Case 8 A 16-year-old seeking emergency contraception: contraceptive choices through reproductive life

Case 8 A 16-year-old seeking emergency

contraception: contraceptive choices

through reproductive life

Louise is 16 years old and has dropped into her local

sexual health clinic to pick up condoms. She has been

seeing Tom for 5 weeks and two nights ago they had

unprotected sex. Louise knows that this puts her at risk of

pregnancy and is frightened. She is studying for her

A-levels and plans to go to university. Pregnancy would be

a disaster for her.

What could reduce Louise’s risk

of pregnancy?

She could take emergency contraception (EC). There are

two options: oral (levonorgestrel (1500μg)) or the intrauterine device (IUD).

Louise has heard something about the ‘morning after pill’

but she was not sure where to get it and she thinks it is too

late to use this.

The ‘ morning after pill ’ is a misnomer for EC which can

be taken up to 72 hours (3 days) after unprotected sex and

in some cases up to 120 hours (5 days) after ovulation.

What other information do you need to

know in order to give EC safely?

• The date of her last menstrual period ( LMP ). Her risk

of pregnancy depends on what day in her cycle she had

unprotected sexual intercourse:

days 8 – 17 = 20 – 30% risk of pregnancy

days 1 – 7 and >17 = 2 – 3% risk of pregnancy

• The date and time of any episodes of unprotected

sexual intercourse since her LMP and how many

hours have elapsed. You need to establish if it is over

72 hours.

• Medical and drug history. Taking a liver enzyme

inducer drug means the dose of levonorgestrel needs to

be doubled (Box 8.1 ). An IUD would be better in this

situation.

• Prior use of emergency contraception. You need to ask

if she had vomiting or an allergic reaction.

Louise has never used EC before. She has no relevant past

medical history and is not on any drugs. She had

unprotected sexual intercourse 54hours ago on day 11 of

a regular 28-day cycle. The sex was consensual. She and

Tom have been using condoms but forgot on that

occasion. She had no other unprotected episodes since her

period.

What important points need to be

raised about each method before Louise

can make a choice?

Oral EC: 1500mg levonorgestrel

The efficacy depends on the time taken:

• Within 24 hours of unprotected sexual intercourse = 95% reduction in expected pregnancies

• Within 25 – 48 hours of unprotected sexual intercourse = 85% reduction in expected pregnancies

• Within 49 – 72 hours of unprotected sexual intercourse = 58% reduction in expected pregnancies

Nausea is common (14%) and 1% of women taking

EC vomit. If she vomits within 2 hours, she needs a

further dose together with an antiemetic. If her next

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.

Box 8.1 Liver enzyme inducing drugs

Rifampicin

Rifabutin

St John’s wort

Griseofulvin

Anticonvulsants (phenytoin, carbamazepine, barbiturates,

primidone, topiramate, oxcarbazepine)

Tacrolimus

Certain antiretroviral (HIV) drugsCase 8 63

PART 2: CASES

period is lighter or absent, she needs to do a urine pregnancy test. You need to advise her to abstain from sex

until her next period.

Copper IUD

• >99% reduction in expected pregnancies

• Immediate contraception

• She needs to return after her next period for removal

or thread check if she plans to continue to use it

• IUD can be given up to 5 days after unprotected sexual

intercourse or 120 hours after expected ovulation (day 19

in Louise ’ s case)

Louise does not like the idea of an IUD and opts for oral

EC.

What else would you like to discuss

with her?

• Her intended contraception use.

• Her risk of sexually transmitted infection (STI). Consider Chlamydia screening +/− antibiotic prophylaxis (1 g

azithromycin) if at risk of STI.

What contraceptive methods could

Louise use?

From the history so far, Louise is suitable for all methods.

You could show her a leaflet outlining all her choices.

What specific information would you

like to know to aid her decision?

