are irregular bleeding, amenorrhoea and weight gain the latter can be marked in some cases. Preliminary warning minimizes anxiety about these. Excessive bleeding may resolve if the next injection is given early but not less than 4 weeks since the last dose.
Premarin 1. Either is given daily for 21 days, after which there is a withdrawal bleed, and courses may be repeated if an acceptable bleeding pattern does not follow. There is no proof of this—nor that it is not so. The WHO study of heart disease in current users was somewhat reassuring, but more data are urgently needed. The relative contraindications are also almost identical except that the frequency of ectopic pregnancies and ovarian cysts is reduced, transforming those WHO 3 conditions for the POP into indications WHO 1. Some 71 studies show a reduction in HDL cholesterol levels, which combined with the hypo-oestrogenism story above means that arterial disease risk is WHO 2 or even 3 according to degree.
There is also that built-in lack of immediate reversibility see p. Follow-up Aside from ensuring the injections take place at the correct intervals and if not, see p.
Excessive bleeding and amenorrhoea are managed as already described. Blood pressure is normally checked initially, but there is absolutely no need for it to be taken before each dose: the studies fail to show any hypertensive effect. Applying the lessons from the media and legal saga which led to withdrawal of Norplant, it is clear that good prior counselling is crucial. This discussion should be backed by a good e. FPA leaflet and well-documented. Implants contain a progestogen in a slow-release carrier, made either of dimethylsiloxane as in Norplant with 6 implants, and the very similar two-rod Norplant II, now called Jadelle or ethylene vinyl acetate EVA; Implanon.
Inserted into the medial upper arm, after an initial phase of several weeks giving higher blood levels they deliver almost constant low daily levels of the hormone Figure Mechanism of action and effectiveness At the time of writing Implanon was the only marketed implant in the UK. It works primarily by ovulation inhibition, supplemented by the usual mucus and endometrial effects. The implant contains 68 mg of etonogestrel—the new 73 Figure 13 Implanon by courtesy of Organ on Laboratories Ltd.
This is dispersed in an EVA matrix and covered by a 0. Though the implant is not difficult to insert or remove, specific training is essential. In a comparative study the mean insertion time was 1. This was approximately four times faster for both procedures than for Norplant.
If still amenorrhoeic pregnancy risk should be excluded p. It has much in common with Cerazette p. There is no evidence that Implanon would increase the risk. In my view the relative contraindications are as for the POP p. They are all WHO 2. Follow-up and management of side effects No treatment-specific follow-up is necessary including no need for BP checks.
In the pre-marketing randomized comparative trial of Implanon with Norplant, the bleeding patterns were very similar, with one main difference.
As expected for an anovulant method, amenorrhoea was significantly more common The infrequent bleeding and spotting rate was In a comparative study the mean body weight increase over 2 years was 2. As with DMPA, forewarning about weight is essential: some individuals do put on an unacceptable amount of weight.
Since Implanon suppresses ovulation and does not supply any oestrogen, the same long-term questions as with DMPA arise over possible hypo-oestrogenism p. However, the initial findings on both oestrogen levels and bone density are very reassuring. Local adverse effects such as infection of the site, migration, difficult removal and scarring are very infrequent. Discomfort at insertion and removal can be minimized by good training.
Women in their thirties have not been requesting them because they were told, in their twenties, to avoid that method. However, a woman in her later reproductive years with, say, two children is the ideal user, especially if she is not yet sure that her family is complete: the devices have not changed but she has.
Currently some doctors are complying too readily with requests for male or female sterilization which originate partly out of myths about this alternative. This is more than four times as effective Figure 15 as the Nova T in preventing both intrauterine and dangerous ectopic pregnancies.
Unlike that largely outdated option, it retains its efficacy with the passage of time Figure See, however, p. There is now the Nova T , with a greater surface area of copper wire. The manufacturer claims an overall efficacy Pearl rate of 0. The Multiload, even in its thicker wire version, was also significantly less effective than the TCu in the WHO studies, and they found no evidence of the expected better expulsion rate compare GyneFix, p.
Mechanism of action In studies, fertilized ova are almost never retrievable from the genital tract of copper IUD users, hence they must operate mainly by preventing fer tilization. Reproduced with kind permission of Dr G Cardy. However, this seems to be primarily a back-up mechanism when devices are in situ long term.
