Last partial update: July 2016 - Please read disclaimer before proceeding

 

Types of contraceptives using female hormones

There are two basic types of contraceptives that use female hormones.

A. Those using both an oestrogen and a progestogen

    1. The combined oral contraceptive pill (COCP), usually just called ‘the pill’.
    2. Vaginal rings incorporating both types of hormone
    3. Transdermal (skin) patches that use both types of hormones

B. Those using a progestogen alone

    1. The minipill
    2. Implanon. A small progestogen containing rod that is inserted under the skin
    3. An Intrauterine device (IUD) that contains a progestogen
    4. Injections of long acting progestogens

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The Combined Oral Contraceptive Pill (COCP) (commonly just called ‘The Pill’)

Types of COCP.

By far the most common contraceptive used is the COCP, which is usually just called 'The Pill'. It is made up of two hormones, oestrogen and progestogen. Oestrogen and progestogen are the two types of main female sex hormones occurring naturally in the body. There are numerous different types of synthetic (woman/man-made) oestrogen and progestogen that are used in the COCP and thus there many different versions of the COCP, according to the type of oestrogen and progestogen being used and the amount.  

a. The COCP gives a 28-day cycle:

At present, all COCPs work on a 28-day cycle. Active hormone containing tablets are usually taken for 21 days and then either no tablet is taken for the remaining 7 days (in the case of packs containing only 21 tablets per month) or sugar tablets are taken for the seven days (in the case of packs containing 28 tablets). The reason that 28 day packs exist is to keep women in the habit of taking a pill each day. (Taking medication is difficult for all people to remember, men and women, and this task should not be underestimated. Remember that at least 20 per cent of women on the COCP forget at least one tablet per month; and this unfortunately is the main reason why about one third of unplanned pregnancies occur in women taking the COCP as a mans of contraception.)

Some types of COCP have the same concentration of each hormone in all 21 active tablets in each pack while others vary the amounts.

Packs containing 24 active tablets and 4 inactive tablets: Packs containing 24 active tablets are now also available. (e.g. ‘Yaz’). These packs have the advantage of reducing daily oestrogen dose and thus oestrogen side effects such as breast tenderness without reducing the likelihood of pill failure and pregnancy. They also reduce the likelihood of failure and pregnancy due to a missed pill.

Creating longer cycles by missing inactive tablets: When using packs where the active tablets are all the same, it is not uncommon for doctors to advise women that it is alright to just take active tablets for two to three cycles without a break. This can reduce the number of ‘periods’ to about four per year without significantly increasing the pill failure / pregnancy rate. (Packs with this type of pill regimen are available in Europe.) As well as reducing period number (and thus menstrual blood loss), this technique reduces the likelihood that a missed pill will result in pill failure / pregnancy. Periods when they occur can also be less painful and result in less bleeding.
Taking active tablets continuously should not be done for longer than this as it is quite likely to result in unscheduled ‘break-through’ bleeds. The main reasons that this regimen is not more commonly recommended is that such break-through bleeding is more likely to occur and it can make the diagnosis of a pregnancy that has occurred on the COCP more difficult. (Remember that occasionally women who become pregnant while taking the COCP can still have slight periods early on in the pregnancy.)

b. Low dose COCPs

In an effort to reduce pill side effects and simulate more natural levels of body hormones, the amount of the oestrogen in COCPs has been gradually reducing over the years. In older women, where oestrogen side effects are more of a concern, they are certainly the preferred COCP option. Low dose pills that are commonly prescribed today are certainly easier to take but the trade-off (there always is one!!) is that the safety margin regarding pregnancy prevention is less. Thus, missing the odd tablet is a risky. The dose of oestrogen in modern low dose COCPs is about 20 micrograms of ethynyl oestradiol or less, although less than 30micrograms is considered a low dose.

How does the COCP work?