1 Contraindications to taking oestrogen:

Multiple risk factors for arterial cardiovascular disease

(CVD) (e.g. smoking, diabetes, hypertension, ischaemic

heart disease, stroke, complicated heart disease)

Personal or close family history of venous thromboembolism (VTE)

Migraine with aura

Breast cancer or carrier of BRCA gene mutation

Gall bladder and liver disease/tumours

BMI => 35

A sustained systolic blood pressure (BP) of >140 or

diastolic of >90 mmHg

2 Her menstrual history. Certain methods make periods

lighter, more regular, less painful and can help premenstrual symptoms.

3 Lifestyle. Some long - acting reversible contraceptive

(LARC) methods would particularly suit those working

shifts or crossing time zones.

4 Which methods would she not consider?

Combined oral contraception (COC) and progesterone only pill (POP) may not be suitable if she finds

swallowing tablets difficult

Depo - medroxyprogesterone acetate (DMPA) and

progesterone only implant (POI) if needle - phobic as

they require a needle insertion

The IUD, IUS and diaphragm/cap may be difficult

to fit if she has difficulty with vaginal examinations

What examinations do you need to do?

• Height and weight for BMI

• Blood pressure

Louise has no relevant medical, family or drug history, has a

BMI of 28 and a BP of 120/78mmHg.

What are her options?

• DMPA

• IUD

• IUS

• COC/patch

• POP or POI

• Barrier methods

What options would not be advisable?

Male or female sterilization is not suitable as these are

irreversible.

What key counselling points would you

include to help Louise decide the best

method for her?

See Table 8.1 .

How is the implant inserted?

This is inserted with local anaesthetic under the skin in

the medial aspect of the upper part of the non - dominant

arm. It should be easily palpable.

KEY POINT

The intrauterine system (IUS) cannot be used for EC.64 Part 2: Cases

PART 2: CASES

Table 8.1 Advantages and disadvantages of methods of long-acting reversible contraception.

Advantages Disadvantages

DMPA Very effective

Inhibits ovulation

Administered every 12 weeks

Periods usually absent after third injection

May improve dysmenorrhoea and protect

against uterine cancer and PID

Contraceptive effect lasts 14 weeks

Injection

Irregular bleeding common first few

months

Expect weight gain of 2–3kg/year

Progestogenic side-effects common

(acne, bloating, breast tenderness and

mood change)

Reduced BMD while using

Periods and fertility may take a

number of months to return to

normal

Does not protect against STIs

UK MEC recommends other

methods if a patient is <18 or

>45 years

Limited evidence shows a

decrease in BMD during use, but

gained back on discontinuation

Peak bone mass is achieved

during the teen years

POI Lasts for 3 years

Rapid return of fertility on removal

Very effective

Inhibits ovulation

Some protection against PID and uterine

cancer

Bleeding pattern is unpredictable:

20% amenorrhoea, 40% unusual

pattern, 40% irregular bleeding

Progestogenic side-effects common

Does not protect against STIs

Rarely, removal difficult

Etonogestrel flexible rod

measuring 4cm × 2mm

BMD, bone mineral density; DMPA, depo-medroxyprogesterone acetate; PID, pelvic inflammatory disease; POI, progesterone only

implant; STI, sexually transmitted infection; UK MEC, Medical Eligibility Criteria.

Louise has a friend who had a POI, but she had it removed

as she bled all the time.

What would you advise Louise?

Bleeding problems with progesterone only methods

(DMPA, POI, POP and IUS) are very common and can

lead to discontinuation and risk of pregnancy. Counselling must give realistic expectations. Unpredictable

bleeding (heavy, spotting or prolonged) may occur but

usually improves over 6 months. You can add the COC

for cycle control or a non - steroidal anti - inflammatory

drug such as mefenamic acid.

Louise does not like needles and wants to know about

pills.

What are the differences between

combined oral contraception and

progestogen only pills?

See Table 8.2 .

Many of Louise’s friends take the COC.

Which would you consider starting

her on?

• Microgynon 30

• Loestrin

These contain levonorgestrel or norethisterone. While

the COC has an increased risk of VTE, the absolute

risk is very small. When prescribing for the first time,

however, always try to prescribe the drug with the lowest

risk (Box 8.2 ).Case 8 65

PART 2: CASES

Table 8.2 Comparison of combined oral contraceptive (COC) and progesterone only pill (POP).

