Contraceptive devices INTRA-UTERINE CONTRACEPTIVE DEVICES

7.3.4 Contraceptive devices INTRA-UTERINE CONTRACEPTIVE DEVICES

Indications see notes above

Intra-uterine devices Cautions see notes above; also anaemia, menorrhagia

(progestogen intra-uterine system might be prefer- The intra-uterine device (IUD) is suitable for older

able, section 7.3.2.3), endometriosis, severe primary parous women and as a second-line contraceptive in

dysmenorrhoea, history of pelvic inflammatory dis- young nulliparous women who should be carefully

ease, diabetes, fertility problems, nulliparity and screened because they have an increased background

young age, severely scarred uterus (including after risk of pelvic inflammatory disease.

endometrial resection) or severe cervical stenosis; Smaller devices have been introduced to minimise side-

valvular heart disease or history of endocarditis (Table effects; these consist of a plastic carrier wound with

2, section 5.1); drug- or disease-induced immuno- copper wire or fitted with copper bands; some also have

suppression (risk of infection—avoid if marked

a central core of silver to prevent fragmentation of the immunosuppression); epilepsy (risk of seizure at time copper. Fertility declines with age and therefore a cop-

of insertion); increased risk of expulsion if inserted per intra-uterine device which is fitted in a woman over

before uterine involution; gynaecological examination the age of 40, may remain in the uterus until meno-

before insertion, 6–8 weeks after then annually but

counsel women to see doctor promptly in case of Cilag) is no longer available, but some women may have

significant symptoms, especially pain; anticoagulant the device in place until 2009. The intra-uterine devices

pause. The intra-uterine device Gyne-T 380 c (Janssen-

therapy (avoid if possible); remove if pregnancy Multiload c Cu250 and Multiload c Cu250 Short (Organon)

occurs; if pregnancy occurs, increased likelihood that have been discontinued, but some women may have the

it may be ectopic

devices in place until 2011. Contra-indications pregnancy, severe anaemia, recent sexually transmitted infection (if not fully

A frameless, c copper-bearing intra-uterine device investigated and treated), unexplained uterine bleed- (GyneFix ) is also available. It consists of a knotted,

ing, distorted or small uterine cavity, genital malig- polypropylene thread with 6 copper sleeves; the device

nancy, active trophoblastic disease (until return to is anchored in the uterus by inserting the knot into the

normal of urine- and plasma-gonadotrophin concen- uterine fundus. The healthcare professional inserting (or

tration), pelvic inflammatory disease, established or removing) the device should be fully trained in the technique

marked immunosuppression; copper devices: copper and should provide full counselling backed by the patient

allergy, Wilson’s disease, medical diathermy information leaflet.

Side-effects uterine or cervical perforation, displace- The timing and technique of fitting an intra-uterine

ment, expulsion; pelvic infection may be exacerbated, device are critical for its subsequent performance and

menorrhagia, dysmenorrhoea, allergy; on insertion: call for proper training and experience. Devices should

pain (alleviated by NSAID such as ibuprofen 30 min-

not be fitted during the heavy days of the period; they utes before insertion) and bleeding, occasionally epi- are best fitted after the end of menstruation and before

Obst

leptic seizure and vasovagal attack

the calculated time of implantation. The main excess risk of infection occurs in the first 20 days after insertion

Flexi-T 300 (FP) Intra-uterine device

etrics,

and is believed to be related to existing carriage of a , copper wire, surface area approx. 300 mm wound on vertical stem of T-shaped plastic carrier, sexually transmitted disease. Women are considered to

impregnated with barium sulphate for radio-opacity, mono-

be at a higher risk of sexually transmitted diseases if: filament thread attached to base of vertical stem; preloaded

gynaec

. they are under 25 years old or in inserter, net price = £9.47 For uterine length over 5 cm; replacement every 5 years (see also

. they are over 25 years old and

notes above)

ology

. have a new partner or

Flexi-T + 380 (FP)

have had more than one partner in the past year or , copper wire, surface area approx. 380 mm wound on vertical stem of T-shaped plastic carrier

Intra-uterine device

and ,

. their regular partner has other partners. with copper sleeve on each arm, impregnated with barium sulphate for radio-opacity, monofilament thread attached to

In these women, pre-insertion screening (for chlamydia base of vertical stem; preloaded in inserter, net price =

urinary-tract

and, depending on sexual history, Neisseria gonorrhoeae)

should be performed. If results are unavailable at the For uterine length over 6 cm; replacement every 5 years (see also time of fitting an intra-uterine device for emergency notes above)

contraception, appropriate prophylactic antibacterial

GyneFix (FP)

cover should be given. The woman should be advised Intra-uterine device , 6 copper sleeves with surface area of 330 mm on polypropylene thread, net price = £26.64

disor

to attend as an emergency if she experiences sustained pain during the next 20 days.