While there are many versions of the COCP, they all act to prevent pregnancy in the same way; that is, by stopping a woman's ovaries from releasing an egg cell each month, which means that a pregnancy cannot begin. They do this by providing a higher level of oestrogen and progesterone than is normally present in the body and this inhibits the body’s production of the female sex hormones that are responsible for egg development and release. (This is what actually happens during pregnancy, where higher natural levels of oestrogen and progesterone inhibit egg release as there is no need for them during pregnancy.) They also act by ithickening cervical mucous and by preventing implantation of fertilized eggs, should egg release occur.
Menstrual periods on the COCP: The COCP also takes over control of when menstrual periods occur. Normally, this is under the control of oestrogen and progesterone produced by the body and it is a natural monthly sudden drop in the level of these hormones that causes menstrual periods. The COCP acts to suppress body production of these hormones and creates an artificial period by mimicking this sudden drop in hormone levels. (This occurs during the seven day sugar tablets or no tablet period, where no active hormones are administered.) This withdrawal of oestrogen and progesterone from the body causes the lining of the uterus to shed, which is what a menstrual period is. (It is termed a withdrawal bleed because it is caused by hormone withdrawal.)
No longer than seven days without active ‘hormone-containing’ tablets
It is important that the period when no active hormone is taken is not longer than seven days, otherwise the normal body hormone system starts to work again and egg release may occur.

Do I need to have a period every month on the pill?

At present, COCP packs are designed to give a withdrawal bleed with each 28 day cycle, with bleeding usually commencing about 3 days after the last active hormone-containing tablet is taken. This has been done to reassure women that things are normal and that they have not become pregnant during the cycle. (It is worth mentioning here that, very occasionally, women can still have slight period type bleeding when they have become pregnant while still taking the COCP. So if you are suspicious that you might be pregnant, it is definitely worth checking even f your periods are still occurring.)

There is, however, no need for a woman to have a period-like withdrawal bleeding each month and it may well be that in the future COCP packs will be designed to give longer intervals between withdrawal bleeds. Increasing the length of the cycle up to about 49 days (from the present 28 days) has been shown to cause no difference in the withdrawal bleeding episodes that do occur. Cycles longer than 49 days are associated with an increase in episodes of slight bleeding between periods (‘break-through bleeding’ or spotting) but less bleeding with withdrawal bleeds that are supposed to occur when hormone tablets are stopped at the end of each cycle.

At present, it is possible to extend the length of cycles using most currently prescribed pills. (Talk to your doctor.)

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Beneficial effects of the COCP

a. COCP and cancer

The COCP reduces the risk of some cancer and increases (slightly) the risk of others. Its longterm use has no effect on overall cancer death rates. (In fact, the use of the pill has no effect on death rates from all causes, not just cancer.)

Cancer risk reduced by long-term (over five years of continuous use) COCP use

  • cancer of the ovary by 50%
  • cancer of the endometrium (lining of the womb) by up to 50%
  • colorectal cancer by 20 to 40%.

Cancer risk increased by COCP use

  • Breast cancer – Risk is increased slightly, but evidence for this association is less than perfect. (As an indication of the likely effect; if 10 in 1000 women have a diagnosis of breast cancer by age 45, using the COCP before this age would increase this rate to 11 in 1000.) The risk decreases after ceasing COCP use to approach the level of those who have not used the COCP 10 years after cessation.
  • Cervical cancer – Slightly increased risk

b. Other very beneficial effects of the COCP

As well as preventing pregnancy, the COCP can have other very beneficial effects.

  • It can reduce acne.
  • It can reduce facial hair growth.
  • It can reduce pain and bleeding associated with menstrual periods both in degree and length of time. Less bleeding can help reduce anaemia that occurs in women who have heavy menstrual periods.
  • It can reduce the incidence of non-cancerous breast lumps, and cysts on the ovary.
  • It can reduce the risk of getting a serious pelvic infection.

Some types of pill are better at helping with menstrual cycle symptoms and acne than others and it is best to discuss this with your doctor when selecting the type of pill you are going to use. You can also use the pill to purposely miss a menstrual period. Again you will need to talk to your do to about how to go about this.

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The COCP in adolescence and young adulthood

Acne and to a lesser extent hirsutism (excessive facial hair growth) can be problems in adolescents and selecting a pill with a progestogen that has anti-androgenic (anti male hormone-like) effects can help these problems and indeed, the COCP is sometimes prescribed primarily for this purpose. The results, however, are somewhat unpredictable. The best progesterone for this purpose is cyproterone, usually used in a dose of 2mg in each tablet. It is, however, more likely to cause weight gain, breast tenderness and mood disturbances including mood swings and depression. If these side effects are a problem, then alternative progestogens include gestodene, desogestrel and drospirenone.

It generally takes about three months of treatment with the COCP for improvement in acne to occur.