COC POP

What is in it? Ethinyl oestradiol and a progestogen Progestogen only

Advantages Regular, lighter periods

Reduced period pain

Inhibits ovulation

Protects against ovarian and uterine cancer

Avoid periods by running packs together (outside

product licence)

No oestrogen

No serious side-effects

Inhibits ovulation (Cerazette)

Disadvantages Minor side-effects: nausea, headache (if these are focal

COC would be contraindicated), breakthrough

bleeding, discharge and mood changes

Serious side-effects rare but include: VTE, MI, ischaemic

strike, cervical cancer and possibly breast cancer

Minor side-effects: progestogenic and unpredictable

bleeding

May be less effective if >70kg – recommend two

tablets per day (one tablet if Cerazette)

Tight dosage timing (not Cerazette)

The newest POP Cerazette has advantages over

traditional POPs in that, like the COC, it has a

12-hour dosage widow (compared to 3hours) and

inhibits ovulation

How to take 1 tablet for 21 days and then a 7-day break 1 tablet every day

MI, myocardial infarction; VTE, venous thromboembolism.

Box 8.2 Risk of venous thromboembolism

Non-combined oral

contraception (COC)

users

5 per 100,000 woman years

Levonorgestrel or

norethisterone

containing COC

15 per 100,000 woman years

Desogestrel or

gestodene containing

COC

25 per 100,000 woman years

Pregnancy 60 per 100,000 woman years

Louise’s older sister uses the patch.

What advantages does it have

over COC?

Compliance is easier as one patch is applied once a

week rather than taking one pill per day. Absorption is

not affected by vomiting, diarrhoea or antibiotics.

Some women can develop a skin reaction to the

adhesive.

At this stage you ask Louise if she would like to discuss

non-hormonal methods.

Are these methods really an option

for Louise?

Male condoms are readily available and have an important role in safe sex. On their own, however, they have a

high failure rates in teenagers when fertility is at its peak.

Female condoms are expensive, noisy and need to be

fitted prior to sex. This makes them unpopular with

teenagers.

Diaphragms, caps and natural family planning (NFP)

require considerable motivation and are rarely used by

this age group.

Young age and no previous delivery do not preclude

use of the IUS or IUD but they are not popular methods

in this age group. Fitting often requires a local anaes66 Part 2: Cases

PART 2: CASES

thetic. STI screening is usually required before insertion,

and safe sex advised.

Louise agrees on the COC and you also give her free

condoms and advice on safer sex.

Would you offer her anything else?

A Chlamydia test. Her age confers a 10% risk of Chlamydia infection. The majority of Chlamydia infections

are asymptomatic and unrecognized infections can cause

PID which can lead to ectopic pregnancy, tubal factor

infertility and pelvic pain.

Nine years later, Louise is 25 and has been on DMPA for 2

years. She is considering a break from hormonal

contraception. She and her partner Bob have been together

for 2 years. She is nulliparous.

What are her non-hormonal

contraceptive options?

• IUD

• Male and female condoms

• Diaphragm/cap with spermicide

• NFP

What further information do you need

to assess suitability?

IUD

You need to ask if she has had any other partners in the

past year to assess her risk of STIs. Contraindications

include pregnancy, copper allergy, unexplained vaginal

bleeding and uterine abnormalities.

Diaphragm/cap

Does she have a history of urinary tract infections (UTIs)?

Is she is comfortable touching her own genitals to fit the

cap?

KEY POINT

The Medicines and Healthcare Products Regulatory Agency

recommends that females should be reviewed after 2 years

of DMPA in order to re-evaluate the risks and benefits of

continuing use in view of its effect on bone mineral

density (BMD).

Natural family planning

Is her mentrual cycle regular? Can she commit to

daily monitoring and charting? Is she aware of the failure

rate?

Louise is interested in the IUD or diaphragm.

