Contraception

Current care | Published: 27.04.2017 Print
Working group set up by the Finnish Medical Society Duodecim, the Finnish Gynaecological Association, the Finnish Association for General Practice

Contraception

Current Care Guidelines
Working group set up by the Finnish Medical Society Duodecim, the Finnish Gynaecological Association and the Finnish Association for General Practice
27.4.2017

Current Care Guideline in Finnish «Raskauden ehkäisy»1

Please note that the guideline in Finnish, Raskauden ehkäisy «Raskauden ehkäisy»1, has been partially updated on December 5th, 2022. Therefore this English version is not currently up to date.

Core contents

  • Contraception and birth control services must be easily accessible all year round.
  • There is no age limit for contraception, and it is not necessary to perform a gynaecological examination before contraception is started.
  • Testing for chlamydia, among others, should be considered (sexually transmitted diseases, STDs). Pap smear specimens of the uterine cervix should be taken in accordance with the screening guideline. See the Current Care guideline ‘Cytological changes in the cervix, vagina and vulva' «Kohdunkaulan, emättimen ja ulkosynnytinten solumuutokset»2, «Kohdunkaulan, emättimen ja ulkosynnytinten solumuu...»1.
  • The choice of contraceptive method should be based on the person's wishes and a realistic assessment of the situation. Choosing a suitable contraceptive method increases the likelihood of continued use.
  • In practice, the most effective reversible methods are intrauterine devices (IUDs, coils) and implants, as these are not susceptible to user-related errors (forgetfulness). Sterilisation is an irreversible method.
  • The risk of venous thromboembolism (VTE) only increases in connection with the use of combined hormonal contraceptives. Even then, it is lower than the risk of thromboembolism associated with pregnancy.
  • Condoms are the only contraceptive method that protects against STDs.
  • The main importance of follow-up visits is to identify any emerging contraindications and to discuss any unhealthy lifestyle factors (smoking, obesity, lack of exercise) and any high-risk sexual behaviour (maintaining and promoting fertility and reproductive health) and to prevent and treat STDs.
  • The most effective type of postcoital contraception is a copper IUD inserted within 5 days of unprotected intercourse.
  • Emergency contraceptive pills are available over-the-counter from pharmacies. These are most effective when taken within 12 hours after unprotected intercourse.
  • Postpartum contraception should be planned during gestation.
  • Post-abortion contraception should be planned already when issuing a referral for the abortion.
  • Rhythm methods and similar natural methods are not reliable birth control methods.

Tables

Scope of the guideline

  • The guideline only discusses contraception. Other indications for contraceptive methods are not discussed.

Aims

  • The guideline aims to:
    • improve healthcare professionals' awareness of birth control options, their efficacy, safety and contraindications
    • help healthcare professionals to choose, together with the user, the method best suited for each individual contraception user.

Target group

  • The target group is healthcare professionals (HCPs).

