Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
7.3 Contraceptives
Women requiring contraception should be given information about and offered a choice of all methods including LARC (long-acting reversible contraception). See contraceptive methods decision aid below for more information.
Interactions

See also charts below

The effectiveness of combined oral contraceptives, progestogen-only oral contraceptives, contraceptive patches, and vaginal rings can be considerably reduced by interaction with drugs that induce hepatic enzyme activity (e.g. carbamazepine, eslicarbazepine, modafinil, nelfinavir, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John’s Wort, topiramate, and, above all, rifabutin and rifampicin) during use and for 28 days after stopping. Women using enzyme-inducing drugs should be offered a reliable contraceptive method that is unaffected by enzyme-inducers.

See Which combined oral contraceptive pill is suitable in a patient who is taking hepatic enzyme-inducing drugs, such as carbamazepine, phenytoin, rifampicin or rifabutin? for advice on suitable oral contraceptive use in a woman using enzyme-inducing (EI) anti-epileptic or anti-tubercle drugs. It covers tricycling and pill-free interval, breakthrough bleeding, additional contraceptive methods and stopping EI drugs.

Contraceptive hormones can affect serum levels of drugs such as lamotrigine with potential significant clinical side effects. Women taking lamotrigine should be advised that combined hormonal contraception may interact with lamotrigine; this could result in reduced seizure control or lamotrigine toxicity. The risks of using CHC could outweigh the benefits.

Hormonal contraceptives and antibacterials that do not induce liver enzymes

Advice on interactions between combined hormonal contraceptives and antibacterials that do not induce liver enzymes has been updated to take into account the recommendations of the Faculty of Sexual and Reproductive Healthcare Clinical Guidance: Drug Interactions with Hormonal Contraception (January 2011).

Additional contraceptive precautions are no longer necessary when antibacterials that do not induce liver enzymes are taken with combined oral contraceptives, (unless diarrhoea or vomiting occurs), contraceptive patches or vaginal rings. Click here for more information.

Some other interactions of hormonal contraceptives have been updated in Appendix 1 of the BNF: Interactions (under Oestrogens and Progestogens)
7.3.1 Combined hormonal contraceptives
Low strengthEthinylestradiol / norethisterone
as Loestrin® 20
20mcg/1mg tablets: £2.70 (63)
Ethinylestradiol / gestodene
as Millinette® 20/75
20mcg/75mcg tablets: £5.41 (63)NB: Third-generation COCs containing the progestogens gestodene or desogestrel are associated with a higher risk of VTE.
Ethinylestradiol / desogestrel
as Bimizza® 20/150
as Munalea® 20/150
as Gedarel® 20/150
20mcg/150mcg tablets: £5.04 (63)
20mcg/150mcg tablets: £5.07 (63)
20mcg/150mcg tablets: £5.08 (63)
NB: Third-generation COCs containing the progestogens gestodene or desogestrel are associated with a higher risk of VTE.
Ethinylestradiol / drospirenone
as Eloine®
20mcg/3mg tablets: £14.70 (84)
Standard strength:Ethinylestradiol / levonorgestrel
as Levest®
as Maexeni®
as Rigevidon®
30mcg/150mcg tablets: £1.80 (63)
30mcg/150mcg tablets: £1.88 (63)
30mcg/150mcg tablets: £1.89 (63)
Levest® is a cost-effective alternative to Microgynon 30® and Ovranette®.
Ethinylestradiol / norethisterone
as Loestrin® 30
30mcg/1.5mg tablets: £3.90 (63)
Ethinylestradiol / norgestimate
as Lizinna®
as Cilique®
35mcg/250mcg tablets: £4.64 (63)
35mcg/250mcg tablets: £4.65 (63)
Ethinylestradiol / gestodene
as Millinette® 30/75
30mcg/75mcg tablets: £4.12 (63)

NB: Third-generation COCs containing the progestogens gestodene or desogestrel (e.g. Femodene®) are associated with a higher risk of VTE.
Millinette® 30/75 is a cost-effective alternative to Femodene®
Ethinylestradiol / desogestrel
as Cimizt® 30/150
as Munalea® 30/150
as Gedarel® 30/150
30mcg/150mcg tablets: £3.80 (63)
30mcg/150mcg tablets: £4.18 (63)
30mcg/150mcg tablets: £4.19 (63)
NB: Third-generation COCs containing the progestogens gestodene or desogestrel are associated with a higher risk of VTE.
Ethinylestradiol / drospirenone
as Yacella®
as Lucette®
30mcg/3mg tablets: £8.30 (63)
30mcg/3mg tablets: £9.35 (63)
Cost effective equivalent to Yasmin®
Mestranol / norethisterone
as Norinyl-1®
50mcg/1g tablets: £2.19 (63)
Ethinylestradiol / norethisterone (tri phasic)
as Synphase®
35mcg/500mcg,
35mcg/1mg, &
35mcg/500mcg tablets: £3.60 (63)
Ethinylestradiol / levonorgestrel (tri phasic)
as TriRegol®


as Logynon®
as Logynon® ED
30mcg/50mcg
40mcg/75mcg
30mcg/125mcg tablets: £2.43 (63)

30mcg/50mcg,
40mcg/75mcg, &
30mcg/125mcg tablets: £3.82 (63)
ED tablets £4.00 (84)
Please note that the evidence is too limited to make a definite recommendation regarding the effectiveness of combined oral contraceptives after bariatric surgery. The FSHR GDG recommend that women who have had bariatric surgery should be advised of potential reduced effectiveness of COC and should consider a non-oral method of contraception.