Suitable for all uterine sizes; replacement every 5 years

ders

An intra-uterine device should not be removed in mid-

Load 375 (Durbin)

cycle unless an additional contraceptive was used for Intra-uterine device , copper wire, surface area approx. 375 mm , wound on vertical stem of U-shaped plastic carrier,

the previous 7 days. If removal is essential post-coital impregnated with barium sulphate for radio-opacity, mono- contraception should be considered.

filament thread attached to base of vertical stem; preloaded If an intra-uterine device fails and the woman wishes to

in inserter, net price = £8.00 continue to full-term the device should be removed in For uterine length over 7 cm; replacement every 5 years (see also

notes above)

the first trimester if possible. Mini TT 380 Slimline (Durbin) Intra-uterine device , copper wire, wound on vertical stem of T-shaped plastic carrier with copper sleeves fitted flush on to distal portion of each horizontal arm, total surface area

7.3.5 Emergency contraception BNF 57

approx. 380 mm , impregnated with barium sulphate for

Type B Diaphragm with Coiled Metal Spring

radio-opacity, thread attached to base of vertical stem; easy- loading system, no capsule, net price = £11.70

Opaque rubber with coiled metal spring, sizes 60–100 mm For minimum uterine length 5 cm; replacement every 5 years (see

(rising in steps of 5 mm), net price = £6.59 also notes above)

Type C Arcing Spring Diaphragm

Multiload Cu375 (Organon) Opaque rubber with arcing spring, sizes 60–95 mm (rising in Intra-uterine device , as Load 375, with copper surface area

steps of 5 mm), net price = £7.49 approx. 375 mm and vertical stem length 3.5 cm, net price = £9.24

Silicone contraceptive diaphragms For uterine length 6–9 cm; replacement every 5 years (see notes above)

Type B Diaphragm with Coiled Metal Spring

Silicone with coiled metal spring, sizes 60–90 mm (rising in Nova-T 380 (Schering Health)

steps of 5 mm), net price = £8.35 Intra-uterine device , copper wire with silver core, surface

Brands include Milex Omniflex

ders area approx. 380 mm wound on vertical stem of T-shaped

plastic carrier, impregnated with barium sulphate for radio-

Type C Arcing Spring Diaphragm

opacity, threads attached to base of vertical stem, net price = £13.50

Silicone with arcing spring, sizes 60–90 mm (rising in steps of

disor

For uterine length 6.5–9 cm; replacement every 5 years (see notes Brands include 5 mm), net price = £8.35 Milex Arcing Style above)

T-Safe CU 380 A (FP) Fertility thermometer Intra-uterine device , copper wire, wound on vertical stem of

Fertility (Ovulation) Thermometer (Zeal) T-shaped plastic carrier with copper collar on the distal

Mercury in glass thermometer, range 35 to 398C (graduated portion of each arm, total surface area approx. 380 mm ,

urinary-tract in 0.18C), net price = £1.94

impregnated with barium sulphate for radio-opacity, threads attached to base of vertical stem, net price = £10.29 For monitoring ovulation for the fertility awareness method of

and contraception , For uterine length 6.5–9 cm; replacement every 10 years (see

notes above) TT 380 Slimline (Durbin)

ology

Intra-uterine device , copper wire wound on vertical stem of

aec

T-shaped plastic carrier, with copper sleeves fitted flush on to distal portion of each horizontal arm, total surface area

gyn

approx. 380 mm , impregnated with barium sulphate for

7.3.5 Emergency contraception

radio-opacity, thread attached to base of vertical stem; easy- loading system, no capsule, net price = £11.70 For uterine length 6.5–9 cm; replacement every 10 years (see also

etrics,

notes above)

Hormonal methods

UT 380 Short (Durbin)

Obst

Intra-uterine device, copper wire wound on vertical stem of Hormonal emergency contraception involves the use of T-shaped plastic carrier, total surface area approx. 380 mm ,

