321 Clinical

Contraception in sea-going service personnel

Surg Lt DM Hawkins; Surg Lt Cdr R Booth

Abstract

The right to make an informed choice about contraception should be afforded to every individual serving within the United Kingdom (UK) Armed Forces. This article looks at the responsibilities and approach that healthcare professionals should take within a Primary Care setting, summarises the common contraceptive options available, discusses the associated advantages and disadvantages of each technique, and considers operational factors in a military environment that combine to influence the final contraceptive choice an individual makes.

Case Study A 19-year old Able Rate joined the Royal Navy (RN) and at her joining medical it was noted that she had been on Microgynon™ combined oral contraceptive pill for approximately three years. During this time, her menstrual periods remained light; she never experienced adverse effects, demonstrated good compliance, and was happy to remain on this contraceptive regimen.

Over the course of the next eighteen months, she was reviewed by a number of Medical Officers and Civilian Medical Practitioners on a quarterly basis, with Microgynon™ re-prescribed on each occasion. The appropriate Defence Medical Information Capability Programme (DMICP) template was used, with weight, smoking status, compliance and any issues or comments documented accordingly. In December 2010, a discussion regarding long-acting reversible contraception (LARC) was documented for the first time. The patient agreed to give LARC some thought and a review appointment was made for one month. She was subsequently started on the progestogen-only pill Cerazette™. It was noted by the consulting doctor that both the patient’s mother and grandmother had a positive history of cerebrovascular events and the combined oral contraceptive pill was discontinued.

Upon review at two months, the patient reported that she was content on Cerazette™ and wished to continue with this medication. She was amenorrhoeic, highly compliant, had given up smoking and her weight and blood pressure were stable. However, due to supply issues, it was explained that Cerazette™ was no longer a viable option for her. She had no plans to start a family, and was keen to investigate other contraceptive options. Furthermore, she expressed a particular desire to remain amenorrhoeic, as she was due to deploy overseas in the coming months, and not only wanted to avoid the inconvenience of having her period, but also felt it preferable not to have to take a daily pill when considering the constantly changing time zones. She subsequently had the -releasing subdermal implant Nexplanon™ fitted without complication. She has remained amenorrhoeic throughout and this form of long-acting reversible contraception has particularly suited her busy working role and active lifestyle.

Introduction for inventing a primitive by placing partly The desire to control fertility has been an issue for women squeezed lemons over the cervix of his lovers (1, 2). and men through the ages. As a result, the practice of contraception is as old as human existence itself. Ancient Fortunately, the voluntary control of fertility in current papyrus scripts describe the use of vaginal pessaries of times is no longer dependent on such imaginative crocodile dung and fermented dough; oriental women are contraceptive measures, but still remains of great known to have drunk lead and mercury to control fertility importance in modern society. Family planning is a and the famous womaniser Giovanni Casanova took credit global concern with the UK population alone predicted to J Royal Naval Medical Service 2014, Vol 100.3 322

