Blood Glucose Control (Blood Sugar Levels)

Our blood glucose level, or blood sugar level,?is the amount of glucose (sugar) in the blood. The amount of glucose in the blood is measured in millimoles per litre (mmol/l). Glucose levels are measured most commonly to diagnose or to monitor diabetes. It is also important to keep an eye on blood glucose levels during certain situations - for example: during pregnancy, pancreatitis and with increasing age. Normally, blood sugar levels stay within a narrow range during the day. A good level is between 4 to 8mmol/l. After you consume food, your blood sugar level will rise and after you have had a night's rest, they will usually be lowest in the morning.

Diabetes is a common disease in our society, affecting 2-5% of the general population, with many more people unaware that they may be affected by this condition. Diabetes results from a lack of insulin, or insensitivity of the body towards the level of insulin present. Thus if you have diabetes, your blood sugar level may move outside the normal limits.???

Carbohydrate foods are the body's main energy source. When they are digested, they break down to form glucose in the bloodstream. If you make sure you eat regular meals, spread evenly throughout the day, you will help maintain your energy levels without causing large rises in your blood sugar levels. It is also important to maintain a stable and balanced blood sugar level, as there is a limited range of blood sugar levels in which the brain can function normally. Regular testing of your blood sugar levels allows you to monitor your level of control and assists you in altering your diabetes management strategy if your levels aren't within the expected/recommended range.

Long term complications, including eye disease, kidney problems, nerve problems, cerebrovascular disease such as strokes, and cardiovascular disease such as heart attacks, heart failure and high blood pressure, can be significantly reduced. Based on studies of people with type 1 diabetes (Diabetes Control and Complications Trial : DCCT) and type 2 diabetes (United Kingdom Prevention of Diabetes - UKPDS), maintaining near normal blood sugars and glycated haemoglobin levels significantly reduces the risks of complications arising from diabetes.

Good blood sugar control is important for most people in the general population. However, if you have a condition such as diabetes, pancreatitis, hyperthyroidism / hypothyroidism or Cushing's syndrome, it becomes even more important to achieve good sugar control. If you are pregnant or planning to become pregnant, it is also essential to maintain good sugar levels to ensure both your own and your baby's wellbeing.

Stable blood sugar levels significantly reduces the risk of developing diabetic complications at a later date. Depending on the level of control achieved, these problems may start to appear 10 - 15 years after diagnosis with type 1 diabetes and often earlier in patients with type 2 diabetes.

Blood sugar levels are usually measured on a daily basis with a home blood sugar level testing kit. There are several brands and varieties available, but they will all consist of a measuring device and disposable paper strips. To check your blood sugar level, you are usually required to prick your finger tip with a lancet (a small, fine, sharp needle). Then you have to put a small amount of blood on the paper strip and place the strip into the measuring device. After about 15-30 seconds the blood sugar level will be displayed. These blood sugar measuring devices are available at most local pharmacies and also through Diabetes Australia.

There have been new meters that test alternative sites that have been released. These meters allow you to test alternative sites,such as the forearm, upper arm, base of the thumb and thigh. However, testing at different sites may give you results that are different from those obtained from the fingertip. It has been shown that blood sugar levels in the fingertips show changes more quickly than those in alternative testing sites.

People who have type 1 diabetes should measure their blood sugar levels at least once a day, either in the morning before breakfast or at bedtime. Those with type 2 diabetes and are on insulin treatment should also measure their blood sugar levels one - two times a day. For those type 2 diabetics who are on a special diet or oral tablets, blood sugar levels should be measured once or twice a week before mealtime or one to two hours after a meal.

The recommended range of blood sugar levels are:

4 to 7 mmol/l before meals.< 10 mmol/l one to two hours after meals.About 8 mmol/l at bedtime.

When your blood sugar levels are in the extreme ranges - either a fasting blood sugar greater than 15-20mmol/L or less than 3-4mmol/L, and especially if there are two or more abnormal readings, you should seek medical attention. However, you will find out the normal value of blood sugars for your own body and these levels provided are just arbitrary values - some people will feel no symptoms at a level of 20mmol/L whereas others may have symptoms of a high blood sugar such as thirst, urinating frequently, lethargy and vomiting. Regardless, you should contact your local doctor to see if better control of your blood sugar levels can be obtained.

