BNF for Children 2011-2012

BNFC 2011–2012 7.3.2 Progestogen-only contraceptives 405PARENTERAL PROGESTOGEN-ONLYCONTRACEPTIVESCautions see notes above and under preparations;possible risk of breast cancer, see oral progestogenonlycontraceptives (section 7.3.2.1); history duringpregnancy of pruritus or of deterioration of otosclerosis,disturbances of lipid metabolism; interactions:see notes above and Appendix 1 (progestogens)Counselling Full counselling backed by patient informationleaflet required before administrationContra-indications see notes above; history of breastcancer but can be used after 5 years if no evidence ofdisease and non-hormonal contraceptive methodsunacceptableHepatic impairment see Oral Progestogen-onlyContraceptives, section 7.3.2.1Pregnancy not known to be harmful; for Implanon cor Nexplanon c if pregnancy occurs remove implantBreast-feeding progestogen-only contraceptives donot affect lactation; see also notes aboveSide-effects see notes above; injection-site reactionsCervical cancer Use of injectable progestogen-only contraceptivesis associated with a small increased risk of cervicalcancer; this increased risk may be similar to that seen withcombined oral contraceptives, see p. 399. The risk of cervicalcancer with other progestogen-only contraceptives is not yetknown.Licensed use consult product literature for thelicensing status of individual preparationsIndication and doseContraception see also notes above and underpreparations (roles vary according to preparation)For dose see under preparationsInjectable preparationsDepo-Provera c (Pfizer) AInjection (aqueous suspension), medroxyprogesteroneacetate 150 mg/mL, net price 1-mL prefilledsyringe = £6.01, 1-mL vial = £6.01. Counselling, seepatient information leafletDose. By deep intramuscular injection150 mg within first 5 days of cycle or within first 5 daysafter parturition (delay until 6 weeks after parturition ifbreast-feeding); for long-term contraception, repeatedevery 12 weeks (if interval greater than 12 weeks and 5days, rule out pregnancy before next injection and advisepatient to use additional contraceptive measures (e.g.barrier) for 14 days after the injection)Noristerat c (Bayer Schering) AInjection (oily), norethisterone enantate 200 mg/mL,net price 1-mL amp = £3.38. Counselling, see patientinformation leafletDose. By deep intramuscular injectionGiven very slowly into gluteal muscle, short-termcontraception, 200 mg within first 5 days of cycle orimmediately after parturition (duration 8 weeks); may berepeated once after 8 weeks (withhold breast-feeding forneonates with severe or persistent jaundice requiringmedical treatment)ImplantsNexplanon c (Organon) TAImplant, containing etonogestrel 68 mg in radiopaqueflexible rod, net price = £79.46. Counselling, seepatient information leafletDose. By subdermal implantationNo hormonal contraceptive use in previous month, 1implant inserted during first 5 days of cycle; postpartum,1 implant inserted 21–28 days after delivery; in breastfeedingmothers, 1 implant inserted after 28 days postpartum;abortion or miscarriage in the second trimester,1 implant inserted 21–28 days after abortion or miscarriage;abortion or miscarriage in first trimester, 1 implantinserted within 5 days; changing from other hormonalcontraceptive, consult product literature; remove implantwithin 3 years of insertion7.3.2.3 Intra-uterine progestogen-onlydeviceThe progestogen-only intra-uterine system, Mirena c ,releases levonorgestrel directly into the uterine cavity.It is used as a contraceptive, for the treatment ofprimary menorrhagia and for the prevention of endometrialhyperplasia during oestrogen replacementtherapy. This may therefore be a contraceptive methodof choice for women who have excessively heavymenses.The effects of the progestogen-only intra-uterine systemare mainly local and hormonal including prevention ofendometrial proliferation, thickening of cervical mucus,and suppression of ovulation in some women (in somecycles). In addition to the progestogenic activity, theintra-uterine system itself may contribute slightly to thecontraceptive effect. Return of fertility after removal israpid and appears to be complete.Advantages of the progestogen-only intra-uterine systemover copper intra-uterine devices are that theremay be an improvement in any dysmenorrhoea and areduction in blood loss; there is also evidence that thefrequency of pelvic inflammatory disease may bereduced (particularly in the youngest age groups whoare most at risk).In primary menorrhagia, menstrual bleeding is reducedsignificantly within 3–6 months of inserting the progestogen-onlyintra-uterine system, probably because itprevents endometrial proliferation. Another treatmentshould be considered if menorrhagia does not improvewithin this time (section 6.4.1.2).Cautions and contra-indications Generally thecautions and contra-indications for the progestogenonlyintra-uterine system are as for standard intrauterinedevices (section 7.3.4). Although the progestogen-onlyintra-uterine system produces little systemicprogestogenic activity, it is usually avoided for 5 yearsafter any evidence of breast cancer. However, the systemcan be considered for a woman in long-term remissionfrom breast cancer who has menorrhagia andrequires effective contraception. Since levonorgestrelis released close to the site of the main contraceptiveaction (on cervical mucus and endometrium) progestogenicside-effects and interactions are less likely; inparticular, enzyme-inducing drugs are unlikely to significantlyreduce the contraceptive effect of the progestogen-onlyintra-uterine system and additional contraceptiveprecautions are not required.7 Obstetrics, gynaecology, and urinary-tract disorders