Update on long- and short-acting contraceptive methods

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One of my challenges as a GP is keeping on top of new medicines or updated indications or new PBS [Pharmaceutical Benefits Scheme] listings for current medications. Luckily for me and all of you, today we're going to talk through an update on long- and short-acting contraceptive methods. I'm Laura Beaton, your host for this episode, and I'm joined by Dr Emma Mason, a lecturer in sexual and reproductive health at the University of Sydney. She's also a GP, but she works exclusively in sexual and reproductive health. Emma, along with her colleague Kirsten Black, have written an article for Australian Prescriber, and today I'm delighted to get to chat through the key updates and gain some clinical pearls. Emma, thank you so much for coming on the show.

Thanks for having me, Laura.

There's so many choices for contraception available in Australia, which is really great to be able to provide this wide variety to patients. However, I find it can be a bit daunting to feel like we can adequately cover all the options at an initial consultation that might've been booked as 15 minutes in general practice. And so, I wanted to start off today with the general principles and approach we can take when helping patients choose the best contraception option that might suit them. What approach do you take when having that initial consultation?

Yeah, so there's lots of things that influence the choice of contraception for patients. So I really want to find out when a patient first comes, what they're looking for in a contraceptive and what their needs are at the moment. That might include their reproductive stage of life, their future fertility plans, reversibility, what their lifestyle is like, and what they know about contraceptives as well, and what their maybe past experiences might have been. So I'm really wanting to know what their needs and what their values are. And then medically, I suppose I'm assessing for any medical contraindications or precautions that might exist, which might mean some types of contraceptives are off the table or some might be more suitable for that person. And also, things like drug interactions is what I'm looking for medically.

I note that now the general advice is actually to offer a long-acting reversible contraceptive if there isn't a medical [contra]indication. What do we know about the uptake of LARCs [long-acting reversible contraceptives] in Australia? How are we going?

So in the article we reference some statistics which show that about 10% of women in Australia are using a long-acting reversible contraceptive, and that's actually low compared to other similar countries. So we know in countries like Sweden, their uptake of LARCs is about 30%. So about 30% of women in some countries overseas are using LARCs, but we're only really seeing 10% of women taking up LARCs in Australia, and there's lots of reasons for that.

What about patient information and knowledge and education around IUDs [intrauterine devices]? What do we know about what Australian people know about IUDs?

We know that most women about reproductive age actually don't know much about the IUDs. In some recent data, we found that 7 in 10 women reported they knew nothing or only a little bit about hormonal IUDs. I think really giving education around the options of contraception is really, really important, and just giving people that knowledge that they can select the right contraceptive for them is a really key point.

And I guess if we're thinking about access to these, which are the first line of contraceptive, if there isn't a medical contraindication, I know lots of our listeners won't be working in say, a family planning clinic or have a colleague who is a GP IUD inserter, how do you suggest GPs go about increasing the access in their community to LARCs?

Yeah, great question. I think there's a lot of research going on in this space as well about increasing access to LARCs. I mean, a lot of GPs do insertions and removals of Implanons, but I think the insertion and removal of IUD can be a bit harder to get access to this. So I think knowing your local referral networks, because everywhere in Australia will be different in terms of your local referral networks, but maybe having a go-to referral network or just being familiar with your local network can be really helpful. And there are some good resources online that gives some direction about local networks as well.

I'm a big proponent of HealthPathways. I use it all the time. If your local area has been updated for referral pathways for IUD insertion, it can be a really helpful resource. And I guess, if you are a GP who is interested in this space or if you're getting lots of questions around this and you want some more support, there's lots of good practitioner support. And I will say, the AusCAPPS [The Australian Contraception and Abortion Primary Care Practitioner Support] Network is probably one of my go-tos for some advanced advice on IUDs and sexual and reproductive health. I'm not sure if you use that network-

Yes.

... a lot as well, Emma, but it's free for clinicians and it's a really excellent community of practice and you'll be able to get really up-to-date resources and also really good peer support around troubleshooting as well.

Yeah, and the other thing I love on AusCAPPS is they have an interactive map. So you can actually go to your home state and you can go to the interactive map and find providers, for example, medical abortion providers or IUD inserters in your states. I think that's a really awesome resource to have too.

