Family planning and sexual health

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9 Family planning and sexual health

Chapter Contents

Family planning

The Pearl index

Barrier methods

Hormonal methods

Intrauterine devices

Natural family planning

Lactational amenorrhoea

Urinary hormone kit

Emergency contraception

Permanent methods

Contraception in teenagers

Contraception around the menopause

Contraception and operations

Psychosexual medicine

Clinical presentation

Sexually transmitted infections

Clinical features

Molluscum contagiosum

Crabs (pubic lice)

Tropical genital ulcers

Pelvic inflammatory disease

Pathophysiology

Clinical features

Differential diagnosis

Other vaginal infections

Candida (thrush)

Bacterial vaginosis

Sexual health

The World Health Organization defines sexual health as a state of physical, emotional, mental and social well-being related to sexuality. Sexual health requires positive and respectful approaches to sexuality and safe sexual experiences free of coercion, discrimination and violence. In such a way a woman can enjoy sex without putting herself or others at risk of physical or emotional harm.

In practice, sexual health means effective contraception, prevention of sexually transmitted infections (STIs), appropriate psychosexual help for sexual problems and support after sexual assault.

Family planning

Over 70% of women of reproductive age use some form of regular contraception. The decision on which method of contraception to use should be tailored to the individual’s social, gynaecological and medical history. Whichever form is chosen, it is vital to give adequate education about how the method should be used and what to do if there is a failure in usage such as a missed pill or split condom. A trained nurse commonly performs this in a family planning or general practitioner setting. However, gynaecologists often need to advise on, prescribe or deal with problems relating to contraception.

The Pearl index

The Pearl index is used to rate the effectiveness of a contraceptive method and is defined as the number of women who will become pregnant if 100 women use that form of contraception properly according to instructions for 1 year (or the percentage of women experiencing an unwanted pregnancy in 1 year of use). This is distinct from the actual failure rate, which is found with ‘typical use’ rather than ‘perfect use’ of the method. Table 9.1 shows the Pearl index for the different contraceptive options.

Table 9.1 Pearl index (the number of unwanted pregnancies per 100 women after 1 year of ‘perfect’ use of the following)

No contraception	80–90
Male condom	2
Female condom	5
Diaphragm and cap	4–8
Combined oral contraceptive pill	< 1
Progesterone-only pill	1
Injectable progestogens	< 1
Progestogen implants	< 1
Contraceptive patch	< 1
Intrauterine contraceptive device	1–2
Levonorgestrel-releasing intrauterine system (LNG-IUS)	< 1
Natural family planning	2–6
Urinary hormone kit	6
Female sterilization	0.5
Male sterilization	0.05

Poor compliance and incorrect use apply particularly to condoms, contraceptive pills and natural family planning, where the actual failure rates are 14%, 5% and 25%, respectively. Long-acting reversible contraceptives (LARCs) are encouraged for those women who need reliable contraception and where compliance with remembering to use a contraceptive may be poor. LARCs include the contraceptive implant and injection as well as the intrauterine contraceptive device (IUCD) and system.

History

The important factors to be considered in the history are:

The decision about contraception is always made between the doctor and the patient after explanation of:

• How the contraceptive is used

• Side effects

• Future fertility intentions.

Barrier methods

Male condom

This is a latex rubber or polyurethane sheath, often coated with spermicidal lubricant. It is used by 18% of couples in the UK.

Mode of action

A condom acts as a physical barrier to prevent sperm entering the vagina.

How to use

The condom is placed over the erect penis before contact with the female genitalia. After ejaculation it is removed with all ejaculate inside and checked for any defects.

Benefits

Benefits are its use only during sexual intercourse, protection from viral and bacterial STIs, ready availability (free on the National Health Service (NHS)) in different sizes and colours and absence of hormonal side effects.

Disadvantages

Disadvantages are interruption of love-making, some reduction in sensitivity for the male partner, occasional allergy of the man or woman to the latex or spermicide used and reliance on the male partner being motivated to use a condom on all occasions. If allergy occurs, polyurethane, low-allergy or non-spermicidal condoms should be tried. Failure occurs from damage to the condom from fingernails, jewellery or oil-based lubricants and from the condom slipping off or splitting. Pregnancy can also occur if the penis is in contact with the vagina when the condom is not in place (before or after ejaculation).