New guidelines (FSRH CHC guidance January 2019) suggests that the traditional 21/7 CHC regimen with a monthly withdrawal bleed confers no health benefit over other patterns of CHC use. In addition, symptoms associated with the hormone-free interval can be problematic and ovarian activity during a 7-day HFI could risk escape ovulation (particularly with lower doses of EE and if use is not perfect). ‘Tailored’ CHC regimens in which there are fewer (or no) HFI and/or shortened HFI can be safely used to avoid withdrawal bleeds and associated symptoms and theoretically reduce the risk of contraceptive failure.
Suggested tailored regimens (using a monophasic EE CHC) are described in the document linked above. Women should be told about tailored regimens and given their choice of regimen based on their preference. Tailored CHC regimens can reduce the frequency of withdrawal bleeds and can reduce withdrawal symptoms associated with the HFI; however, unscheduled bleeding is common.
7.3.2 Progestogen-only contraceptives (POPs)Desogestrel75mcg tablets £2.44 (84)
Norethisterone 350mcg
as Noriday®
350mcg tablets: £2.10 (84)

NB: This pill only has a 3 hour window
Levonorgestrel
as Norgeston®
30mcg tablets £0.92 (30)NB: This pill only has a 3 hour window
7.3.2.3 Intra uterine POP systemMirena®



Jaydess®




Levosert®
T-shaped plastic frame levonorgestrel 20 micrograms/24 hours, net price = £88.00. Replace after 5 years

13.5mg: £69.22. Replace after 3 years

52mg T-shaped intrauterine system (releasing approx 20 microgram/24 hrs), 1=£66.00.Replace after 5 years
Five year use license



Smaller frame and smaller reservoir. Approved for use in the CASH service where a coil is appropriate but Mirena is not suitable or not tolerated. Three year life license. Contraception only

Remove and replace after 5 years
Long-acting reversible contraception
(LARC)
LARC methods are more cost-effective than COC pill even at one year.
Please see NICE guidance on Features of the larc methods to discuss with women (Sept 14) and Choice of method for different groups of women (Sept 14)
Medroxy-progesterone
as Depo-Provera®

Medroxy-progesterone
as Sayana Press®
150mg/ml prefilled syringe: £6.01 (1)


104mg/0.65ml susp in pre-filled injector, 1=£6.90.
Etonogestrel
as Nexplanon®
68mg implant: £83.43Nexplanon® is bioequivalent to Implanon® (discontinued); it has the same release rate and 3-year duration of action. Nexplanon® also has a different application device and insertion technique. Please visit http://www.nexplanontraining.co.uk/ or contact SDM directly for training.
7.3.5 Emergency Hormonal Contraception (EHC)Levonorgestrel 1500mcg tablet
as Upostelle®
1500mcg tablet: £3.75 (1) Available via PGD through many pharmacies across Somerset, free of charge to all patients under 25 years.Over 25's should contact their GP.
Levonorgestrol 1500mcg is the first-line oral preparation for patients presenting within 72 hours of UPSI or contraceptive failure.
DO NOT PRESCRIBE AS THE OTC PREPARATION: Levonelle One Step® (as over twice the cost of the POM product.)
Ulipristal acetate 30mg tablet ▼
as EllaOne®
30mg tablet: £14.05 (1)Patients presenting between 72 hours and 120 hours may be offered the choice of ulipristal acetate or intrauterine device and the risks and benefits of each method should be discussed with the patient.
Ulipristal is licensed for emergency contraception within 120 hours (5 days) after unprotected sexual intercourse (UPSI).
Pregnancy should be excluded before ulipristal is taken.
EllaOne is excluded from the MHRA alert affecting ulipristal for uterine fibroid treatment
Please note that patients who have a BMI >26 or are greater than 70kg may require more than the standard 1.5mg dose of levonorgestrel.
Consider double dose (3mg) or CI-IUD or ulipristal.Link

Women taking enzyme inducing medication may require further measures. EC providers should advise women using enzyme-inducing drugs that the
effectiveness of UPA-EC and LNG-EC could be reduced.

Women requiring EC who are using enzyme-inducing drugs should be offered a Cu-IUD if appropriate. A 3 mg dose of LNG can be considered but women should
be informed that the effectiveness of this regimen is unknown. A double-dose of UPA-EC is not recommended.
Link to FSRH guideline
Pre-operative treatment of uterine fibroids Ulipristal acetate 5mg tablet
as Esmya®
5mg tablet: £ 114.13 (28)MHRA alert on use of ulipristal for uterine fibroids

With immediate effect, Esmya should not be used unless:

*The new restricted indication is met, and the patient does not have an underlying liver disorder; more than one treatment course is now authorised only in women who are not eligible for surgery
*Liver function monitoring is performed before, during and after treatment courses
*The rare risk of liver damage and need for liver function monitoring have been discussed and the patient knows the signs and symptoms of liver injury and what to do if they occur.
Changed from AMBER drug to RED drug by Somerset Prescribing Forum (Mar 18).
The emergency contraceptive ellaOne also contains ulipristal acetate (single-dose, 30mg). No cases of serious liver injury have been reported with ellaOne and there are no concerns with this medicine at this time.

FSRH Clinical Guidance: Drug Interactions with Hormonal Contraception

Contraceptive methods decision aid