7 levonorgestrel. It is effective if taken within 72 hours (3

impregnated with barium sulphate for radio-opacity, thread attached to base of vertical stem; net price = £10.53

days) of unprotected intercourse; taking the dose as For uterine length 5–7 cm; replacement every 5 years (see also

soon as possible increases efficacy. Levonorgestrel notes above)

may also be used between 72 and 120 hours after UT 380 Standard unprotected intercourse [unlicensed use] but efficacy (Durbin)

Intra-uterine device , copper wire, surface area approx. decreases with time. Hormonal emergency contra- 380 mm , wound on vertical stem of T-shaped plastic carrier,

ception is less effective than insertion of an intra-uterine impregnated with barium sulphate for radio-opacity, thread

device (see below). attached to base of vertical stem; net price = £10.53 For uterine length 6.5–9 cm; replacement every 5 years (see also

If vomiting occurs within 2 hours of taking levonor- notes above)

gestrel, a replacement dose should be given. If an anti- emetic is required domperidone is preferred.

When prescribing hormonal emergency contraception

Other contraceptive devices

the doctor should explain: .

that the next period may be early or late; Rubber contraceptive caps

Type A Contraceptive Pessary that a barrier method of contraception needs to be

Opaque rubber, sizes 1 (50 mm), 2 (55 mm), 3 (60 mm), 4 used until the next period; (65 mm), 5 (75 mm), net price = £6.85

the need to return promptly if any lower abdominal

Type B Contraceptive Pessary

pain occurs because this could signify an ectopic Opaque rubber, sizes 22 to 31 mm (rising in steps of 3 mm),

pregnancy (and also in 3 to 4 weeks if the subse- net price = £8.46

quent menstrual bleed is abnormally light, heavy or

Type C Contraceptive Pessary brief, or is absent, or if she is otherwise concerned).

Opaque rubber, sizes 1 to 3 (42, 48, and 54 mm), net price = Intra-uterine pregnancy despite treatment: see Appen- £7.26

dix 4 (levonorgestrel). Silicone contraceptive caps

Interactions The effectiveness of hormonal emer-

Silicone Contraceptive Pessary

gency contraception is reduced by enzyme-inducing Silicone, sizes 22, 26, and 30 mm, net price = £15.00 Brands include FemCap

drugs; a copper intra-uterine device can be offered instead or the dose of levonorgestrel should be

Rubber contraceptive diaphragms increased to a total of 3 mg taken as a single dose

Type A Diaphragm with Flat Metal Spring

[unlicensed dose—advise women accordingly]. There Transparent rubber with flat metal spring, sizes 55–95 mm

is no need to increase the dose for emergency contra- (rising in steps of 5 mm), net price = £5.78

ception if the patient is taking antibacterials that are not Brands include Reflexions

enzyme inducers.

BNF 57

7.4 Drugs for genito-urinary disorders 449

LEVONORGESTREL

7.4.1 Drugs for urinary

Indications emergency contraception Cautions see notes above; past ectopic pregnancy;

retention

severe malabsorption syndromes; active trophoblastic disease (until return to normal of urine- and plasma-

Acute retention is painful and is treated by catheterisa- gonadotrophin concentration); pregnancy (see notes

tion.

above and Appendix 4); breast-feeding (Appendix 5); Chronic retention is painless and often long-standing. interactions: see notes above and Appendix 1 (pro-

Catheterisation is unnecessary unless there is deteriora- gestogens)

tion of renal function. After the cause has initially been Contra-indications acute porphyria (section 9.8.2)

established and treated, drugs may be required to Side-effects menstrual irregularities (see also notes

increase detrusor muscle tone. above), nausea, low abdominal pain, fatigue, head- ache, dizziness, breast tenderness, vomiting

Benign prostatic hyperplasia is treated either surgically or Dose

medically with alpha-blockers (see below). Dutasteride and finasteride (section 6.4.2) are alternatives to alpha-

1.5 mg as a single dose as soon as possible after coitus blockers, particularly in men with a significantly (preferably within 12 hours but no later than after 72

enlarged prostate.

hours)

1 Levonelle c One Step (Schering Health) Tablets , levonorgestrel 1.5 mg, net price 1-tab pack =

Alpha-blockers

1. Can be sold to women over 16 years; when supplying The selective alpha-blockers, alfuzosin, doxazosin, emergency contraception to the public, pharmacists should

indoramin, prazosin, tamsulosin and terazosin relax refer to guidance issued by the Royal Pharmaceutical

smooth muscle in benign prostatic hyperplasia produ- Society of Great Britain

cing an increase in urinary flow-rate and an improve- Levonelle c 1500 (Schering Health) A ment in obstructive symptoms.