Ideally, therefore, women should use another method additionally from 7 days before planned device removal, or removal should be postponed until the next menses. If a device must be removed earlier e. Over the age of 30 there is also a reduction in rates of expulsion and of pelvic inflammatory disease, which is not believed to be the result of the older uterus resisting infection but because the older woman is generally less exposed to risk of infection through her own lifestyle or that of her only partner.
This is a remarkably short list as compared with hormonal methods. This is counterintuitive because one would think it would increase the miscarriage rate. In fact the data for all devices studied show that the miscarriage rate is at least halved by removal of the device in the first trimester. The woman should of course be warned that an increased risk of miscarriage still remains. If the threads are already missing when she is seen and other causes are excluded see below , the pregnancy is at increased risk of second trimester abortion which could be infected and antepartum haemorrhage and premature labour.
If the woman goes on to full term it is essential to identify the device in the products of conception; if it is not found, a postpartum X-ray should be arranged in case the device is embedded or has perforated. There is no evidence of associated teratogenicity with conception during or immediately after use of copper devices or indeed of cancer developing in the uterus of long-term users. There are at least six causes of this condition, three with and three without pregnancy see Box on p.
An intra-abdominal IUD is just as useless at stopping pregnancy as one that has been totally expelled. More commonly the woman is already pregnant and the threads have been drawn up or the device has altered its position in situ. First, insert a long-handled Spencer-Wells forceps into the cervical canal and open the jaws carefully under direct vision. In most of the remainder the thread was drawn down and the device removed using either the Emmett retriever or the Retrievette. Appropriate analgesia is important: as a routine we give mefenamic acid mg about 30 minutes before the examination but, in addition, local anaesthesia should be offered see below.
If these manoeuvres fail, referral to the hospital gynaecologist may be necessary. In the study at the MPC only 2. Investigations that may be helpful include ultrasound scan and an X-ray another IUD may usefully be inserted as a uterine marker. Perforation has a general estimated risk whether for framed or frameless devices of about 1 per insertions, but the exact rate depends crucially on the skill of the clinician.
Perforated devices should now almost always be removed at laparoscopy. Infection This is the great fear we all have about intrauterine devices. Just as the pill has been blamed for problems we now know were due to smoking, copper IUDs have been blamed for infections that were really acquired sexually. Modern copper devices have a monofilamentous thread. They provide no protection against PID in contrast to the LNG IUS—see below and the infections that occur may perhaps be more severe as a result of the foreign body effect, yet they do not themselves cause infection.
The WHO study by Farley et al reinforces the above view. They reported on a database from WHO RCTs including approximately 23 insertions worldwide, and in every country the same pattern emerged Figure There was an IUD-associated increased risk of infection for 20 days after the insertion. However the weekly infection rate 3 weeks after insertion went back to the same weekly rate as before insertion, i.
In China there were no infections diagnosed at all in spite of insertions. PID, pelvic inflammatory disease. Note the weekly rate of PID returns to the preinsertion background rate for the population studied. Much more probably, although the doctors in all the centres were searching for truly monogamous couples, they were only successful in this search in China during the s; China is not unique in this respect today.
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In the other countries PID-causing organisms especially Chlamydia trachomatis are pre sumed to have been present in a proportion of the women. The process of insertion would interfere with natural defensive mechanisms as confirmed through instrumentation in other contexts, such as therapeutic abortion. This would enable organisms to spread from the lower genital tract, where they had previously resided, into the upper genital tract including the fallopian tubes.
To summarize these WHO findings: 1 The greatest risk is in the first 20 days, possibly caused by pre-existing carriage of sexually transmitted infections. Risk thereafter, as with preinsertion, relates to the background risk of STIs high in Africa, but so low in mainland China in the late s that it seems to have been virtually absent in the study population. In emergency contraception cases pp. As a minimum, the woman should be given clear details of the relevant symptoms of PID, and instructed as a routine to telephone the practice nurse about a week postinsertion The sexual history, particularly of a new partner in the previous 6 months, is of relevance, although never sufficient.
In a study at the MPC during the mid s the background rate of Chlamydia carriage was 2. Otherwise contact tracing is impossible and reinfection possibly worsened by the IUD foreign body effect will simply occur later. Actinomyces-like organisms These organisms ALOs are frequently reported in cervical smears, more commonly with increasing duration of use of 87 the device. If there are relevant symptoms excessive discharge, pain, dyspareunia, tenderness or signs then the device should be removed and sent for culture, with a low threshold for hospital referral.