Now I know a lot of what we wanted to talk about today are recent updates. And so, in the IUD space we've had an update of the rebate for IUD insertion. But actually, the biggest update is probably in the LARC space has been after we had the new lower dose levonorgestrel IUD, so the 19.5 milligram device, the Kyleena. Now we have extended approval for the duration of the Mirena IUD. How has this changed your practice or how you talk about these IUDs for patients?

Yeah, so I think it was last year in 2024 that the Mirena IUD was approved in Australia for use for up to 8 years for contraception. And this was based on some really great data out of the US, which showed that the efficacy for contraception was really similar at the 8-year mark compared to the 5-year mark. So I think that's really great because 8 years with a hormonal IUD, the Mirena is really cost effective.

Good bang for your buck.

Absolutely. Patients love that it can last for 8 years, but if you want to get it taken out earlier, it's completely reversible as well. But there are some times where it should only be used for 5 years as well. So if you are using it for the endometrial protection component of menopause hormonal therapy, it should only be used for 5 years and then it is licenced for 5 years for the management of heavy menstrual bleeding. Although there is some guidance, which is saying if heavy menstrual bleeding has not returned at the 5-year mark, you can continue the Mirena IUD for up to 8 years.

Thanks, Emma. And I think that's the conversation I'm having with people. Their Mirena has come up for their 5-year exchange and I have a discussion, what's your bleeding pattern like? And if actually the indication that it's being used, maybe it's not a contraceptive indication, maybe they're just using it for heavy menstrual bleeding or maybe they're using it for both. If actually their bleeding pattern is acceptable to them and they're not anaemic, we're having that shared decision that actually, it can stay in until such time as it's either 8 years or the bleeding pattern becomes pretty unmanageable.

Yeah, I think I had about 3 patients last week who came in for a Mirena exchange and ended up deciding to keep it for the full 8 years because they were still amenorrhoeic with the Mirena, so they were very happy.

Yes, yes. I am still keeping a reminder in for 5 years to discuss, but counselling people that actually that 5-year mark, it does not mean that it has to be changed always, but at least at that 5-year it's an opportunity for discussion like, is this still the right product for you?

Yeah, and I think Laura, the other point is around menopause and perimenopause. So if the Mirena IUD is inserted after the age of 45, it can actually be continued until the age of 55. I think that's a great option for women who are going through perimenopause as well.

Yeah. And I guess, just to be clear, this is only the Mirena IUD, not the low-dose Kyleena. Let's talk about the short-acting options. So what are the updates that GPs should know about in the pill space?

Great question. So there's a few new formulations of the combined oral contraceptive pill that have been released, which just have a different form of estrogen in them. So there's one which contains an estrogen called estetrol and drospirenone, the brand name is Nextstellis. That's kind of the main new pill that's on the market. But the kind of exciting thing is that a few new combined oral contraceptive pills have come onto the PBS recently, I think from the 1st of May, which is great. And they're also drospirenone-containing combined oral contraceptive pills, so drospirenone, ethinylestradiol. So it's great to have some more options on the PBS to make things more affordable for patients.

It's great to have these options when we get to that troubleshooting stage. What's the reported benefit of the new estetrol?

The proposed benefit is that it potentially has a lower VTE [venous thromboembolism] risk and a lesser impact on haemostasis compared with other estrogen preparations.

Maybe the jury's still out on how long we have to...

Yeah. I'm not sure if we've seen that borne out clinically, but in the trial and in the formulation data, that's what was reported.

And I guess in the progestogen space we are seeing many more of the products that have the drospirenone in them and the new progesterone-only pill, brand name Slinda, with drospirenone, has pretty exciting clinical use, which is that we don't have to have that 3-hour rule anymore for the mini pill or progesterone-only pill. We get to counsel patients that actually, this one has a 24-hour missed pill window. How has that changed how you counsel people about the use of progesterone-only pills?

Yeah, so I love this extra option for a progesterone-only pill. And having the 24-hour missed pill window, I think, is amazing because it gives people so much more flexibility and we can rely on the progesterone-only pill with that 24-hour window in a different way, I suppose, compared to the 3-hour missed pill window. It's a great option for people who can't have estrogen-containing regimes or might have a contraindication or don't want an estrogen-containing regime. And then just having that 24-hour window just gives so much more flexibility. So I have really been excited about this option and it's just recently come onto the PBS as well, which I think is fantastic. And in terms of counselling people around it, I'm just talking about the missed pill window, the effectiveness and that it doesn't contain estrogen.