What main counselling points would

you raise? She and Bob are planning to

travel for 6 months. Does this affect

your counselling?

IUD

• Advantages:

highly effective

immediate action

lasts for up to 10 years

rapid return of fertility on removal

no hormones

no drug interactions

• Disadvantages:

during insertion the IUD can, rarely, perforate and

enter the abdominal cavity

there is a small chance of infection during the first

20 days following insertion

the IUD can expel in 5% of cases, most commonly

in the first 3 months of use

if the device fails, there is a 20% chance the pregnancy will be ectopic

periods can become heavier, longer and more

painful. Intermenstrual bleeding is also common

• Follow - up:

check at 3 – 6 weeks to view threads

women are advised to check threads after each

period or at regular intervals

• Removal:

anytime, by pulling gently at threads. Ask patients

to abstain from sex or use condoms for a week before

to avoid possible pregnancy.

For women who travel the IUD is ‘ forgettable ’ and

cannot get lost. There is no oestrogen so there is no

increased risk of a VTE.

KEY POINT

An IUD is suitable for nulliparous women. Prior to

insertion, consider STI swabs in women under 25 years or

those with a new partner in last 3 months or more than

one partner in the past year.Case 8 67

PART 2: CASES

Diaphragm

• Advantages:

over 90% efficacy if used correctly

hormone free

no drug interactions

some protection against STIs

• Disadvantages:

needs to be put in before sex

spermicide can be messy

UTIs can be a problem with diaphragms

correct insertion needs to be taught

latex diaphragms and caps can be damaged by oil -

based products

• How is it fitted:

a trained fitter performs a vaginal examination and

chooses from a range of diaphragms

the fitter tries a suitable size and model and then gets

the patient to insert it

the patient returns 1 – 2 weeks later with it inserted

to check the fit

For women who travel the diaphragm offers some protection against STIs but condoms would also be recommended. There is no oestrogen so there is no increased

risk of a VTE. Spermicide might prove difficult to access

in remote areas.

Louise is now 35 years old and has used the IUD on and off

for 15 years. She has three children and feels that her family

is complete. Her youngest is 3 months

KEY POINT

Vasectomy protocols vary between units, but from around

8 weeks after a vasectomy, a semen kit is mailed out and

men are asked to provide a sample of ejaculation to be

examined for sperm. Two negative samples are usually

requested before the operation is deemed effective and

contraception can be stopped.

old and she is exclusively breastfeeding with no periods.

Her relationship with Bob is strained but they are still

together. She had a ruptured appendix in Thailand when

she was travelling which required an open

appendicectomy and prolonged recovery. Her periods were

getting heavier and more painful. She smokes 10

cigarettes per day and is taking St John’s wort for

postnatal depression.

Does she need contraception

at the moment?

No. Her baby is less than 6 months old, she is exclusively

breastfeeding and amenorrhoeic. Lactational amenorrhoea

produces 98% natural contraceptive cover. She must be

advised that this effectiveness reduces when weaning starts

and the amount of breast milk consumed reduces.

From her history, what are the pros and

cons for her contraceptive options?

See Table 8.3 .

Table 8.3 Advantages and disadvantages of various types of contraception.

Type Advantages Disadvantages

DMPA High efficacy

Amenorrhoea

No drug interactions

Suitable while breastfeeding

Suitable for smokers

Reversible

Review after 2 years

Weight gain

Unpredictable bleeding

Progestogenic side-effects

POI High efficacy

Lasts 3 years

Suitable for smokers

Suitable while breastfeeding

Reduced efficacy with LEIs such as St John’s wort

Unpredictable bleeding

Progestogenic side-effects

Continued on p. 6868 Part 2: Cases

PART 2: CASES

Type Advantages Disadvantages

IUS (progestogencoated IUD)