User perspective

Starting contraception

Table 1. Important matters when choosing a birth control method
Important matters when choosing a birth control method
Check Weight and height (BMI)1)
Health status (medical conditions, planned procedures)2)
Gynaecological history (e.g. troublesome bleeding or menstrual pain)
Smoking status1)
Age
Duration of need for contraception
Client's personal views and beliefs
Previous contraceptive failure
VTEs in the near family and family history of breast or gynaecological cancer
Blood pressure1) and blood pressure during previous pregnancy
Medications and use of natural products3)
STDs (chlamydia, gonorrhoea, HIV etc.)4)
Sexual victimisation
Childbirth and lactation5)
Inform Contraception options
Condom use to protect against STDs
Initiation
Dosing
Efficacy6)
Benefits and AEs7)
Price
Opportunities for STD testing (offer irrespective of user's relationship status)
Switching from one contraceptive product to another (see Table «Switching contraceptive methods...»12)
Remind Potential effects of changes in health status on the safety and efficacy of each contraceptive method
1) See Current Care guidelines Hypertension «Kohonnut verenpaine»5, Obesity (adult) «Lihavuus (lapset, nuoret ja aikuiset)»6 and Tobacco dependence and cessation «Tupakka- ja nikotiiniriippuvuuden ehkäisy ja hoito»7
2) See Table «The effect of medical conditions and risk factors on the choice of contraception methods...»4
3) See Table «Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)...»9
4) See Current Care guideline Sexually transmitted infections «Seksitaudit»4
5) See Table «Postpartum contraception...»5
6) See Table «Contraceptive efficacy of different contraceptive methods (Pearl index = how many out of 100 women become pregnant during one year of use)...»7
7) See Table «Health effects of birth control methods in alphabetical order...»8
Table 2. Contraindications to the use of combined hormonal contraceptives
Absolute contraindications Relative contraindications1)
Deep vein thrombosis (VTE) or a high risk of VTE:
  • acute or previous VTE
  • known hereditary or acquired VTE tendency (e.g. APC resistance, antithrombin III deficiency, protein C deficiency)
  • VTE in a 1st degree relative with no predisposing factors
  • surgery involving lengthy immobilisation
  • high risk of VTE due to multiple risk factors (e.g. obesity: BMI >35 kg/m2 plus another risk factor1))
  • postpartum period: 3 months after childbirth in non-lactating women, 6 months in lactating women
Risk factors for VTE:
  • postpartum period
  • overweight (BMI >30 kg/m2)
  • temporary immobilisation
  • some medical conditions (cancer, SLE, inflammatory bowel disease)
  • age over 35 years
Arterial thromboembolism (ATE) or a high risk of ATE:
  • current or previous myocardial infarction or ischaemic stroke or a condition predicting these (angina pectoris, TIA)
  • known hereditary or acquired ATE tendency (e.g. phospholipid antibodies, lupus anticoagulant)
  • migraine with aura
  • high risk of ATE due to multiple risk factors (e.g. diabetes mellitus with end organ damage, severe hypertension or dyslipoproteinaemia, migraine without aura in a woman aged over 35)1)
Risk factors for ATE:
  • age over 35 years
  • smoking
  • elevated blood pressure
  • overweight (BMI >30 kg/m 2)
  • positive family history (ATE in a 1st degree relative)
  • some medical conditions (diabetes mellitus, cardiac valvular defect, atrial fibrillation, SLE)
Vaginal bleeding (unexplained)
Severe hepatic condition or hepatic tumour
Pregnancy or suspected pregnancy
Sex hormone-dependent cancer (e.g. breast cancer)
Hypersensitivity to the active ingredient or any of the excipients.
References: European Medicines Agency (EMA) «http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Combined_hormonal_contraceptives/European_Commission_final_decision/WC500160274.pdf»4 and Finnish Medicines Agency Fimea «http://www.fimea.fi/-/yhdistelmaehkaisyvalmisteiden-hyodyt-ovat-edelleen-riskeja-suuremmat»5
1) If the patient has two or more risk factors, they may, together, constitute an absolute contraindication to the use of combined hormonal contraceptives. The risk-benefit ratio should be assessed individually.
Table 3. Contraindications to the use of progestin-only contraception and copper IUD use
Contraindications to the use of progestin-only products Contraindications for progestin-containing IUDs Contraindications for copper IUDs
Pregnancy or suspected pregnancy Pregnancy or suspected pregnancy Pregnancy or suspected pregnancy
Unexplained vaginal bleeding Unexplained vaginal bleeding Unexplained vaginal bleeding
VTE (acute) Gynaecological infection Gynaecological infection
Progestin-dependent tumour Progestin-dependent tumour Menorrhagia or tendency to anaemia
Active hepatic condition Active hepatic condition Wilson's disease
Structural uterine anomaly or uterine tumour that prevents the correct placement of the IUD in the uterine cavity Structural uterine anomaly or uterine tumour that prevents the correct placement of the IUD in the uterine cavity 