Let's turn now, Emma, to some specific patient groups where some contraception options are really preferred over others. Maybe let's start with people who are immediately postpartum and I guess, ideally we're trying to aim for interpregnancy interval of at least 12 months. And so, with that in mind, what are the options that are preferred? What can be started and how long do we have to wait?

Yeah, so for people who are postpartum, it's great to kind of have a discussion around contraception because fertility can return at different times for different people and an interpregnancy interval of at least 12 months has better outcomes both maternally and neonatally. So progesterone-only methods are preferred in the immediate postpartum period. So an oral progesterone-only pill would be very suitable and having the option now with the drospirenone-only, progesterone-only pill is great because it's that 24-hour missed pill window. Things like the contraceptive implant and the contraceptive injection can be started immediately postpartum as well.

The IUD is a little bit more complicated in terms of when it can be initiated. So for all IUDs, they can be inserted either at the time of caesarean section or vaginal delivery. I think it's more common to have them inserted at the time of caesarean section within that 48-hour period. Otherwise, it's advised to wait at least 4 to 6 weeks before having the IUD inserted. And then for the estrogen-containing regimes, it really depends on a few factors. So we don't initiate them immediately after postpartum. We might have to wait several weeks, but it also depends on breastfeeding status and risk of venous thromboembolism, and there's some really clear guidance in the UK Medical Eligibility Criteria (MEC) around this.

Yeah, the UK MEC is one of my most commonly used bookmarks. One of the other cohorts people have a lot of concerns around contraception, are people who have had migraine or history of migraine.

Yeah, and I think in the UK MEC again, there's some really great guidance around migraine and migraine with aura and which methods are contraindicated. So we know that for people who've had a migraine with aura, estrogen-containing methods of contraception are contraindicated, so we should select a progesterone-only method of contraception. And then there's a bit of guidance around initiating and continuing certain forms of contraception with a migraine without aura as well.

Thinking about other cohorts of people that we may not want to be adding extra estrogen and increasing VTE risk, people with higher body sizes or with obesity, what are some considerations that you take into account when counselling them about contraception options that are most suitable for them?

Yeah, so we look at the UK MEC again and that has some guidance around which is related to BMI [body mass index] and an elevated BMI. So for people with an elevated BMI above 35 or greater, estrogen-containing contraceptives are not recommended. And then we think about things like are certain contraceptive options related to weight gain? It's proposed that potentially the contraceptive injection is associated with increased weight gain and also in people who might have different body sizes, we might need a longer needle length if we are administering the contraceptive injection. And then we also think about actually interestingly with different weight loss medications that might cause diarrhoea or vomiting or people who've undergone bariatric surgery, they might have different ability to absorb say, oral contraceptives, so a non-oral contraceptive method might be preferable. So things like an IUD or a contraceptive implant.

And look, that's similar advice we've been giving to people with gastrointestinal illness and you think about your absorption of the pill on that day may be affected. Thinking about someone's absorption of an oral medication is an important principle, no matter what we're prescribing.

Absolutely.

All right, let's think about a few more specific cohorts of patients. So we talked about postpartum, what about post-abortion? And I guess, now that mifepristone, misoprostol is available for all GPs to prescribe, what are the limitations or options available for providing contraception after a medical termination of pregnancy?

So if we're just talking medical termination of pregnancy, initiating the discussion about contraception at the time of abortion is really important. Contraceptive care is part of abortion care. So I always have that discussion either at their first visit or on the day of prescribing the mifepristone, misoprostol for the medical termination of pregnancy, and just see what the patient's preferences and wishes are. People can get pregnant very quickly after a medical abortion. I always counsel people around that. So we can actually start most methods pretty much immediately after the medical abortion apart from IUDs. So most other methods can be started immediately and if you commence a method within 5 days of a medical abortion, it's effective immediately, which I think is great.

And thinking about surgical abortion at that time, I guess IUDs could be placed at the same time as the procedure, so really all available to them as well, as long as there's no medical contraindications for anything to be continued.

Absolutely. And after a medical abortion, an IUD is still a possibility, but we need to confirm the products of conception have been expelled and the person hasn't had post-abortion infection, so they might want a bridging contraception while they're waiting to get an IUD. So that's also a possibility of using something like an oral contraceptive, while they're waiting to get their IUD placed.

Emma, you work in a clinic that focuses on sexual reproductive health and my assumption is that you see a lot of young people and so when you're assessing a young person and their contraceptive needs, how does the conversation change?

