Contraceptive methods

This leaflet provides an overview of the different methods of contraception.

The best method is one that can be used consistently and that does not cause disturbing side effects. Consideration should also be given to the method's effectiveness, convenience of use, impact on menstruation, financial cost and protection against sexually transmitted diseases as well as how quickly pregnancy is possible after discontinuing the method.

Finding the most suitable contraceptive may require time and trying different methods, but there is an effective and suitable contraceptive for everyone.

HORMONAL CONTRACEPTIVES

Combined hormonal contraception (CHC) means that these contraceptives contain two hormones (oestrogen+gestagen) that suppress ovulation, prevent the thickening of the uterine lining, suppress the follicle-stimulating hormone and make the cervical mucus thicker.

When using CHC, the amount of blood and pain during menstrual bleeding decreases, the risk of developing malignant tumours in the ovaries or endometrium is lower and the risk of ovarian cysts and benign breast tumours also decreases. Due to the reduced amount of lost blood, CHC prevents worsening of iron deficiency anaemia. CHC users have also reported a decrease in acne, premenstrual syndrome (PMS) and ovulatory symptoms.

CHC is divided into three forms:

Oral contraceptives (also known as ‘pills’) are tablets that are taken orally at the same time every day. The most common regimens are 21+7 and 24+4, meaning that tablets are taken for 21 or 24 days, followed by a 7-day or 4-day pill-free period or 7 or 4 days of placebo tablets. During this time, menstruation-like bleeding from the vagina usually occurs. Bleeding may decrease, bleeding time may shorten or, in rare cases, bleeding may disappear completely. If there is vomiting or diarrhoea, it is necessary to use a condom in addition to the pill because the effectiveness of the pill decreases.
A vaginal ring is a soft silicone ring inserted in the vagina and removed after three weeks. This is followed by a 7-day ring-free period during which menstruation-like bleeding occurs. It is important to regularly check that the ring is in place in the vagina (for example, before and after intercourse).
A transdermal patch is applied to the skin for 7 days, and the patch is changed every week. In the fourth week, no patch is applied. During this time, menstruation-like bleeding from the vagina occurs.

Contraindications for CHC

CHC methods have several contraindications, such as deep vein thrombosis, high blood pressure, certain heart diseases, severe diabetes, migraine with aura, stroke, liver disease, breast cancer, etc. While using CHC, there is a risk of venous thromboembolism, but this risk is lower than during pregnancy or the postpartum period.

Side effects and interactions of CHC

CHC can cause nausea, breast tenderness, bloating, mood swings, irregular bleeding or spotting (mostly within the first two to three months of use). If a pill is forgotten, irregular bleeding may also occur. Combined hormonal methods may have unwanted interactions with other medications, so it is important to inform the doctor of all medications used as well as any chronic or past illnesses.

Progestogen-only hormonal methods (POPs)

These methods contain only one hormone (progestogen). Progestogen-only pills inhibit ovulation, prevent the thickening of the uterine lining and make the cervical mucus thicker.

Hormonal products containing only progestogen are categorised as follows:

Oral preparations (also known as ‘mini-pills’) are tablets that are taken by mouth at the same time every day, one tablet a day. There is no pill-free period. Up to 40% of mini-pill users may experience irregular vaginal bleeding. The mini-pill is not recommended for women who have had gastric reduction surgery and use certain types of epilepsy medications.
A subcutaneous implant is a soft, flexible rod that is inserted under the skin of the upper arm and lasts for up to three years. The implant does not require daily remembering. This contraceptive may also cause irregular vaginal bleeding.
Intramuscular injections
There are several intrauterine hormonal devices (IUD). The device is inserted into the uterus for 3–8 years. Intrauterine hormonal contraceptives can be used by women who have not yet given birth. The device does not require daily remembering. Menstrual bleeding and pain during menstruation are reduced and, in some women, bleeding stops altogether. However, at the beginning of using intrauterine hormonal contraceptives, irregular spotting/bleeding may occur, which usually subsides by the end of the first year of use. IUDs have few side effects. See also the patient information leaflet ‘Insertion of an intrauterine device or IUD’.

Contraindications for the use of progestogen-only products

Contraindications for the use of progestogen-only methods include breast cancer, severe liver disease and severe depression.

Intrauterine device containing copper (copper IUD)

This device contains medical copper and is 99.2–99.9% effective. Copper damages sperm and the device has a mechanical effect to prevent pregnancy. Copper IUDs do not contain hormones. The device is inserted into the uterus and does not require daily attention from the user. A copper IUD can be in the uterus for five years and can be removed at any time. When using a copper IUD, menstruation may be longer or heavier. Intrauterine contraception can also be used by women who have not yet given birth.

Effectiveness of intrauterine devices

Intrauterine devices are effective when inserted into the uterus up to five days after unprotected intercourse. The likelihood of pregnancy when correctly inserted with a copper-containing IUD is 0.1%, and with a hormonal IUD 0.3%.