Treatment will have to be vigorous, usually prolonged, if pelvic actinomycosis is actually confirmed—it is a potentially life-threatening condition, although very rare. More usually the finding occurs in asymptomatic women. In a study reported from the MPC in three groups of women were followed up: one group was simply monitored and the ALO finding commonly persisted , and in two groups the device was removed with or without immediate reinsertion of another copper IUD.
In both these second two groups follow-up smears were free of ALOs. As a result, simple removal with reinsertion has become the usual practice at the MPC, without antibiotic treatment. A cervical smear is repeated after 6 months, then at normal intervals. Meticulous 6-monthly follow-up, including a check for symptoms and bimanual examination of asymptomatic women, is the other management option especially perhaps for the LNG IUS, pp. Ectopic pregnancy Is this problem caused by copper IUDs?
This also appears to be a myth. The main cause is previous tubal infection with one or both tubes being damaged. The non-causative association with IUDs comes about because they tend to be even more effective at preventing pregnancy in the uterus than in the tube. Therefore the ratio of extra- to intrauterine pregnancies is higher than expected. Ectopic pregnancies are actually reduced in number because very few sperm get through the copper-containing uterine fluids to reach 88 an egg, so very few implantations can occur, in any damaged tube.
However, there are even fewer implantations in the uterus. Thus in the ratio of ectopic to intrauterine pregnancies, the denominator is even lower than the numerator, allowing the ratio to increase—even though both types of pregnancy are actually reduced in frequency. The estimated rate of ectopic pregnancy for sexually active Swedish women seeking pregnancy is 1.
The risk in users of the Gyne T and its clones is estimated as 0. But the ectopic rate for the Nova T old version is not so good, about 0. Clinically, caution about ectopic pregnancy is still necessary: Any IUD user with pain and a late period or irregular bleeding has an ectopic pregnancy until proved otherwise. A past history is a relative contraindication WHO 3 to the method see below , particularly in nulliparae Pain and bleeding As already stressed: Pain and bleeding in IUD users signify a dangerous condition until proved otherwise As well as excluding conditions such as infection and an ectopic pregnancy or miscarriage, malposition of any framed device contrast GyneFix, see below can cause pain through uterine spasms.
Copper devices do increase the duration of bleeding by a mean of 1—2 days, and they also increase the measured volume of bleeding by about a third. Drug treatments may reduce the loss but are not very satisfactory long term. The most successful therapies are mefenamic acid mg 8-hourly and tranexamic acid 1—1.
Which device? The TCu and GyneFix p. Indeed, the Copper T first year failure rate was brilliant, about 0. GyneFix is for women expected to benefit from its low risk of expulsion, malposition and frame-related pain. For Multiload IUDs see pp. Duration of use Studies show reduced rates of discontinuation with increasing duration of use, whether for expulsion, infection or bleeding and pain.
Nova T devices should be removed on efficacy grounds after 3 years or maximum 5 years in all women under But it may not be so licensed, see pp. Main established contraindications to copper IUDs contrast p. Counselling by doctor or nurse After considering the contraindications, there should be an unhurried discussion with the woman of the main points above, particularly regarding her infection risk, the failure rate and the importance of reporting pain as a symptom.
The woman should always be given a user-friendly backup leaflet, and assured that in the event of relevant symptoms she will receive prompt advice and, as indicated, a pelvic examination. Timing of insertions must avoid an implanted pregnancy p. Insertion of devices A pocketbook such as this is not the right medium for teaching insertion techniques.
The Faculty training leading to the Letter of Competence in Intrauterine Contraception Techniques is strongly recommended. This is a one-to-one apprenticeship, supplemented by videos and practice with an appropriate pelvic model, following the illustrations in each packet. Training should include more attention than in the past to the issue of analgesia; at the MPC women routinely receive mefenamic acid mg while in the waiting room.
Local anaesthesia by intracervical injection should be taught, and offered as a choice.
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It should almost always be used if the cervix has to be dilated or the uterine 92 cavity explored. Note that: 93 GyneFix This unique frameless device Figure 18 features a knot, which is embedded by its special inserter system in the fundal myometrium. Below the knot, its polypropylene thread bears six copper bands and locates them within the uterine cavity. It appears to retain the efficacy and other advantages of the Cu T , but once properly implanted has a much lower expulsion rate 0.