Yeah, so it's important to assess their ability to provide consent. So just things like checking their understanding of contraceptive methods, check that they're understanding the risks and benefits of each and that they can give consent. So using things like the Gillick competence to make sure that they're able to consent, thinking about coercion and thinking about mandatory reporting as well. So asking about their sexual partners and who they are and considering if mandatory reporting might come into it. And then we should also think about confidentiality, telling the young person about confidentiality and its limitations as well.

There are so many options out there available for contraception. I wonder what tools you use with young people because one of the things you talked about with your conversations is, what are they expecting about contraception, what have they heard about? There's lots of information out there of varying refute on the internet, and I tend to use one of the Family Planning Alliance charts, which goes with all the contraception options ranked by efficacy. What kind of resources do you use or how many appointments does it take with a young person to provide them their first contraception option?

Yeah. So Laura, I think I use the exact same chart as you. It shows a comparison of the long-acting contraceptive methods and how efficacious they are at preventing pregnancy compared to the shorter acting options. It's so good to use a visual tool because it really helps people understand the differences and the different categories between the types of contraception. I've also got a few little props in my room, so I've got some fake Implanons that I can show patients and some little model Mirenas that I can show patients and also some pill packets that I can show patients. So I think seeing them and visually understanding what they are, just gives people a bit more of an understanding. And I think the thing that young people seem to be concerned about, this is absolutely anecdotally in my practise, they have heard a lot about side effects, I think online, and they really want to have an honest and upfront discussion about potential side effects and risks of contraception.

I don't think this is just anecdotal. I also find that actually a lot of people are concerned about side effects, which is actually quite a nice segue now to talk about troubleshooting adverse effects of contraception because most medications have a side effect. It's rare that there is no side effects at all to any medication, but if the benefits outweigh the risks and if actually the side effects are pretty manageable, we can troubleshoot them. Often, we can get someone an option that suits them really well for at least the medium term. And I actually probably find that troubleshooting contraception options is actually a harder consultation than initiating contraception.

Table 4 in your article is really great. If any of our listeners haven't read the article yet, I recommend you head to Australian Prescriber. It's free online and there's a really great table that goes through all the common adverse effects and some troubleshooting management options. So maybe we can talk through a few of those key points now that might be able to help people who can't get their eyeballs on the article straight away. And for the rest of you who can get it, I would recommend bookmarking it because I think it's going to be really helpful in your consultations. Let's talk about annoying bleeding. If someone is having annoying bleeding, what do you do?

The first thing I think that's really important is just to kind of set patients' expectations around bleeding patterns before starting the contraceptive method. Then people know a bit of what to expect and they might maybe feel more comfortable if their bleeding pattern does change, if it's in line with the expected changes. And then the second thing I think is really important, I always invite patients to come back if they're having problematic bleeding, I say, ‘Please, please come back to me and we can manage it together.’ And the evidence shows this as well. If you do some counselling prior to prescribing, patients are more likely to continue with their chosen contraceptive method. But say a patient does come back, if a patient has either an intrauterine device or a contraceptive implant and they're having problematic bleeding, sometimes you can just talk to them and counsel them on the expected bleeding pattern and their bleeding pattern might be within the range of normal.

You would always want to rule out other causes of bleeding. So we might do things like a pregnancy test, we might do a cervical screening test, test for STIs [sexually transmitted infections] to make sure there's no other causes of bleeding that we don't want to miss and just put it down to contraception-related bleeding. And then if the bleeding is really troublesome or the patient is really bothered by it, if there's no medical contraindications, we could add a combined oral contraceptive pill for say, 3 months. It can be continuous or can be cyclical, and that sometimes just stabilises the bleeding pattern and that can make the bleeding pattern more favourable for the patient. And if the bleeding is really heavy, we could use something like a 5-day course of a non-steroidal anti-inflammatory drug or a tranexamic acid.

I totally agree with you. I actually, for the most part, set reminders for 3 months when we're starting a new option because a lot of these products you can prescribe for 12 months and actually if the person's not happy after 2 months, the chance of them not continuing it for the next 8 is actually pretty high. And I'd love to share a wonderful bit of counselling advice that I heard from Dr Sonia Grover at a conference a couple weekends ago. There are so many different options out there for contraception, and if one doesn't suit you, that's fine. There are other ones we can choose.