Effect of age, lifestyle and health on the choice of hormonal contraception

Age

Table 4. The effect of medical conditions and risk factors on the choice of contraception methods
Medical condition or risk factor (in alphabetical order) Combined hormonal contraceptives Progestin-only products Hormonal IUD Copper IUD
Age (see figures «Women’s risk of arterial and venous events requiring hospitalisation in relation to ageing, smoking and combined contraceptive use»1 and «Women’s risk of fatal arterial and venous events in relation to ageing, smoking and combined contraceptive use»2) Can be used by healthy persons of all ages
Any medical conditions and overweight should be considered 		Can be used Can be used Can be used
Anaemia Can be used
May reduce the quantity of menstrual bleeding
See Current Care guideline Menorrhagia «Runsaat kuukautisvuodot»8 «Menorrhagia (online). Current Care guideline. Work...»210		 Can be used
May reduce the quantity of menstrual bleeding
See Current Care guideline Menorrhagia «Runsaat kuukautisvuodot»8 «Menorrhagia (online). Current Care guideline. Work...»210		 Can be used
May reduce menstrual bleeding 		May increase bleeding
Bowel diseases Can be used
Any malabsorption may influence pill efficacy 		Can be used
Any malabsorption may influence pill efficacy 		Can be used Can be used
Breast cancer Absolute contraindication
BRCA carrier status is not a contraindication 		Absolute contraindication
BRCA carrier status is not a contraindication 		Relative contraindication
BRCA carrier status is not a contraindication 		Can be used
Cardiovascular disease Severe hepatic cirrhosis is an absolute contraindication
See Table «Contraindications to the use of combined hormonal contraceptives...»2. 		Severe hepatic cirrhosis is an absolute contraindication
See Table «Contraindications to the use of combined hormonal contraceptives...»2. 		Can be used Can be used
  • Unstable angina pectoris and history of myocardial infarction
 Absolute contraindication Can be used Can be used Can be used
  • Valvular heart disorder
 Relative contraindication
Absolute contraindication in patients with pulmonary hypertension, tendency to atrial fibrillation or history of endocarditis 		Can be used Can be used Can be used
Cirrhosis of liver Severe hepatic cirrhosis is an absolute contraindication.
See Table «Contraindications to the use of combined hormonal contraceptives...»2. 		Severe hepatic cirrhosis is an absolute contraindication
See Table «Contraindications to the use of combined hormonal contraceptives...»2. 		Can be used Can be used
Cholelithiasis Not recommended while the disease is active Not recommended while the disease is active Can be used Can be used
Diabetes
See Current Care guideline Diabetes «Tyypin 2 diabetes»9 «Diabetes (online). Current Care guideline. Working...»25		 Can be used but may impair glucose tolerance
Diabetic end-organ damage is an absolute contraindication
See Current Care guideline Diabetes «Tyypin 2 diabetes»9 «Diabetes (online). Current Care guideline. Working...»25		 Can be used Can be used Can be used
Ectopic pregnancy «Ectopic pregnancy (online). Current Care guideline...»209
 Can be used Can be used Can be used Can be used
Not the preferred contraceptive method
Endometriosis Can be used
Use of the product may treat endometriosis 		Can be used
Use of the product may treat endometriosis 		Can be used
Use of the product may treat endometriosis 		Can be used
Not the preferred contraceptive method
Epilepsy Can be used
However, note that carbamazepine, in particular, impairs the contraceptive efficacy of combined hormonal contraceptives and that combined hormonal contraceptives may reduce the concentrations of lamotrigine and valproate
See Table «Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)...»9		 Can be used
However, note that carbamazepine, in particular, impairs the contraceptive efficacy of progestin products
See Table «Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)...»9		 Can be used Can be used
Headache Can be used
Use should be discontinued if headache worsens during use (See Migraine in this table) 		Can be used Can be used Can be used
Hyperlipidaemias Not the first choice in patients with familial hypercholesterolaemia
Contraindicated if the hyperlipidaemia is associated with coronary heart disease 		Can be used Can be used Can be used
Hyperprolactinaemia Can be used Can be used Can be used Can be used
Hypertension Absolute or relative contraindication depending on blood pressure levels
May increase blood pressure and thus increase arterial risks 		Can be used Can be used Can be used
Infectious diseases
  • Ordinary infectious diseases (rhinitis, gastroenteritis etc.)
 Can be used
Vomiting or diarrhoea may nevertheless impair absorption of the pills 		Can be used
Vomiting or diarrhoea may nevertheless impair absorption of the pills 		Can be used Can be used
  • HIV infection
 Can be used
Check drug-drug interactions (See Table «Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)...»9) 		Can be used
Check drug-drug interactions (See Table «Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)...»9) 		Can be used Not the preferred choice
  • Hepatitis
 In viral hepatitis, systemic hormonal contraceptives may further impair hepatic function and their use is therefore not recommended In viral hepatitis, systemic hormonal contraceptives may further impair hepatic function and their use is therefore not recommended Can be used Can be used
Mental health problems Can be used, follow patient's mood
Poor mental status may nevertheless impair adherence
Check any drug-drug interactions 		Can be used, follow patient's mood
Poor mental status may nevertheless impair adherence
Check any drug-drug interactions 		Can be used Can be used
Migraine Migraine with aura is an absolute contraindication in all age groups; migraine without aura is an absolute contraindication in those aged over 35 Can be used Can be used Can be used
Obesity +
See Current Care guideline Obesity (adult) «Lihavuus (lapset, nuoret ja aikuiset)»6 «Obesity (adult) (online). Current Care guideline. ...»22		 Can be used
Not a contraindication as such
Remember other risk factors related to obesity
See Current Care guideline Obesity (adult) «Lihavuus (lapset, nuoret ja aikuiset)»6 «Obesity (adult) (online). Current Care guideline. ...»22		 Can be used Contraceptive efficacy may nevertheless be impaired if BMI ≥35 kg/m2 Can be used Can be used
Polycystic ovary syndrome (PCOS) 1) Can be used Can be used Can be used Can be used
Rheumatoid conditions Can be used Can be used Can be used Can be used
Smoking (see figures «Women’s risk of arterial and venous events requiring hospitalisation in relation to ageing, smoking and combined contraceptive use»1 and «Women’s risk of fatal arterial and venous events in relation to ageing, smoking and combined contraceptive use»2) Absolute contraindication in women aged over 35 Can be used Can be used Can be used
Thyroid disorders Can be used Can be used Can be used Can be used
Uterine fibroids (leiomyomata) Can be used Can be used Can be used
Note, however, that fibroids protruding into the uterine cavity may prevent insertion 		Can be used
Note, however, that fibroids protruding into the uterine cavity may prevent insertion
May also increase bleeding
Varicose veins and a history of superficial thrombophlebitis Can be used Can be used Can be used Can be used
VTE in a 1st degree relative Absolute contraindication if there are no predisposing factors
Assess known thrombophilic factors 		Can be used Can be used Can be used
History of VTE Absolute contraindication Can be used Can be used Can be used
1) In addition to contraception, also to treat menstrual disorders and excessive male sex hormone production. Women with PCOS are often also overweight, which increases the health risks related to combined hormonal contraception, including the risk of VTE.
BRCA = breast cancer associated gene 1 or 2
PCOS = polycystic ovary syndrome
Picture 1.