Another important consideration for all women is mid-cycle bleeding and this is a common reason for younger women to stop taking the COCP. This can usually be prevented by not having too low a dose of oestrogen in the COCP and thus most younger women are prescribed COCPs with medium doses of ethinyloestradiol (the most commonly used oestrogen) of 30 to 35 micrograms in each tablet. The side effects of oestrogen are less of a problem in younger women and thus this dose of oestrogen is not a problem. In older women it is better to try to use the smallest dose of oestrogen possible.

Combined pills containing cyproterone acetate
(Brand names: Brenda 35-ED, Diane 35-ED, Juliet 35-ED). All these COCPs contain 35 micrograms of eithinyl oestradiol.

Combined pills containing drospirenone
(Brand names: Yasmin, Yaz) The COCP ‘Yasmin’ contains 21 active tablets with  30 micrograms of eithinyl oestradiol and the non-steroidal progesterone drospirenone. The COCP ‘Yaz’ contains 24 active tablets with  20 micrograms of eithinyl oestradiol and the non-steroidal progesterone drospirenone.
As well as reducing unwanted acne and facial hair, drospirenone also has a mild diuretic effect which helps reduce fluid retention symptoms associated with premenstrual syndromes, and is associated with less weight gain, which is a common side effect of the COCP.

Other delivery options for hormone contraceptive
Remembering to take a tablet each day is difficult for everyone and the hectic life that  young people lead means they have a high incidence of forgetting medication. An option is to use longer acting delivery options, such as skin patches than need nly be applied once a week or vaginal rings that are inserted once a month.

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Some women can not take the COCP

You should not take it if you:

  • have had a deep venous thrombosis (blood clot), stroke or heart attack
  • have severe liver problems
  • have a migraine with visual disturbances starting before the headache (aura)
  • have unusual bleeding from your vagina, that has not been diagnosed.
  • are breast feeding

You may not be able to take the pill if you:

  • have high blood pressure, diabetes, gall bladder disease, active liver disease, kidney disease, some blood problems, tuberculosis, severe depression, or are on some other medications
  • have had cancer of the breast or cervix
  • are over 35 and smoke, or you are under 35 and smoke more than 15 cigarettes a day.

You will need to tell your medical practitioner if any of the above apply to you.

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Side effects of the COCP

a. Common less harmful side effects

As with any medication, there are side effects and these can be a considerable problem. About a third of women who commence the COCP cease use in the first year!! Many are relatively minor and transient. If they persist, then changing the type of pill can often help. The most common are as follows.

  • Nausea
  • Slight bleeding in between periods, often termed break-through bleeding or spotting. (This mostly occurs in the first few periods and then settles down.)
  • Breast tenderness Again this tends to be less of a problem after a couple of months.
  • Brown pigmentation on the face. This is due to oestrogen in the COCP and occurs with sun exposure. Wearing a hat will help and as can changing to a COCP with a lower dose of oestrogen or the minipill, which contains no oestrogen. The pigmentation is not permanent but can months to fade.
  • Weight gain (usually only slight)
  • Less uncommon side effects include headaches, reduced sex-drive and mood changes (feeling irritable).

b. Very uncommon but more serious side effects

The COCP also increases very slightly the likelihood of more serious medical problems. It needs to be stressed that these problems are rare, especially in well young women, and are generally only a concern in older women, especially if they smoke or have an increased risk of these problems. (See above list of women who can not take the COCP.) For younger women, the physical and psychological consequences of an unplanned pregnancy far outweigh any increased risk of these conditions. The conditions that are slightly more common when taking the COCP are as follows.

  • Increased blood clotting, which increases the risk of:
    • clots in the veins in the legs (termed ‘deep vein thromboses’). This is the most common clotting problem and the only condition that young women who don’t smoke need to be wary of. Symptoms include swollen, painful calves and chest pain, coughing up blood or shortness of breath. (See your doctor if these occur.)
    • Heart attacks and strokes (Sudden severe chest pain is the most common sign of heart attack. Severe headache, disturbance of speech or eyesight, numbness or weakness of your face or of a limb can be a sign of a stroke.) These conditions are really only a significant concern for ‘older’ women (over 35 years) with other risk factors for these conditions, such a smoking.
  • High blood pressure
  • Liver disease, mostly in people with existing liver disease
  • Migraines
  • Depression
  • Gall bladder disease

Clots and using the COCP when having surgery or flying: With many types of surgery there is an increased risk of clotting. As the COCP can increase this risk further, doctors often advise women to go off the COCP for a month or so before having their surgery. Obviously other contraception needs to be used during this time. Clots in the lower legs can occur when flying. It is important to do regular leg exercises and drink plenty of fluids when flying long distances.