Female condom

This polyurethane sheath is inserted to line the vagina and act as a barrier to sperm reaching the cervix. It can be inserted at any time before intercourse. It has similar advantages and disadvantages to the male condom, but is not a commonly used contraceptive.

Diaphragm and cap

A diaphragm is a dome-shaped rubber device. The three types of diaphragm are flat, coil and arcing spring, depending on the amount of vaginal support. Contraceptive caps (Vimule, vault or cervical) are much smaller rubber or silicone devices that attach to the cervix by a suction effect.

Mode of action

Both devices are used with spermicidal gel or cream and act by creating a spermicidal barrier, preventing motile sperm reaching the cervix.

How to use

Two strips of spermicidal cream or gel are placed on either side of the diaphragm (caps should be one-third filled) and the device is inserted downwards and backwards into the vagina. The position is checked to ensure it is covering the cervix. It can be inserted up to 3 hours prior to sexual intercourse and extra spermicide is needed if it is more than 3 hours between insertion and sexual intercourse or if having sex for a second time. It must be left in the vagina for at least 6 hours after intercourse (up to 30 hours), then removed and washed in soapy water and stored in its plastic box. It is replaced every 2 years or earlier if damaged. Pelvic examination in the clinic is used to estimate the appropriate size of diaphragm (between 5 and 10 mm diameter).

Benefits

Advantages are no interruption to sexual intercourse, use only when needed, no loss of sensation for either partner, some protection against STI and a slight reduction in cervical cancer.

Disadvantages

Disadvantages are that a doctor or nurse is needed to fit the device, the technique needs to be learnt, occasional allergy occurs to rubber or spermicide and the man may be aware of the device. It is not a common form of contraception and offers little protection against most STIs. Side effects include recurrent urinary tract infections, which may be relieved with a smaller device. Diaphragms also need to be refitted if there is more than 3 kg weight change and after childbirth.

Contraindications

Contraindications to use are unwillingness to touch the genitalia, inability to reach and identify the cervix, poor pelvic floor support to hold the device in place, history of toxic shock syndrome, recurrent urinary tract infection and allergy to rubber or spermicide.

Hormonal methods

Combined oestrogen and progesterone contraceptives

Seventy per cent of women aged 20–24 and 25% of all women aged 15–45 use a contraceptive pill in the UK.

Combined oral contraceptive pill

Combined oral contraceptive pills (COCPs) contain ethinyloestradiol (except Norinyl-1, which contains mestranol) and a progestogen.

Mode of action

The main mode of action of the COCP is the inhibition of ovulation, but thickening of the cervical mucus and thinning of the endometrium also occur.

Types of combined oral contraceptive pill

Different ethinyloestradiol strengths are suitable for different groups:

• Low-strength (20 μg): suitable for women with circulatory risk factors, such as venous thrombosis or arterial disease risks.

• Standard-strength (30 or 35 μg): suitable for most women.

• High-strength (50 μg) (no longer licensed): previously used in obese women, those with breakthrough bleeding or on enzyme-inducing medication.

The progestogens are classed as ‘second-generation’ (e.g. norethisterone and levonorgestrel) or ‘third-generation’ (e.g. desogestrel and gestodene). The third-generation pills have a small increased risk of thrombosis, but may still be more suitable for women with acne, hirsutism, breast tenderness, weight gain and breakthrough bleeding on other preparations.

Monophasic COCP preparations are generally used, with all tablets in the pack containing the same quantity of oestrogen and progestogen. Biphasic and triphasic pills vary in the dose of progestogen and/or oestrogen during the pill cycle and can be used to obtain better cycle control in those with breakthrough bleeding (bleeding starting outside the normal pill-free interval) or in those who do not have a withdrawal bleed on monophasic preparations. ‘Everyday’ pill packs contain 21 active pills and seven placebo pills instead of the normal pill-free interval.

How to use

Standard packs contain 21 pills which are taken continuously, followed by a 7-day break during which time a withdrawal bleed commences. The next pack of pills is then started on the 8th day, regardless of whether the bleed has finished.

