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Contraception

There are several types of contraception available, but none is 100% effective (apart from abstinence) and some have possible side effects. Not all methods suit everyone due to different personal preferences and an individual's medical history, so it is advisable to discuss the issues with a nurse or doctor before making a decision. All methods of contraception are available free on the NHS from reproductive and sexual health clinics and some GPs.

Barrier methods

Condoms, diaphragms and caps are all barrier methods. These methods form a physical barrier that prevents sperm from reaching and fertilising the egg.

The male condom

The male condom is a thin sheath made of latex or polyurethane that is rolled over the erect penis before sexual intercourse. Condoms are 98% effective, but it is important that they are put on correctly, avoiding the possibility of them being torn by nails and rings. Care must also be taken with the use of oil based products, e.g. baby oil, vaseline etc, which can cause condoms to split. If the penis touches the vagina before the condom is put on, or if the condom slips off or appears torn at any point during sexual intercourse, emergency contraception (see below) should be sought to prevent pregnancy. Condoms also protect against sexually transmitted infections (STIs) and HIV and so should be used with all new relationships. It is common for women to use two methods of contraception e.g. the pill to prevent pregnancy and condoms to protect from infection. Condoms are easily available free from sexual health centres and some GPs, and for purchase from chemists, supermarkets etc.

The female condom

The female condom (sometimes referred to as the Femidom) is made of polyurethane and is inserted into the vagina at any time before sexual intercourse. There is an inner ring, which should be pushed back to rest just above the pubic bone, and an outer ring, which lines the labia, that secures it loosely in place. Like the male condom, it protects against STIs and HIV as well as pregnancy. As it is made from thin polyurethane some believe it offers greater physical stimulation than male condoms. However, the penis can push the condom out of place or it can slip, so it is advisable to guide the penis inside the condom to prevent pregnancy. Female condoms are considered 95% effective if used properly, and are available free from sexual health clinics or for sale at chemists, supermarkets etc.

The diaphragm and cap

The diaphragm is a flexible dome that covers the cervix inside the vagina. The cap is smaller and fits around the base of the cervix. They are 92-96% effective if used correctly. They are made of varying sized silicone or rubber and should be used in conjunction with a spermicidal gel. They are reusable (though should be replaced about once a year) and are initially fitted by a doctor or nurse. They can be placed in the vagina any time before sexual intercourse and should remain in place for at least 6 hours after sexual intercourse to enable the spermicide to work. Diaphragms (but not caps) may cause cystitis, although ensuring a good fit often helps. Diaphragms and caps do not protect against STIs and HIV. Once a woman knows the size and type she uses they can be bought from chemists.

Hormonal methods

Combined hormonal methods

These three methods (pill, patch and vaginal ring) contain two hormones, oestrogen and progestogen.

The combined pill

The combined pill (often referred to as just 'the pill') is more than 99% effective against pregnancy. With most brands there are 21 active pills followed by a 7 day break (or in some brands 7 inactive pills). In the pill-free week the woman will experience a withdrawal bleed or period. Taking the pill temporarily stops ovulation, so a woman will not release an egg for fertilisation. Additionally, it thickens the mucus around the cervix, making it difficult for sperm to penetrate and also thins the lining of the womb decreasing its ability to accept a fertilised egg. Whilst on the pill, periods may become lighter and PMS symptoms may be less. It is advisable to take the pill at the same time every day. Efficacy is reduced if pills are missed, there is vomiting or severe diarrhoea, or other medication e.g. antibiotics are taken. St John's Wort also decreases the efficacy of the pill. Research has also shown that the pill decreases the risk of certain cancers (ovarian, womb and colon). Temporary side effects (headaches, mood swings, nausea and breast tenderness) usually settle after two or three packs. If not, changing to a different pill may help. There is a low risk of certain serious side effects, so a woman's medical history, lifestyle (smoking, obesity, level of fitness) and family medical history will be noted before prescribing. At any medical consultation a woman should always mention that she is taking the pill.

The contraceptive patch

The contraceptive patch is a small skin-coloured patch (like a plaster) which releases oestrogen and progestogen. It works like the combined pill, is over 99% effective against pregnancy and can be applied to most areas of the body apart from the breasts or where there is broken or sensitive skin. The patch is changed every seven days and needs to be worn for three out of four weeks for 28 day protection. Periods are usually lighter and PMS may reduce. Its efficacy, benefits, risks and side-effects are similar to the combined pill.

The vaginal ring

The vaginal ring is a latex-free flexible transparent ring that is inserted into the vagina. It works likes the combined pill and is over 99% effective. It does not need to be fitted by a health professional and most women find it easy to insert. It stays in place for three weeks and is then removed for one week. In the 'ring free week' the woman will experience a bleed. The ring can remain in place during intercourse and also with tampon use. Its efficacy, benefits, risks and side-effects are similar to the combined pill.

Progestogen-only methods

These methods include pills, the injection, the implant and the intra-uterine system.