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Starting the COCP


Generally, the COCP is commenced during a menstrual period. The exact day varies with each pack. The date that you are protected from becoming pregnant thus varies also and you will need to discuss this with your doctor. It is necessary to use condoms or some other form of contraception until the pill is definitely working and of course, those women who are not in long-term relationships need to use condoms EVERY TIME THEY HAVE SEX to prevent the risk of sexually transmitted diseases.

The ‘Quick-start’ technique
While it is not recommended practice (and the product is not licensed for this use), in some circumstances some doctors are happy to start the pill as soon as it is prescribed rather than waiting until the patient’s next period. (Women who would like more information about this option need to discuss it with their treating doctor.) It’s only real advantage is that it has been shown to increase compliance in some women.

 

Missing a tablet(s) - What happens?

As already mentioned, missing a pill is very common and it is important to get into the habit of taking your pill at the same time every day and making sure that you always have a pack of pills with you. Having a spare pack in your travelling bag and a couple of spare tablets in your purse is a good idea. It is also a good idea to keep your prescription for repeats in your purse.
What you do if you miss a tablet(s) depends on how many you miss. (Obviously, missing a sugar tablet does not matter.)

Missing a single tablet

If the pill you missed was due to be taken less than 24 hours ago, you can safely take it straight away and take your next oil at the usual time. You will still be adequately covered with regard to contraception for the month.

Missing more than one tablet in a row or missing several individual tablets

If the tablet is more than 24 hours overdue (that is you have missed more than one tablet) or have missed one tablet more than once in the same cycle, still take a single tablet as soon as possible and resume taking your tablets with the next tablet that is due. However, you can not assume that the COCP will provide adequate contraception for this month and you need to use another form of contraception such as condoms (which of course many women will be doing anyway!!). You may also be at risk of becoming pregnant, depending on where you are in your cycle when you miss the pills.
Last week of the cycle: If you are in the last week of a pack, pregnancy is unlikely to occur. You should finish off the pack and avoid having a withdrawal bleed at the end of this cycle by NOT bothering to take the sugar tablets for seven days or missing seven days of tablets. You should just go straight on to the active hormone-containing tablets again. (It is best to discuss this with your doctor as women who are on a COCP that consists of different types of active tablets can have abnormal bleeding when doing this. Your doctor can help you avoid this.)
Middle weeks of the cycle: If you are in the middle weeks of the cycle, you should just continue taking the current pack and use another form of contraception for the rest of the month. There is a risk of becoming pregnant if you had vaginal sex within the previous week and you should talk to your doctor regarding the need for emergency contraception.

When am I most at risk of becoming pregnant if I miss more than one pill in a row?

Starting a pill pack late: 
If you start a pill pack more than 24 hours late and have had vaginal sex in the active hormone-containing pill break, you are at risk of becoming pregnant and should consider seeking emergency contraception (See later section.)
Missing a pill in the first sevens days of a new pack: 
If you miss more than one pill during the first seven days of a new pack and have had vaginal sex during the active pill-free break or early in the present cycle, then again you are at risk of becoming pregnant and may need emergency contraception.

Missing several hormone-containing tablets in a row may cause you to have a bleeding episode.

If you are worried about missing pills, do not sit at home and worry. Ring your doctor or you can ring the Family Planning Healthline on 1300 65 88 86.

 

Other times when the pill may not work

There are several occasions when the COCP may not work even though it is taken correctly.

During these times, other contraceptive measures need to be taken and continued for seven days after the problem has gone (or the other medication ceased). Again, if they occur during the early stages of a COCP pack and you have had vaginal sex recently, the need for emergency contraception should be discussed with your doctor.

Periods on the pill and pregnancy

As stated above, women can occasionally still have period-like bleeding when they have become pregnant while taking the COCP. The COCP is not perfect and if you are at all worried that you have become pregnant while taking it you should seek medical advice.

On the other hand it is not uncommon for women on the COCP to miss their monthly withdrawal bleed and much of the time this is not due to being pregnant. However, it is unwise to assume that this is the case and it is usually worthwhile doing a pregnancy test, especially the first time that this occurs.

Pregnancy after being on the COCP

Most women are able to become pregnant within six months of stopping the COCP. However, a small number do not get their periods after stopping the COCP and some of these women can have difficulty becoming pregnant. Any woman who has not had periods three months after stopping the COCP should seek medical advice.

