MARGARET PYKE TRUST

Updates on methods of non-long-acting reversible contraception (non-LARC) was the focus of a comprehensive talk by Dr Maryam Nasri, Associate Specialist in Contraception and Sexual Health, Central North West London NHS Foundation Trust, that opened this year’s Margaret Pyke Conference.

Dr Nasri highlighted some of the major changes in recent months, starting with the CHC guidelines from 2018. These suggest that a woman can self-complete a checklist to provide the information needed by clinicians to assess eligibility for contraception and to aid provision of a repeat prescription. "As long as it is a validated questionnaire then it is considered to be as good as a consultation between a clinician and patient. This will help in the future with reducing appointment times and it will be easier for women to obtain repeat prescriptions," she pointed out.

Dr Nasri also drew attention to a quick reference guide to facilitate decision-making around the suitability of using CHC that is available to Faculty of Reproductive and Sexual Healthcare (FSRH) members on the FSRH website and which helps with providing optimal contraception for an individual patient.

Another highlight was contraception in the postnatal period, with Dr Nasri emphasising the need to start women on suitable and effective contraception 21 days postnatally. “We need to embark upon this conversation when women are pregnant to avoid them having this conversation too late,” she said, sharing a story of a young lady who epitomised this precise situation. “We should not leave it for the woman to discuss this at the 6-week postnatal check because the time for action will have passed.”

Advice on tailored regimens has also been reviewed recently, she pointed out. Dr Nasri explained that in giving information to women, it is now possible to continue with CHC (monophasic pill, patch or ring) without the need for a monthly withdrawal bleed. “This bleed does not confirm the woman is not pregnant and it is not needed physiologically,” she said. “If a woman uses a pill at her convenience then she can have a break if she wishes, but she needs to have used the pill for 21 days consecutively each time she has a break. But importantly, if the woman extends the pill-free week for greater than seven days in duration then there is risk of pregnancy.”

“We want to reduce the pill-free week as much as possible. If a woman has breakthrough bleeding then she should stop the pill for four days, have a period and then resume taking the pill again,” explained Dr Nasri. By so doing, the woman has shortened the pill-free interval, shortened any symptoms related to this, and not allowed the ovaries to wake up effectively, she added. She stressed that there are no rules related to how many packs the woman can have, so a patient can receive an annual supply and use this to her convenience, as long as she uses it for 21 days consecutively.”

New guidance is also available on the missed pill rules. The major change is to the pill-free interval. “Earliest ovulation occurs eight days after the last pill was taken so extending that week is risky and not advised. If the patient does extend it then she needs to use barrier methods.”

Moving on to perimenopause contraception, Dr Nasri acknowledged that this was not without its challenges. “The CHC can be continued up to 50 years if there are no contraindications but has to be stopped at 50 years of age. From 50 years onwards, it is recommended to use the progesterone-only methods and the intrauterine devices, other than depot medroxyprogesterone acetate (DMPA).” Furthermore, during perimenopause, if the CHC pill is not contraindicated and if the woman needs hormone replacement therapy (HRT), then the pill is a user-friendly way to provide HRT and contraception up to the age of 50.”

Of particular pertinence is the choice of contraceptive methods in the many UK women who have a BMI above 25 kg/m². “For these women it is important to choose the right contraception because not only do we want to do no harm, but we also want our patients to plan pregnancies,” Dr Nasri pointed out.

Overweight/ obese women have more complicated pregnancies with poorer outcomes than women of normal weight. “Weight can affect contraception and vice versa. Basically, for obese women we try to avoid CHC because oestrogen increases risk of venous thromboembolism and they are already at risk. Depot is considered on an individual basis, if they don’t have any other risk factors. Other methods of contraception are usually acceptable, and it is not necessary to use a double dose of progesterone-only pill as this is not evidence based. Also, contrary to some belief, the implant is effective up to three years and does not need to be removed earlier in these women.”