If your blood sugar reaches very high levels at any time, you will need to adjust your food intake or insulin dose. Blood sugar levels rise in the blood after breakdown of carbohydrates in the food we consume.

The Glycaemic Index (GI) is a measure of the effect that a carbohydrate containing food has on blood sugar levels, compared to the effect of the same amount of pure sugar, on blood sugar levels. Foods with a low GI (less than 55) means that they cause a slower and lower rise in blood sugar levels. These include types of bread such as mixed-grain and fruit and oat breads, barley, pasta, noodles, beans, sweet potatoes, green peas and milk. Foods with a high GI (greater than 70) means that they cause a faster and higher rise in blood sugar levels. High GI foods include white bread, brown rice, jasmine rice, French fries and coffee.

Limiting your intake of high GI foods will help bring down the average GI of your meal and prevent marked surges in blood sugar. If you are a diabetic, high blood sugar levels may need to be controlled by increased amounts of insulin, if you are already on insulin treatment. If you are only taking tablets to control the blood sugar levels, this may need to be reviewed, to optimize treatment of your diabetes. In any case, high sugar levels can make you feel unwell, with symptoms as described above and you should consult your doctor if this arises.

Diet and exercise play a very important role in helping control blood sugar levels. Research has shown that by eating a diet with a lower GI and rich in healthy foods, people with diabetes can reduce their average blood sugar levels and reduce the risk of complications. There are various factors that affect the GI of a food. These include: the types of sugar in the food, the way it is prepared, the type of starch, and it's fat and fibre content. Although you don't have to avoid all high GI foods, you should try and combine them with low or intermediate GI foods when possible.?

Some tips for maintaining a healthy diet and incorporating the GI index into your daily routine include:

Follow the dietary guidelines for Australians, trying to incorporate a variety of foods into your eating plan. Try and use low GI foods instead of high GI foods when possible. Try and have at least 3 low GI foods throughout the day, especially during mealtimes.

Physical activity is an important part of optimizing glucose / diabetic control. It has many benefits, including: helping lower blood sugar levels, reducing weight, improving blood pressure and cholesterol levels and also improving muscle strength and stability. It also helps the body decrease it's insulin resistance and burn excess sugar. The National Physical Activity Guidelines for Australians recommends that at least 30 minutes of moderate intensity physical activity be performed on most days of the week.

If you are thinking about starting regular physical activity, it is important that you slowly build up achievable goals over the next few weeks, gradually increasing the intensity. It is essential to closely monitor your blood sugar levels during physical activity. When you first start exercising, it is recommended that you test your blood sugar levels before, during and after physical activity. This gives you an idea of the way your body responds to exercise. Some of the signs of a low blood sugar level include feeling light headed, faint, sweating and weak. If this occurs, you should stop what you are doing and take some quickly absorbed glucose such as jellybeans or glucose tablets. Everyone is different, so it is important to know how you respond to exercise.

Overall, the long term benefits of eating a good diet and exercising regularly far outweigh the short term excuses and effort that is needed to initiate these changes.?

Glucose control has been shown to be very important in helping prevent particular diseases, especially if you have diabetes. Studies have been done, which show that in adults with diabetes, persistently elevated blood sugar levels is associated with an increased risk of peripheral arterial disease, (a condition affecting the arteries which results in reduced blood flow). There have also been studies which show that poor blood sugar control and an unhealthy diet is linked to cardiovascular disease (affecting the heart and major blood vessels). This is because the body's ability to use sugar for energy is not optimized and the blood fats (triglycerides) are increased, leading to cardiovascular disease.

In the long term, poor control of blood sugar levels in diabetic patients leads to both heart and blood vessel disease, kidney failure, nerve damage, eye problems and heart disease. Gaining optimal control over blood sugar levels is therefore essential to ensure that these long term consequences are avoided.

If you are affected by type 2 diabetes, medications may be used as an adjunct to manage your condition at a later stage. Factors such as diet, exercise and loss of weight are very important in managing blood sugars - if you have tried to make changes in all these areas and are still not successful in gaining good control of your blood sugars, there are many types of medications that can help you manage your diabetes. These medications are usually taken orally, to help lower blood sugar levels. There are different classes of medications, which work on different parts of the body, to try and alter the levels of insulin and sugar in the body.

