Uro-Tainer Twin Suby G citric acid 3.23% catheter
maintenance solution (B.Braun Medical Ltd)
60 ml . NHS indicative price = £4.89 . Drug Tariff (Part IXa)
OptiFlo S saline 0.9% catheter maintenance solution (Bard Ltd)
Uro-Tainer M sodium chloride 0.9% catheter maintenance
indicative price available . Drug Tariff (Part IXa)
Uro-Tainer sodium chloride 0.9% catheter maintenance
price = £3.57 . Drug Tariff (Part IXa)
The Fraser Guidelines (Department of Health Guidance (July
2004): Best practice guidance for doctors and other health
professionals on the provision of advice and treatment to
young people under 16 on contraception, sexual and
reproductive health, available at www.tinyurl.com/bpg16)
should be followed when prescribing contraception for
women under 16 years. The UK Medical Eligibility Criteria for
Contraceptive Use (available at www.fsrh.org) is published by
the Faculty of Sexual and Reproductive Healthcare; it
categorises the risks of using contraceptive methods with
pre-existing medical conditions.
Hormonal contraception is the most effective method of
fertility control, but can have major and minor side-effects,
especially for certain groups of women. Hormonal
contraception should only be used by adolescents after
Intra-uterine devices are a highly effective method of
of parity, but are less appropriate for those with an increased
risk of pelvic inflammatory disease.
Barrier methods alone (condoms, diaphragms, and caps)
are less effective but can be reliable for well-motivated
couples if used in conjunction with a spermicide.
Occasionally sensitivity reactions occur. A female condom
(Femidom®) is also available; it is pre-lubricated but does not
Combined hormonal contraceptives
Oral contraceptives containing an oestrogen and a
progestogen (‘combined oral contraceptives’) are effective
preparations for general use. Advantages of combined oral
. reduced dysmenorrhoea and menorrhagia;
. reduced incidence of premenstrual tension;
. less symptomatic fibroids and functional ovarian cysts;
. reduced risk of ovarian and endometrial cancer;
. reduced risk of pelvic inflammatory disease.
Combined oral contraceptives containing a fixed amount
of an oestrogen and a progestogen in each active tablet are
termed ‘monophasic’; those with varying amounts of the two
hormones are termed ‘phasic’. A transdermal patch and a
vaginal ring, both containing an oestrogen with a
progestogen, are also available.
Combined Oral Contraceptives Monophasic
Norethisterone 1 mg Norinyl-1®
Combined Oral Contraceptives Monophasic
Combined Oral Contraceptives Phasic 21-day
Oestrogen content Progestogen content Brand
Combined Oral Contraceptives Phasic 28-day
The majority of combined oral contraceptives contain
ethinylestradiol p. 759 as the oestrogen component;
mestranol and estradiol are also used. The ethinylestradiol
content of combined oral contraceptives ranges from 20 to
40 micrograms. Generally a preparation with the lowest
oestrogen and progestogen content which gives good cycle
control and minimal side-effects in the individual woman is
chosen. It is recommended that combined hormonal
contraceptives are not continued beyond 50 years of age
since more suitable alternatives exist.
. Low strength preparations (containing ethinylestradiol
20 micrograms) are particularly appropriate for women
with risk factors for circulatory disease, provided a
combined oral contraceptive is otherwise suitable.
. Standard strength preparations (containing ethinylestradiol
30 or 35 micrograms or in 30–40 microgram phased
preparations) are appropriate for standard use. Phased
preparations are generally reserved for women who either
do not have withdrawal bleeding or who have
breakthrough bleeding with monophasic products.
