Dr Thomas Stuttaford answers yours questions on contraception

A1: So far as contraception is concerned it is even more important to treat everybody as an individual because the choice of method has to be selected to fit their age, domestic situation, smoking history, temperament and their own past medical history as well as their families medical history. It is therefore important for women to establish a good, chatty relationship with their own GP, or one of the doctors at whatever clinic is providing family planning advice. In general it is unusual for a woman still to be taking the combined pill at the age of 47. Some doctors would suggest that it is better if the combined pill is only taken for ten to fifteen years. In my own practice we usually tried to arrange for women to come off the combined pill at about the age of 35 or 36 and to change to either the mini pill - this is not quite as contraceptively certain as the combined pill - or to have a Mirena intra uterine device fitted. This particular intra uterine device has the advantage over an ordinary IUD in that it reduces the incidence of bleeding and it isn’t so likely to render the patient vulnerable to infection. Standard IUDs can act as a ladder for organisms to gain access from the vagina to the intrauterine cavity.

The normal pattern of bleeding as the menopause approaches is for the blood loss to be less and for the time between the bleeds to become greater.

It is not usually necessary to replace the pill with some form of hormone replacement therapy but just so that there can be no doubt about pregnancy I usually recommend either the mini pill, or recently more often a Mirena intrauterine device for women at this time of their life.

You raise an important point about the tests that can be done to determine whether someone taking the combined pill is still pre-menopausal. The standard advice is that the patient should first come off the pill, use a condom and let the almost immediate break-through bleeding pass. They should then have a completely normal cycle, for only after they have had their first true period, rather than break-through bleed, have a hormone assay carried out by a competent laboratory. The laboratory will measure the FSH, LH and oestradial levels. It is then also possible to measure your ovarian reserve - how long your ovaries are likely to continue operating. I always sent my patients to the Doctor’s Laboratory at 55 Wimpole Street, W1 but the NHS will run a similar if less speedy service.

Q2: I am a virgin who is contemplating having sex with her boyfriend. We have discussed various different methods of contraception and would like to have one method, as well as a back up method. As I am reluctant to go on the pill or anything that effects your hormones too much, as I fear weight gain and heavy periods, we came to the conclusion that condoms and spermicide would be the best option for us. Are there any other options available to us that we have missed? Name and address withheld.

A2: Condoms have the advantage that they also reduce the risk of any shared genital infection, whether one of the classic sexually transmitted diseases or only the normal bacteria and fungal spores that everyone’s genitalia and crotches harbour. Unfortunately it is very difficult to persuade men to always wear a condom. The condom may be safer from the point of view of infection than other methods of contraception but it is not as reliable as a contraceptive as the pill. I therefore usually recommend the pill, it is also easier if someone is not very sexually experienced.

The combined pill has advantages as well as disadvantages so far as general health is concerned. Most people don’t suffer from heavy weight gain or heavy periods from a pill. If you do decide to use condoms it is important to use a spermicide as well.

The pill is contra indicated if you or your family have a history of arterial or venous thrombosis or if there is a very bad family history of arterial disease. The doctor who was prescribing the pill would advise you about this. Some forms of liver disease make the pill undesirable as does SLE, one of the connective tissue inflammatory diseases. Any change in the amount of migraine suffered after taking the pill should be discussed with your doctor. Whoever is prescribing the pill will obviously keep an eye on your blood pressure and explain that although there is a small but real increase in the incidence of breast cancer the incidence of some other tumours is reduced.

You would probably find that the long acting progestogen injections, implants etc. would be more likely to cause weight gain, skin troubles, irregular bleeding than does the ordinary combined pill.

Q3: I hope you will forgive an over long question? I am 26. I stopped taking the combined pill (Loestrin 20) in March 2007 and have been using condoms for contraceptives. I would like your advice as to the best form of contraceptive for me. I took Loestrin 20 for nearly five years and it was fantastic. No weight gain, very little PMS and hardly any pain in periods (period pain and PMS were my main reasons for going on the pill). Before this I used the progesterone only implant for about four months but this caused bad skin, depression and weight gain.

Around January 2006 Loestrin 20 stopped working for me, caused horrid skin rashes over my face, extreme bloating and weight gain and near suicidal PMS/mood swings. My doctor refused to believe any of this was caused by the pill, however in March I decided to stop taking it and overall the weight gain, rashes and PMS have all gone. My periods have been erratic and my new doctor has suggested trying the mini pill as she thinks I may have had problems with the oestrogen in the combined pill. However because of the previous problems with the progesterone only implant, I don’t know if this is best.

I am very anxious about trying a new pill as I can’t face the horrid side effects which I have not had a lot of luck with. If you could suggest something that would be fantastic. Would it be worth me trying Loestrin 20 again as when it worked it was very good? I am a non smoker, healthy BMI, with no children. Name and address withheld.

A3: Loestrin is a very standard combined pill containing a mixture of an oestrogen and progesterone type hormone, in this case ethinylestradiol 20 and norethisterone acetate 1mg. They are taken for three weeks with one week off. Usually the worst side effects are caused by the progestogen component of the pill. It is noticeable that in women taking HRT it is the progestogen element of the HRT that leads to shouting matches at breakfast and plates hurled across the dining room table. Progestogen is also more likely to cause skin troubles but these can be related to either of the hormones. I would recommend that women should discuss the Mirena intrauterine device with their doctors. The Mirena is a T shaped IUD with a reservoir that very slowly releases levonorgestrel daily for five years. It is more effective than the standard copper IUD at preventing pregnancy and less likely to cause infection or heavy periods. The incidence of ectopic pregnancy in women using a Mirena IUD is less than in women taking no contraceptive measures and its effectiveness as a contraceptive approaches that of sterilisation. A Mirena works for five years but fertility usually recovers quite quickly after it has been removed should a woman want another pregnancy. I have never yet had a patient who has been unhappy with a Mirena, but unfortunately as they are quite expensive not every local medical authority will be prepared to pay for it.

