BNF for Children 2011-2012

406 7.3.3 Spermicidal contraceptives BNFC 2011–20127 Obstetrics, gynaecology, and urinary-tract disordersSide-effects Initially, changes in the pattern andduration of menstrual bleeding (spotting or prolongedbleeding) are common; endometrial disorders should beruled out before insertion and the patient should be fullycounselled (and provided with a patient informationleaflet). Improvement in progestogenic side-effects,such as mastalgia and in the bleeding pattern usuallyoccurs a few months after insertion and bleeding mayoften become very light or absent. Functional ovariancysts (usually asymptomatic) can occur and usuallyresolve spontaneously (ultrasound monitoring recommended).INTRA-UTERINE PROGESTOGEN-ONLY SYSTEMCautions see notes above; history of depression;advanced uterine atrophy; systemic lupus erythematosuswith positive (or unknown) antiphospholipidantibodies; not suitable for emergency contraception;interactions: see notes above and Appendix 1 (progestogens)Contra-indications see notes aboveHepatic impairment see Oral Progestogen-onlyContraceptives, section 7.3.2.1Pregnancy avoid; if pregnancy occurs remove systemBreast-feeding progestogen-only contraceptives donot affect lactationSide-effects see notes above; also abdominal pain,expulsion; peripheral oedema; depression (sometimessevere), nervousness; salpingitis, and pelvicinflammatory disease; pelvic pain, back pain; rarelyuterine perforation, hirsutism, hair loss, pruritus,migraine, rashLicensed use not licensed for use in women under18 yearsIndication and doseSee under preparationMirena c (Bayer Schering) AIntra-uterine system, T-shaped plastic frame(impregnated with barium sulphate and with threadsattached to base) with polydimethylsiloxane reservoirreleasing levonorgestrel 20 micrograms/24 hours, netprice = £85.66. Counselling, see patient informationleafletDoseContraception and menorrhagiaInsert into uterine cavity within 7 days of onset ofmenstruation, or any time if replacement, or any time ifreasonably certain the woman is not pregnant and thereis no risk of conception (additional precautions (e.g.barrier methods) necessary for next 7 days), or immediatelyafter first-trimester termination by curettage;postpartum insertions should be delayed until at least 4weeks after delivery; effective for 5 yearsNote When system is removed (and not immediatelyreplaced) and pregnancy is not desired, remove duringfirst few days of menstruation, otherwise additionalcontraceptive measures required for at least 7 daysbefore removalPrevention of endometrial hyperplasia during oestrogenreplacement therapyInsert during last days of menstruation or withdrawalbleeding or anytime if amenorrhoeic; effective for 4 years7.3.3 SpermicidalcontraceptivesSpermicidal contraceptives are useful additional safeguardsbut do not give adequate protection if used aloneunless fertility is already significantly diminished. Theyhave two components: a spermicide and a vehicle whichitself may have some inhibiting effect on sperm activity.They are suitable for use with barrier methods, such asdiaphragms or caps; however, spermicidal contraceptivesare not generally recommended for use withcondoms, as there is no evidence of any additionalprotection compared with non-spermicidal lubricants.Spermicidal contraceptives are not suitable for use inthose with or at high risk of sexually transmitted infections(including HIV); high frequency use of the spermicidenonoxinol ‘9’ has been associated with genitallesions, which may increase the risk of acquiring theseinfections.Products such as petroleum jelly (Vaseline c ), babyoil and oil-based vaginal and rectal preparations arelikely to damage condoms and contraceptivediaphragms made from latex rubber, and mayrender them less effective as a barrier method ofcontraception and as a protection from sexuallytransmitted infections (including HIV).Gygel c (Marlborough)Gel, nonoxinol ‘9’ 2%, net price 30 g = £4.25Excipients include hydroxybenzoates (parabens), propylene glycol,sorbic acidCondoms No evidence of harm to latex condoms and diaphragmsPregnancy toxicity in animal studiesBreast-feeding present in milk in animal studies7.3.4 Contraceptive devicesIntra-uterine devicesThe intra-uterine device (IUD) is a suitable contraceptivefor women of all ages irrespective of parity; however,it is less appropriate for those with an increasedrisk of pelvic inflammatory disease e.g. women under 25years (see below). The most effective intra-uterinedevices have at least 380 mm 2 of copper and havebanded copper on the arms.Smaller devices have been introduced to minimise sideeffects;these consist of a plastic carrier wound withcopper wire or fitted with copper bands; some also havea central core of silver to prevent fragmentation of thecopper.A frameless, copper-bearing intra-uterine device(GyneFix c ) is also available. It consists of a knotted,polypropylene thread with 6 copper sleeves; the deviceis anchored in the uterus by inserting the knot into theuterine fundus. The intra-uterine devices Multiload cCu250 and Multiload c Cu250 Short (Organon) havebeen discontinued, but some women may have thedevices in place until 2011.The timing and technique of fitting an intra-uterinedevice are critical for its subsequent performance. Thehealthcare professional inserting (or removing) thedevice should be fully trained in the technique and