Contraception: Initiation, Choice of Method and Follow-Up

Essentials

• The division of tasks between a physician and a nurse may vary and is agreed on locally. In Finland, a public health nurse may provide a young woman with the initial set of contraceptive pills under the supervision of a physician.
• In conventional use, the long-acting reversible methods, such as implants and IUDs, are more effective than the short-acting ones, since they are not associated with memory lapses.

Starting contraception for a young woman Interventions for Preventing Unintended Pregnancies Among Adolescents, Interventions to Improve Contraception Use

Starting contraception for an adult

• Aspects of history as above
• History of pregnancies (toxaemia, hepatic cholestatis of pregnancy, ectopic pregnancies, caesarean sections)
• Examine the gynaecological status, including examination of the breasts, and measure blood pressure.
• Take a Pap smear (if it has not been taken in 5 years in mass screening) and screen for infections as needed.

Matters to be taken into account when selecting contraception method

• Age
• Common state of health (chronic diseases Contraception in Patients with Systemic Diseases, overweight)
• Smoking
• Use of alcohol or other drugs; regularity of lifestyle
• Parity-nulliparity
• Duration and amount of menstrual bleeding, pains during menses
• Required duration of contraception, plans for future pregnancies
• Required effectiveness of contraception
• Breast-feeding (see tableT1), time since last delivery
  • Progestogen-only contraception (pills, implants or injections) may be started immediately postpartum.
  • A non-lactating woman may start combined oral contraceptives 3 months after delivery and a woman applying exclusive breastfeeding 6 months after delivery.
• The relationship of the couple (frequency of intercourse, varying partners or a stable relationship?)
• The woman's motivation and her own preferences concerning the contraception method
• Previously used contraception methods and their suitability
• Always consider the relationship between the need and risks of contraception.

Suitability of the contraceptive methods for different situations

• For hormonal contraception, see also Hormonal Contraception.
• In typical settings, the long-acting reversible methods, such as implants and IUDs, are more effective than the short-acting ones, since they are not associated with memory lapses or other user errors.
• The advantages of the combined pills Hormonal Contraception make them the primary method of contraception for women,
  • who are young (no lower age limit) and nulliparous
  • whose menses are either irregular, of long duration, profuse or painful
  • who have problems associated with the menstrual cycle
  • who suffer from acne, greasy hair or skin, or hirsutism
  • who are inclined to develop ovarian cysts.
• Hormone-releasing vaginal rings and skin patches
  • have the same effect as combined pills
  • are well suited for a woman who does not want or has difficulties in remembering daily pill-taking.
• Progestogen-only pills (minipills)Hormonal Contraception can be considered when combination pills are contraindicated. These can be used e.g. by women who
  • have a high blood pressure or blood pressure that increases during use of combination pills
  • have classic migraine with aura
  • are above 35 years of age and smoking (a combination containing natural oestrogen is an alternative)
  • breast-feed.
• Contraceptive implantsHormonal Contraception are suitable for women of any age,
  • who need contraception for a long period
  • who do not have contraindications for progestogens.
• A hormone-releasing intrauterine device Hormonal Contraception is a good alternative for a woman who wants an IUD, but
  • has profuse menstrual bleeding
  • has bleeding that increases with a copper IUD.
  • A hormone-releasing intrauterine device is a suitable method also for young nulliparous women's first contraception.
  • Three different hormone-releasing IUDs are available in the market.
• A copper IUD Intrauterine Device is a safe and effective method for a woman with a stable relationship.
  • A copper IUD is a suitable method also for young nulliparous women's first contraception.
• The condom Other Methods of Contraception is the only method that completely prevents infection. It should therefore always be used in new and casual relationships, even if another contraception method is used simultaneously.

Follow-up

• At every follow-up visit every one or two years, regardless of the method used
  • discuss with the woman about her life situation and habits (e.g. smoking Smoking Cessation, overweight, alcohol/drugs), satisfaction with the method, and possible risks for sexual health
  • measure the blood pressure and evaluate the possible contraindications that may have emerged to the method in use.

• Gynaecological examination every two or three years on the average; for an IUD user, if possible, once between IUD changes and always if there are symptoms
• Breasts are examined as needed (the patient complains of a symptom or has found a lump).
• Consider taking a Pap smear every 5 years if the woman has not participated in mass screenings.
• It is advisable to keep the threshold for testing for infections (especially chlamydia) quite low.
• A copper IUD meant for 5 years may be used for as long as 10 years, if no side-effects have occurred. If the woman is 40 years of age or older when an IUD containing ≥ 300 mm² of copper is inserted, the IUD may be used until a year has passed after the last menstrual cycle.
• A hormone-releasing IUD meant for 5 years may be used for as long as 7 years.