Tablets , levonorgestrel 1.5 mg, net price 1-tab pack = £5.11

Cautions Since selective alpha-blockers reduce blood pressure, patients receiving antihypertensive treatment

Intra-uterine device may require reduced dosage and specialist supervision.

Caution may be required in the elderly and in patients Insertion of an intra-uterine device is more effective

with hepatic impairment (Appendix 2) and renal impair- than the hormonal methods of emergency contra-

ment (Appendix 3). For interactions see Appendix 1 ception. A copper intra-uterine contraceptive device

(alpha-blockers).

(section 7.3.4) can be inserted up to 120 hours (5

days) after unprotected intercourse; sexually trans-

mitted diseases should be tested for and insertion of Contra-indications Alpha-blockers should be avoided the device should usually be covered by antibacterial

Obst

in patients with a history of postural hypotension and micturition syncope.

etrics,

prophylaxis (e.g. azithromycin 1 g as a single dose). If intercourse has occurred more than 5 days previously, the device can still be inserted up to 5 days after the

Side-effects Side-effects of selective alpha-blockers gynaec

earliest likely calculated ovulation (i.e. within the mini- include drowsiness, hypotension (notably postural mum period before implantation).

hypotension), syncope, asthenia, depression, headache, dry mouth, gastro-intestinal disturbances (including

ology

nausea, vomiting, diarrhoea, constipation), oedema, blurred vision, rhinitis, erectile disorders (including priapism), tachycardia, and palpitations. Hypersensi-

, and

tivity reactions including rash, pruritus and angioedema have also been reported.

urinary-tract

7.4 Drugs for genito-urinary

ALFUZOSIN HYDROCHLORIDE disorders

Indications see notes above Cautions

disor

see notes above

7.4.1 Drugs for urinary retention

Contra-indications see notes above; severe hepatic

ders

7.4.2 Drugs for urinary frequency, enuresis,

impairment

and incontinence

Side-effects see notes above; also flushes and chest

pain

7.4.3 Drugs used in urological pain

Dose

7.4.4 Bladder instillations and urological

2.5 mg 3 times daily, max. 10 mg daily; ELDERLY surgery initially

2.5 mg twice daily

7.4.5 Drugs for erectile dysfunction

First dose effect First dose may cause collapse due to hypotensive effect (therefore should be taken on retiring to

For drugs used in the treatment of urinary-tract infec- bed). Patient should be warned to lie down if symptoms such as dizziness, fatigue or sweating develop, and to remain lying

tions see section 5.1.13. down until they abate completely

7.4.1 Drugs for urinary retention BNF 57 Alfuzosin hydrochloride (Non-proprietary) A maintenance (and max.) 2 mg twice daily; ELDERLY

Tablets , f/c, alfuzosin hydrochloride 2.5 mg, net price initiate with lowest possible dose 60-tab pack = £21.20. Label: 3, counselling, see dose

First dose effect First dose may cause collapse due to above

hypotensive effect (therefore should be taken on retiring to

c Xatral bed). Patient should be warned to lie down if symptoms such (Sanofi-Synthelabo) A as dizziness, fatigue or sweating develop, and to remain lying Tablets , f/c, alfuzosin hydrochloride 2.5 mg, net price

down until they abate completely 60-tab pack = £21.20. Label: 3, counselling, see dose

above

Preparations Section 2.5.4

Modified release Besavar c XL (Winthrop) A Tablets , m/r, yellow/white, alfuzosin hydrochloride

TAMSULOSIN HYDROCHLORIDE ders

10 mg, net price 30-tab pack = £13.28. Label: 3, 21, 25, Indications see notes above counselling, see above

Cautions see notes above; also cataract surgery (risk

disor

Dose benign prostatic hyperplasia 10 mg once daily of intra-operative floppy iris syndrome) Acute urinary retention associated with benign prostatic hyper- plasia in men over 65 years, 10 mg once daily for 2–3 days during