Biguanides

Biguanides are becoming increasingly popular in helping patients with diabetes gain control over their blood sugars, especially in those who are overweight. For example: Glucophage, Diabex and Diaformin (Metformin) belong to this class. These medications work by helping the body use insulin more effectively. Some side effects include nausea, diarrhoea and on rare occasions - lactic acidosis, especially in patients who have kidney, liver or heart disease.

Sulfonylureas

Sulfonylureas are one of the commonly prescribed medications to help control diabetes. This group of medication works by acting on cells, to help your body make insulin. Some examples of this group include: Daonil (Glibenclamide) and Diamicron (Glicazide). They have few side effects, such as bloating, weight gain, allergic skin rashes and gastrointestinal disturbances (ie nausea, diarrhoea) and should be avoided by people who are allergic to sulpha. Due to the fact that this class of drugs increases the release of insulin, an important side effect to be aware of is hypoglycaemia. You should learn to recognize the signs and symptoms that you experience when your blood sugar levels are low - light headedness, sweating, hunger, etc.

Alpha-glucosidase inhibitors

This group includes medications such as Glucobay (Acarbose), which work by blocking an enzyme called alpha glucosidase, resulting in a slower absorption of sugar in your digestive system. These medications are often used in combination with another diabetes medication, such as a biguanide or sulfonylurea. Alpha glucosidase inhibitors are often associated with side effects such as abdominal discomfort and flatulence.

Thiazolidinediones

Thiazolidinediones act to make cells more sensitive to insulin. Examples of this group of medication include: Avandia (Rosiglitazone) and Actos (Pioglitazone). Side effects which may be experienced with this group of medication include: swelling (retention of fluid), weight gain, and liver problems.

Meglitinides

This is a newer group of oral agents developed to help control blood sugar levels. Novonorm / Prandin (Repaglinide) work by causing a rapid, transient increase in insulin secretion from the pancreas, helping control blood sugar especially after meals. It is usually taken with meals and adjusted according to the number and timing of meals eaten. Some side effects that may be experienced include: nausea, diarrhoea and blurred vision.

Insulin

Insulin is the body chemical that is responsible for lowering blood sugar levels and in patients with type II diabetes the body becomes resistant to its effects and can eventually stop producing it at all. So if your blood sugar levels are not controlled well enough on antidiabetic tablets, then your doctor many consider using insulin injections, along with your tablets, to lower it.

You will usually start on a fairly small injected dose of long-acting insulin, or a mixture of long and short acting insulins, which will have an effect for up to 24 hours. These injections are often given in the morning, the evening, or both, but always at the same time. The dose starts at around 10 units per day (although this will vary from person to person) and is injected below the skin (not into the muscle) of the arm, belly or thigh. This can be extremely effective in lowering blood sugar levels, but precautions must be taken because if too much insulin is given there is the risk of your blood sugar going too low and causing a 'hypoglycaemic' episode. To avoid this, measurements of blood sugar level should be taken at least once every day and preferably more often. One reason for this is to make sure that the dose is as effective as possible, because it means adjustments to the dose can be made by the patient every few days.

Below is a table describing one system, although your doctor may prefer a different method and they should always be consulted if you are unsure about what dosage is correct for you.

Fasting blood sugar for the previous
3 consecutive daysTitration every 3 days;
managed by the patientNo change or reduction of 2 units
(at the discretion of the investigator)No change or increase of 2 units
(at the discretion of the investigator)

It is important to know that this should always be concurrent with frequent blood glucose measurement and discussion with a physician.

?For more information on nutrition, including information on?types and composition of food, nutrition and people, conditions related to nutrition, and diets and recipes, as well as some useful videos and tools, see Nutrition.?Australian Medicines Handbook. [online]. Insulins. July, 2007. Available at URL: http://www.amh.net.au (last accessed 03/09/07)Bate K, Jerums G. Preventing complications of diabetes, MJA 2003; 179 (9): 498-503 Couper J, Prins J. Recent advances in therapy of diabetes, MJA 2003; 179 (8): 441-447 Davies M, Storms F, Shurler S et al. 'Improvements of Glycemic Control in Subjects With Poorly Controlled Diabetes: Comparison of two treatment algorithms using insulin glargine.' Diabetes Care 28(6):1282-88, 2005.DeWitt D, Hirsch I. 'Outpatient Insulin Therapy in Type 1 and Type 2 Diabetes Mellitus'. JAMA 289(17):2254-64, 2003.Hoffman L, Nolan C, Wilson D. et al. The Australasian Diabetes in Pregnancy Society Consensus Statement on Gestational Diabetes Mellitus Management Guidelines. MJA; 1998: 169; 93-97 Kumar P, Clark M. Clinical Medicine United Kingdom: WB Saunders; 2002. Longmore JM, Hope RA, Longmore M. et al. Oxford Handbook of Specialties; USA: Oxford University Press Inc. 2001 MIMS Australia. [online] Insulin Glargine (Lantus). May 25, 2006. Available at URL: http://www.mims.com.au (last accessed 03/09/07)Murtagh J. General Practice - Diabetes. Australia: McGraw-Hill Australia Pty Ltd; 2003 Rao P, Gatlin W. Perioperative Management of the Patient With Diabetes, Surgery 2002; 77-81. Rohlfing C, Wiedmeyer, H, Little R, et al. Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial. Diabetes Care 2002; 25:275