The graph shows an estimate of the number of events requiring hospitalisation over one year per 100,000 women.

Adapted from Farley TM, Meirik O, Chang CL et al. Combined oral contraceptives, smoking, and cardiovascular risk. J Epidemiol Community Health 1998;52:775-85

Picture 2.

The graph shows an estimate of the number of deaths over one year per 100,000 women.

Adapted from Farley TM, Meirik O, Chang CL et al. Combined oral contraceptives, smoking, and cardiovascular risk. J Epidemiol Community Health 1998;52:775-85

Adolescents

Adolescents and the law

  • Under Finland's Act on the Status and Rights of Patients, a minor patient can decide on his/her treatment if his/her age and level of development allow it (Finlex legal database «https://www.finlex.fi/fi/laki/ajantasa/1992/19920785»8). It is generally accepted that an adolescent aged 15 has achieved the level of development intended by the law.
  • A minor requesting contraception may decide independently on his or her contraceptive use, but the overall situation must be carefully assessed, especially for those under the age of 15.
  • Finland's Criminal Code (Chapter 20, § 6) defines two age-of-consent limits:
    • The purpose of the 18-year age-of-consent limit is to protect adolescents from sexual abuse by a person in a position of trust (e.g. parents, teachers, coaches).
    • The 16-year age-of-consent limit prohibits sexual relationships and sexual acts with a person under 16. Dating relationships in which the adolescents are of a similar age and level of psychological development constitute an exception to this rule. (Criminal Code, Chapter 20, § 7a.)

Smoking

Substance abusers

Weight

Medical conditions

Special groups

Disabled persons

Developmental and intellectual disability

  • Developmental and intellectual disabilities do not prevent the use of any contraceptive method.

Impaired mobility

  • Women with impaired mobility may be at greater risk of developing VTE.

Multiculturalism

Postpartum contraception

Methods

Table 5. Postpartum contraception
Method Initiation after childbirth Points to note
Lactational amenorrhoea (LAM) Immediately Protects against pregnancy for 6 months if the infant receives no nourishment other than breast milk, the woman breastfeeds regularly (at least every 4 hours, even at night) and her menstruation has not yet started
Condom Immediately Effective when used correctly
Progestin-only oral contraceptives Immediately
Contraceptive implants Immediately
Progestin injection Immediately
Combined hormonal contraceptives (pills, vaginal ring, patch) Non-lactating women at 3 months
Lactating women at 6 months
IUD, hormonal IUD Postpartum check-up Lactating women whose menstruation has not yet started after childbirth have an increased risk of perforation
Sterilisation Referral from the out-patient maternity clinic Sterilisation Act (Finlex legal database, «https://www.finlex.fi/fi/laki/ajantasa/1970/19700283»17)
Irreversible method
Emergency contraception Only required if more than 3 weeks have passed after childbirth
After ulipristal pills, breastfeeding is not recommended for a week

