Contraceptive methods are used to prevent pregnancy and sexually transmitted infections (STIs).
Contraception allows women/couples to explore plan on childbearing and family planning.
Hormonal contraception is a method with high rate of effectiveness and ease of administration. It is the widely used method of reversible contraception.
It does not protect against STIs/HIV.

Patient Education

Patient Education Regarding Combined Oral Contraceptives (COCs)

  • COC may be used from menarche to menopause
  • If COC is started initially between days 1-5 of the menstrual cycle, there is no need for additional contraception
    • If started beyond this period, pregnancy should be excluded and additional contraception for 7 days is advised
  • Ovulation is effectively inhibited after COC use for 7 consecutive days
  • COC should be taken every day, at around the same time, for 21 consecutive days followed by 7 steroid-free days
    • Women using a 21-day preparation should be cautioned not to exceed the 7-day pill-free interval
  • If COC pill is taken >24 hours after the scheduled time, it is considered missed
    • For missed dose, the pill should be taken as soon as it is remembered and subsequent pills taken at the usual time
    • Delaying the start of COC by >24 hours or missing one or more doses of COC during the 1st week may decrease protective contraception
    • Use back-up contraception with missed doses in the 2nd or 3rd week of hormone use until the COC has been used for 7 consecutive days 
    • Eliminate hormone-free interval when 1 or more days of COCs are missed in the 3rd week to maintain contraception
  • Contraception is not needed in the 1st 3 weeks after childbirth and it is not recommended because there is increased risk of venous thromboembolism (VTE)
  • Non-breastfeeding women should start COC 21 days postpartum
    • If started beyond this, additional contraception is needed for 7 days
  • Women should be informed on symptoms which would prompt immediate medical consultation (eg warning signs of VTE, headache, eye problems, jaundice, abdominal pain)
  • Follow-up visit 3 months after the 1st prescription of COC to assess blood pressure (BP), medical problems, and give further instructions
  • Fertility is restored within 1-2 weeks after stopping the combined OC
    • Post-pill amenorrhea is more common in women with history of very irregular menstruation but rarely persists up to 6 months

Patient Education Regarding Transdermal Patch

  • Patch is applied to clean, dry, hair-free skin on the buttock, abdomen, upper outer arm, or upper torso
    • Avoid placing the patch on exactly the same site for 2 consecutive weeks
    • Avoid irritated or broken skin, breasts or skin in contact with tight clothing or cosmetics
    • Smooth edges down upon application
    • Women should check the patch everyday, making sure all edges remain closely attached to the skin
    • Location of patch should not be changed in mid-week
  • After ruling out pregnancy, patch can be applied anytime with backup contraception for 7 days
  • If started on 1st day of menstrual cycle, no backup contraception needed
  • New patch is applied every week for 3 weeks, followed by 1 patch-free week
  • If patch change is delayed by up to 48 hours in the middle of the cycle, there is no need for additional contraception
  • If the patch-free interval is >9 days, a new patch should be applied and backup contraception for 7 days should be used
  • Early detachment of the patch and delayed removal or application are considered missed or incorrect use of contraception
  • Avoid adhesive bandages, tattoos or decals on top of the patch which may affect absorption of hormones
  • Same return of fertility as COC after discontinuing the method

Patient Education Regarding Vaginal Contraceptive Ring

  • Ring is inserted into the vagina within the first 5 days of menstruation and left in place for 3 weeks (1 cycle)
    • A cycle of continuous ring use should be followed by a 1-week ring-free interval to allow withdrawal bleeding
    • If ring is used >3 weeks, the same ring may afford protection from unplanned pregnancy for up to 35 days only
  • Vaginal ring is not recommended to be removed during intercourse
    • Women who want to remove it may do so without any backup method as long as the ring is put back in place within 3 hours
  • Expulsion or delayed removal or insertion of the vaginal contraceptive ring is considered missed or incorrect use of contraception; however, when a vaginal ring falls out, it may be placed back in within 3 hours after washing the ring with water
  • Fertility after discontinuation is immediate and excellent
    • Average return to ovulation is 11 days

Patient Education Regarding Progestin-only Pills (POPs)

  • Initial pill may be taken within day 1-5 of the menstrual cycle and then taken once daily continuously with no hormone-free days
    • No additional contraception needed
  • Initial pill may also be taken at any other time, provided that pregnancy has already been ruled out
    • Additional contraception should be used for the 1st 48 hours
  • In postpartum women, pill can be started from day 21 with no additional contraception
    • If started after day 21, additional contraception is needed for the 1st 48 hours
  • Pills must be taken at the same time each day (at least within 3 hours) for traditional POPs
  • Efficacy is reduced if dose is delayed by >3 hours when using traditional POPs
    • Back-up contraceptive method is recommended for 48 hours if a woman is >3 hours late taking the dose
    • Back-up method may also be recommended each months at mid-cycle
  • Desogestrel, a novel POP, has 12-hours pill intake window
    • Delay in intake of Desogestrel 75-mcg tablet up to 12 hours does not reduce contraceptive efficacy
  • Fertility returns rapidly to baseline after discontinuation
  • If patient develops new symptoms of migraine, stroke or heart disease while on POPs, discontinue use
    • Note, however, that no causal association has been linked between POP use and cardiovascular (CV) diseases [eg stroke or myocardial infarction (MI)]

Patient Education Regarding Contraceptive Implants

  • Depending on formulation may consist of 1-6 matchstick-sized rods containing the hormone and is inserted into the inner aspect of the upper arm
  • Implant is inserted during the 1st 5-7 days of the cycle (depending on product used)
    • If inserted after this, additional contraception is required for the 1st 7 days
  • May be inserted immediately postpartum regardless of breastfeeding status 
  • Fertility is restored rapidly and completely after 3-6 weeks of removal

Patient Education Regarding Injectable Progestins

  • Injectable is given within the 1st 5-7 days of menstrual cycle every 8-12 weeks (depending on product used) to provide contraception for up to 2-3 months
    • Do not massage area where shot was given for a few hours because it may reduce efficacy
  • Women should be counseled about the likelihood of menstrual disturbance and the potential for a delay in return to full fertility
    • May take up to 10 months for depot medroxyprogesterone acetate (DMPA)  and 6 months for Norethisterone enanthate

Patient Education Regarding IUD

  • It is inserted in the uterus during the 1st 7 days of menstrual cycle (can be inserted at any time if not pregnant) and is effective for up to 5 years
  • May be inserted within 48 hours after delivery, >6 weeks after postpartum and immediately post abortion except for septic abortion 
    • A higher continuation rate and risk of expulsion are associated with immediate insertion postpartum or post-cesarean section
  • Routine antibiotic prophylaxis prior to insertion is not indicated 
  • Women should be advised of the risk of pelvic inflammatory disease in the 1st 20 days following insertion  
  • Women at increased risk of STIs should be tested before IUD insertion, though it is not necessary to delay insertion pending test results or to remove the IUD during treatment for a positive test result 
  • Return of fertility is rapid and complete after removal
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Pearl Toh, 16 Apr 2018
Oral micronized progesterone (OMP) may provide relief for perimenopausal women who had hot flashes and night sweats, according to a study presented at the ENDO 2018 Annual Meeting.
Tristan Manalac, 23 Dec 2017
Contemporary hormonal contraceptives appear to increase the risk of breast cancer, particularly in those with long durations of exposure, a recent study from Denmark has shown.
Pearl Toh, 24 Nov 2017
Intrauterine device (IUD), an established contraception method, may also offer protection against cervical cancer, suggests a meta-analysis.