The progestogen-only pill (POP or mini-pill)

The POP is taken by women who require a method without oestrogen, whether for personal preference, lifestyle conditions (breastfeeding etc) or medical reasons (e.g. raised blood pressure, a history of deep vein thrombosis etc). It is 99% effective but failure to take it at the same time every day reduces efficacy. Most POPs need to be taken within 3 hours but there is one type (Cerazette) which allows a 12 hour delay. Most common antibiotics do not affect the POP. Periods tend to become irregular or in some cases may stop completely. There is a low risk of ovarian cysts but these are usually not dangerous and disappear without treatment. If a woman becomes pregnant while on the POP, there is a very slightly increased risk of an ectopic pregnancy. The POP is both popular and useful for women over the age of 30.

The contraceptive injection

There are two types of contraceptive injection: Depo-Provera that protects for 12 weeks and Noristerat that protects for 8 weeks. Both injections contain progestogen and they work by preventing ovulation. The injection is more than 99% reliable. It is injected into a muscle, normally in the bottom. Like the combined pill, the injection may reduce heavy periods and PMS. It also protects to some extent against pelvic inflammatory disease and cancer of the uterus. The injection commonly affects a woman's periods by making them irregular and with occasional spotting. After two or three injections most women have very little bleeding and their periods may even stop completely. These changes are not harmful. Fertility and periods may not return for a few months after a woman stops using the injection. The injection increases the appetite and may cause weight gain. As it is a long acting form of contraception, a woman will have to tolerate any possible side effects, until the injection runs out.

Contraceptive implants

Also referred to as just the implant, this contraceptive is a small flexible rod (about the size of a hairgrip) that is fitted under the skin of the upper arm, releasing progestogen. It lasts for up to three years, is more than 99% effective and works by stopping ovulation. It is fitted by a trained nurse or doctor under local anaesthetic, and therefore discomfort is minimal. Once fitted it doesn't need to be checked unless there is a problem. The main side effect is irregular bleeding – this can range from virtually no bleeding through to persistent and heavy bleeding. Unlike the injection, fertility returns within the first month following removal of the implant.

Intrauterine system (IUS)

The IUS is a small T-shaped device that is fitted in the womb, releasing progestogen. It lasts for five years and is more than 99% effective. It is common for women to experience irregular light bleeding and spotting for the first few months after fitting, which usually settles. It is an ideal method for women with heavy periods as they usually get much lighter, less painful and may stop completely. A small number of women experience temporary side effects (headaches, acne, breast tenderness), and may develop non-dangerous ovarian cysts. The device can be removed if unpleasant side effects persist. The IUS must be fitted by a doctor or nurse and needs to be checked by a health professional a few weeks after it is fitted. A woman will be taught to self-check the IUS is in place by feeling the threads high in the vagina.

Other contraceptive methods

Intrauterine devices (IUD)

The IUD (also referred to as the coil) is a small device (no longer than a matchstick) made of copper and plastic that is inserted into the womb. It works by preventing the sperm from entering in the cervix, womb or fallopian tubes, by thickening the mucus around the cervix and by thinning the womb's lining, making it difficult to accept a fertilised egg. IUDs are over 99% effective against pregnancy and last from five to ten years depending on the type used. Fertility returns as soon as the device is removed. Periods may become heavier and more painful, though this may ease after the initial few months. There is also a small risk of infection following insertion. IUDs must be fitted by a doctor or nurse and require a check up three to six weeks after insertion. A woman will be taught to self-check the IUD is in place by feeling the threads high in the vagina.

Male sterilisation (vasectomy)

Male sterilisation involves an operation performed on the scrotum (usually under local or general anaesthetic) which cuts or blocks the tubes that carry sperm from the testicles to the penis. This means that when a male ejaculates there will be no sperm present in the semen. Following vasectomy the man will be asked to produce a semen sample at least eight weeks following vasectomy. If there are no sperm present he will be told he can stop using contraception. Approximately 1 in 2000 vasectomies fails and the tubes may rejoin but this is uncommon. Some vasectomies can be reversed (this is expensive and rarely available on the NHS) but it should be considered a permanent form of contraception. After the operation, the scrotum may become bruised, swollen and painful. A small number of men experience bleeding, abnormal swelling or an infection, which will require professional advice and treatment as soon as possible. Pain normally disappears within the following weeks but some experience prolonged pain. This usually goes away with anti-inflammatory medicine and rest. Waiting lists for vasectomies on the NHS can be long, so patients can also pay for private treatment.