The majority of these women usually had ‘problems’ with irregular periods before they started the COCP and thus are just resuming their previous irregular pattern.

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Other methods of delivering the hormones (oestrogen and progesterone) contained in the COCP

As noted already, about 50 per cent of women miss one or more tablets each ‘pill cycle’. (It should be noted that most people find the task of taking medicines every day without fail difficult to adhere to.) With this in mind, easier methods of delivering the hormones contained in the pill have been developed, including a vaginal ring and a skin patch, which need to be inserted or applied only once a week.
These two new administration techniques are discussed below. It is necessary to read the section on the pill (above) before reading them.

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Vaginal Ring (NuvaRing)

The NuvaRing is a soft plastic ring (about 55mm in diameter and 4mm in cross-section) that contains the same type of hormones as the COCP. (The oestrogen is ethynyl oestradiol and the progesterone is etonogestrel.) The hormones are slowly released over 10 days from the ring and absorbed into to the body through the vaginal mucosa.

As the hormones aren’t initially metabolised by the liver, a considerably smaller dose compared to the COCP (about 50% less) can be given and this reduces the likelihood of side effects such as breast soreness and nausea. It also makes it a better choice than the COCP for women close to menopause.

Administration / insertion
The ring is inserted by holding it between thumb and forefinger and placing it in your vagina. If it feels uncomfortable it can simply be pushed in further. The position is not critical and the vaginal muscles keep it in place, even during sex. Rarely, it can be expelled when straining to pass a bowel motion. (Unfortunately this is usually not noticed but as mentioned it is a very uncommon event.) It can be removed by inserting a finger into the vagina and pulling it out. Women used to using tampons should not have problems with its use.

A new ring is inserted before day 5 of the cycle (day 1 being the first day of menstrual bleeding) and is left in place for three weeks. It is then removed and a new ring is inserted a week later. Thus, a cycle similar to that provided by the pill is achieved.

The ring sits high in the vagina, usually at the back but positioning is not vital. It is better if the ring is left in place during sexual intercourse although it can be removed if it causes discomfort. (This is unusual.) If the ring is removed (or expelled), it needs to be replaced within three hours to continue providing protection. There is apparently a insertion demonstration available on ‘YouTube’.

Important - Incorrect use and pregnancy
It is important that the period where no ring is in place lasts no longer than 7 days; otherwise there is a risk of failure and pregnancy occurring.
This same problem occurs if the ring is removed for longer than 3 hours during the three-week cycle of hormone administration.

If either of these scenarios occurs and you have had vaginal sex in the past week, then emergency contraception is necessary and this should be discussed with your doctor. If you have not had sex in this period, then you need to use another form of contraception for the next seven days to avoid pregnancy or not have sex during this seven-day period.

Side effects and contraindications (Please read this section regarding the pill)
Side effects are similar to those of the pill, although they should be less noticeable (because the dose of hormone administered is less); especially breast soreness and nausea.

In addition to the pill’s side effects, the NuvaRing can also cause additional vaginal discharge to normal and occasional vaginal infections (in about 5% of users). About 15% of couples report feeling the ring during sexual intercourse but few found this a problem.
Contraindications are similar to those for the pill. (See above.)

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Transdermal contraceptive patch (Ortha Evra patch) (Not yet available in Australia as at March 2009))

The ORTO EVRA patch, which is applied to the skin, is new method of delivering the hormones contained in the pill that is not yet available n Australia. (The oestrogen is ethynyl oestradiol and the progesterone is norelgestromin.) It is a 4.5cm x 4.5cm square in shape and can be applied to the buttocks, abdomen, upper arm and upper torso any part of the skin except the breasts. (It is most commonly applied to the buttocks.) It should not be applied to the breasts.

A new patch needs to be applied each week and the 28 day pill-like cycle is created by using 3 patches over 3 weeks and then having a week where no patch is applied. Each patch actually lasts for 10 days and thus this gives an added safety factor in case the woman forgets to change the patch on the correct day. 

The patches generally attach well with few (about 4%) dislodging. This can be reduced by ensuring that cream (e.g. moisturing or sun cream) is not placed under the patch and cleaning the area of skin well before application. If a patch does dislodge it needs to be reapplied immediately and if it does not reapply fully it needs to be replaced.

If a patch is left off for more than 24 hours, another form of contraception needs to be used for the following week.