High efficacy

Lasts 5 years

95% decrease in menses by 3 months

65% amenorrhoeic at 1 year

Suitable for smokers and breastfeeding

No drug interactions

Reversible

Unpredictable bleeding common for first 3–6 months

Progestogenic side-effects

IUD High efficacy

Suitable for smokers and breastfeeding

No drug interactions

Reversible

May make periods heavier or more painful but you can

consider adding tranexamic acid or NSAID to reduce pain and

bleeding

Female sterilization Suitable for smokers and breastfeeding

No drug interactions

Periods might improve with removal of

IUD

Failure rate 1/200; >DMPA, POI and IUS

Usually performed laparoscopically, so risk of vessel and

organ damage higher as she has a midline scar

Risk of general anaesthetic

Postoperative recovery

Small increased risk of ectopic pregnancy

Reversal often not funded by the NHS

Male sterilization Usually performed under local anaesthetic

1/2000 failure rate once azoospermia

confirmed

No effect on erectile function, testicular or

prostatic cancer, or CVD

Takes at least 2 months before effective

Bruising, swelling and pain in scrotum is common

Reversal often not funded by the NHS

COC/patch Unsuitable for smokers ≥35 years because of increased CVD

risk

Affected adversely by liver enzyme inducers such as St John’s

wort

Unsuitable while breastfeeding as may affect breast milk

volume

POP Suitable for smokers and while

breastfeeding

Affected by liver enzyme inducers such as St John’s wort

Progestogenic side-effects

Unpredictable bleeding common

Male and female

condoms

See previous section

Consider advance provision of EC

Table 8.3 ContinuedCase 8 69

PART 2: CASES

Table 8.3 Continued

Type Advantages Disadvantages

Diaphragm/cap See previous section

Consider advance provision of EC

Natural family

planning

Up to 98% effective if used according

to teaching and instructions

More effective when taught by a

specific NFP teacher

Examples include cervical secretions,

basal temperature, cervical changes

(position and consistency)

Can help to plan or avoid pregnancy

Hormone free

No drug interactions

Acceptable to all faiths and cultures

Efficacy user dependent

Takes up to 6 months to learn

Daily recording

Events that affect the menstrual cycle (illness, stress,

breastfeeding) may make fertility indications more difficult to

interpret

Fertility motion devices can be purchased from pharmacies or

over the Internet but can be expensive

COC, combined oral contraception; CVD, cardiovascular disease; DMPA, depo-medroxyprogesterone acetate; EC, emergency

contraception; IUD, intrauterine device; IUS, intrauterine system; LEI, liver enzyme inducer; NFP, natural family planning; NSAID,

non-steroidal anti-inflammatory drug; POI, progesterone only implant; POP, progesterone only pill.

Table 8.4 Contraceptive options for the perimenopausal woman.

DMPA Amenorrhoea and decreased BMD prior to loss of BMD in the menopause

POI Unpredictable bleeding may be difficult to differentiate from organic pathology, e.g. endometrial polyps, DUB or

endometrial cancer

IUS Unpredictable bleeding (as POI)

May help heavy painful periods

Can be used as the progesterone component of HRT (licensed for 4 years’ use)

If fitted at 45 years old, can be retained for 7 years

IUD If inserted from 40 years, can remain until the menopause

May contribute to DUB that needs investigation for alternative pathology

Female

sterilization

Midline scar increases risks of surgery at a time when fertility is falling

COC/patch Unsuitable as she has continued to smoke

Compared with non-users, COC carries an increased risk of ischemic stroke, MI and VTE, which is magnified

considerably by smoking

Any increased risk of breast cancer is likely to be small

Continued on p. 7070 Part 2: Cases

PART 2: CASES

Table 8.4 Continued

Louise decided to use DMPA. She is now aged 45

years old and has been amenorrhoeic for a number of years.

She and Bob split up 4 years ago. She still smokes and was

diagnosed with coeliac disease 2 months ago. She has

started experiencing some hot flushes and night sweats.

Although she has an occasional partner, Jim, she wants to

know when she can stop contraception as she is sure she is

‘going through the change’.

What advice would you give her?

The average age for the menopause in the UK is 51 years.