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Contraception (Birth Control)

Contraceptives, also commonly referred to as family planning or birth control methods, are a range of devices, procedures and medications which assist women to prevent pregnancy. The way they prevent pregnancy differs, but most methods are either hormone or barrier dependent.

Contraceptive methods which are hormone dependent may either:

Alter the body's hormones so that an egg cannot be fertilised. Contraceptives that do this are commonly known as hormonal contraceptive methods; orMonitor the changes to hormone levels which naturally occur throughout the menstrual cycle, and avoid sex during periods when it is possible to become pregnant. These known as fertility awareness methods.

Barrier methods on the other hand rely on a physical barrier, which prevents the male's sperm and the female egg coming into contact during sexual intercourse, and in doing so, prevents fertilisation.

Hormonal contraceptives are typically long term methods which provide protection at all times whilst they are being taken, regardless of whether the user is sexually active.

Emergency contraceptives are also hormonal contraceptives which can be taken immediately (within five days) after unprotected sexual intercourse to prevent pregnancy occurring.

Barrier methods are inserted or applied just prior to sexual intercourse. They must be applied before each act of intercourse to protect against pregnancy.

Hormonal contraceptives are used by fertile women (i.e. women who experience menstrual cycles, typically aged 15-49) who wish to prevent pregnancy. They are typically used by women who are regularly sexually active, and therefore require ongoing protection from pregnancy.

Barrier methods of contraception are also used by women of reproductive age who wish to prevent pregnancy. However, they are particularly appropriate for women who also need to protect themselves from STIs (i.e. women who have partners of unknown STI status).

In Australia, more than?70% of all adult women and?95% of fertile women use a method of contraception. Oral contraceptive pills, used by 33.6% of women who use contraception, are the most commonly used method, followed by female sterilisation (22.5%), condoms (21.4%) and vasectomy (19.3%). Around 19% of Australian women who have ever had sex have used an emergency contraceptive, and 53% of emergency contraceptive users have used this method only once.

Contraceptives allow women to control their fertility and thus decide when and if they bear children. Enabling women to control their fertility and particularly to adequately space births (i.e. have a break from pregnancy for at least two years after childbirth) has numerous health benefits for women and their infants.

Women are better positioned to participate in social life, find employment and attain education when they are using contraceptives and do not risk falling pregnant. As these activities generally increase women's status in society, contraceptives indirectly promote the rights and status of women.

Women who become pregnant very quickly after childbirth have worse pregnancy outcomes (e.g. they are more likely to suffer from a serious medical condition or to die during pregnancy). Their babies are also more likely to have poor health outcomes (e.g. to be born at a low birth weight). The World Health Organisation estimates that globally, 100,000 maternal deaths could be averted every year, if all women who did not want any more children were able to avoid pregnancy. These deaths occur for the most part in developing countries where contraceptive coverage is low.

There are a number of non-reproductive health benefits associated with the use of some contraceptive methods. Combined (i.e. oestrogen and progesterone) hormonal methods are associated with a decreased risk of ovarian and endometrial cancers. Progesterone only injections also protect against these cancers and also against uterine fibroids. Contraceptive implants and female sterilisation have been shown to reduce the risk of pelvic inflammatory disease.

Enabling women to avoid pregnancy prevents the psychological health effects of unwanted pregnancy and reduces the demand for abortion. In Australia, 22.6% of women who have ever been pregnant have terminated at least one pregnancy, indicating a significant proportion of Australian women have at some stage in their life dealt with emotional stress related to unwanted pregnancy.

