Oral progestogen-only

7.3.2.1 Oral progestogen-only

Ethinylestradiol with Drospirenone

contraceptives

Yasmin c (Bayer) A Tablets , f/c, yellow, drospirenone 3 mg, ethinylestra-

Oral progestogen-only preparations may offer a suitable alternative when oestrogens are contra-indicated

£14.70 (including those patients with venous thrombosis or a

7.3.2 Progestogen-only contraceptives BNF 57 past history or predisposition to venous thrombosis),

ORAL PROGESTOGEN-ONLY

but have a higher failure rate than combined prepara-

tions. They are suitable for older women, for heavy

CONTRACEPTIVES

smokers, and for those with hypertension, valvular (Progestogen-only pill, ‘POP’) heart disease, diabetes mellitus, and migraine. Men-

Indications contraception strual irregularities (oligomenorrhoea, menorrhagia)

Cautions arterial disease; sex-steroid dependent can- are more common but tend to resolve on long-term

cer; past ectopic pregnancy; malabsorption syn- treatment.

dromes; active trophoblastic disease (until return to normal of urine- and plasma-gonadotrophin concen-

Interactions Effectiveness of oral progestogen-only tration); functional ovarian cysts; active liver disease; preparations is not affected by antibacterials that do not

recurrent cholestatic jaundice; history of jaundice in induce liver enzymes. The efficacy of oral progestogen-

pregnancy; interactions: see notes above and ders only preparations is, however, reduced by enzyme-indu-

Appendix 1 (progestogens) cing drugs and an additional or alternative contracep-

Other conditions The product literature advises caution in disor tive method is recommended during treatment with an

patients with history of thromboembolism, hypertension, diabetes mellitus and migraine; evidence for caution in these

enzyme-inducing drug and for at least 4 weeks after- conditions is unsatisfactory wards—see p. 439 and Appendix 1 (progestogens).

Contra-indications pregnancy; undiagnosed vaginal bleeding; severe arterial disease; liver tumour; acute

Surgery All progestogen-only contraceptives (includ- porphyria (section 9.8.2); history of breast cancer but ing those given by injection) are suitable for use as an

can be used after 5 years if no evidence of disease and urinary-tract alternative to combined oral contraceptives before

non-hormonal contraceptive methods unacceptable Side-effects menstrual irregularities (see also notes

, and major elective surgery, before all surgery to the legs, or before surgery which involves prolonged immobilisa- above); nausea, vomiting, headache, dizziness, breast tion of a lower limb.

discomfort, depression, skin disorders, disturbance of

ology appetite, weight changes, changes in libido

Breast cancer There is a small increase in the risk of having aec Starting routine One tablet daily, on a continuous

breast cancer diagnosed in women using, or who have recently used, a progestogen-only contraceptive pill; this

gyn basis, starting on day 1 of cycle and taken at the same time each day (if delayed by longer than 3 hours contra-

relative risk may be due to an earlier diagnosis. The most important risk factor appears to be the age at which the

ceptive protection may be lost). Additional contracep- contraceptive is stopped rather than the duration of use; the

etrics, tive precautions are not necessary when initiating treat-

risk disappears gradually during the 10 years after stopping ment.

and there is no excess risk by 10 years. The CSM has advised that a possible small increase in the risk of breast cancer

Obst Changing from a combined oral contraceptive Start on

should be weighed against the benefits the day following completion of the combined oral

Dose

7 contraceptive course without a break (or in the case of . 1 tablet daily at same time each day, starting on day 1 ED tablets omitting the inactive ones).

of cycle then continuously; if administration delayed for 3 hours (12 hours for Cerazette After childbirth c Start any time after 3 weeks postpar- ) or more it should

tum (increased risk of breakthrough bleeding if started

be regarded as a ‘missed pill’, see notes above earlier)—lactation is not affected.

Cerazette c (Organon) A

Tablets

Missed pill The following advice is now recom- 28-tab pack = £8.85 mended by family planning organisations:

The Scottish Medicines Consortium has advised (September 2003) that Cerazette should be restricted for use in women

‘If you forget a pill, take it as soon as you remember and carry on with the next pill at the right time. If the pill was

who cannot tolerate oestrogen-containing contraceptives or in whom these preparations are contra-indicated

Femulen c (Pharmacia) A use another method, such as the condom, for the next 2

more than 3 hours (12 hours for Cerazette ) overdue you are not protected. Continue normal pill-taking but you must also

Tablets days.’ , etynodiol diacetate 500 micrograms. Net The Faculty of Sexual and Reproductive Healthcare

recommends emergency contraception (see p. 448) if c Micronor (Janssen-Cilag) A one or more progestogen-only contraceptive tablets are

Tablets , norethisterone 350 micrograms. Net price 3 missed or taken more than 3 hours (12 hours for

Cerazette c ) late and unprotected intercourse has Norgeston c (Bayer) A occurred before 2 further tablets have been correctly

Tablets , s/c, levonorgestrel 30 micrograms. Net price taken.