The progestogens ethinylestradiol with desogestrel p. 798,
ethinylestradiol with drospirenone p. 798, and
ethinylestradiol with gestodene p. 799 may be considered for
women who have side-effects (such as acne, headache,
depression, breast symptoms, and breakthrough bleeding)
with other progestogens. Drospirenone, a derivative of
increased plasma-potassium concentration might be
Dienogest with estradiol valerate p. 797 is in the combined
oral contraceptive Qlaira ®. Nomegestrol is the progestogen
contained in the combined oral contraceptive Zoely ®, in
The progestogen norelgestromin is combined with
ethinylestradiol in a transdermal patch (Evra ®). The vaginal
contraceptive ring contains the progestogen etonogestrel
combined with ethinylestradiol (NuvaRing ®).
Oestrogen-containing contraceptives should preferably be
discontinued (and adequate alternative contraceptive
arrangements made) 4 weeks before major elective surgery
and all surgery to the legs or surgery which involves
prolonged immobilisation of a lower limb; they should
normally be recommenced at the first menses occurring at
least 2 weeks after full mobilisation. A progestogen-only
contraceptive may be offered as an alternative and the
oestrogen-containing contraceptive restarted after
if a patient admitted for an elective procedure is still on an
oestrogen- containing contraceptive, thromboprophylaxis
(with unfractionated or low molecular weight heparin and
graduated compression hosiery) is advised. These
recommendations do not apply to minor surgery with short
duration of anaesthesia, e.g. laparoscopic sterilisation or
tooth extraction, or to women using oestrogen-free
Combined hormonal contraceptives or hormone
replacement therapy (HRT) should be stopped (pending
investigation and treatment), if any of the following occur:
. sudden severe chest pain (even if not radiating to left
. sudden breathlessness (or cough with blood-stained
. unexplained swelling or severe pain in calf of one leg;
. serious neurological effects including unusual severe,
prolonged headache especially if first time or getting
progressively worse or sudden partial or complete loss of
vision or sudden disturbance of hearing or other
perceptual disorders or dysphasia or bad fainting attack or
collapse or first unexplained epileptic seizure or weakness,
motor disturbances, very marked numbness suddenly
affecting one side or one part of body;
. hepatitis, jaundice, liver enlargement;
. blood pressure above systolic 160 mmHg or diastolic
95 mmHg; (in adolescents stop if blood pressure very
. prolonged immobility after surgery or leg injury;
. detection of a risk factor which contra-indicates
Progestogen-only contraceptives
Oral progestogen-only contraceptives
Oral progestogen-only preparations alter cervical mucus to
prevent sperm penetration and may inhibit ovulation in
some women; oral desogestrel-only preparations
consistently inhibit ovulation and this is their primary
mechanism of action. There is insufficient clinical trial
evidence to compare the efficacy of oral progestogen-only
contraceptives with each other or with combined hormonal
contraceptives. Progestogen-only contraceptives offer a
suitable alternative to combined hormonal contraceptives
when oestrogens are contra-indicated (including those with
venous thrombosis or a past history or predisposition to
venous thrombosis, heavy smokers, those with hypertension
above systolic 160 mmHg or diastolic 95 mmHg, valvular
heart disease, diabetes mellitus with complications, and
Parenteral progestogen-only contraceptives
Medroxyprogesterone acetate p. 810 (Depo-Provera ®,
SAYANA PRESS ®) is a long-acting progestogen given by
injection; it is at least as effective as the combined oral
preparations but because of its prolonged action it should
never be given without full counselling backed by the patient
about the likelihood of menstrual disturbance 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. Troublesome bleeding has been
reported in patients given medroxyprogesterone acetate in
the immediate puerperium; delaying the first injection until
6 weeks after birth may minimise bleeding problems. If the
woman is not breast-feeding, the first injection may be given
within 5 days postpartum (she should be warned that the risk
of troublesome bleeding may be increased).
other methods of contraception are inappropriate;
. in all women, the benefits of using medroxyprogesterone
acetate beyond 2 years should be evaluated against the
. in women with risk factors for osteoporosis, a method of
contraception other than medroxyprogesterone acetate
Norethisterone enantate (Noristerat ®) is a long-acting
progestogen given as an oily injection which provides
contraception for 8 weeks; it is used as short-term interim
contraception e.g. before vasectomy becomes effective.