The ability to control their fertility also allows women to better control other aspects of their life, for example to decide when and for what reasons they get married. Since contraceptives became widely available in the 1970s, women's fertility and marriage patterns have changed considerably in Australia. Women now marry and have children later in life and on average, have less children. These demographic changes are likely to have lessened the emotional and economic burden of child-rearing, as families now typically have longer to accumulate financial resources prior to childbirth. Smaller family sizes also mean that parents have more time and resources to dedicate per child.

Limitations

Contraceptives must be accessed and then used consistently and correctly to effectively protect against pregnancy. Even in countries like Australia where contraceptives are inexpensive and widely available, around 5% of women who do not wish to become pregnant are not using contraceptives. Some 22.6% of women in Australia who have ever been pregnant, have terminated at least one pregnancy and many of these pregnancies may have been prevented in the first place if the women were using effective contraceptive methods.

There are also limitations regarding the effectiveness of various contraceptive methods, and no method is 100% effective. For example, male condoms are thought to be effective in protecting against unwanted pregnancy in 97% of cases and the effectiveness of hormonal contraceptive methods is much higher.

One of the key limitations of most contraceptive methods (male and female condoms being the exception), is their failure to protect against STIs. Individuals who have sex with partners of unknown STI-status (i.e. partners whom they have not been for an STI check with) should use condoms for STI prevention. Condoms can be used either alone or in combination with another contraceptive method.

Side effects

There are some, typically minor, side effects associated with some forms of contraceptives, and particularly with hormonal methods. These include:

The side effects of each method are detailed more fully on pages dedicated to each method- see below for further information.

Health risks

There are also some health risks associated with various forms of contraceptives. Combined oral contraceptives are associated with very or extremely rare cases of:

Blood clots;Heart attack;Stroke.

Intrauterine contraceptive devices (IUDs) are associated with rare cases of pelvic inflammatory disease [LINK to URL: Pelvic Inflammatory Disease] and may also increase the risk of anaemia in women who already have low blood haemoglobin.

Contraceptive methods (with the exception of sterilisation) do not affect fertility irreversibly. With most methods, fertility returns immediately after contraceptive use has stopped.

General considerations

The aim of using contraceptives is to prevent pregnancy. Pregnancy prevention is most likely if a contraceptive method which suits the individual's lifestyle, sexual behaviours and other characteristics is chosen.

There are many different contraceptive methods available and choosing the most suitable method may be confusing. The most appropriate contraceptive method will depend on characteristics of the woman wishing to prevent pregnancy, for example her age, parity, future fertility desires and health. The woman's lifestyle is also a determining factor, and other factors, for example the patient's geographic location and financial situation may also play a role.

When choosing a contraceptive method it is useful to speak to your doctor about contraceptive options. Many contraceptives also require a prescription. A doctor can offer advice on which method/s are suitable and about the benefits and limitations of each available method. Many women will have heard about and/or be interested in using a particular method, and women who have a method in mind should let their doctor know that they would prefer this method. Unless there is a medical reason not to, a doctor will usually prescribe a woman's preferred method.

Women assessing contraceptive options should bear in mind that the best contraceptive method is not necessarily the one which is the most effective in theory. In order to prevent a pregnancy in the real world, contraceptive methods must be used both correctly and consistently. For example, although combined hormonal contraceptives are the most effective means of preventing pregnancy, they are also more likely than other methods to cause side effects. Globally, side effects are the most common reason women stop using contraceptives. In Australia, some 23% of fertile women who do not wish to become pregnant and do not use contraceptives, cite side effects as their reason for non-use. Thus, for women who experience side effects, combined hormonal contraceptives may be an inappropriate method, despite their high level of effectiveness.

A woman must fully consider her ability to use the contraceptive method correctly and consistently. Women who are forgetful or have erratic schedules (e.g. shift workers) may find it difficult to comply with contraceptive regimes which require daily action (i.e. oral contraceptive pills), particularly if that action has to be taken at the same time each day (e.g. the progesterone-only oral contraceptive must be taken at the same time +/- 3 hours). Women who wish to hide their contraceptive use from partners may be better able to use a method which requires less frequent administration than oral contraceptive (e.g. an injection, implant or intrauterine device (IUD)).