When to start

The first packet should be started in the first 7 days of the cycle, in which case it is effective immediately. In an amenorrhoeic or oligomenorrhoeic woman the COCP can be started at any time, but pregnancy must first be excluded and additional contraception should be used for the first 7 days. Women undergoing termination of pregnancy (TOP) should start on the day of the operation and the COCP can be commenced immediately after a miscarriage. Postnatally it should be avoided for 6 weeks due to the higher thrombosis risk and possible irregular bleeding.

Benefits of the combined oral contraceptive pill

Benefits of the COCP are control of painful, heavy and irregular periods, a reduction in ovarian cancer (50% reduction if taken for more than 5 years; effect lasts after stopping pill) and endometrial cancer (40% reduction if taken for more than 5 years), less benign breast disease, reduction in functional ovarian cysts, improvement in premenstrual tension and endometriosis, control of fibroids and improvement in acne and hirsutism. The effect of the pill disappears immediately on stopping the pill (there is no evidence for the ‘post-pill amenorrhoea’ theory) – women are just as likely to become pregnant whether or not they have just finished the COCP.

Disadvantages of the combined oral contraceptive pill

Disadvantages are the need to remember to take a pill everyday, lack of protection against STIs and an increase in cervical cancer (though this may relate to the lack of barrier protection against human papillomavirus (HPV)). The increased risk of breast cancer is still under investigation.

Side effects

Serious side effects are thrombosis, hypertension and migraine. The pill should be stopped if these are suspected. More minor side effects include irregular bleeding in the first few cycles, weight gain or loss, reduced libido, nausea, bloatedness, breast tenderness, headache and mood change. Most of these symptoms do not persist after the first 3 months of use.

Contraindications

Contraindications include pregnancy, hypertension (> 160/100 mmHg), severe migraine, previous history or high risk of thrombosis, ischaemic heart disease, cardiovascular accident, liver disease, porphyria, diabetes, smokers over 35 years and unexplained irregular vaginal bleeding. The COCP is contraindicated with breastfeeding as it may impair milk production.

Drug interactions

Drug interactions must be avoided. Enzyme inducers such as antiepileptics and griseofulvin increase metabolism of the COCP and a high-strength pill should be used if there is no suitable alternative contraceptive. However, with rifampicin and rifabutin the enzyme-inducing effect is too potent and the COCP should not be used at all until 8 weeks after stopping. Some broad-spectrum antibiotics such as ampicillin and doxycycline interfere with COCP absorption. The COCP antagonizes the effects of many antihypertensives, diuretics, warfarin, antidepressants and diabetic drugs. Corticosteroid concentrations are increased by the COCP.

Missed pills

A ‘missed pill’ is one that is either completely forgotten or taken more than 12 hours after the normal time. It should be taken once remembered and the rest of the packet continued, with a barrier method of contraception used in addition for 7 days. If the pack ends within those 7 days then the next pack should be started straightaway, without a break. The ‘7-day rule’ is a helpful guide: it takes 7 days of continuous pills for ovulation to be suppressed and 7 days without pills for ovarian activity to resume.

If vomiting or severe diarrhoea occurs within 3 hours of taking the pill, extra precautions should be taken, as for a missed pill.

Women taking some antibiotics (e.g. ampicillin or doxycycline) should continue to take the pill but use a barrier contraceptive until 7 pill-taking days after completing the course of antibiotics. The exception is long-term antibiotics, such as those for acne, where the barrier method needs only to be used for the first 3 weeks until the gut flora adjusts.

Thrombosis risk with the combined oral contraceptive pill

The risk of thrombosis is increased by COCP use, but is far less than the risk of thrombosis in pregnancy. The rate of thrombosis per 100 000 women per year is shown in Table 9.2.

Table 9.2 Rate of thrombosis per 100 000 women per year of combined oral contraceptive use

Previously healthy non-pregnant, non-pill-taking woman	5
Woman taking second-generation COCP	15
Woman taking third-generation COCP	25
Pregnant woman	60

COCP, combined oral contraceptive pill.