Female sterilisation

Female sterilisation is a minor operation that permanently prevents a woman from being able to get pregnant. It is usually carried out under general anaesthetic, and involves blocking or sealing the fallopian tubes (tubal occlusion). A new method, known as hysteroscopic sterilisation, does not involve making any cuts but is not yet widely available. The only hysteroscopic method used in the UK at present is the Essure method. The surgeon inserts a tiny titanium coil into the fallopian tubes through the vagina and womb. Body tissue then grows around the coil and blocks the fallopian tube. A woman who has been sterilised will still release an egg every month but it will be absorbed naturally by her body with no risk of conception. Female sterilisation is over 99% effective though, as with vasectomies, the tubes can rejoin. The operation is more intrusive than a vasectomy (it is performed between the navel and bikini line) creating a small risk of complications such as internal bleeding or infection. Though some methods of sterilisation can be reversed, this is expensive and rarely available on the NHS, so it should be considered a permanent form of contraception. As with vasectomies the NHS waiting lists can be lengthy so some women may prefer to go privately.

Natural family planning (fertility awareness)

Natural family planning involves observing and recording a woman's natural signs (or fertility indicators) on each day of her menstrual cycle. The main signs recorded are body temperature, cervical secretions (mucus) and the cycle length. Changes in these factors can enable a woman to identify her fertile time (approximately 8 days) and therefore not have sex (or use another method of contraception) during that period to prevent pregnancy. However, because sperm can survive five (or even up to seven) days, in practice for many couples the 'unsafe period' will last around two weeks. If correctly taught by a fertility awareness specialist and adhered to strictly, this method is 98% effective. A woman may need to record her observations every day for up to six months to learn the method effectively. If a woman becomes tired, stressed, ill or uses hormonal methods of contraception this will affect her cycle making the signs difficult to interpret and reduce its reliability. GPs and family planning clinics do not often provide fertility awareness teachers, so a woman would normally need to find her own (see contacts at end of article) and some charge a fee. Fertility monitoring devices (available from chemists) measure hormonal changes to predict a woman's fertile time. Brands differ in reliability. Breastfeeding can also be used as a natural family planning method providing that a woman is both fully or nearly fully breastfeeding, her periods have not returned and the baby is less than six months old. If guidelines are carefully followed, breastfeeding can be up to 98% effective against pregnancy.

Abstinence

Abstinence involves both partners refraining from sexual intercourse. This method is 100% reliable (if strictly adhered to) and allows partners to explore different ways of showing their love and commitment to each other. This choice must be practised by both partners in a relationship and requires strong communication skills for the happiness of both involved.

Emergency contraception

Emergency contraception can be used if a woman has had unprotected sex or if a form of contraception has failed (a split condom or missed pills). There are two forms: the emergency contraceptive pill or the emergency intrauterine device (IUD).

Emergency contraceptive pill

Emergency hormonal contraception is never as reliable as a regular method.

There are two types of emergency contraceptive pill, also called 'the morning after pill'. The most popular type is a progestogen called levonorgestrel which can be taken up to 72 hours after unprotected sex. It is more effective the sooner it is taken. It works by stopping ovulation, preventing fertilisation and stopping an egg implanting itself in the womb. Emergency contraception may disrupt a woman's period. If the woman thinks her next period is different from usual or is more than a week late, it is recommended she should do a pregnancy test.

Emergency contraception is available free from reproductive and sexual health clinics, GPs, NHS walk-in centres and some A&E departments and chemists. It can also be bought without a prescription for approximately £26 at other chemists (if aged over 16 years).

Recently a new hormone, ulipristal (ellaOne), has become available. It can be used up to 120 hours (5 days) after unprotected sex and is only available with a prescription. Currently there is limited data on this method as it is so new.

Emergency intrauterine device (IUD)

An IUD (as described above) can be fitted as an emergency contraceptive method up to five days after unprotected sex or up to five days after the earliest predicted date of ovulation (i.e. day 19 of a regular 28 day cycle). It is over 99% effective at whatever stage it is fitted in the process. It can be removed by a trained doctor or nurse at a woman's next period if this is what she wants or she can keep it for an ongoing method of contraception. Even if a woman does not want the IUD to be removed it is advisable to see a doctor or nurse 3 to 4 weeks after it is fitted to check that she is not pregnant and discuss any problems.

Useful contacts

British Pregnancy Advisory Service

For advice, call 08457 30 40 30

Website: www.bpas.org

Brook Advisory Centres

Helpline: 0808 802 1234 (Mon-Fri 9am-7pm)
24 hour information line: 020 7950 7700

Website: www.brook.org.uk

Family Planning Association (FPA)

Helplines: 0845 122 8690 (Mon-Fri 9am-6pm) for England or
0845 122 8687 for N. Ireland

Website: www.fpa.org.uk

Marie Stopes International

Helpline: 0845 300 8090 (24 hours)

Website: www.mariestopes.org.uk

National Health Service Direct

Phone: 0845 4647 (24 hours)

Website: www.nhsdirect.nhs.uk

Natural Family Planning Methods

Email: admin@fertilityuk.org

Website: www.fertilityuk.org

Sources

Brook

www.brook.org.uk
[accessed March 2010]

FPA information leaflets

www.fpa.org.uk/information/leaflets
[accessed March 2010]

NetDoctor.co.uk

www.netdoctor.co.uk
[accessed March 2010]

NHS Direct

www.nhsdirect.nhs.uk
[accessed March 2010]

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