Similar to women in steady relationships, women who have casual sexual partners need contraceptive protection. However women who have sex with casual or multiple partners also have an increased risk of contracting STIs. The need to protect against STIs is thus an important consideration in terms of contraceptive choice for these women, who should use male or female condoms to protect against STIs, either alone or in conjunction with another contraceptive method. Women who are concerned about their ability to enforce condom use at every act of sexual intercourse (e.g. commercial sex workers, young women with limited skills in negotiating contraceptive use) should use another contraceptive method (e.g. oral contraceptive pills) in addition to condoms.

Medical history and examination

When a woman visits a doctor for a contraceptive prescription, the doctor will usually begin by asking questions about the woman's general health. This allows the doctor to assess whether the woman has any health issues which may make using some types of contraceptives dangerous. The doctor is likely to ask about:

Cardiovascular risk factors;Other medications being taken;Allergies;Health problems, including: Migraines (contraindication for hormonal methods);Gonorrhoea (contraindication for IUD);Chlamydia (contraindication for IUD);Acquired immune deficiency syndrome without antiretroviral treatment (contraindication for IUD).

The woman's height, weight and blood pressure are often also checked, as these may influence the choice of contraceptive method, or the period for which it is effective (e.g. implantable contraceptives are effective for a shortened period of time in women who weigh > 70 kg, compared to women who weigh < 70 kg).

Pelvic examinations are not typically necessary, unless indicated by the method (e.g. pelvic examination is necessary to select a correctly fitting diaphragm). Screening for cervical cancer (i.e. a pap smear) is not a prerequisite for contraceptive prescription as it has no bearing on the effectiveness of contraceptive methods.

Considerations for adolescent women

While only around 5% of babies born in Australia are born to adolescent mothers, statistics show that one quarter of all adolescent women become pregnant unintentionally. Around half of these pregnancies are terminated.

Adolescent women are at a particularly high risk of becoming pregnant when they do not want to be, as they may be under-educated about contraception and pregnancy, or scared to access contraceptives. Their lifestyle and restrictions may make it more difficult to use some contraceptive methods.?

Young women assessing their contraceptive options should consider the following points:

Young women are often more sensitive to the side effects of hormonal contraceptives than older women. When taking hormonal contraceptives for the first time, young women should be prepared to experience some side effects (which typically diminish over time). Women who expect side effects are better prepared for them and less likely to stop using contraceptives when they experience them;Young women may find it more difficult to take contraceptive pills on a daily basis (e.g. because they are scared that their parents will find the pills). Contraceptive methods which can be taken without others knowing, (e.g. injectables) may therefore be more acceptable for at least some adolescent women;Young women, and particularly those who are not married, are more likely than their older counterparts to have multiple sexual partners. This increases their risk of STIs and using contraceptive methods which also protect against STIs (male and female condoms), or dual methods of contraception (e.g. oral contraceptive pill and condoms) is particularly important for young women with multiple sexual partners;Young women may have less control over when they have sex and whether they can access contraception. Young women may therefore have a greater need for emergency contraceptives. However, research amongst Australian university students revealed poor knowledge of emergency contraception. Many students were unaware that emergency contraceptive pills are available over the counter, and that they could be used for days after unprotected intercourse, not only the morning after. Young women who are using contraceptive methods which may occasionally fail (e.g. condom) should be aware of a place where they can access emergency contraceptive pills and may wish to discuss the benefits and limitations of this method with a doctor;Young women are more likely to develop complications during pregnancy than their older counterparts, as their bodies are still growing. Preventing pregnancy in young women is thus extremely important as it is also likely to prevent high-risk pregnancies which result in complications.

Considerations for women who have recently given birth

Preventing pregnancy in the two years after the birth of the most recent child is particularly important, as women who become pregnant too soon after giving birth have poorer pregnancy outcomes, and their infants have poorer health outcomes. When choosing a contraceptive method, these women should take the following into account:

The oestrogen in combined oral contraceptives impairs lactation. Therefore oestrogen-based methods are not recommended for breastfeeding women as they may negatively affect the health of the feeding baby;Progesterone only contraceptives do not affect breast milk production;While there is no evidence that progesterone affects the development of a breastfed infant, its affects on the infant's brain development have not been adequately studied;Progesterone only methods are usually not recommended within six weeks of childbirth for women who are breastfeeding;Women that gave birth childbirth six weeks or longer ago can safely use progesterone only methods, even if they are breastfeeding;Exclusive and regular breastfeeding provides a degree of contraceptive protection in the first six months after childbirth. However, women who wish to increase the reliability of their contraceptive protection should use an additional method.

