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For the young: Effective and convenient alternatives to the pill

For women with children: Alternative to sterilisation

Many women find themselves in need of a contraceptive that they can use safely and reliably over a long time without the worry of an unplanned and unwanted pregnancy at that particular time. Those who have completed their family and those who are absolutely certain that they do not and will not want children could consider sterilisation. This is permanent and in many cases irreversible. For the reminder, the most effective option is a long acting reversible contraceptive that is ideally user-independent. This means, it is applied, it works and the user does not need to remember to do or take anything. She does this in the knowledge that when the time of her choosing to try for a baby comes, the contraceptive can be removed and her fertility is back. We are therefore discussing available long acting reversible contraceptives, how they work, effectiveness, and potential side-effects. While we are at it, we will try to debunk a few myths about some of them.

One of the main weaknesses of short acting contraceptives that are user dependent is that the failure rate is rather high meaning there are a lot of unwanted pregnancies despite the use of the contraceptive. When used properly and in ideal circumstances, the pill is highly reliable with a very low failure rate. However, it requires a great deal of discipline, following the instructions faithfully. Not everybody is able to do that. This is why, even though the quoted failure rate of the combined pill in the first year of ideal use is less than 1%, the failure rate typically seen is close to 4%. For the ‘mini-pill’ (Pregestogen only Pill), typical use failure rate observed is 5%.

Intrauterine Copper device (IUCD or ‘coil’)

The term ‘coil’ is an unfortunate relic of history tat refuses to go away. In the early years of contraceptive devices inserted inside the uterus, the device was coil-shaped. This has long since disappeared from use. The name has stuck.

Copper devices are so –called because they contain copper on their ‘arms’ and the main stem. They work by inhibiting fertilization and implantation. A copper contraceptive device is highly effective with a failure rate of less than 2% after 5 years of use. Modern copper devices are effective for 10 years. However, it can be removed at any time when the user so wishes and fertility returns within days of removal of the device. Removal involves just tagging at the soft threads which are left protruding through the cervix. The user is never aware of the presence of the device in her womb.

Debunking myths about the ‘coil’ intrauterine contraceptive device (IUCD)

Ø The IUCD (‘coil’) does not increase the risk of ectopic pregnancy and in fact rates of ectopic pregnancy are lower among users compared to those not using any contraceptive.

Ø The IUCD does not increase risk of pelvic infection

Ø The IUCD can be used at any age for women in their reproductive years, up to the menopause.

Ø The IUCD can be used in girls and women who have not had children provided they are sexually active

Ø The IUCD can be used by women who have had caesarean section or who have never had a vaginal delivery

Ø The IUCD can be inserted at any time during the menstrual cycle provided it has been confirmed that the woman is not pregnant

Ø The IUCD does not need to be checked annually. The first check usually six weeks after insertion or after the first period post-insertion is usually sufficient.

Ø The IUCD does not cause infertility

Ø The IUCD does not cause weight gain

Problems associated with the IUCD

The intrauterine contraceptive device is largely problem-free. It is also truly user-independent meaning that, once inserted, it is effective immediately and the user does not need to remember to do anything to maintain effectiveness. The only active intervention she will be required to do is initiating action for removal when she no longer needs it or if it is causing problems. The only issue that has been associated with the intrauterine device in a small minority of users is menstrual problems such as prolonged periods or inter-menstrual spotting. Even this tends to settle after a few months.

Mirena (Levonorgestrel releasing intrauterine device)

Many women will be aware of the Mirena contraceptive device that has been around for several years now. Even though there is a tendency to lump it together with other intrauterine contraceptive devices, it works in a completely different way. Its descriptive name is a Levonorgestrel releasing intrauterine device

The Mirena device consists of a small reservoir of the progestogen hormone called Levonorgestrel. When the device is sitting within the uterine cavity it releases the hormone steadily and in minute amounts. It is this hormone’s effect on the lining of the womb (endometrium) that is responsible for the contraceptive effect. The reservoir lasts five years.

Mirena presence in the uterus inhibits the lining of the womb and thereby prevents impMirena in the uteruslantation. The cervical mucus also becomes thick and through this effect, sperm penetration is inhibited to a significant degree. In the majority of users, ovulation is maintained. The estrogen hormone levels also remain within normal range. Mirena’s contraceptive effect is established within a week of insertion. It cannot therefore be used for emergency contraception. Once removed, the contraceptive effect disappears within days. Mirena is a very effective contraceptive and its failure rate is even lower than that of female sterilisation.

One of the ‘bonus effects’ of Mirena is the regulation of menstruation for users. Most users find that the menstrual loss is sharply reduced once Mirena has been in place for 6 months or more. In many cases, periods stop altogether. It is therefore an ideal choice for women who want an effective long term contraceptives and are also suffering from heavy and/or prolonged periods. Mirena will be effective for both. There is a tendency for bleeding to be erratic in the first 3 to 6 months after insertion.

Debunking the myths about Mirena:

Ø Mirena does not increase risk of pelvic infection. In fact, there is evidence to suggest that it may reduce the risk of getting pelvic inflammatory disease (PID)

Ø Mirena does cause weight gain

Ø Mirena does not cause sub-fertility

Ø Mirena does not cause premature menopause

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Long Acting Reversible Contraceptives (LARCs)

By Dr J Kabyemela, MD