swell to 82.3 million by 2071 (3), and on a smaller scale make informed decisions about their care (7). Particular the effective control of reproduction can significantly emphasis should be given to the risks and benefits of each contribute to an individual’s personal goals, aspirations contraceptive method and well-being. This is particularly relevant to the highly motivated and professional sea-going Service personnel Medical Officers (MOs) should be aware of all currently of the RN, who not only have to consider factors such as available contraceptive options, including LARC. They efficacy, safety, side-effects, advantages, disadvantages and should be aware of the cost efficiency of LARC andof non-contraceptive benefits, but also how the often arduous, the fact that LARC reduces numbers of unintended austere and unpredictable environment in which they serve pregnancies. Within Defence Primary Healthcare may impact on their choice of contraceptive, and vice establishments (including deployed sea-going units), the versa. The focus of this article is on contraceptive choices appropriate DMICP template should be used to act as a for female sea-going service personnel, with specific prompt for the user, and allows for thorough documentation reference to how occupation and operational capability of a focussed medical history, including family, menstrual, may influence that choice. contraceptive and sexual history. It also acts as an aide memoire to identify potential contraindications to various Research continues into methods of contraceptive methods. for men: however, other than sterilisation, use remains the only method of contraception that directly When considering contraceptive options in individuals involves the male partner in contraceptive choice. Further with concurrent medical conditions, theoretical increases in in-depth discussion on condom use and sexual health health risks may exist. In this case, healthcare professionals behaviours of Service personnel will not be discussed in should refer to the UK Medical Eligibility Criteria for this article. Contraceptive Use (8). Finally, pregnancy should be excluded before initiating any contraceptive method and, Clinical picture if required, an interim method of contraception should be Discussing contraception with all female personnel in supplied. the Armed Forces is considered good clinical practice. Within the RN this should be performed not only on an Clinical management opportunistic basis, but formally during basic training at 75% of women aged 16-49 years use some type of HMS Raleigh and Britannia Royal Naval College (BRNC) contraception, with each form having its own advantages, for Ratings and Officers respectively. Furthermore, disadvantages, contraindications and efficacy (9). The most direction and guidance on contraception within the RN common methods are discussed below. is formally laid down in a variety of references. These include Book of Reference (BRd) 1991 which states that Periodic abstinence / Natural family planning all RN personnel should have access to information on contraception and the prevention of sexually transmitted Many natural family planning methods are available, infections (STIs) incorporated into induction briefs for new which were commonly employed for centuries before the joiners (4). BR3 states that it is a mandatory requirement advancement of science and, particularly, the emergence to provide information on contraception and contraceptive of hormonal contraceptives. These include behavioural services to all personnel (5). Finally, the Surgeon General methods such as continuous abstinence, outercourse has stated that education on contraception must be part of (such as and alternatives to penile-vaginal a sexual health education package during recruit training, intercourse) and withdrawal techniques such as Coitus where Service personnel are in a position to make an interruptus and Coitus reservatus. Natural fertility informed choice on acceptable and effective contraception awareness-based methods are grounded in a more scientific to ensure that every pregnancy is planned (6). It is also approach, and remain one of the most widely used methods important to consider the relatively wide age-range of of fertility regulation, primarily due to religious and females serving in the RN, with different contraceptive cultural beliefs (10). Techniques to determine a woman’s requirements, choices and challenges applying to different fertile period, and therefore periods of required abstinence, individuals. Occupational considerations will be discussed include assessing the characteristics of the cervical mucus, in detail later. basal body temperature and stage in the . Although such physiological parameters do offer a degree Clinical consultation of guidance on when natural contraception is offered, The consultation itself should be patient-focussed, and considerable commitment from both partners is required; take into account the individual’s contraceptive needs it is associated with a high failure rate, and complete and preferences, with all women given detailed evidence- abstinence and a predictable menstrual cycle are both pre- based information that will afford them the opportunity to requisites. 323 Clinical