The withdrawal bleed occurs usually starts about four days after the start of the hormone free period and last 5 to 6 days, slightly longer than that experienced with the pill. There was also slightly more break-through bleeding (spotting) in the first three months.

Failure rates with typical use are thought to be slightly higher (about 90%)  than that experienced with COCP use (about 92%).

Oestrogen side effects are potentially higher than in the low dose pill
The actual oestrogen dose over each cycle is about 50% higher than for a low dose pill and thus it is potentially associated with a higher risk of clotting, including clots in the legs, strokes and heart attacks. (This has not been shown clinically.)

Side effects are similar to those with the pill, although rash associated with the patch also occurs and is not uncommon (about 20%). The application site should be rotated to reduce rash incidence.

Obesity and the patch
Failure rate with the patch may be slightly higher in women weighing over 90kg.

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The ‘Minipill’

The minipill is a contraceptive pill that contains a small amount of progestogen only. (There is no oestrogen.) It works by making the mucous at the top of the vagina and in the cervix thicker which stops sperm entering the uterus and in some women it also inhibits egg release.
It is not quite as effective as the COCP but has the advantage of being able to be used by women who can not take oestrogen. This includes;

Women who can not take the minipill include those with

Unlike the COCP, the minipill needs to be taken every day with no 7 day break once a month. Thus, there are no sugar tablets and all packs are 28 day packs. The pill is started on the first day of the menstrual period. If the women is breast feeding and not having periods then it can be started at any time. Maximum contraceptive protection takes about seven days.

Missing a minipill
If you miss a tablet, take one as soon as you remember and then go back on the once a day regimen. You will need some other form of contraception for at least three days and if you had sex around the time that you missed a tablet, see your doctor as emergency contraception may well be necessary.

Other times when the minipill may not work
There are several occasions when the minipill may not work even though it is taken correctly.

During these times, other contraceptive measures need to be taken and continued for seven days after the problem has gone (or the other medication ceased). Again, if they occur during the early stages of a minipill pack and you have had vaginal sex recently, the need for emergency contraception should be considered.

Very uncommonly, the progesterone causes affects other parts of the body, causing symptoms such as vaginal dryness, flushing, headaches, nausea, acne, and mood. (The use of progestogens may be contraindicated in women with depression.)

Menstrual periods and the minpill
Menstrual periods vary considerably on the minipill. Some women have normal periods, others have none and others have irregular periods. This can make it difficult to tell whether you may have become pregnant and thus if you feel pregnant on the minipill, see your doctor to have a pregnancy test done. Slight spotting between periods also occurs commonly with the minipill.

Ectopic pregnancy (pregnancy outside the uterus, usually in the tubes) is slightly more common in women taking the minipill. This is a dangerous condition and is another reason why you need to see your doctor if you feel are pregnant.

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Contraception while breast feeding

Breast feeding itself does usually stop periods and works reasonably as a contraceptive. (During the first six months it has a success rate of about 98% as long as the baby is being exclusively breast fed and periods have not recommenced. However, this is often a time that women definitely do not want to become pregnant and for these women it is often best to use another form of contraception. Pills containing oestrogen are not useful as they will cause milk flow to stop and most women opt for a progesterone only pill, the minipill, which is discussed above.

A very small amount the progesterone does enter the breast milk and will thus be consumed by the baby. It is very unlikely that tis would cause the baby any problems at the time of consumption or in the future but this aspect of the minipill has not been formally studied.

There are other ways of delivering progesterone only contraception, including Depo Provera (long acting) injections and the Implanon rod that is inserted under the skin. The effects of progesterone ingestion by babies, via the use of Depo Provera as a contraceptive for their breast feeding mothers, has been studied well studied and has not shown any adverse side effect on the babies at the time of ingestion or later in life. While it may be reasonable to extrapolate these results to other forms of progesterone-only contraception, approval for their use in breast feeding women has not been formally given in Australia. Despite this, as stated above, the contraceptive most commonly used by breast feeding women in Australia is the minipill.

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Progestogen implants (inserted under skin) 'Implanon'

Implanon is a small rod containing a progestogen that is inserted under the skin, usually on the inside of the non-dominant upper arm, where it can provide contraception for up to three years. This process is done under local anaesthetic and is thus not painful or only slightly uncomfortable. It should not be left in longer than three years. It is very effective with a failure rate of less than 1% and it very easy to use. It is particularly useful in women who can not take oestrogen or who have problems with COCP intestinal absorption (e.g. inflammatory bowel disease.) and in women who have persistent problems with forgetting to take oral contraceptives.

