7.3.2 Progestogen-only contraceptives

First Choice:
norethisterone  
Second Choice:
desogestrel  

Norethisterone: Noriday®

Desogestrel: Cerazette®, Cerelle®, Nacrez®, Aizea® and Zelleta® are interchangeable

Formulations/Dose
  • norethisterone 350micrograms tablets (3x28–tab pack).
  • desogestrel 75micrograms tablets (3x28–tab pack).
Prescribing Notes
  • Progestogen–only pills (POPs) are associated with irregular bleeding in up to 40% of users. Bleeding patterns do not tend to improve with time and are not likely to be any different with a different progestogen.
  • There is no evidence for any clinical advantage of any one brand of POP.  In line with NHS Lothain policy on branded generic prescribing, POP should be prescribed by their generic drug name, not the brand name.
  • The traditional POP is suitable for all women over the ages of 40 years.
  • Desogestrel is more expensive (than norethisterone) but has been shown to inhibit ovulation to a substantially greater extent than other POPs. It should be reserved for women who cannot tolerate oestrogen containing contraceptives or in whom those preparations are contraindicated. It may also be recommended for women with a history of ectopic pregnancy who take a POP.
  • Desogestrel is also recommended for less compliant women as they are still protected up to 12 hours after missing a pill, whereas only for 3 hours with other POPs.
  • It is no longer recommended that women who weigh over 70kg are prescribed two progestogen-only pills a day.
  • The efficacy of the POP will be affected by enzyme-inducing drugs and an alternative contraceptive method should be sought.

Long-acting progestogen-only methods
(a) injectable progestogen-only methods

First Choice:
medroxyprogesterone acetate - intramuscular (Depo-Provera®)
ormedroxyprogesterone acetate - subcutaneous (Sayana® Press)
Formulations/Dose
  • Depo–Provera® injection (medroxyprogesterone acetate 150mg/mL aqueous suspension): by deep intramuscular injection, 150mg within first 5 days of cycle or within first 5 days after parturition (delay until 6 weeks after parturition if breast–feeding); for long–term contraception, repeated every 12 weeks (if interval greater than 12 weeks and 5 days, exclude pregnancy before next injection and advise patient to use additional contraceptive measures (e.g. barrier) for 14 days after the injection).
  • Sayana® Press injection (medroxyprogesterone acetate 104mg/0.65mL suspension for injection): by subcutaneous injection, 104mg within first 5 days of cycle or within first 5 days after parturition (delay until 6 weeks after parturition if breast-feeding); for long-term contraception repeat every 13 weeks (+/- 1 week) if interval greater than 14 weeks exclude pregnancy before next injection, advise patient to use additional contraceptive measures (e.g. barrier) for 7 days after the injection).
Prescribing Notes
  • Medroxyprogesterone acetate is available as two formulations to be given via different routes, Depo–Provera® via intramuscular injection and Sayana® Press via subcutaneous injection. Choice of preparation will depend on individual patient factors and service provision.
  • Medroxyprogesterone acetate can cause menstrual dysfunction and weight gain. By the end of the first year of use, 80% of women will have become amenorrhoeic or have scanty infrequent periods.
  • When medroxyprogesterone acetate is stopped ovarian activity can take up to a year to recover.
  • Medroxyprogesterone acetate is associated with hypoestrogenism and amenorrhoea. Bone mineral density decreases slightly during the first two years of method use. There is no evidence for an increased risk of osteoporosis or fracture either during use or in later life.
  • Medroxyprogesterone acetate injection is only indicated in adolescents (12-18 years), when other contraceptive methods are considered unsuitable or unacceptable, due to unknown long-term effects of bone loss associated with medroxyprogesterone acetate injection during the critical period of bone accretion. Young women often find compliance with condoms or oral contraceptives difficult.

  • Medroxyprogesterone acetate use should be reviewed after 2 years in women of all ages. 

  • The effectiveness of medroxyprogesterone acetate is unaffected by enzyme-inducing drugs and the inter-injection interval need not be altered.
(b) contraceptive implants

First Choice:
etonogestrel (Nexplanon®)
Formulations/Dose
  • Nexplanon® implant (etonogestrel 68mg in a radiopaque, non-biodegradable, progestogen-only flexible implant). Consult product literature for insertion and removal instructions.
Prescribing Notes
  • Nexplanon® insertion and removal requires specialist training.
  • Nexplanon® is a low dose long–acting progestogen which suppresses ovulation in all women. Contraceptive effect lasts for 3 years.
  • No more than 20% of women will experience amenorrhoea; the rest may have unpredictable and sometimes prolonged bleeding. This point should be covered carefully during counselling. The COC can be given to regulate bleeding.
  • Nexplanon ® is more cost effective than either the combined pill or condoms even if used for only one year. 
  • Nexplanon ® is affected by concomitant use of enzyme-inducing drugs. An alternative contraceptive method should be sought.
(c) hormone releasing intra-uterine systems

First Choice:
Mirena ®
Second Choice:
Jaydess ®
Formulations/Dose
  • Mirena® intra–uterine device releasing levonorgestrel 20micrograms/24hours: insert into uterine cavity within 7 days of onset of menstruation (anytime if replacement); effective for 5 years.
  • Jaydess® intra–uterine device releasing levonorgestrel 13.5micrograms/24hours: insert into uterine cavity within 7 days of onset of menstruation (anytime if replacement); effective for 3 years.
Prescribing Notes
  • Jaydess® is approved for use in younger women or nulliparous women who cannot be fitted with a Mirena® IUS, or women who previously discontinued Mirena® IUS due to side effects but want another choice of LARC.
  • These are highly effective methods of contraception. Many women experience quite frequent and prolonged spotting for the first 3–6 months; thereafter amenorrhoea is common. Patients should be counselled accordingly.
  • Systemic absorption may cause side-effects e.g. acne or greasy skin.
  • Mirena® is also licensed for heavy menstrual bleeding and hormone replacement therapy.