An etonogestrel-releasing implant (Nexplanon ®) is also
available. It is a highly effective long-acting contraceptive,
consisting of a single flexible rod that is inserted
subdermally into the lower surface of the upper arm and
provides contraception for up to 3 years. The manufacturer
advises that in heavier women, blood-etonogestrel
concentrations are lower and therefore the implant may not
provide effective contraception during the third year; they
advise that earlier replacement may be considered in such
patients—however, evidence to support this
recommendation is lacking. Local reactions such as bruising
and itching can occur at the insertion site. The contraceptive
effect of etonogestrel is rapidly reversed on removal of the
Intra-uterine progestogen-only device
The progestogen-only intra-uterine systems Mirena ®,
Jaydess ® and Levosert ® release levonorgestrel p. 806 directly
into the uterine cavity. Mirena ® is licensed for use as a
contraceptive, for the treatment of primary menorrhagia and
for the prevention of endometrial hyperplasia during
oestrogen replacement therapy. Jaydess ® and Levosert ® are
licensed for contraception, and Levosert ® is additionally
licensed for the treatment of menorrhagia. These may
therefore be a contraceptive method of choice for women
who have excessively heavy menses.
The effects of the progestogen-only intra-uterine system
are mainly local and hormonal including prevention of
endometrial proliferation, thickening of cervical mucus, and
suppression of ovulation in some women (in some cycles). In
addition to the progestogenic activity, the intra-uterine
system itself may contribute slightly to the contraceptive
effect. Return of fertility after removal is rapid and appears
Advantages of the progestogen-only intra-uterine system
over copper intra-uterine devices are that there may be an
improvement in any dysmenorrhoea and a reduction in
blood loss; there is also evidence that the frequency of pelvic
inflammatory disease may be reduced (particularly in the
youngest age groups who are most at risk).
In primary menorrhagia, menstrual bleeding is reduced
significantly within 3–6 months of inserting the
progestogen-only intra-uterine system, probably because it
prevents endometrial proliferation. Another treatment
should be considered if menorrhagia does not improve
All progestogen-only contraceptives (including those given
by injection) are suitable for use as an alternative to
combined hormonal contraceptives before major elective
surgery, before all surgery to the legs, or before surgery
which involves prolonged immobilisation of a lower limb.
Spermicidal contraceptives are useful additional safeguards
but do not give adequate protection if used alone unless
fertility is already significantly diminished. They have two
components: a spermicide and a vehicle which itself may
have some inhibiting effect on sperm activity. They are
suitable for use with barrier methods, such as diaphragms or
caps; however, spermicidal contraceptives are not generally
recommended for use with condoms, as there is no evidence
of any additional protection compared with non-spermicidal
Spermicidal contraceptives are not suitable for use in
those with or at high risk of sexually transmitted infections
(including HIV); high frequency use of the spermicide
nonoxinol ‘9’ p. 811 has been associated with genital lesions,
which may increase the risk of acquiring these infections.
The intra-uterine device (IUD) is a suitable contraceptive for
women of all ages irrespective of parity; however, it is less
appropriate for those with an increased risk of pelvic
inflammatory disease e.g. women under 25 years.
The most effective intra-uterine devices have at least
380 mm2 of copper and have banded copper on the arms.
wire or fitted with copper bands; some also have a central
core of silver to prevent fragmentation of the copper.
may remain in the uterus until menopause.
A frameless, copper-bearing intra-uterine device (Gyne
Fix ®) is also available. It consists of a knotted, polypropylene
thread with 6 copper sleeves; the device is anchored in the
uterus by inserting the knot into the uterine fundus.
Caution with oil-based lubricants
Products such as petroleum jelly (Vaseline ®), baby oil and
oil-based vaginal and rectal preparations are likely to
damage condoms and contraceptive diaphragms made from
latex rubber, and may render them less effective as a barrier
method of contraception and as a protection from sexually
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