The main problem is irregular periods, which is relatively common. Periods can vary from no bleeding at all to frequent irregular bleeding that causes considerable inconvenience. Other side effects include headaches, weight gain and breast tenderness.

However, it is the irregular bleeding that principally leads to about 25% of users opting for early removal if the implant. Other relatively uncommon side effects include skin problems (acne), weight gain, breast tenderness and mood changes. (The use of progestogens may be contraindicated in women with depression.)

It works by inhibiting egg release and by keeping the lining of the uterus thin so that fertilised eggs can not grow there. As with the minpill, it can be used in women who can not take oestrogen or who experience unacceptable oestrogen side effects.

Contraindications include a past history of breast cancer (especially if diagnosed within the last five years), a current clot (deep venous thrombosis) or clot in the lung (pulmonary embolus), undiagnosed abnormal vaginal bleeding, active viral liver disease (hepatitis) and use with drugs affecting the liver.

As with all forms of hormonal based contraception that only uses progesteron, it is quickly reversed (within a week or two) once administration ceases; in this case with the removal of the implant. Again, this is usually quite a simple, non-painful process.

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The Progestogen IUD (‘Mirena’)

See section on IUDs (Intrauterine devices for more information on IUDs)

This is a small ‘T’ shaped device that has a cylinder containing progesterone around its stem. It works by preventing the normal thickening in the lining of the uterus that occurs in the later half of each menstrual cycle and this prevents implantation and growth of fertilised eggs. It also causes a thickening of vaginal mucous that helps prevent sperm entering the uterus and in the first year of use can inhibit egg release.

It causes irregularity in menstrual periods in the first four to six months, which usually then settles leading to regular period bleeding that is considerably lighter than normal. (The reduction in menstrual blood loss can be as high as 90%.) This is a considerable advantage for women in their forties who often have heavier periods. Use in the United Kingdom had reduced the need for treatment of dysfunctional (heavy) bleeding by hysterectomy in this age group by about 40%.

It is also a good option for women over 35 who smoke or have other risk factors for vascular disease. Recent use has also shown that it can be considered for use in younger women and in women who have not had a baby, although it does increase the risk of pelvic infections and should not be used where a current pelvic infection is present. (Thus, in these women tests for pelvic infection should be done prior to insertion.) Women with a past history of pelvic infection should consider other contraceptive options.

Very uncommonly, the progesterone causes affects other parts of the body, causing symptoms such as vaginal dryness, flushing, headaches, nausea, acne, and mood. (The use of progestogens may be contraindicated in women with depression.)

Progesteron IUDs can be left in place for up to five years.

 

Other sexual health information for parents and adolescents on this web site

Preventing teenage pregnancy
See section 'Preventing teenage pregnancy'

Contraception for adolescents and teenagers. There is a separate section in the web site that deals in detail with contraception options for adolescents and young adult women.

See section 'Contraception for adolescents and young women - preventing unwanted pregnancy'


Unplanned pregnancy - What are the options?

See section 'Unplanned pregnancy options'


Sexually transmitted diseases and their prevention

This focuses on Chlamydia and Genital Hepres, the two most common sexually transmitted diseases in young people. Other diseases such as HIV/AIDS are also covered.

See section 'Sexually Transmitted Diseases and their prevention'

 

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Further information

Further reading regarding teenager sexual health

Sexwise by Dr Janet Hall. Published by Random House Australia.
(What every young person and parent should know about sex. Dr Hall empowers her readers by telling them the facts - and giving it to them straight.)

Unzipped by Bronwyn Donaghy. Published by Harper Collins 
(A book that deals frankly and sympathetically with the crucial role that love and emotions play in every aspect of adolescent sexuality.)

Further titles regarding puberty and adolescent sexuality are available on the Children’s Hospital at Westmead web site. www.chw.edu.au/parents/books. (Both the above books are mentioned on this web site and are recommended by staff at this hospital.)

Further information on sexual health

Sexual health information
www.shinesa.org.au

Family Planning NSW
https://www.fpnsw.org.au

The Resource Center for Adolescent Pregnancy Prevention web site
(A good USA site that provides information and skills for both adolescents and for educators about preventing unwanted teenage pregnancies.)
www.etr.org/recapp

 

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