Malpositioning is also less likely than with framed IUDs. Special training for the implantation is essential, even by doctors accustomed to inserting the existing devices. A new inserter mechanism to reduce perforation risk is under evaluation. Figure 18 The GyneFix intrauterine copper implant. A hybrid, with this superb new implantation technique but releasing LNG or another potent progestogen, is a highly desirable future development. However, this is where the similarity ends. The user of this method can expect: a dramatic reduction in amount and, after the first few months discussed below , duration of blood loss 95 Dysmenorrhoea and for unexplained reasons the premenstrual syndrome PMS are frequently improved.
The LNG IUS is the contraceptive method of choice for most women with heavy menses or who are prone to irondeficiency anaemia. It should be the first-line long-term primary care treatment for excessively heavy menses— for which it is fully licensed in all circumstances except where contraception will never be required i.
Although existing IUDs do not themselves cause PID, they fail to prevent it and they tend to worsen the attacks that occur see above. The risk is certainly not eliminated, but the data available make it possible to offer the LNG IUS to some young women requesting a default state contraceptive who would not be good candidates for conventional copper IUDs. The data on file and published for this device show as for the banded copper IUDs a definite reduction in that risk, which can be attributed to its greater efficacy by mechanisms that reduce the risk of pregnancy in any site, whether uterine or extrauterine.
An improved insertion system is expected soon. A more important problem is the high incidence in the first postinsertion months of uterine bleeding which, although small in quantity, may be very frequent or continuous and can cause considerable inconvenience. Later in the use of the method amenorrhoea is commonly reported.
For both these effects, particularly the first, forewarned is forearmed—implying the need for good counselling. In my experience, women can accept the early weeks of frequent light bleeding as a worthwhile price to pay for all the other advantages of the method, if they are well informed in advance of LNG IUS fitting, and coached and encouraged as appropriate while it is occurring. The amenorrhoea can be explained and interpreted to a woman as an advantage— not an adverse side effect but a positive benefit of the method.
Women should also be forewarned that, although this method is mainly local in its action, it is not exclusively so. These do usually improve, often within 2 months, in parallel with the known decline in the higher initial LNG blood levels. Some clinicians find that early removals for this particular reason can be minimized by each woman having a short preliminary trial with a LNG-containing POP.
Functional ovarian cysts are also more common, although they are usually asymptomatic. Until more data are available copper IUDs e. GyneFix should normally be used for that indication Almost all the relative contraindications listed above pp. However, the insertion tube is wider 4. This again highlights the importance of good training a video is available from the manufacturer , and of maintaining experience.
Conclusions This method fulfils many of the standard criteria for an ideal 98 contraceptive Box. This is because, after the initial months of frequent uterine bleedings and spotting, the usual outcomes of either intermittent light menses or amenorrhoea are very acceptable to most women. Adverse side effects are few and in general they are in the nuisance category rather than hazardous. Evidence continues to accumulate of the non-contraceptive benefits previously described, and others are emerging. However, this method does require initial and some ongoing medical interventions and also fails against the fifth criterion in the Box below.
There is no known protection against sexually transmitted viruses and no complete protection against other STIs. See pp. The indications for GyneFix and Mirena are unchanged. The POEC is already available over the counter in some countries e. Norlevoin in France and in the UK discussions are in progress about the appropriate safeguards. POEC—one hormone is best! Reference: WHO, Lance ; — Numbers rounded to nearest integer.
Table 11 Relative efficacies in each hour period. Note: On the basis of previous research into conception probabilities, 92 out of each presenting in the study would not have conceived after the single exposure if untreated. Tables 10 and The main advantages of POEC are reduced rates of nausea and vomiting; it is also more effective Contraindications Absolute contraindications to the hormone methods are few and listed in Table There is no upper age limit to any of the methods if sufficient risk of conception is present.
However, in selected cases after cervical swabs for Chlamydia trachomatis at least and prophylactic antibiotic cover p. Other exposures to risk earlier than the one presented with need particular consideration. The mode of action sometimes not always being post-fertilization may pose an absolute contraindication to some individuals. Most modern ethicists and this author consider that blocking of implantation is contraception, not abortion.