Mechanical barriers The COCP is a highly effective option; it is convenient to The male condom is the most common barrier method of use, easy to reverse and also offers relief from menstrual contraception and acts as a barrier to the passage of semen irregularities. Associated problems and side effects mainly into the vagina. are supplied free of charge in all relate to pro-oestrogenic effects such as breast tenderness medical centres, ships and shore establishments in the RN: and breakthrough bleeding along with an increased risk they protect against STIs, and may also offer protection of venous thromboembolism (VTE), when compared with against cervical cancer. Although disadvantages include non-users. Historically, there were concerns about the use the requirement for prior planning, lack of spontaneity of the COCP and an increased risk of myocardial infarction and a reduction in sensitivity, regular condom use is an (MI), breast cancer and atherogenesis, but current evidence important message to promote to both male and female suggests that oral contraceptive use is more likely to Service personnel, regardless of concurrent methods of be a co-factor to the development of such conditions contraception that may be used. when other pre-existing risk factors are present. Relative contraindications relate to VTE risk factors such as an Female condoms consist of a flexible pre-lubricated established personal or family history of VTE, obesity, polyurethane sheath that is intended for one time use smoking and long-term immobility. Risk factors for arterial in the same way as male condoms. Benefits include a disease include a personal or family history, hypertension degree of protection to the labia and base of penis during and diabetes. The COCP is also unsuitable for use in intercourse, and it can be inserted up to eight hours before women with an established history of migraine or increased intercourse. However, the devices are generally considered frequency of headache on commencing a COCP. cumbersome, can be difficult to insert, and are not as widely available as male condoms, whilst also being relatively Progestogen-only pill (POP) more expensive to buy. The POP is not widely used across the world, but 5% of 16-49-year-old women in the UK use the POP and Diaphragms and caps are alternative female barrier methods it is particularly useful in women where the COCP is of contraception. Both are dome-shaped devices that fit contraindicated (8). Prevention of conception occurs in a over the cervix and prevent the passage of sperm to the similar manner to that of the COCP, but with the added cervix when used in conjunction with a spermicidal agent. effect of reduction of cilial motility in the fallopian tubes. Although benefits include the avoidance of parenteral Like the COCP, the POP is reliable if taken correctly, hormones, and spontaneity of sex as a result of prior easily reversed and convenient. Pro-oestrogenic side insertion, women must be well motivated and practiced in effects associated with the COCP are also avoided, and their use. Urinary tract infections are more common, and it can be used by those with COCP contraindications and diaphragms/caps have fallen out of favour due to the need also during breast-feeding. Amenorrhoea is a recognised to protect against STIs (11). side effect, but this is often considered beneficial. The most significant disadvantage of the POP is the meticulous Hormonal Contraceptives need for compliance as most preparations must be taken Combined oral contraceptive pill (COCP) within a three-hour time frame each day. Although novel The introduction of ‘the pill’ in the early 1960s played preparations are licensed for a twelve-hour window of use, a significant role in reducing the risks of unplanned in general, the POP should be reserved for women who pregnancies associated with the sexual liberation movement display excellent compliance and motivation. of the time, and the COCP today remains the mainstay of hormonal contraception, with many different formulations Long-acting reversible contraception (LARC) being available and 25% of women between 16 and 49 The efficacy of hormonal and barrier methods of years of age taking it in the UK for fertility control (9). contraception are ultimately dependent on the correct and consistent compliance of the users. Methods of contraception The COCP consists of a combination of synthetic oestrogen that are not reliant upon daily compliance are known as and progestogen and can be classified as either a 1st-, long-acting reversible contraception and are defined as a 2nd- or 3rd-generation formulation, as determined by the contraceptive method that requires administration less than hormonal content and period of development. The COCP once per menstrual cycle or month (7). prevents conception in three ways: 1. The indirect prevention of ovulation via its action on Intrauterine contraceptive devices (IUCD) follicle-stimulating hormone (FSH) and luteinising IUCDs are a very safe and effective method of hormone (LH); contraception, and very popular worldwide. With 2. The thickening of cervical mucus preventing established contraceptive benefits and cost efficiency, penetration of sperm; IUCDs are becoming increasingly popular in younger 3. The reduction of endometrial receptivity. females, and IUCD use is not contraindicated in nulliparou J Royal Naval Medical Service 2014, Vol 100.3 324

