Contraception must be able to prevent the occurrence of an unwanted pregnancy in a reversible manner, as opposed to sterilization.
The ideal contraception is totally effective, with good tolerance and good acceptability while preserving future fertility, it is not available at present. Meanwhile the ideal contraceptive effectiveness of contraception is measured by the Pearl Index: number of pregnancies per 100 women during 12 cycles.
The choice of contraception must take into account the request of the patient, must for good adherence and acceptability but shall include medical cons-indications requiring careful examination.
Recall that the consultation for contraception is an opportunity for the doctor to inform the patient on the prevention of sexually transmitted infections (STIs), on birth control and the decrease in fertility with age, particularly after 35 years.It also enables the screening of cervical cancer of the uterus and breast.
This is the most used contraception in France, about 30% of women. We distinguish:
– The estrogen plus progestin contraception (COP: “the pill”);
– The microprogestative contraception;
– The macroprogestative contraception.
They each have their indications, contraindications and side effects.
Estrogen contraception (Table I):
The main mechanism of action is through inhibition of ovulation through the antigonadotropic combined effect of estrogen and progestin.
The estrogen used is a synthetic compound, ethinyl estradiol, moderately antigonadotrophic the doses used.
The different progestins used have a strong antigonadotropic power and also have a peripheral action by acting on the quality of the cervical mucus, the atrophy of the endometrium making it unsuitable for implantation and decreasing tubal motility.
The classification of pills based on:
– The dose of ethinyl estradiol: normodosée 50 mcg and mini-containing between 40 and 15 micrograms. One normodosée pill on the market: Stédiril® only used in some indications;
– The method of administration of steroids: Combined (or monophasic) when the composition is fixed over the cycle, when biphasic two types of tablets exist and triphasic tablets when the dosage varies three times;
– The type of progestin used: derivatives norethisthérone are the first generation progestogens; levonorgestrel and norgestrel are the second generation progestins; gestodene, desogestrel and norgestimate, less androgenic, are the third generation progestins.
Three progestins used contraception preganes are derivatives or derivative of spironolactone:
– Cyproterone acetate (D IANE 35® and its generics) does not have the AMM (marketing authorization) in contraception but for acne,
– Chlormadinone acetate (Bellara®)
– Drospirenone (Jasmine® / Jasminelle®).
These are as follows:
– Good Pearl index when use is optimal;
– Good tolerance, particularly in the cycle, improving compliance;
– Decrease in dysmenorrhea and volume of rules;
– Other effects: decrease of endometrial cancer by 40 to 50% still persisting in the ruling of the COP and decrease ovarian cancer by 40 to 80% after 10 years of use, reduction in colorectal cancers. In some cases, the COP can treat acne (third generation pills / to drosperinone) while the COP of second generation may instead worsen signs of hyperandrogenism.
– The risk of being forgotten;
– Vascular accidents (rare but serious);
– Small increase in risk of breast cancer if prolonged use at a young age.
Cons-indications (Box 1):
The main cons-indications of COCs are:
– Personal and family history venous thromboembolism (family thrombophilia) because ethinyl estradiol has a procoagulant effect and epidemiological studies have shown an increased relative risk under COP. All COP increases the risk of thromboembolism, regardless of the pill generation. It was reported a higher frequency with COP third generation / second generation are therefore in a second-line COP;
– Arterial thromboembolic history and early arterial stroke in the family;
– There is a synergistic effect of other vascular risk factors, namely smoking, age, high blood pressure:
– Hypertension is a cons-indication for COP
– Against tobacco is a relative contraindication, absolute after 35 years,
– Dyslipidemia, aggravated by hormonal (increased triglycerides and LDL-cholesterol);
– Non-insulin dependent diabetes is an against-indication for hormonal contraceptives because of associated vascular field; Type 1 diabetes do not against-indicates the use of COP if it is perfectly balanced in a young woman without complications of his diabetes; However, alternatives are to offer after a time of evolution (macroprogestatifs for example);
– Estrogen-dependent neoplasia;
– Severe liver disease;
– Severe migraines with aura;
– Diseases thromboembolic risk and / or high arterial: systemic lupus, antiphospholipid, Behçet’s disease;
– Hemodialysis patients.
Box 1. Contraindications to the pill
The combination of two factors is a cons-indication for COP:
Age ≥ 35 years
Smoking greater than or equal to 15 cigarettes a day
History of migraine without aura
The presence of only one of these factors is a cons-indication for COP:
Migraine with aura or worsening under COP
Possibly complicated diabetes
Thrombophilia and venous or arterial accidents
The low-dose pills may be a solution:
The low-dose pills are started the first day of menstruation for the first cycle, with once daily for 21 days, 7 days a halt to the onset of withdrawal bleeding. The pills 15 mg (Melodia® and Minesse®) have 24 active pills because lower doses does not allow a judgment of more than four days, and there are four placebo tablets thus allowing continuous shooting limiting the risk of forgetting .