Considerations for women nearing menopause

As a woman approaches menopause, her menstrual cycle typically becomes irregular and may disappear for months at a time. This usually occurs between 45-55 years of age, and some 50% of women will be infertile due to menopause by age 50, and 96% by age 55. A woman is considered post-menopausal and infertile when she has not experienced a menstrual cycle for 12 consecutive months.

Until a woman is confirmed as post-menopausal, it is important that she continue to use contraceptives if she wishes to prevent pregnancy. As women approaching menopause typically do not want any more children and pregnancy at this stage of life comes with a high risk of complications, preventing pregnancy amongst this group is extremely important. The following points should be considered by women approaching menopause:

Permanent methods of contraception (e.g. male or female sterilisation) may be particularly suitable for women who do not wish to have any more children;Older women are more likely to have conditions of the reproductive system which contraindicate sterilisation;For women over 35 years of age who smoke or experience migraine headaches, hormonal methods are often unsuitable;Emergency contraceptives can be used safely by older women, even older women for whom long term hormonal methods are unsuitable;Fertility awareness methods are unsuitable for women approaching menopause as their menstrual cycle is irregular.

Hormonal contraceptive methods

Hormonal contraceptives work to prevent pregnancy by changing the hormonal environment of the woman's body so that ovulation and therefore conception cannot occur. Ovulation occurs during the menstrual cycle, in response to changing hormone levels. Oestrogen and progesterone both play an important role. By taking hormonal contraceptives, a woman artificially changes her body's natural hormone levels, in such a way that the hormonal balance necessary to trigger ovulation does not arise.

Barrier methods

Barrier methods work by providing a barrier which prevents the mixing of sexual fluids during intercourse. As the male partner's sperm never come into contact with the female partner's oocyte, pregnancy is prevented.

Combined oral contraceptive pill

The combined oral contraceptive pill, commonly referred to simply as "the pill" is a pill containing two hormones, oestrogen and progesterone. Combined oral contraceptives work by preventing the release of eggs from the ovaries. They must be taken every day to effectively prevent pregnancy.

Progesterone only contraceptive pill

Progesterone only contraceptive pills, also known as the mini pill, are similar to combined oral contraceptives except that they do not contain oestrogen. This makes them a suitable alternative for women who are breastfeeding or unable to use oestrogen methods. The progesterone only contraceptive pill protects against pregnancy in two ways:

By preventing ovulation (i.e. the release of an egg from the ovaries); and By thickening the cervical mucus, and thus making it more difficult for sperm to travel through the cervix to the uterus.

Emergency contraceptive pills

Emergency contraceptive pills, colloquially known as "morning after" pills, are hormonal pills taken after sexual intercourse which may have accidentally caused the woman to become pregnant (e.g. sexual intercourse in which a condom broke or slipped off). They can be taken up to 5 days after unprotected intercourse, but the sooner they are taken, the less likely a pregnancy is to occur. The pills are similar to other oral contraceptives and can contain oestrogen and progesterone or progesterone alone. They work by delaying the release of eggs from the ovaries.

Progesterone only injectable contraceptives

Progesterone only injectable contraceptives are injections containing a progestin similar to progesterone produced naturally in females. The injections work primarily by preventing the release of an egg from the ovaries. Intramuscular injections (and more recently and rarely subcutaneous injection, that is an injection under the skin) are performed at a health facility every two or three months, depending on the brand. In Australia the most commonly available contraceptive injections last three months and are branded Depo Provera. As they do not contain oestrogen, progesterone-only injectables can be used safely during lactation.

Combined contraceptive patches

The combined oral contraceptive patch is a small square of hormone-containing adhesive plastic. It is attached to the woman's body and constantly releases oestrogen and progesterone into the blood stream, through the skin. The patch must be replaced weekly for three weeks, and is then removed for the fourth week to allow menstrual bleeding.

Combined vaginal ring

The combined vaginal ring is a flexible, hormone-containing ring which is placed in the vagina. It constantly releases two hormones, oestrogen and progesterone, which prevent oocytes being released from the ovaries. The vaginal ring is a relatively new device but initial studies suggest that it is highly effective in preventing pregnancy. In Australia it is marketed as Nuvaring.