Contraceptive Option Benefits Risks or Consequences Periodic abstinence and No chemicals or hormones High failure rate: 40-250 natural family planning No side effects Requires motivation and discipline May need to keep daily records Sex must be avoided at specific times Barrier methods – male/female No medical side effects Failure rate: 20-200 condom, diaphragm, cap Protect against sexually transmitted Requires proper use each and every time you have sex infections and possibly cervical cancer Potential failure due to splitting, falling off Widely available and poor positioning Requirement for ‘preparation’ can be off-putting Diaphragm fitting required initially Combined oral contraceptive Side effects uncommon (transient Failure rate: 3-90 pill (COCP) nausea, headaches or breast tenderness) Requires daily compliance Can ease dysmenorrhoea in some Personal/family history, smoking and obesity Reduces risk of some cancers (ovarian all (relative) contraindications and endometrial in particular, colon and Increased risk of VTE compared with women not uterine also) taking COCP Does not interfere with sex Small increased risk of breast cancer Can cause rise in blood pressure and requires regular checks Concurrent medication use and GI disturbance can decrease efficacy Does not protect against STI and HIV Progestogen-only pill (POP) Lower risk of VTE compared to COCP Failure rate: 3-90 Does not interfere with sex Periods often irregular and unpredictable, can become amenorrhoeic Side effects include labile mood, increase in acne and breast discomfort (often settling after 3 months) Requires daily compliance within defined time period Concurrent medication use and GI disturbance can decrease efficacy Does not protect against STI and HIV Intrauterine contraceptive device Can offer contraceptive cover for Failure rate: 6-8 (IUCD) 5-10 years (dependant on coil type) Periods may initially become heavier and No daily pill more painful Does not interfere with sex Hormonal variant may result in progestogen No side effects with copper variant related side effects as with POP Hormonal variant often results in lighter Increased risk of pelvic inflammatory disease periods/amenorrhoea if fitted when STI present Increased risk of ectopic pregnancy (50 in 1000) if you fall pregnant with IUCD IUCD may be spontaneously expelled (50 in 1000 women in first year) Small risk of uterine perforation (1 in 100 placements) Does not protect against STI and HIV Progestogen-only subdermal implant No daily pill Failure rate: 0.5 Up to 3 yrs continuous contraceptive cover Some women dislike invasive nature of Does not interfere with sex procedure Can be used whilst breastfeeding Unpredictable periods/bleeding common Easily removed and with rapid loss of Progestogen-related side effects as with POP contraceptive effect following Does not protect against STI and HIV Progestogen-only injection No daily pill Failure rate: 2-60 Contraceptive cover for up to 12 weeks Injection required every 12 weeks Does not interfere with sex Periods may become irregular but may also cease Can be used when breastfeeding Progesterone related side effects as with POP May ease pre-menstrual tension, possible but uncommon dysmenorrhoea and menorrhagia Weight gain common Can lead to decreased bone mineral density Does not protect against STI and HIV *Failure rates (a statistical estimation of the number of unintended pregnancies) may be calculated and reported using a life table method or the Pearl Index. The former, also termed a decrement table, calculates a separate effectiveness rate for each month during a study period, as well as for a standard period of time (usually 12 months). This removes time-related biases, inherent in the Pearl Index calculation, which assumes a constant failure rate over time (described below). Table 1. Benefits, risks and consequences of common contraceptive methods. Number of pregancies x 12 Failure rates* are shown as number of pregnancies per 1000 women when Pearl Index = x 100 (Number of women x Number of months) method used correctly. 325 Clinical