Follow-up for contraception

Table 6. Beliefs related to contraception
Common beliefs on contraception Research findings
Contraceptive products cause weight gain. The use of hormonal contraceptives does not result in weight gain.
All hormonal contraceptives cause VTEs. The risk of VTE only applies to combined hormonal contraceptives.
Hormonal contraception causes cancer. The use of combined hormonal contraceptives is associated with a slightly increased risk of breast cancer, which disappears 5 years after their use is discontinued.
Combined hormonal contraceptives reduce the risk of ovarian, uterine and colorectal cancer.
Progestin-only products reduce the risk of uterine cancer.
Contraception causes infertility. Fertility is generally restored during the next menstrual cycle to a level consistent with the woman's age (except when using contraceptive injections). In women with endometriosis or PCOS, hormonal contraceptives treat the woman's underlying condition and may improve fertility once contraception is withdrawn.
Condoms prevent STDs and may thus prevent infertility.
Sterilisation is a permanent method of contraception.
Pauses in contraception are healthy and detoxify the body. There should be no breaks in taking contraceptive products, except as specified in the instructions in the package.
The risk of VTE associated with combined hormonal contraceptive use is highest immediately after the start of product use and also after a pause, even a short one (1 month).
In women who have had superficial thrombophlebitis, all types of hormonal contraception are forbidden. A history of a small superficial thrombophlebitis has not been shown to increase the risk of VTE.
All contraceptive products can be used.
However, bear in mind the difference between superficial and deep VTEs.
Antibiotics impair contraceptive efficacy. The most commonly used antibiotics generally do not impair contraceptive efficacy.
See Table «Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)...»9.
Liver function tests should be monitored. The monitoring of liver function tests is not required.
An active hepatic condition is a contraindication to the use of hormonal contraceptives.
Hormonal contraceptive methods "make you go mad". Hormonal contraceptive products may influence mood, but their effects are individual and they may also improve mood and alleviate PMS symptoms.
Hormonal contraception has not been shown to cause depression.
Sterilisation is 100% certain to prevent fertilisation. Sterilisation is the most effective method of contraception. The contraceptive efficacy of sterilisation is not 100%.
Hormonal IUDs, for example, have better contraceptive efficacy than sterilisation.
See Table «Contraceptive efficacy of different contraceptive methods (Pearl index = how many out of 100 women become pregnant during one year of use)...»7.
Progestin-containing products make your skin appear unhealthy. Skin effects are individual.
Combined hormonal contraceptives generally treat acne.
Progestin-containing products may be associated with an oily skin.
A Pap smear test should be taken before IUD insertion. A Pap smear test is not required before IUD insertion if the woman is asymptomatic.
After childbirth, an IUD can only be inserted once the woman's menstruation has started or she no longer breastfeeds. An IUD may be inserted at any time after childbirth.
However, particularly in breastfeeding women, the uterus may be soft and IUD insertion may be associated with an increased risk of perforation.
Particular caution and a careful insertion technique is then required.
Hormones are unsuitable for women in my family. Whether hormonal products are suitable or not does not depend on family history.

Continuity of use

Combined hormonal contraception

  • Combined hormonal contraceptives contain
    • oestrogen (a female sex hormone)
      • The majority of products contain ethinylestradiol (EE), the effect of which is more potent than that of natural oestrogen (estradiol).
      • Estradiol valerate and estradiol hemihydrate are metabolised into natural oestrogen.
      • No differences have been detected in the efficacy, AEs and contraindications of contraceptive products containing different oestrogens.
    • progestin (luteal body hormone).
      • The progestin used varies depending on the combined hormonal contraceptive product involved.
      • The AEs related to combined hormonal contraceptives may be due to the progestin, in which case a switch to a product using a different progestin may be helpful.
  • The contraindications are the same for all routes of administration.
  • Routes of administration:
    • Pills are taken by mouth (oral use).
    • A ring is placed in the vagina (vaginal use).
    • A patch is applied to the skin (cutaneous use).
  • Monocyclic contraceptives (pills in which all pills contain the same quantity of hormones, patches, vaginal rings) can also be used without pauses (so-called long cycle).
  • Fertility is restored to a level consistent with the woman's age when she discontinues the use of the product «Mikkelsen EM, Riis AH, Wise LA et al. Pre-gravid o...»66, «Heffner LJ. Advanced maternal age--how old is too ...»67.

Mechanism of action and contraceptive efficacy

Table 7. Contraceptive efficacy of different contraceptive methods (Pearl index = how many out of 100 women become pregnant during one year of use)
Use as instructed Typical use Reference
No contraception 85 85 «World Health Organization (WHO). Medical Eligibili...»21
Barrier methods
  • Female condoms
 5 21 «World Health Organization (WHO). Medical Eligibili...»21
  • Male condoms
 2 15 «World Health Organization (WHO). Medical Eligibili...»21
  • Diaphragm
 6 16 «World Health Organization (WHO). Medical Eligibili...»21
Combined hormonal contraception
  • Oral contraceptives
 0.0–1.26 0.0–2.18 «Mansour D, Inki P, Gemzell-Danielsson K. Efficacy ...»211
  • Vaginal ring
 0.31–0.96 0.25–1.23 «Mansour D, Inki P, Gemzell-Danielsson K. Efficacy ...»211
  • Patch
 0.59–0.99 0.71–1.24 «Mansour D, Inki P, Gemzell-Danielsson K. Efficacy ...»211
Progestin-only contraception
  • Oral contraceptives
 0.14 0.41 «Mansour D, Inki P, Gemzell-Danielsson K. Efficacy ...»211
  • Injection
 0.3 3 «World Health Organization (WHO). Medical Eligibili...»21
  • Implant
 0.05 0.05 «World Health Organization (WHO). Medical Eligibili...»21, «Trussell J. Contraceptive failure in the United St...»119
IUDs
  • Hormonal IUD
 0.1–0.2 0.1–0.2 «World Health Organization (WHO). Medical Eligibili...»21, «Trussell J. Contraceptive failure in the United St...»119
  • Copper IUD
 0.6 0.8 «World Health Organization (WHO). Medical Eligibili...»21, «Trussell J. Contraceptive failure in the United St...»119
Sterilisation
  • Female sterilisation
 0.5 0.5 «World Health Organization (WHO). Medical Eligibili...»21, «Trussell J. Contraceptive failure in the United St...»119
  • Male sterilisation
 0.1 0.15 «World Health Organization (WHO). Medical Eligibili...»21
Other methods
  • Chemical contraception (spermicides)
 18 29 «World Health Organization (WHO). Medical Eligibili...»21
  • Body temperature
 0.4 24 «Mansour D, Inki P, Gemzell-Danielsson K. Efficacy ...»211
  • Rhythm method
 3–5 25 «World Health Organization (WHO). Medical Eligibili...»21
  • Withdrawal method
 4 27 «World Health Organization (WHO). Medical Eligibili...»21