The risk of thromboembolic events also depends on age, weight, smoking history and family history of thrombosis, so the risk of the COCP needs to be individually assessed. Women should be counselled about any individual increased risk and a joint decision can then be made with the doctor about starting, after considering other methods of contraception. A thrombophilia screen should be performed before starting the COCP for women with a family history of thrombosis.

Contraceptive patch

The contraceptive patch contains oestrogen and progesterone and the mode of action is as for COCP. It is applied on the first day of the period and changed on the 8th and 15th days (once a week). It is removed on day 21 and a withdrawal bleed starts during the patch-free week. Benefits, disadvantages and side effects are similar to those with the COCP.

Progesterone-only pill

The progesterone-only pill (POP) is also known as the mini-pill.

Mode of action

POPs thicken the cervical mucus to inhibit sperm entry through the cervical canal. They also thin the endometrium and in a few women inhibit ovulation.

How to use

POPs are taken as a continuous preparation, in 28-day packs, with no break between packs. The POP must be taken at the same time each day and, if taken more than 3 hours late, contraceptive efficacy is immediately reduced. Similarly, diarrhoea and vomiting also impair absorption (and therefore efficacy) of the pill. Missed pills (or those taken late or with diarrhoea or vomiting) should be managed as for COCP.

The dose is doubled (two pills daily) in women over 70 kg.

Most women continue to menstruate, though some may have lighter periods and a few become amenorrhoeic. Heavy or irregular bleeding can occur in the first few months.

When to start

As for the COCP, they are started in the first 7 days of the cycle, on the day of TOP, immediately after miscarriage or at any time in an oligomenorrhoeic or amenorrhoeic woman as long as pregnancy has been excluded and extra precautions are used for 7 days. They can be started immediately postpartum.

Benefits of progesterone-only pill

POPS are beneficial when there are concerns regarding potential side effects of oestrogen-containing pills or if the COCP is contraindicated, for example in older women, smokers, immediately postpartum, whilst breastfeeding, and when there is a risk of deep venous thrombosis, hypertension, migraine or diabetes. They may also help with premenstrual syndrome.

Disadvantages of progesterone-only pill

Disadvantages are reduced efficacy compared with the COCP and the close time interval for taking the pills.

Side effects

Side effects are an increase in functional ovarian cysts and a higher risk of ectopic if pregnancy occurs. Acne, headache, breast tenderness, nausea and irregular bleeding tend to settle after a few months. Weight change occurs in a few. There is a small increase in breast cancer diagnosis.

Contraindications

Contraindications are pregnancy, previous ectopic pregnancy, problematic functional ovarian cysts, severe arterial disease (myocardial infarction or cerebrovascular accident, active liver disease, porphyria, undiagnosed irregular vaginal bleeding and breast cancer.

Drug interactions

Enzyme-inducing drugs, but not broad-spectrum antibiotics, interfere with the effectiveness of POPs. Management with enzyme-inducing drugs is as for the COCP.

Injectables and implants

Injectables

Medroxyprogesterone acetate (12 mg) and norethisterone enantate (200 mg) are the two available forms of injectable contraceptives, given by intramuscular injection into the buttock every 12 and 8 weeks, respectively.

Mode of action

Injectables act by inhibiting ovulation, and also thickening cervical mucus and thinning the endometrium. Norethisterone enantate is used as a short-term contraceptive only (maximum two doses). They are given initially on day 1–5 of the cycle, or within 5 days of parturition, but should be delayed until 6 weeks in breastfeeding women.

Irregular bleeding is normal in the first few months and most women become amenorrhoeic thereafter. After the last injection fertility may return immediately or be delayed by up to 18 months.

Benefits

Benefits are high efficacy, no need to remember to take a pill, no interference with intercourse and use where oestrogens are contraindicated. They also do not have the increased ovarian cysts or ectopic risk of oral progesterone-only preparations because they reliably inhibit ovulation.

Disadvantages

Disadvantages are the possible delayed return of fertility and side effects of weight gain, progestogenic side effects and persistent irregular bleeding. There is a possible increased risk of osteoporosis with long-term medroxyprogesterone acetate use and current recommendations suggest that prescribers re-evaluate suitability of treatment after 2 years.