women of any age. Evidence suggests that the latest banded not quickly reversible, and menstrual irregularities are copper IUCDs are better than the COCP and as effective as found in the majority of women using this method. Weight surgical sterilisation (12). gain can occur, as can depression and a transient loss of bone mineral density, all of which can persist for up to Copper coils affect the viability of sperm and ova by twelve months post cessation (14). causing a thickening of cervical mucus, induce motility changes in uterotubal fluid and prevent fertilisation and The clinical characteristics of the different methods of implantation due to a localised inflammatory response contraception are summarised in Table 1. of the endometrium. The Mirena Coil is an intrauterine system that works in much the same way as a copper coil, Several other contraceptive methods are available but not but also consists of a reservoir containing the progestogen widely employed, such as hormone-releasing vaginal rings , which releases 20 mcg of hormone per day and sponges, hormone-eluting transdermal patches, and for up to five years. Both methods are effective, convenient spermicidal lubricants, but these are rarely recommended, and reversible with dysmenorrhoea improved and nor popular. Male and female surgical sterilisation remains amenorrhoea induced in many women, particularly with popular for couples who have completed their families and the Mirena Coil. Periods may be heavier during the first novel experimental contraceptives such as a pregnancy few cycles: theoretically uterine perforation is possible, vaccine are in development (15). and the risk of spontaneous expulsion is more likely in the first few months, but in general IUCDs are very well (EC) tolerated. However, it is important to note that IUCDs offer EC is defined as the use of a drug or device after unprotected no protection against STIs. sexual intercourse (UPSI) to prevent unwanted pregnancy. Currently, three methods are licensed for use in the UK Progestogen-only subdermal implant (Table 2) (16). The progestogen-only implant (Nexplanon™) consists of a single flexible rod that is inserted subdermally into the lower The rationale for prescription of EC should be discussed surface of the upper arm. It contains 68 mg of etonogestrel (Table 3), with all women informed about the different that is eluted by diffusion and offers contraceptive methods of contraception with regards to efficacy, protection for three years before replacement is required. adverse effects, interactions and the need for additional The action, cautions and contraindications of Nexplanon™ contraceptive precautions (16). Advice should also be are very similar to those of oral progestogens, but such given that oral EC methods do not provide contraceptive parenteral preparations reliably inhibit ovulation and cover for subsequent UPSI and appropriate contraception therefore protect against ectopic pregnancy and functional or abstinence is required to avoid further risk of pregnancy. ovarian cysts (13). Irregular bleeding is common in the first The opportunity should also be taken to discuss long term year of use, and some practical problems can be associated contraceptive provision, and a full sexual health screen with the minor surgical procedure of inserting, removing should be offered. and replacing the implant but, typically, the subdermal implant is a very well tolerated contraceptive. Occupational considerations As previously discussed, it is the MO’s responsibility to Depomedroxyprogesterone Acetate (DMPA) – ensure that every individual is able to make an informed progestogen-only injection decision on acceptable and effective contraception, to The DMPA injection is a long-acting, reversible ensure that every pregnancy in planned. Furthermore, the contraceptive consisting of a synthetic progestogen that Armed Forces are unique in the sense that the environments is slowly released into the systemic circulation with in which we serve are often isolated and physically pharmacologically active levels achieved within 24 hrs. demanding and therefore due consideration must be given Contraceptive protection is offered for up to three months to these factors. with levels dropping to ‘undetectable’ after seven to nine months. A variation of the commonly used DMPA The RN’s core business is to operate at sea for long periods formulation ‘Depo-Provera’™ is ‘Noristerat’™, which of time, and the clinical challenges encountered often relate contains norethisterone enantate and is licensed for short- to the experience of the consulting medical professional term use providing contraceptive cover for eight weeks, for rather than the medical supplies onboard. This highlights the example during the period before a partner’s importance of ensuring that sexually active females have a becomes effective. As with the Nexplanon™ subdermal reliable form of contraception in place prior to deployment. implant, the action, cautions and contraindications are Individuals may also wish to consider deferring the start very similar to those of oral progestogen. The main of a new method of contraception immediately before disadvantages of injectable progestogens are that they are deploying, to avoid unwanted side effects where limited J Royal Naval Medical Service 2014, Vol 100.3 326

Table 2. Methods of emergency contraception available in the UK. options are available to remove or reverse the contraceptive avoided, as the clearance of serum progestin and mean time causing the problems. to ovulation can be up to ten months (17).