Contraindications for intrauterine devices

It is not possible to insert an intrauterine device in cases of uterine cavity deformity and/or acute pelvic inflammatory disease.

BARRIER METHODS

A condom, or barrier method, prevents sperm from entering the uterus and reaching the egg. Additionally, condoms provide protection against sexually transmitted diseases. Condoms are available for purchase without a prescription.

When using male condoms as the only contraceptive method, statistically, 13 out of 100 women become pregnant within the first year of use. When using female condoms, an average of 21 out of 100 women become pregnant within the first year of use.

It is important to know that when using a condom, only water-based lubricants should be used, as oil-based lubricants can weaken the condom structure, leading to breakage. It is also crucial to check the expiration date on the condom package before use – expired condoms are more prone to breakage.

STERILISATION

In Estonia, sterilisation is regulated by the Termination of Pregnancy and Sterilisation Act (https://www.riigiteataja.ee/akt/113032019134). Sterilisation is an irreversible method of contraception.

A legally competent adult may undergo sterilisation if at least one of the following conditions is met:

the person has at least three children
the person is older than 35
pregnancy poses a risk to the woman's health
other contraceptive methods are contraindicated
there is a risk of having a child with severe mental or physical health damage
the person’s illness or health problem hinders the raising of a child

Female sterilisation

Sterilisation is suitable for a woman who is sure that she does not want to become pregnant in the future. Sterilisation is only carried out at the woman's request if the legal conditions are met. Sterilisation is an operation in which the fallopian tubes are cut or removed. The operation can be performed laparoscopically or during another operation, such as a planned caesarean section. See also ‘Female sterilisation advice sheet and patient information’, https://www.itk.ee/sites/default/files/2021-07/TOTD_25.11.11_1.2-12_149-08.pdf.

Male sterilisation

Sterilisation is suitable for a man who is sure that he no longer wants to have children in the future. Sterilisation is only carried out at the man's own request, if the legal conditions are met. Men undergo a vasectomy procedure, where the vas deferens are cut through small skin incisions to prevent sperm from entering the ejaculate. Male sterilisation is carried out by urologists and andrologists.

LESS EFFECTIVE CONTRACEPTIVE METHODS

In addition to the methods mentioned above, some less effective contraceptive methods are as follows:

measuring the basal body temperature (working principle of a fertility monitor)
withdrawal method
the calendar method (avoiding sexual intercourse on specific days within a menstrual cycle)

Such methods are not effective, as each organism is individual and the menstrual cycle can be influenced by many factors. For example, with the withdrawal method, approximately 20 out of 100 women become pregnant unintentionally.

EMERGENCY CONTRACEPTION

Emergency contraception is divided into two categories:

oral emergency contraceptives (SOS pills)
intrauterine emergency contraceptives (copper or hormone-containing intrauterine devices)

After unprotected intercourse, it is possible to take the SOS pill, which, if taken at the right time, protects against unwanted pregnancy in up to 98.5% of cases. There are two types of SOS pill available in Estonia, both of which work by inhibiting ovulation. The SOS pill should be taken within 72 hours (ulipristal acetate within 120 hours) after unprotected intercourse. The later the medication is taken, the less effective it is against unwanted pregnancy. If pregnancy has already occurred, the SOS pill will not induce a miscarriage.

HOW LONG CAN CONTRACEPTIVE METHODS BE USED?

Contraceptives can be used from the first menstrual period until menopause and there is no need to take a break in between unless you want to become pregnant. If risk factors or contraindications arise, the suitability of the method should be considered and, if necessary, changed.

PREGNANCY AFTER DISCONTINUING CONTRACEPTION AND ITS EFFECT ON FERTILITY

Contraception (except sterilisation) does not increase the risk of infertility. Usually, a woman's fertility is restored within one to two menstrual cycles. If your menstrual periods were irregular before using contraceptives, there is a high probability that menstruation will remain irregular after discontinuing the method. With intramuscular contraceptive injections, ovulation and menstrual cycles return within six months to a year after the last injection.

SIDE EFFECTS OF CONTRACEPTIVE METHODS

Contraceptives can also have side effects. It is important to know that side effects are very individual. Most women experience minimal, transient or no side effects. It is always important to read the leaflet on the medication/medical device.

It is important to talk to your doctor about the side effects and find a solution together.

More information: PEARL INDEX-BASED EFFECTIVENESS OF CONTRACEPTIVE METHODS (Table 1)

Where can I get more information? Seksuaaltervis.ee -> contraceptives https://seksuaaltervis.ee/info/rasedus/rasestumisvastased-vahendid
Choose the best solution for you, together with your doctor or midwife, based on your health, needs and wishes.

ITK1183
Approved by the decision of the Care Quality Commission of East Tallinn Central Hospital on 10.01.2024 (protocol no. 1-24)