Medical risks should be discussed, especially: —the failure rate see Table 11 , but remind the woman that these figures relate to a single exposure. The failure rate is very close to nil for the IUD method. However, a past history of ectopic pregnancy or pelvic infection remains a reason for caution and forewarning with any of the methods.
If an anti-emetic is requested, the best seems to be domperidone Motilium , 10 mg with each dose. If either contraceptive dose is vomited within 2 hours, the woman may be given further tablets or, in a particularly high-risk case, a copper IUD should be inserted. Contraception both in the current cycle in case the POEC method merely postpones ovulation and long term should be discussed.
The IUD option covers both aspects. If the COC is chosen it should be started as soon as the woman is convinced her next period is normal, usually on the first or second day, without the need for additional contraception thereafter. Vaginal examination is rarely necessary and there are very good reasons to omit it, for example, in an anxious teenager. Mid-packet pill omissions after 7 tablets have been taken never indicate emergency treatment unless at least 4 have been missed.
Towards the end of a packet, omission of the next PFI will suffice. Delay in taking a POP tablet for more than 3 hours, implying loss of mucus effect, followed by exposure during the 48 hours before contraception is expected to be restored. If the POP user is fully breastfeeding p. Further exposure in the same cycle, e. Additional courses of POEC, for example, are acceptable if all are taken before any possible implantation. But this additional use is of course outside the terms of the licence see pp. Use later than 72 hours after exposure. Although 6 COEC and POEC have so far been tested only up to 72 hours after the earliest act of unprotected intercourse, they may also be given later—though with uncertainty about the diminishing chance of success, as is clear from Table Neither method should be used if calculations suggest that any earlier act could have led to the presence by now of an early implanted pregnancy.
Overdue injections of DMPA with continuing sexual intercourse. At the MPC we simply give the next dose from day 85 to 91 i. Later, in addition, we exclude an implanted pregnancy so far as possible, by the coital history and a sensitive pregnancy test and offer POEC or a copper IUD. In all circumstances of use of emergency contraception, always counsel the women regarding possible failure and provide no guarantee that any fetus will be normal.
Research continues and alternatives such as mifepristone may supersede the current methods in due course. In spite of their wellknown disadvantages they all notably condoms provide useful protection against sexually transmitted infections. All users of this type of method should be informed about emergency contraception, in case of lack of use or failure in use. Beware ad hoc use of substances from the kitchen or bathroom cupboard! Water-based products such as KY jelly, and also glycerine and silicone lubricants, are not suspect. The Durex Information Service has produced a useful leaflet listing common vaginal preparations which should be regarded as unsafe to use with rubber condoms and diaphragms, and there may be others: Preparations unsafe to use with rubber condoms or diaphragms Arachis oil enema Nizoral Baby oil Nystan cream pessaries OK Cyclogest Ortho Dienoestrol Dalacin cream Ortho-Gynest Ovestin OK Ecostatin Petroleum jelly Fungilin Premarin cream Gyno-Daktarin Sultrin Gyno-Pevaryl Pevaryl OK Vaseline Monistat Witepsol-based preparations Sheaths or condoms Condoms are the only proven barrier to transmission of HIV, yet at the time of writing it still remains impossible in the UK for most couples to obtain this life-saver free of charge from their GP.
Condoms are second in usage to the pill under the age of 30 and to sterilization above that age. One GP has reported a failure rate as low as 0. Failure, often unrecognized at the time, can almost always be attributed to incorrect use, mainly through escape of a small amount of semen either before or after intercourse. Some are entirely satisfied with the condom, whereas others use it as a temporary or back-up method; for many who have become accustomed to alternatives not related to intercourse it is completely unacceptable. Some older men, or those with sexual anxiety, complain that its use may result in loss of erection; they should perhaps encourage their female partners to use the female condom see below.
True rubber allergy can also occur, rarely, but is often solved by use of plastic condoms e. Avanti or non-spermicidal lubricant. Modern rubber condoms have reduced allergenic residues from the manufacturing process. For women who dislike the smell or messiness of semen, the condom solves their problem. By simulating the vagina it is designed to overcome the undeniable interference with penile sensation that occurs during the penetration phase of intercourse. It thus forms a well-lubricated secondary vagina.