Benefits

Table 8. Health effects of birth control methods in alphabetical order
Symptom or problem Hormonal Non-hormonal
Combined hormonal contraceptives Progestin-only products Hormonal IUD Copper IUD Condom Sterilisation
Acne ↓ ↑ ↑ - - -
Endometriosis symptoms ↓ ↓ ↓ - - -
Uterine cancer ↓ ↓ ↓ - - -
Menstrual pain ↓ ↓ / - ↓ ↑ - -
Menstrual bleeding ↓ ↓ / - ↓ ↑ - -
Risk of VTE ↑ - - - - -
Mood changes ↑↓ ↑↓ ↑↓ - - -
Ovarian cyst formation ↓ ↑ ↑ - - -
Ovarian cancer ↓ - - - - ↓
Weight - - - - - -
PMS symptoms ↓ ↑↓ ↑↓ - - -
Headache ↑↓ ↑↓ ↑↓ - - -
Benign breast lesion ↓ - - - - -
Breast tenderness ↑ ↑ ↑↓ - - -
Breast cancer risk ↑ ? ↑↓ - - -
Pelvic inflammatory disease ↓ ↓ ↓ - - -
Bowel cancer ↓ - - - - -
↑ Increases
↓ Prevents or reduces
↑↓ May increase or prevent/reduce
- No effect
? No information on effect

Disadvantages

Picture 3.

The graph shows the risk of venous thromboembolism (VTE) as the number of VTE events per 10,000 women.

Source: Fimea. Permission granted for re-publication.

Contraindications

Progestin-only contraception

  • Progestin-only contraceptive products only contain progestins, i.e. luteal body hormone derivatives.
  • Administration methods:
    • Pills are taken every day without breaks.
    • Implants are placed subcutaneously in the upper arm by a HCP under local anaesthesia.
      • In 2015, there were two products on the market: a 3-year contraceptive capsule (etonogestrel, one capsule) and a 5-year contraceptive implant (levonorgestrel, two capsules).
      • There are no significant differences between the capsule brands in terms of their efficacy or AEs.
    • A contraceptive injection (medroxyprogesterone acetate) is given intramuscularly by a HCP every 3 months.
    • For hormonal intrauterine devices, see section Hormonal IUDs.
  • Fertility is restored to a level consistent with the woman's age when she discontinues the use of progestin-only contraception «Heffner LJ. Advanced maternal age--how old is too ...»67, «Spencer AL, Bonnema R, McNamara MC. Helping women ...»112.

Mechanism of action and contraceptive efficacy

Benefits

Disadvantages

Contraindications

Intrauterine contraception (IUDs)

Hormonal IUDs

  • In 2015, there were three products on the market:

Mechanism of action and contraceptive efficacy

Contraindications

Benefits

Disadvantages

Contraindications

Copper IUDs

Picture 4.

With all products, the best contraceptive efficacy is achieved by taking the emergency contraceptive within 12 hours after unprotected intercourse.

Mechanism of action and contraceptive efficacy

Benefits

Disadvantages

Contraindications

Drug-drug interactions

Table 9. Drug-drug interactions that should be considered in the choice of contraception. Drug-drug interactions can also be checked via the SFINX-PHARAO interaction database (subject to a fee, requires log-in ID)
Drug class Medicinal agent Mechanism Points to note
Agents used to treat HIV infection Ritonavir Saquinavir Hepatic enzyme induction Concomitant use reduces the blood hormone concentrations achieved with contraceptive products
Antiepileptics Carbamazepine Phenobarbital Phenytoin Primidone Lamotrigine Hepatic enzyme induction Copper and hormonal IUDs are the methods of choice as there may be changes in the blood concentrations of either the contraceptive product or the antiepileptic, particularly when using oral contraceptives. This may influence the efficacy of the medicines.
Antituberculotics Rifabutin Rifampicin Hepatic enzyme induction Concomitant use reduces the hormone concentrations achieved with contraceptive products
Emergency contraception Ulipristal Binds with the progesterone receptor May reduce the efficacy of progestin-containing contraceptives
Heartburn medications that increase gastric pH Antacids Proton pump inhibitors H2 receptor antagonists Increase gastric pH May reduce the efficacy of ulipristal emergency contraception
Herbal remedy St. John's wort extract Hepatic enzyme induction Concomitant use reduces the hormone concentrations achieved with contraceptive products
References «World Health Organization (WHO). Medical Eligibili...»21, «Faculty of Sexual and Reproductive healthcare clin...»164, «Faculty of Sexual and Reproductive Healthcare Cli...»165, «Virkus RA, Løkkegaard EC, Bergholt T et al. Venous...»259