Contraindications

Contraindications are pregnancy, undiagnosed vaginal bleeding, severe arterial disease and liver disease. The effect of norethisterone entantate (but not medroxyprogesterone acetate) is diminished by enzyme-inducing drugs and should not be used in conjunction with these.

Implants

The etonogestrel-releasing implant is the only implant currently available and is a progestogen rod (40 × 2 mm) inserted subdermally into the upper inner arm under local anaesthetic. Another implant, the levonorgestrel-releasing subdermal system (Norplant), consisting of six subdermal rods, has been discontinued, but a few women may still present to have the rods removed.

Mode of action

The etonogestrel-releasing implant thickens cervical mucus, thins the endometrium and, in a few women, ovulation is inhibited.

How to use

The etonogestrel-releasing implant can be inserted in the first few days of the cycle or immediately after childbirth, TOP or miscarriage. Twenty per cent of women become amenorrhoeic and 26% have irregular spotting, which usually settles within the first year. No failures have been reported. It should be replaced after 3 years or 2 years if the body mass index is greater than 35 kg/m². The implant is removed fairly easily and periods and fertility return to normal immediately.

Benefits

Benefits are that it is extremely effective, causes no interference with sexual intercourse, has some protection against PID and endometrial cancer, can be used with breastfeeding, and is useful when oestrogen-containing products are contraindicated or cause side effects.

Disadvantages

Disadvantages include progestogenic side effects in some women (headache, breast tenderness, weight gain, mood disturbance) and most women experience irregular bleeding within the first year, which then settles. Some, however, are then amenorrhoeic or have persistent irregular bleeding. There is an increase in functional ovarian cysts and possible increase in depression. Occasionally, bruising, itching or infection occurs at the site of the implant.

Contraindications

Contraindications are the same as for injectables, but also include severe depression. The implant should not be used with enzyme-inducing drugs.

Levonorgestrel-releasing intrauterine system

This is a flexible intrauterine rod on a T-shaped frame, which releases 20 μg levonorgestrel every 24 hours. It is shown in Figure 9.1.

Figure 9.1 The levonorgestrel-releasing intrauterine system.

Mode of action

It thickens the cervical mucus and thins the endometrium, with inhibition of ovulation in some cycles for some women.

How to use

The LNG-IUS is fitted in the first 7 days of the cycle, or later if another contraceptive is used for 7 days after fitting. It can be inserted immediately after TOP or miscarriage and 6 weeks postnatally. Antibiotic cover is needed for insertion, as for other intrauterine devices. The intrauterine system should be changed after 5 years.

Most women have very light or absent bleeding after 2–3 months of irregular bleeding. Fertility returns immediately on removal. The LNG-IUS should be removed if pregnancy does occur as there is a theoretical teratogenic risk.

Benefits

Benefits are a reduction in bleeding, reduced dysmenorrhoea and reduced incidence of PID. There is also a significantly reduced ectopic risk and few progestogenic side effects, due to the local action. There is no significant effect of enzyme-inducing drugs.

Disadvantages

Disadvantages are irregular bleeding in the first 3 months (the commonest reason for early removal), increased risk of functional ovarian cysts, risks of expulsion and perforation. If progestogenic side effects do occur, they usually resolve within the first few months.

Contraindications

Contraindications are pregnancy, undiagnosed irregular bleeding, active liver disease, severe arterial disease, mechanical heart valves, untreated STI and a history of ovarian or endometrial carcinoma. Nulliparity is not a contraindication, though fitting may be less well tolerated.

Intrauterine devices

Used by about 5% of women, IUCDs are copper-containing devices on a T-shaped frame. They have two threads attached to the lower end, which protrude from the ectocervix and curl around the lips of the cervix and are grasped for removal. A frameless device is also available, which is attached to the uterine fundus by a knot.

Mode of action

Copper is spermicidal and toxic to the early embryo. The device also creates an inflammatory response in the endometrium to prevent implantation.