And the analogy that she used for young people was buying shampoo at the supermarket. There are so many different options for all different types of hair for all different reasons, and if your mom went and bought you a shampoo that didn't quite suit you, you'd let her know, and then you could try another one next time. And so, letting young people know or really anybody, you can come back to me and tell me about what your experience is with this contraception option and if it doesn't suit you, we will definitely find another one.

Yeah, I love that shampoo analogy, Laura. It's great.

So I guess with our long-acting contraception, we've got a couple options with this troublesome bleeding, but what if this is bleeding actually related to a combined pill? What are the options we have to troubleshoot there?

Yes, so there's a lot of options. Again, we should think about excluding other causes and potentially doing some investigations. If someone's having breakthrough bleeding on the combined oral contraceptive pill, if they're taking a low dose pill which might contain 20 micrograms of estrogen, we could slightly increase that estrogen dose to a maximum of 35 micrograms. Or if they're already taking a 30 or 35 microgram estrogen-containing pill, we could consider changing the progestogen in the pill. So changing the pill to a pill that contains a different progestogen. And if it's still really bothersome for them, I think we could consider alternate forms of contraception as well.

And I will say clinically, one of the things I found is people will often report to you the brand name of the pill that they got from the pharmacy and just double checking what actually progestogen is in that pill because I've had some people who've had some troubleshooting options before, but they've actually been put back on the same progestogen, just a different brand name of pill. And so actually, it wasn't going to change anything at all. And I fall into this trap myself, so I often have one of the tables up. Sexual Health Victoria has a really good table for all of the different combined pill options and all the brand names, and actually what estrogen, progestogen is in each of them. I find that a really helpful one.

Yeah, absolutely. I always have to get a table up and double check all the estrogens and progesterones and we've got a table in the article, it's Table 3, which contains that information as well.

And look, I think when I'm looking at the different progestogens as well, people often come to me with concerns either before starting contraception or when they're on it around, has this affected my mood? And I guess as well as reviewing for other causes, you do discuss maybe we can swap a progestogen or skip the withdrawal bleeds and have an extended use. Is this something that you find you do often in clinical practice?

I mean, we always talk about mood and mood is certainly a concern from patients. It's possible that any hormonal contraception can impact on mood, but it won't impact everybody and it won't impact everybody in the same way. So I think it's a great point about addressing other causes of mood changes, and then just talking with the patient and seeing what they'd like to do. So yeah, you can do the extended use of the combined oral contraceptive pill. You could switch to a pill which contains a drospirenone, progestogen component or you could try a different form of contraception. The key thing is, just having that review and that open door for review as well to talk about it.

And a lot of the time when I'm thinking about the options, even speaking about people's menstrual pattern and their mood related to their menstrual pattern before they start contraception, can give you a bit of a hint as to which pills actually might suit people better. Because for many people with mood disorders, actually some of the pills are actually very revolutionary for their mental health.

Yeah, absolutely. And actually, I've been using the Therapeutic Guidelines. They have some good guidance around PMDD [premenstrual dysphoric disorder] and prescribing around this as well.

So to finish off, often people talk about side effects related to the estrogen components, so nausea, headaches, breast tenderness. Are these side effects normally things that just settle down? What do you counsel people about these side effects? Or do you often change their formulation if they're complaining about significant nausea, headaches, and breast tenderness?

Yeah, great question. At the initiation of a combined oral contraceptive pill, patients might notice these symptoms a bit more and sometimes it does just settle down over time. So I do often counsel patients, ‘This might be expected. It might just settle down after a couple of months. But again, if it's really bothersome or if it's not settling, please come back.’ So for nausea, of course, we want to exclude pregnancy. We could try a few things, so reducing the estrogen dose is a possibility, if they're not on the lowest estrogen dose containing pill, we could take the pills at night and then the nausea might be less noticeable or we could change to a progestogen-only method. So sometimes, it's the estrogen component that's causing that nausea. Similarly, with the breast tenderness, we could also try reducing the estrogen and/or progestogen dose, or we could use a pill which contains a drospirenone as it has a bit of a mild diuretic effect.

Thank you so much for this article and for your discussion of all the key points today. I've certainly come away with some strategies that are going to help me provide some really good, tailored advice.

Yeah, thanks for having me, Laura. It's great to chat about contraception with you this morning.

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The views of the hosts and guests on this podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. Emma Mason has received funding from ASHM Health for conference attendance in 2024.