Contra-indications see notes above; severe hepatic catheterisation and for one day after removal; max. 4 days

impairment

Xatral c XL Side-effects (Sanofi-Synthelabo) see notes above A , m/r, yellow/white, alfuzosin hydrochloride

Tablets Dose

urinary-tract

10 mg, net price 10-tab pack = £4.42, 30-tab pack = . 400 micrograms daily as a single dose

and £13.28. Label: 3, 21, 25, counselling, see above ,

Dose benign prostatic hyperplasia 10 mg once daily Tamsulosin hydrochloride (Non-proprietary) A

Acute urinary retention associated with benign prostatic hyper- Capsules , m/r, tamsulosin hydrochloride 400 micr-

plasia in men over 65 years, 10 mg once daily for 2–3 days during ograms, net price 30-cap pack = £6.11. Label: 25 catheterisation and for one day after removal; max. 4 days

Brands include Bazetham MR , Contiflo XL, Diffundox XL ology ,

Omnic MR , Stronazon MR , Tabphyn MR

aec

gyn DOXAZOSIN

Flomaxtra c XL (Astellas) A

Tablets , m/r, tamsulosin hydrochloride 400 micr- Indications see notes above and section 2.5.4

ograms. Net price 30-tab pack = £17.55. Label: 25 Cautions see notes above and section 2.5.4 etrics, Contra-indications see notes above Side-effects see notes above and section 2.5.4

TERAZOSIN

Obst Dose Indications see notes above and section 2.5.4 . Initially 1 mg daily; dose may be doubled at intervals

7 Cautions see notes above and section 2.5.4

of 1–2 weeks according to response, up to max. 8 mg Contra-indications see notes above daily; usual maintenance 2–4 mg daily

Side-effects see notes above and section 2.5.4; also weight gain, paraesthesia, dyspnoea, thrombocyto- Preparations

penia, nervousness, decreased libido, back pain and Section 2.5.4

pain in extremities Dose

. INDORAMIN Initially 1 mg at bedtime; if necessary dose may be

doubled at intervals of 1–2 weeks according to Indications see notes above and section 2.5.4

response, up to max. 10 mg once daily; usual main- Cautions see notes above and section 2.5.4

tenance 5–10 mg daily Contra-indications see notes above and section 2.5.4

First dose effect First dose may cause collapse due to Side-effects see notes above and section 2.5.4

hypotensive effect (therefore should be taken on retiring to bed). Patient should be warned to lie down if symptoms such

Dose as dizziness, fatigue or sweating develop, and to remain lying .

20 mg twice daily; increased if necessary by 20 mg down until they abate completely every 2 weeks to max. 100 mg daily in divided doses;

Terazosin (Non-proprietary) A ELDERLY , 20 mg at night may be adequate

Tablets , terazosin (as hydrochloride) 2 mg, net price Doralese c (Chemidex)

A 28-tab pack = £2.27; 5 mg, 28-tab pack = £2.85; 10 mg, Tablets , yellow, f/c, indoramin 20 mg, net price 60-tab

28-tab pack = £7.71. Label: 3, counselling, see dose pack = £25.85. Label: 2

above

Hytrin c (Amdipharm) A

Tablets PRAZOSIN , terazosin (as hydrochloride) 2 mg (yellow)

net price, 28-tab pack = £4.57; 5 mg (tan), 28-tab pack Indications see notes above and section 2.5.4

= £8.57; 10 mg (blue), 28-tab pack = £17.14; starter Cautions see notes above and section 2.5.4 Contra-indications see notes above and section 2.5.4 Side-effects see notes above and section 2.5.4; also

Label: 3, counselling, see dose above paraesthesia, arthralgia, epistaxis, nervousness, dys-

pnoea, hallucinations, and alopecia Dose

Parasympathomimetics

. Initially 500 micrograms twice daily for 3–7 days, The parasympathomimetic bethanechol increases subsequently adjusted according to response; usual

detrusor muscle contraction. However, it has only a

BNF 57

7.4.2 Drugs for urinary frequency, enuresis, and incontinence 451

limited role in the relief of urinary retention; its use has been superseded by catheterisation.

7.4.2 Drugs for urinary

Distigmine inhibits the breakdown of acetylcholine. It

frequency, enuresis, and

may help patients with an upper motor neurone neuro- genic bladder.

incontinence

Urinary incontinence