Efficiency is no longer ensured when forgotten exceed twelve hours so we must advise the use of condoms for seven days and the use of the morning after pill if a report was held in the five days preceding the oblivion.
Forgetting less than 12 hours has no effect, take the missed tablet as soon as possible and continue taking the treatment at the usual time, even if two CP must be taken the same day.
If you forget for more than 12 hours, take the missed tablet, continue treatment at the usual time and use condoms for the next week. If forgetfulness occurs in the last week, continue with the next pack (combined COP) and if a report took place within the last 5 days, use emergency contraception.
Choice of the pill:
The selection takes into account several factors:
– Social Security reimbursement: from 1 to 2 euros for pills reimbursed at least 6 euros for not reimbursed;
– Ground hyperestrogenism (mastodynia, heavy periods, pelvic pain, cyclical edema) rather choose a second generation pill;
– Ovarian disease and ovarian hyperandrogenism: Third generation pills (norgestimate, drospirenone and cyproterone acetate; no contraceptive AMM);
– Continuous pills for forgetful (and Melodia® Minesse®) or patch or ring.
To improve compliance, two other routes of administration of the COP are possible:
– The Evra® patch (outstanding, about 13 to 15 euros): 1 transdermal patch for a week, three weeks on and one week without patch to the occurrence of withdrawal bleeding. To begin the first day of menstruation.
If patch change oblivion, 48 hour security;
– The vaginal ring Nuvaring® (outstanding 13-15 euros) a vaginal ring set up the first day of menstruation for three weeks.
Cons-indicated in cases of vulvar gap and obstinate constipation.
The against-indications are strictly the same as for the classical pathway extradigestif despite the mode of administration. Recent data confirm on a thromboembolic risk with the patch of the same order as the third generation pills.
It is essential to look for drug interactions that could reduce the contraceptive effectiveness of treatment:
– Enzyme inducers;
– Protease inhibitors;
– Decreased gastrointestinal absorption: antibiotics (ampicillin, oxacillin, tetracycline).
The action is essentially peripheral (coagulation of the mucus, endometrium unsuitable for implantation, decreased tubal motility).
This treatment requires taking continuously at regular hours (maximum 3 hours late Microval®, Ogylline® and Milligynon®).
Microval® (levonorgestrel refunded by Social Security), Ogylline® (norgestrienone refunded by Social Security) and Milligynon® are effective after a month of use. Cerazette® (etonogestrel, not reimbursed by Social Security), third generation microprogestatif allows blocking ovulation and forgetting security noon, effective from the first month.
These low-dose contraceptives allow their use in case of land at cardiovascular risk and in lactation period.
Amenorrhea and cycle disorders are common reducing treatment compliance.
The microprogestatifs promote ovarian dystrophies and hyperestrogenism and therefore against-indicated in case of functional ovarian cysts and breast disease.
The history of ectopic pregnancy indicate the use-against
The main action is central, but also by antigonadotropic effect device.
This type of contraception is particularly indicated when there is an estrogen-dependent disease (mastopathy, endometriosis, fibroids, endometrial hyperplasia) or when there is an indication against-estrogen (lupus, thrombophilia, etc.)
However, it should be noted that there is no official approval for contraception, except the Orgamétril® whose clinical and metabolic tolerance is poor.
If cons-indication to estrogen, birth control can be ensured by chlormadinone acetate (Lutéran®) 10 mg: 2 tablets / day, 20 days / 27 starting for the first cycle in the fifth day of menstruation.
The cyproterone acetate 50 mg Androcur® may be offered in certain indications: endometriosis or polycystic ovary syndrome with clinical signs of hyperandrogenism, but the contraceptive effect is obtained in the second cycle; can be added to 2 mg of estradiol per day to improve clinical safety, in the absence of cons-indications or estradiol extradigestive way in women at risk of thrombosis:
– Androcur® 1 tablet per day 20 days / 27;
– Oromone® 2 mg: 1 tablet per day 20 days / 27 in association with Androcur®.
The nomegestrol acetate (1 Lutényl® cp / d 20 d / 27) and promegestone (j Surgestone® 0.5 20/27) can also be proposed.
Other contraceptives progrestatives:
Contraceptive implant Implanon (etonogestrel):
The mechanism of action is substantially equivalent to a device microprogestatif.
The system set up in the bicipital groove of the non-dominant arm allows almost absolute contraceptive security (0.1 pregnancies per 100 woman-years) for three years (two years for weighing over 80 kg).