Sterilisation

Male sterilisation (vasectomy)

Disadvantages

Female sterilisation

  • In Finland, two female sterilisation methods are used.
    • Fallopian tube occlusion, in which the Fallopian tubes are blocked with small clips, inserted laparoscopically under general anaesthesia.
    • Hysteroscopic sterilisation, in which implants are inserted into the Fallopian tubes hysteroscopically under local anaesthesia. This results in scarring and blockage of the Fallopian tubes in 3 months.

Mechanism of action and contraceptive efficacy

Disadvantages

Barrier methods and chemical methods

Male condoms

Benefits

  • Condoms are the only contraceptive method that also prevents STDs when used correctly.
  • Condoms can be combined with other types of contraception.
  • Using condoms has no effect on fertility.

Disadvantages

Contraindications

  • Latex allergy is a contraindication to using latex condoms.

Other methods

Emergency contraception

Table 10. Situations in which contraception may fail
Contraceptive method used
Combined hormonal contraceptives Oral contraceptives: 3 or more pills containing 30–35 mcg EE1) or 2 or more pills of 20 mcg have been missed during the first week of use.
The vaginal ring has been removed from the vagina for more than 3 hours.
The patch has been removed from the skin for more than 24 hours.
Progestin-only oral contraceptives One or more pills have been taken more than 3 hours late or, with desogestrel-containing pills, 12 hours late.
IUD The IUD has been expelled partially or completely or it has been necessary to remove the IUD.
Condom The condom has broken or its use has failed.
Progestin injection The injection is more than 14 weeks late after the previous medroxyprogesterone acetate injection.
1) EE = ethinylestradiol

Methods

Hormonal emergency contraception

Emergency contraception with an IUD

Mechanisms of action

Efficacy

Hormonal emergency contraception

Copper IUD

Undesirable effects

Foetal effects

Drug-drug interactions

Contraindications and use during lactation

  • There is no lower or upper age limit for the use of emergency contraception.
  • Breastfeeding, a history of ectopic pregnancy, smoking, migraine, hepatic conditions, a history of VTE, trombophilia and other cardiovascular conditions are not contraindications «Grimes DA, Lopez LM, O'Brien PA et al. Progestin-o...»113.

Levonorgestrel

Ulipristal acetate

Copper IUD

  • There are no contraindications to the use of a copper IUD, and it has no effect on breastfeeding.
  • See section Copper IUDs.

Dispensing emergency contraceptive pills from the pharmacy (over-the-counter)

Table 11. Preconditions for over-the-counter dispensing of an emergency contraceptive product from a pharmacy (amended from the National Agency for Medicines normative guideline)
The pharmacy may dispense the product for emergency contraception on an over-the-counter basis on the following conditions: The pharmacist must review the following with the client:
Any chronic conditions, regular medication and its suitability in conjunction with the use of the emergency contraceptive involved
The client is only given one pack at a time. Instructions concerning the dose and the package leaflet
When dispensing the product, the pharmacist must provide medication counselling. Possible side effects
When dispensing the product, the pharmacist must provide medication counselling. Instructions on what to do if the woman experiences nausea when using the product
In unclear cases, the client should be advised to contact a doctor. Frequency of emergency contraceptive use
Guidance to take a pregnancy test if the woman's menstrual period is late
The need for a check-up and an appointment with a doctor
The necessity to use condoms to prevent STDs
Pharmaceutical staff have an obligation to inform the client about STDs
Table 12. Switching contraceptive methods
Contraceptive method used Introduction of the next contraceptive method
Combined hormonal contraception Progestin only
Combined hormonal contraception Oral contraceptives Vaginal ring Patch Progestin-only oral contraceptives Hormonal IUD Implant Injection Copper IUD
Oral contraceptives On the day after the last active pill or on the day after the last usual pill-free week or the placebo pill week On the day after the last active pill or on the day after the last usual pill-free week or the placebo pill week On day 1 of withdrawal bleeding; if started on day 2 or later, condoms should be used for 7 days On the day after the last active pill or on the day after the last usual pill-free week or the placebo pill week, in which case condoms should be used for 7 days On the day after the last active pill or during the 7 days after the product On the day after the last active pill or during the next 4 to 7 days, depending on the product On the day after the last active pill or during the next 4 to 7 days, depending on the product At any time
Vaginal ring On the day of removal or, at the latest, when the next ring should be inserted On day 1 of withdrawal bleeding; if started on day 2 or later, condoms should be used for 7 days On the day of removal or, at the latest, when the next ring should be inserted + condom use for 7 days On the day of removal or within 7 days after removal On the day of removal or during the next 7 days On the day of removal or during the next 7 days At any time
Patch On the day of removal or, at the latest, when the next patch should be applied On the day of removal or, at the latest, when the next patch should be applied On the day of removal or, at the latest, when the next patch should be applied + condom use for 7 days On the day of removal or within 7 days after removal On the day of removal or during the next 7 days On the day of removal or during the next 7 days At any time
Progestin-only product
Progestin-only oral contraceptives At any time during the woman's cycle + condom use for 7 days At any time during the woman's cycle + condom use for 7 days At any time during the woman's cycle + condom use for 7 days At any time during the woman's cycle At any time during the woman's cycle At any time during the woman's cycle At any time during the woman's cycle At any time
Hormonal IUD On the day of removal + condom use for 7 days On the day of removal + condom use for 7 days On the day of removal + condom use for 7 days On the day of removal On the day of removal On the day of removal On the day of removal At any time
Implant On the day of removal + condom use for 7 days On the day of removal + condom use for 7 days On the day of removal + condom use for 7 days On the day of removal On the day of removal On the day of removal On the day of removal At any time
Injection At the time of the next injection + condom use for 7 days At the time of the next injection + condom use for 7 days At the time of the next injection + condom use for 7 days At the time of the next planned injection + condom use for 7 days At the time of the next planned injection + condom use for 7 days At the time of the next planned injection At the time of the next planned injection At any time
Copper IUD
Copper IUD At any time during the woman's cycle + condom use for 7 days At any time during the woman's cycle