Another factor that may influence a woman’s choice of The case study above highlights some of the practical contraception is the time frame in which she can expect contraceptive considerations that should be taken into her fertility to return on discontinuing the contraceptive. account in sea-going female personnel. The desire to remain This not only relates to females who may be returning amenorrhoeic and avoid contraception-associated side home from deployment, but also their partners who may effects is often a strong motivational factor, and commonly be deploying, resulting in relatively short windows for determines contraceptive choice. The issue of changing conception. Generally speaking, return to fertility is rapid time zones and OCP compliance is not a significant clinical after reversible hormonal contraceptives are discontinued, issue, but should be discussed with all females deploying with no significant variation in cumulative conception rates where the OCP and particularly the POP is their preferred between the different contraceptive types. It is important to method of contraception. Regardless of contraceptive note that fertility will not return to the same level prior to choice, the message of safe sex should be reinforced and starting contraception, but instead returns to where it would condom use promoted at all times. have been had contraception not been used i.e. declines with age, health and lifestyle. Conclusions Many different contraceptive options are available to With oral contraceptives, ovulation should begin within women, and there are many common methods, but weeks of stopping the pill, and 80% of women will conceive ultimately individual factors govern the preferred method within the first year, which is comparable to the general of choice. It is the responsibility of each healthcare population. Any delays in return of menstruation are more professional within the RN to actively engage with his or likely to be attributable to underlying factors such as age, her practice population to ensure that every serving woman weight, or other medical issues. Theoretically, IUCD is able to make an informed and educated decision on removal should result in an instant return to fertility, but which method of contraception best suits her needs and observationally a slight delay is often noted, not significantly requirements. Furthermore, the Armed Forces often differ different to that found in the general population. There is from the civilian population in the roles and environments no evidence of a delay in return to fertility on removal of in which we ask our people to serve. This turn adds an the progestogen-only subdermal implant. When conception additional series of considerations that must be discussed is desired within a relatively short period of stopping with women to ensure that we are affording our personnel contraception, the progestogen-only injection should be the medical care that they deserve. 327 Clinical

References 1. Skuy P. Tales of Contraception. Janssen-Ortho Inc: Toronto Canada; 1995. 2. Suitters B. The History of Contraceptives. Fanfare Press. London, England; 1967. 3. UK population numbers and world population trend. Optimum Population Trust; 2009. 4. BRd 1991, Chapter 11, Paragraph 1110 – Improved Sexual Health. 5. BR3, Part 5, Chapter 22, Annex 22A – Sexual Health. 6. A strategy for improving the sexual health of the armed forces. Defence Instructions and Notices, 2006 DIN07-016. 7. Long-acting reversible contraception. NICE clinical guideline 30. Issued October 2005, modified April 2013. 8. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists; 2009. 9. Contraception and Sexual Health 2008/2009. Office for National Statistics; 2009. 10. Grimes DA, Gallo MF, Halpern V, et al. -based methods for contraception. Cochrane Database of Systematic Reviews 2004. Issue 4. DOI: 10.1002/14651858.CD004860.pub2 11. Minnis AM, Padian NS. Effectiveness of female controlled barrier methods in preventing sexually transmitted infections and HIV: current evidence and future research directions. Sexually Transmitted Infections. 2005;81:193-200. 12. Andersson K, Odvind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49(1):56-72. 13. British National Formulary 67. Chapter 7 Contraceptives. March-September 2014. 14. Progestogen-only Injectable Contraception. Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists; 2009. 15. Talwar GP. Making of a vaccine preventing pregnancy without impairment of ovulation and derangement of menstrual regularity and bleeding profiles. Contraception. 2013;87(3):280-7. 16. Emergency Contraception. Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, Clinical Effectiveness Unit. August 2011 (Updated January 2012). 17. Long-acting reversible contraception. NICE Clinical Guideline 30. National Institute for Health and Care Excellence. Issued October 2005, modified April 2013.

Authors Surgeon Lieutenant DM Hawkins BSc (Hons), MSc, PhD, MB ChB RN General Duties Medical Officer Medical Officer RFA Argus BFPO 433 Corresponding Author [email protected]

Surgeon Lieutenant Commander R Booth BM MRCGP RN General Practitioner Principal Medical Officer Britannia Royal Naval College Dartmouth TQ6 0HJ