Installation and removal techniques are simple, but nevertheless require training.
Clinical tolerance is imperfect because there is a partial blockage of ovulation and a relative hyperestrogenism in some cases causing mastodynia, cycle disorders and weight gain. We must inform the patient of the possibility of amenorrhea. it is a second-line contraception, which has a great interest in the defects of compliance and in case of mental handicap, not allowing good compliance. Enzyme inductors cancel out the effect and the large obesity which reduces the bioavailability.
Depo-Provera (medroxyprogesterone acetate):
More and more often used for the benefit of the implant. This type of progestin has the same side effects than oral progestogens: weight gain, acne, menstrual problems. The Pearl Index is 0.3. It is only rarely used in France.
They are identical to those of the COP.
Main side effects:
Cycle disorders are frequent in progestogen contraception, ranging from amenorrhea to spotting. We must tell the patient before the treatment initiation to improve the acceptability (70% of users have abnormal cycles).
Hyperestrogenism of signs can appear (mastodynia, cyclical edema, pelvic pain).
The microprogestatifs can encourage the growth of functional ovarian cysts and are therefore against-indicated in patients with a history and discouraged when anticoagulants with INR (International Normalized Ratio) high. Also they are against-indicated in case of estrogen-dependent breast disease and uterine pathology.
The history and the land at risk of ectopic pregnancy cons-indicate the use of microprogestatifs.
The current thromboembolic disease remains a cons-indication; the history of thromboembolic disease is not against-indicate the use of the implant, intrauterine device (IUD) and levonorgestrel microprogestatifs.
Chlormadinone acetate is used off-label (expert opinion).
Intrauterine device (IUD) Copper:
IUDs (or coils) are the second means of contraception used in France. They are carrying a tank with copper, which has a pro-inflammatory action and is toxic to gametes, preventing fertilization and implantation.
IUDs available are Gynelle® 375 Sertalia®, Nova T®, the UT 380, TT 380.
The Pearl Index is 0.8 to 2. In the multipara, IUD contraception is a first-line, effective prolonged, without vascular or metabolic risk.
Traditionally reserved for multipare (for fear of a pelvic infection tubal infertility origin in the nulligeste), it is now accepted that the risk of infection is not increased and no risk of tubal infertility has been demonstrated .
The installation is therefore permitted in nulliparous, second line. The AMM has Sertalia® for nulligeste. It must be recognized that the pose is often more difficult.
There is no interaction hormonal, metabolic, vascular or drug (except anti-inflammatory).
The excellent efficacy and long duration of action make a loose contraception.
Menorrhagia are consistent with a copper IUD.
The pain occurs in some cases, requiring either the withdrawal or the change of IUDs.
They are as follows:
– The ectopic pregnancy history;
– A history of pelvic inflammatory disease;
– The uterine malformations;
– Unexplained gynecological bleeding;
– Septic abortions and post-partum infections;
– Valvular heart disease;
– Wilson’s disease;
– Chronic corticosteroid therapy;
Holdover time is 5 years. The IUD expulsion rate is 1 to 2% higher among nulliparous. In pregnancy, the IUD should be removed to reduce the risk of chorioamnionitis and septic abortion. The removal of the IUD is followed by 20 to 30% of miscarriage.
The risk of infection is greatest in the three weeks following insertion, the risk of PID is increased by 3 to 7, it is necessary to control the laying technique and inform the patient of the risks and warning signs Perforations occur in 0.2 to 8.7 per 1,000 insertions, favored by the doctor’s inexperience, nulliparity, lesions weakening the womb as adenomyosis. The perforation may be delayed and requires the completion of a plain abdominal and laparoscopic excision.
The IUD is a MirénaR broadcasting a progestin (norgestrel), allowing endometrial atrophy which enhances efficiency and often avoids conventional menorrhagia in copper IUDs. It can treat the functional cycle disorders and in some cases adenomyosis. It can be left in place 5 years. The rate of infection and ectopic pregnancy appears to be lower than with the copper IUD, may be due to the anti-mucus action. However it may be responsible for spotting, acne or weight gain and a slightly higher proportion of functional cysts that copper IUDs.
The anti-infective activity is not demonstrated, spermicides do not have preventive action of sexually transmitted infections (STIs). The used agent is benzalkonium chloride
The risk of contraceptive failure is high (Pearl Index 20 per 100 woman-years). The spermicide should be set up before the report, kept for several hours, and must be used regardless of the point in the cycle.
However, this can be a backup solution in a stable relationship, if the reports are predictable. It can be recommended postpartum and is advised against in particular situations-indicating both hormonal contraception and mechanics.