As there is a risk of unpredictable ovulation in the perimenopause, contraception is recommended for 2 years if

the menopause is diagnosed before 50 years or for 1 year

if a woman is over 50 years. A third option is to continue

contraception until 55 years, when 96% of women will

be menopausal and infertile.

Her DMPA-induced amenorrhoea, smoking and coeliac

disease put her at risk of osteoporosis. She should stop

DMPA and should be considered for a bone scan to

measure baseline BMD.

What issues in the perimenopause may

preclude or recommend a contraceptive

option?

See Table 8.4 .

DMPA Amenorrhoea and decreased BMD prior to loss of BMD in the menopause

POP Good efficacy in this age group with reduced fertility

Safe, so often continued until 55 years

Unpredictable bleeding may need investigation to rule out pathology

Male condoms Used effectively in this age group and low fertility improves effectiveness

Older men have increasing rates of erectile dysfunction and condoms can exacerbate this

Diaphragm Prolapse may make fitting and use more difficult

Fluctuating levels of oestrogen may predispose to urethritis and vaginal discomfort

BMD, bone mineral density; COC, combined oral contraceptive; DMPA, depo-medroxypregesterone acetate; DUB, dysfunctional

uterine bleeding; HRT, hormone replacement therapy; IUD, intrauterine device; IUS, intrauterine system; MI, myocardial infarction;

POI, progesterone only implant; POP, progesterone only pill; VTE, venous thromboembolism.Case 8 71

PART 2: CASES

DMPA contains progesterone only but is associated

with amenorrhoea and decreased bone mass and may be

unsuitable for some women. Other LARC methods such

as the POI (3 years), IUD (10 years) and IUS (5 years) have

the advantage of non - user - dependent compliance and

rapid return of fertility on removal.

Less common methods such as diaphragms/caps and

NFP may appeal to women wishing to avoid hormones

because of medical conditions, drug regimes or past side -

effects. Efficacy with these methods can be high, but they

are very much user dependent. On its own, lactational

amenorrhoea is a very effective method until weaning

starts.

When childbearing is complete, many couples con sider

sterilization. Sterilization should be considered permanent

and both methods carry intraoperative and postoperative

risks. In modern society where partnerships commonly

dissolve, LARC methods have the advantage of keeping

fertility options open. Fertility declines from the age of 35

years but contraception is still required to avoid a late

unwanted pregnancy.

CASE REVIEW

Louise presents with contraceptive needs at different ages

and different life stages. There are only a finite number of

methods available and each will have advantages

and disadvantages depending on each individual ’ s

circumstances.

Those aged under 20 years have high fertility and

are at increased risk of STIs. Condoms are excellent at

preventing STI at any age, but are user dependent

and have high failure rates. Relying on oral emergency

contraception is not recommended. Attendance for EC is

a good time to discuss future contraception. You should

advise doubling up with a more effective contra ceptive

method. Do not forget to discuss Chlamydia testing as

prevalence is high in this age group.

No method is precluded by age, but it is important to elicit

a careful clinical history in the form of medical, family, drug

and smoking history and check blood pressure and BMI. Any

findings that increase risk of CVD may mean avoidance of

oestrogen - containing methods, particularly if there are

multiple risk factors. However, in women with no risk

factors, the COC has many health benefits.

KEY POINTS

• EC can be given up to 72hours (3 days) after unprotected

sex and in some cases up to 120hours (5 days) after

ovulation

• Oral EC needs to be taken as soon as possible to

maximize its effectiveness

• Always offer an IUD as an EC option as it is >99%

effective and can continue as contraception

• Prescribe a COC with the lowest VTE risk, even though

the actual risk is very small

• The main advantage of the patch over the COC is

compliance

• Swabs prior to IUD insertion and/or prophylactic

antibiotics are only recommended if there is a risk of STI

• Sterilization under 30 years carries the highest regret and

request for reversal

• Contraception is recommended for 2 years if menopausal

before 50 years or for 1 year if a woman is over 50 years

• Any sex confers a risk of STI, offer testing at the same

time as contraception

ObGyncases (Healthcare Touch)

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