How to use

IUCDs are inserted into the uterine cavity via the cervix in the outpatient setting, under local anaesthetic if needed. Women should be screened first for STIs or given antibiotic cover with azithromycin 1 gram (single dose) or doxycycline 100 mg daily for 7 days. IUCDs are usually inserted in the first 7 days of the cycle, but can be inserted up to day 19 (the earliest predicted implantation date). Otherwise they are fitted immediately after miscarriage or TOP or 6 weeks postpartum.

The threads should be checked by a doctor or nurse after the first month and subsequently on palpation by the woman after each period.

If PID occurs, this is most likely in the first 20 days after insertion, and the IUCD should be removed unless the infection is mild and resolving with antibiotic treatment.

Removal of IUCDs should be in the first 7 days of the cycle. If removed midcycle, emergency contraception should be given if sexual intercourse has occurred within the last 5 days.

Pregnancy with an intrauterine contraceptive device in situ

If pregnancy occurs with the IUCD in situ then there is an increased chance that it will be an ectopic pregnancy and an urgent scan is needed to confirm the pregnancy location. The coil should be removed if the pregnancy is intrauterine as the risk of midtrimester complications outweighs the risk of miscarriage from removal in the first trimester.

Benefits

Benefits are the long-term efficacy and lack of hormonal side effects.

Disadvantages

The main disadvantage is that copper IUCDs increase menorrhagia. There is also an increased PID risk. Perforation can occur at fitting and expulsion is most likely with the first period.

Actinomycosis can occur in women with an IUCD in place. It is very rare in women without an IUCD. The infection is often found incidentally on a cervical smear. If pelvic pain or a mass is present then the IUCD must be removed and the infection treated with penicillin for several months.

Contraindications

Contraindications to the IUCD are pregnancy, undiagnosed irregular vaginal bleeding, untreated STI or high risk of infection, heavy or prolonged periods, anaemia, previous ectopic, previous uterine scarring and mechanical heart valves. Wilson’s disease and copper allergy are also contraindications.

Lost coils

If the threads cannot be identified on speculum, gentle exploration with a coil hook will retrieve them from the cervical canal. If the threads are not found then an urgent scan should be arranged to confirm that the coil has not been expelled and hysteroscopic removal should be arranged in the outpatient clinic. Pregnancy should be excluded in women with a lost coil and alternative contraception prescribed, unless the scan confirms correct positioning of the coil at the fundus. Rarely, the coil is located outside the uterus and is identified on X-ray or ultrasound before laparoscopic removal.

Natural family planning

Sperm may survive for up to 7 days after intercourse and eggs survive for approximately 24 hours after ovulation. Therefore, the fertile period lasts for about 8 days. Natural family planning involves identification of the timing of ovulation to prevent contact between the egg and viable sperm during this time.

Natural family planning is only effective in women who have been properly taught the technique and have a regular cycle. Three methods are used, often in conjunction with each other, to identify the fertile time during which intercourse is avoided or a barrier contraceptive is used: (1) basal body temperature; (2) cervical mucus; and (3) time in cycle.

Basal body temperature

The temperature is taken daily, with a narrow-range fertility thermometer, before getting out of bed and having anything to eat or drink. Ovulation is followed by a basal temperature rise of approximately 0.5°C. By identifying where in the cycle ovulation occurs, the woman can avoid intercourse for 7 days before this and for 1–2 days after the temperature rises.

Cervical mucus

The cervical mucus becomes moist, sticky and white preovulation and then clear, copious and stretchy (spinnbarkeit) at the most fertile time.

Time in cycle

Ovulation occurs 12–16 days before a period.

Pain from ovulation and breast changes are less reliable indicators of fertility.

Advantages

The advantages of natural family planning are the absence of chemicals or hormones, the absence of side effects, and cultural and religious acceptability.

Disadvantages

Disadvantages are that both partners need to be committed to abstinence or condoms during the fertile period (8–9 days in each cycle) and that cycles are altered by stress, illness and travel.

Lactational amenorrhoea

The lactational amenorrhoea method is the reliance on amenorrhoea during breastfeeding as contraception. It is effective in 98% of women who use the method. However, efficacy reduces as soon as:

• The mother menstruates

• The first supplementary milk or ‘solids’ feed is given

• The baby is more than 6 months old.

Urinary hormone kit

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