Combined with spermicides, it is more effective but little prescribed in France (Table II).
The Pearl Index is average (14 pregnancies per 100 woman-years) and failures come from misuse. The laying technique must be explained.
In case of allergy to latex, there are condoms with polyurethane.
The major interest is in preventing STIs and should be recommended in combination with the pill in young women who do not have a fixed partner.
The fats are quickly losing any efficiency latex!
Little used in France, it has several drawbacks: expensive, bulky, noisy.
It concerns contraception used after unprotected sex.
The Norlevo® or Vikela® (norgestrel), “morning after” pill, 1CP administered within 72 hours after intercourse at risk (95% effective if used within 24 hours to 58% between 48 and 72 hours.). It is free for minors and for sale without prescription in pharmacies. It should always be prescribed simultaneously with the pill. We must prevent the possibility of bleeding after taking. A pregnancy test should be applied in the absence of rules on the scheduled date.
An IUD can be inserted for emergency contraception within 5 days after the report, provided not to be in a situation at risk of STIs. Efficiency is very good (failure rate of 0.1 to 0.2%).
ASSESSMENT AND MONITORING:
Before prescribing contraception, you must:
– Track personal or family history of thrombophilia if one considers a COP; a hemostasis tests is specified that in case of thrombosis family pathology;
– Detect infectious pelvic or history of ectopic pregnancy if one considers the IUD insertion;
– Measuring blood pressure and weight: hypertension-cons indicates the COP;
– A track-m astopathie against benign or malignant showing microprogestatifs;
– Detect a migraine with aura common ground in this population-but showing against COPs;
– Prescribe a metabolic balance (glucose, triglycerides and cholesterol) before prescribing COP while significant personal or family history are noted;
– Take advantage of the consultation to achieve the Pap smear test, to be renewed every two years.
Under hormonal, metabolic balance is to prescribe three to six months after the start of the COP. If normality, it is renewable every 5 years.
The tolerance of contraception is evaluated on the absence of signs of hyperestrogenism.
We must assess compliance and re-explain what to do if you forget.
After IUD insertion, a check is required 1-3 months to assess tolerance and annually.
CHOICE OF BIRTH:
The choice must be that of the patient in order to obtain the best possible adherence.
Teen, which will be received without his parents, the choice of first-line condom use is associated with the COP (contraceptive improves security and enables the prevention of STIs in this population at risk).
In first intention, in women without medical history, birth control is the first line COP, especially among nulliparous, and goes towards a second-generation pill because of thromboembolic risk somewhat lower than with pills third generation.
In women over 35, the COP may be continued to quarantine if no other cardiovascular risk factor exists.
If the IUD insertion or progestin contraception is indicated.
In post-partum, as first-line and not breastfeeding a microprogestative contraception is indicated. The COP is against-indicated in the immediate postpartum and for 3 weeks. An IUD can be inserted within 48 hours after birth or after 4 weeks. Breastfeeding is a reliable means of contraception if it is exclusive.
In women with cardiovascular risk (outside the valve disease), IUD contraception is first line.
In obese women (body mass index greater than 30), the COP is a vascular risk factor. We must therefore take into account other risk factors. Furthermore the efficiency of the COP and progestin can be reduced.
At the dyslipémique woman, IUD is recommended.
Progestogen contraceptives may be proposed under cover of a regular monitoring of the lipid profile.
Family history of breast cancer (BRCA mutation off 1 and 2) are not an against-indication for COP.
In women with diabetes, Progestin contraception is a good alternative. Second intention COP may be shown provided that there is no vascular complications. The IUD can be considered if the diabetes is well balanced.
In case of systemic lupus erythematosus or antiphospholipid syndrome, only pregnane progestin or microprogestatifs are allowed. The pregnane progestin are well tolerated but off-label. The copper IUD is cons-indicated because corticosteroids decrease the efficiency and increase the risk of infection low noise.
Dysimmune other pathologies do not imply any special risk of infection outside the IUD and failure, especially copper.
In renal insufficient wife, COP is against-indicated; in the dialyzed and grafted, IUDs and COP are against inappropriate. The preganes the microprogestatifs and levonorgestrel IUD may be prescribed.
Key points are:
– Leave the choice to the patient;
– Not to delay the initiation of contraception for additional medical examinations; Progestin contraception lets wait for the results;
– Inform in advance or prescribe emergency contraception and lines to take in case of forgetfulness;
– Review contraception after 35-50 years (vascular risk, metabolic and cancer);
– Stop the COP during prolonged immobilization;
– Vomiting and severe diarrhea should be seen as an oversight COP or progestin contraception;
– The IUD is not cons-indicated in nulliparous, nulligeste.