Q4: I am 54 years old this year and have been taking Norgeston (Microval) for the last ten years. I am still having periods but they are quite irregular. I have an active sex life so I am worried that if I stop Norgeston there is a chance I could still become pregnant. I have not experienced any menopausal symptons and wonder if I may experience these if I stop taking Norgeston. Name and address withheld.

A4: Norgeston made by Schering also contains levonorgestrel but at much higher doses than would be released by Mirena. Any woman who has any irregular bleeding needs to make certain that this is intrauterine bleeding and not related to any incidental cause. Obviously if the bleeding always followed intercourse you would be immediately concerned. You should certainly discuss your irregular bleeding with your doctor. I have known women older than you who have become pregnant. Unusual but it can happen.

Yours is another case in which a Mirena IUD would be considered once everyone has made certain that there is no other cause for the irregular bleeding.

Q5: I have been on Depo Provera since 1994 and the last injection I had was last May. I was initially advised to change from the pill to the injection during the pill scare of that time. I had no problems on the injection and gained little weight, had no mood swings, no periods, but all was well. I asked each time I needed an injection, if long term use of Depo Provera would affect my fertility and each time was told it would not. Since coming off the injection I took the morning after pill after unprotected sex in December, as I was warned I could still be fertile even without a cycle, after this I had a period. Since then nothing. I went to my GP who sent me off for tests to make sure my hormone levels were normal which apparently they are. But I still have no cycle to speak of. I am very concerned. I am 33, getting married in September and my fiance and I were hoping to try to start a family as soon as possible. We are aware that as I am 33 and he is 37 it may take a while for us to start a family, but am I now worrying unnecessarily? Have I lessened my chances of having a family having taken Depo Provera? Name and address withheld.

A5: Depo Provera does have an effect on ovulation and hence periods after the three month injection has worn off. Periods are not immediately resumed. However Depo Provera does not usually have any long term effects on ovulation and fertility. There is every chance that your periods will have started again spontaneously before your marriage in the autumn but if they don’t there are various drugs that a gynaecologist can prescribe for you to stimulate ovulation once he or she has determined whether you are ovulating. If you are ovulating already you wouldn’t of course need the hormone to stimulate ovulation. I have had patients like you who have had longer than usual period free interludes after leaving off Depo Provera but I can’t remember any in whom it hasn’t been possible to re-stimulate ovulation. You are wise not to postpone pregnancy.

Q6: I am 24, healthy, regularly exercise and have a normal weight (157cm and 52kg) and have low blood pressure. I had the non hormonal coil fitted on the January 7 and before this I was on the Depo-Provera since May 2007, the week of the fitting my third injection was due to run out. I was told I would experience some bleeding whilst the injection wore off. I had bled continuously but lightly during the 30 weeks of the injection, the bleeding was the reason why I wanted to change my contraception. Since the fitting I have experienced heavy bleeding every single day, the bleeding is heavier than any period I can recall. The nurse and the literature with the coil advised against using tampons for the first eight weeks, I therefore have been using sanitary towels (last time I used them I was 14) at a rate of a pack and a half every two days. It has seriously impacted my life, I can’t go swimming, changing in the gym is a nightmare as the bleeding is heavy so if often leaks, my sex life is impossible due to the amount of blood. It has overall left me feeling extremely self conscious and low. I have contacted the clinic about the bleeding and they advised to take the pill in conjunction. They advised the same when i was bleeding with the injection which I did however I suffered serious hormonal changes and had terrible depressive thoughts and feelings and am therefore very reluctant to take it again.

When can I expect this bleeding to stop? Is this a normal symptom of the injection finishing and if so why wasn’t I warned? I am tired of the bleeding and want to resume my usual lifestyle I would never have had the injection if I had known its side effects were so intrusive. Helen, Brighton.

A6: Without seeing you and knowing your case it is impossible to be certain about what is causing the heavy bleeding. I would suspect that it is related to the insertion of the IUD. Standard IUDs are known to cause heavy bleeding, hence the switch to the Mirena when financial considerations make this possible. You may well find that as the standard IUD has caused unacceptable bleeding the authorities will consider fitting a Mirena, even if it is not their usual practice because of the increased cost.

Q7: My doctor is concerned with my blood pressure and has suggested using Mirena as opposed to a combined oral contraceptive. Are there any other options besides an IUC? I live in the United States. Name and address withheld.

A7: We don’t know your age but I have always considered the combined pill as a possible aetiological reason for high blood pressure when this has been detected in a young pre-menopausal woman. Your doctor’s advice seems to be very sound. Avoiding the combined pill would be especially important if you have any family history of high blood pressure, diabetes, arterial disease or of an irregular heart beat. I have found that patients prefer Mirena to using progestogen only pills and furthermore they seem to have fewer side effects. It is necessary to remember that progestogen only pills are also contraindicated if there is any history of arterial or heart disease, a history of clotting disease and that care is needed with these, as well as with the combined pill, in any patient with high blood pressure.