35-tab pack = 98p Noriday c (Pharmacia) A

Diarrhoea and vomiting Vomiting and persistent, Tablets , norethisterone 350 micrograms. Net price 3 severe diarrhoea can interfere with the absorption of oral progestogen-only contraceptives. If vomiting occurs within 2 hours of taking an oral progestogen- only contraceptive, another pill should be taken as soon as possible. If a replacement pill is not taken within 3

7.3.2.2 Parenteral progestogen-only

hours (12 hours for Cerazette c ) of the normal time for

contraceptives

taking the progestogen-only pill, or in cases of persistent vomiting or very severe diarrhoea, additional precau-

Medroxyprogesterone acetate (Depo-Provera c ) is a tions should be used during illness and for 2 days after

long-acting progestogen given by intramuscular injec- recovery (see also under Missed pill above).

tion; it is as effective as the combined oral preparations

BNF 57

7.3.2 Progestogen-only contraceptives 445

but because of its prolonged action it should never be cing drugs; additional contraceptive precautions should given without full counselling backed by the patient

be taken whilst taking the enzyme-inducing drug and for information leaflet . It may be used as a short-term or

4 weeks after stopping it or an alternative contraceptive long-term contraceptive for women who have been

method should be considered if long-term use of the counselled about the likelihood of menstrual distur-

enzyme-inducing drug is contemplated. bance and the potential for a delay in return to full fertility. Delayed return of fertility and irregular cycles may occur after discontinuation of treatment but there is no evidence of permanent infertility. Heavy bleeding has

PARENTERAL PROGESTOGEN-ONLY

been reported in patients given medroxyprogesterone

CONTRACEPTIVES

acetate in the immediate puerperium (the first dose is best delayed until 6 weeks after birth). If the woman is

Indications contraception, see also notes above and not breast-feeding, the first injection may be given

under preparations (roles vary according to prepara- within 5 days postpartum (she should be warned that

tion)

the risk of heavy or prolonged bleeding may be Cautions see notes above and under preparations; increased).

possible risk of breast cancer, see oral progestogen- only contraceptives (section 7.3.2.1); history during

Reduction in bone mineral density and, rarely, osteo- pregnancy of pruritus or of deterioration of oto- porosis and osteoporotic fractures have also been

sclerosis, disturbances of lipid metabolism; interac- reported with medroxyprogesterone acetate. The reduc-

tions: see notes above and Appendix 1 (progestogens) tion in bone mineral density occurs in the first 2–3 years

Counselling Full counselling backed by patient information of use and then stabilises. See also CSM advice below.

leaflet required before administration Contra-indications see notes above; history of breast CSM advice

cancer but can be used after 5 years if no evidence of The CSM has advised that:

disease and non-hormonal contraceptive methods .

in adolescents, medroxyprogesterone acetate c unacceptable

(Depo-Provera ) be used only when other

methods of contraception are inappropriate; see notes above; injection-site reactions Cervical cancer

Side-effects

. in all women, benefits of using medroxyproges- Use of injectable progestogen-only contra- ceptives may be associated with a small increased risk of terone acetate beyond 2 years should be eval-

cervical cancer, similar to that seen with combined oral uated against risks;

contraceptives, see p. 440. The risk of cervical cancer with .

in women with risk factors for osteoporosis a other progestogen-only contraceptives is not yet known. method of contraception other than medroxy-

Dose

progesterone acetate should be considered. . See under preparations

Injectable preparations progestogen given as an oily injection which provides

Norethisterone enantate (Noristerat c ) is a long-acting

Depo-Provera c (Pfizer) A 7

contraception for 8 weeks; it is used as short-term Injection (aqueous suspension), medroxyprogester- interim contraception e.g. before vasectomy becomes

Obst

one acetate 150 mg/mL, net price 1-mL prefilled effective.

syringe = £6.01, 1-mL vial = £6.01. Counselling, see An etonogestrel-releasing implant (Implanon c

etrics,

patient information leaflet sisting of a single flexible rod, is also available; the rod is

), con-

Dose by deep intramuscular injection , 150 mg within first 5 days inserted subdermally into the lower surface of the upper

of cycle or within first 5 days after parturition (delay until 6 weeks after parturition if breast-feeding); for long-term contraception,

gynaec

arm and it provides effective contraception for up to 3 repeated every 12 weeks (if interval greater than 12 weeks and 5 years. The manufacturer advises that in heavier women,

days, rule out pregnancy before next injection and advise patient blood etonogestrel concentrations are lower and there-

to use additional contraceptive measures (e.g. barrier) for 14 days

ology

fore the implant may not provide effective contra-

after the injection)

ception during the third year; they advise that earlier

Noristerat replacement should be considered in such patients— c (Schering Health) A ,

however evidence to support this recommendation is Injection (oily), norethisterone enantate 200 mg/mL,

and

net price 1-mL amp = £3.59. Counselling, see patient lacking. Local reactions such as bruising and itching can

information leaflet

urinary-tract

occur at the insertion site. The contraceptive effect of Dose by deep intramuscular injection given very slowly into Implanon c is rapidly reversed on removal of the

gluteal muscle, short-term contraception, 200 mg within first 5 days implant. The doctor or nurse administering (or removing)

of cycle or immediately after parturition (duration 8 weeks); may the system should be fully trained in the technique and

be repeated once after 8 weeks (withhold breast-feeding for should provide full counselling reinforced by the patient

neonates with severe or persistent jaundice requiring medical .

information leaflet treatment)

disor

The cautions, contra-indications, and side-effects of oral progestogen-only contraceptives apply to parenteral

Implants c ders

progestogen-only contraceptives, except that parenteral Implanon (Organon) A preparations reliably inhibit ovulation and therefore

Implant , containing etonogestrel 68 mg in each flex- protect against ectopic pregnancy and functional

ible rod, net price = £81.00. Counselling, see patient ovarian cysts.

information leaflet Dose by subdermal implantation , no previous hormonal con- traceptive, 1 implant inserted during first 5 days of cycle; par-

Interactions Effectiveness of parenteral progestogen-

turition or abortion in second trimester, 1 implant inserted only contraceptives is not affected by antibacterials that