Available over the counter, along with a well-illustrated leaflet, it is considerably less likely than most male condoms to rupture in use. It is also completely resistant to damage by any chemicals with which it might come into contact. However, couples should be forewarned of the possibility that the penis may become wrongly positioned between the Femidom sac and the vaginal wall. Reports about its acceptability are mixed, and a sense of humour certainly helps. There is clear evidence, however, of a group of women with their partners who use it regularly; sometimes alternating with the male equivalent Figure 20 The female condom Femidom.
Reproduced with kind permission of Chartex International plc. As the first female-controlled method with high potential for preventing HIV transmission it must be welcomed. The cap or diaphragm Once initiated, many couples express surprise at the simplicity of the diaphragm method, although it is often acceptable only when sexual activity takes on a relatively regular pattern.
It may be inserted well ahead of coitus, and so used without spoiling spontaneity. There is very little reduction in sexual sensitivity, as the clitoris and introitus are not affected and cervical pressure is still possible. Spermicide is recommended because no mechanical barrier is complete, although we still lack definitive research on this point. The jelly vehicles gels may provide useful lubrication for older women, for those in the postnatal period and for others slow to lubricate as a result of sexual arousal.
The acceptability of the diaphragm depends on the manner and context in which it is offered. As for the IUD, for those who wish to offer this choice there is no substitute for one-to-one training in the process of fitting the diaphragm and teaching its correct use, backed by an appropriate leaflet. The woman must learn the vital regular secondary check that she has covered her cervix. When there is great difficulty in inserting anything into the vagina, be it tampon, pessaries or a cap, obviously the method is not suitable. This problem may be connected with a psychosexual difficulty which may first present during the teaching of the method, but simple lack of anatomical knowledge is often involved.
The offer of a less wet-feeling alternative for the spermicide may help, especially Delfen foam. Follow-up If either partner complains that they can feel the barrier during coitus the fitting must be urgently checked. It could be too large or too small, or the retropubic ledge may be insufficient to prevent the front slipping down the anterior vagina, or, most seriously, the diaphragm may be being placed regularly in the anterior fornix.
The arcing spring diaphragm is then particularly useful. Chronic cystitis may be exacerbated by pressure from the anterior rim, and the condition often improves with a vault or cervical cap. Diaphragms should be checked annually, postpartum and if there is a 4 kg gain or loss in weight. Female barriers can be used happily and very successfully by many couples, but high motivation is essential. Once again, a good sense of humour helps. Spermicides Although invaluable as adjuncts to caps and condoms, by themselves creams, jellies, pessaries and foams are usually not acceptably reliable although good pregnancy rates have been obtained in some women, especially during the climacteric.
Delfen foam shares with the contraceptive sponge at the time of writing, due to be re-launched in the UK the advantages of being sexually very convenient and unobtrusive in use. Either method can be used by women whose natural fertility is reduced, particularly with increasing age see Table 1. Experience now spans over 70 years. In a review of 14 studies found no established link with congenital malformations and spontaneous abortions. Occasionally a sensitivity to spermicide arises. Direct local irritation may also occur, particularly if nonoxynol-9 is used very frequently as by prostitutes.
This effect has recently ended the advice to use it as an adjunctive virucide, although in normal use it remains entirely acceptable as a spermicide. Research continues. Methods based on fertility awareness These are now a more realistic option for many couples, particularly with the advent of Persona Figure If the method is to be used after pregnancy or any hormone treatment—even just one course of hormonal emergency contraception—there must first be two normal cycles of the acceptable length 23—35 days.
These are well established See Mann R.
London: RCP, — Note: occasionally the same or a very similar name is used in different countries for quite different formulations e. Brevinor , so formulations should be carefully checked against that of any previously used packets. Those brands available in the UK are shown in italics. Phasic pills: for comparison with the monophasics the average daily doses given in the UK brands are given in Table 3 p. Abingdon: Radcliffe Medical. Edinburgh: Churchill Livingstone. Guillebaud J The Pill, 5th edn.
Oxford: Oxford University Press. London: WB Saunders. Meeting Individual Needs Psychosexual Medicine series 6. Many more relevant book titles, videos and useful patient leaflets concerning all methods can be obtained by easy mail order. Read more. Psychiatry for General Practitioners. Statins in General Practice: Pocketbook. A Clinical Guide for Contraception, 5th Edition. A Christian Faith for Today. Pediatric Cardiology for Practitioners.