Working group set up by the Finnish Medical Society Duodecim, the Finnish Gynaecological Association and the Finnish Association for General Practice

Chairperson:

Mervi Halttunen-Nieminen, Doctor of Medical Science, Docent, Specialist in Obstetrics and Gynaecology and in Gynaecological Endocrinology, University of Helsinki and Helsinki University Central Hospital (HUCH) Department of Obstetrics and Gynaecology

Compiling author:

Terhi Piltonen, Doctor of Medical Science, Specialist in Obstetrics and Gynaecology; University of Oulu and Oulu University Hospital (OYS)

Members:

Heidi Alenius, Licentiate of Medicine, Specialist in General Practice, physician-editor; Lempäälä health centre, Duodecim Medical Publications Ltd, Lääkärin tietokannat databases

Laura Apukka, midwife-nurse, sex therapist; City of Helsinki, Herttoniemi health station

Elise Kosunen, Professor in General Practice, Chief Physician; University of Tampere and Pirkanmaa Hospital District primary care unit

Kirsi Pietilä, Doctor of Science (Pharmacy), proprietary pharmacist; Kontulan apteekki pharmacy

Sinikka Sihvo, Doctor of Philosophy, Docent, Head of Research; National Institute for Health and Welfare (THL)

Piia Vuorela, Doctor of Medical Science, Docent, Bachelor of Science (Economics and Business Administration), Specialist in Obstetrics and Gynaecology, Current Care editor; Porvoo Hospital and Finnish Medical Society Duodecim

Eija Väänänen, nurse, midwife, sexology counsellor; City of Vantaa, Myyrmäki health station, contraception and family planning clinic

Tiina Yli-Kivistö, Licentiate of Medicine, Specialist in General Practice; Finnish Student Health Service, Jyväskylä

Experts:

Annika Auranen, Doctor of Medical Science, Specialist in Obstetrics and Gynaecology and Gynaecological Oncology; Turku University Central Hospital (TYKS) Department of Obstetrics and Gynaecology

Johanna Mäenpää, Professor, Chief Physician, Specialist in Obstetrics and Gynaecology and Gynaecological Oncology; Tampere University Hospital (TAYS)

Pekka Nieminen, Doctor of Medical Science, Docent, Specialist in Obstetrics and Gynaecology; Hospital District of Helsinki and Uusimaa (HUS), Kätilöopisto Hospital

Declaration of interests

Heidi Alenius: None.

Laura Apukka: None.

Mervi Halttunen-Nieminen: None.

Elise Kosunen: None.

Kirsi Pietilä: Travel costs (Bayer), speaker honoraria (Bayer), licensing or author honoraria (Duodecim)

Terhi Piltonen: Funding for educational/conference costs from a company (Ferring, travel costs, ESHRE 2014)

Sinikka Sihvo: Expert honoraria (University of Helsinki), speaker honoraria (University of Helsinki, Professio)

Piia Vuorela: None.

Eija Väänänen: None.

Tiina Yli-Kivistö: Funding for educational/conference costs from a company (MSD)

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Article ID: ccg00004 (050.104)
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