Subdermal contraceptive implants

Subdermal contraceptive implants are progesterone-releasing rods, which are inserted beneath the skin of the upper arm. They are usually about the size of a match stick (although capsule size implants are also available) and must be inserted by a trained health professional. Following insertion, they prevent pregnancy for 3-7 years, unless removed. As contraceptive implants contain only progesterone, they are suitable for use during lactation and by women who are unable to tolerate oestrogen. In Australia contraceptive implants are marketed as Implanon.

Minera/levonorgestrel-releasing intrauterine system

The Minera intrauterine system (IUS) is a progesterone-releasing device which is placed in a woman's uterus. It is inserted through the vagina and cervix by a trained health professional and provides long term contraceptive protection (up to five years). It protects against pregnancy by preventing the lining of the uterus (known as the endometrium) from growing. The endometrium supports the early stages of embryo growth and thus prevents endometrial growth prevents pregnancy.

Lactational amenorrhoea

Lactational amenorrhoea is a contraceptive method which takes advantage of the natural contraceptive effect of breastfeeding. It can be used by women who have not experienced menstrual bleeding and have breastfeed exclusively (or almost exclusively), both during the day and at night, since childbirth. The method provides effective contraception for up to six months after childbirth. It works because lactation prevents the release of hormones necessary for ovulation.

Fertility awareness methods

Fertility awareness contraceptive methods are methods in which the patient prevents pregnancy by being aware of her fertility throughout her menstrual cycle. The woman is then able to determine the times at which she might possibly become pregnant and avoid sex, or use other contraceptive methods at those times. As a woman's hormone and fertility levels change throughout her menstrual cycle, her body temperature and the texture of her cervical mucus also change. Women can predict fertility based on these changes, or by monitoring the number of days since their last menstrual bleeding.

Barrier methods

Male condoms

Male condoms are latex or (less commonly) polyurethane sheaths which are inserted on the erect penis prior to sexual activity. They are a popular method of contraception, which provide a high level of protection against both pregnancy and STIs.

For more information, see Male Condoms.

Female condoms

The female condom is a transparent, loose fitting, polyurethane sheath, with a flexible ring at each end. It is 17cm long and has one closed and one opened end. The closed end is inserted into a woman's vagina prior to sexual intercourse, and the male partner then inserts his penis into the open end of the condom during intercourse. Female condoms protect against unwanted pregnancy and STIs.

For more information, see Female Condoms.

Diaphragm

The diaphragm is a soft latex cup which is inserted deeply into the vagina prior to sexual intercourse and left in place for at least six hours after intercourse. It covers the cervix and therefore prevents sperm entering the uterus and coming into contact with an oocyte. Diaphragms come in different sizes and women wishing to use this contraceptive method must visit a trained health professional for a pelvic examination, which will enable the correctly sized diaphragm to be selected. Diaphragms are often used in conjunction with spermicides to increase their effectiveness.

For more information, see?Diaphragm.

Cervical cap

Cervical caps are similar to diaphragms, but for women who have ever given birth, they provide less effective contraceptive protection. They are soft latex cups which are inserted into the vagina prior to intercourse. They fit snugly around the cervical opening and create a barrier which prevents sperm entering the uterus and coming into contact with an egg. Caps are often used in conjunction with spermicides to increase their contraceptive efficacy.

Other methods

Copper-bearing intrauterine device

Copper-bearing intrauterine devices (IUDs) are small, flexible plastic frames surrounded by copper wire, which are inserted by a health professional into a woman's uterus. Copper-containing IUDs protect against pregnancy in two ways:

By reducing the quality of sperm and eggs once they enter the uterus and in doing so reducing the likelihood that fertilisation will occur; andBy causing an inflammatory response in the uterus which prevents a fertilised egg implanting in the lining of the uterus to form a pregnancy.

They are a long lasting contraceptive technique providing up to 12 years protection with similar contraceptive efficacy to female sterilisation or contraceptive implants. Copper-bearing IUDs containing at least 380mm2 of copper have the lowest failure rates.?

Female sterilisation-tubal ligation or hysterectomy

Female sterilisation is a permanent method of contraception which is rarely reversible. Sterilisation can be achieved either by blocking or removing the fallopian tubes (most commonly referred to as tubal ligation) or removing one or more of reproductive organs necessary for pregnancy.

A sterilisation procedure in which the uterus is removed is referred to as a hysterectomy. A procedure in which the uterus, ovaries and fallopian tubes are removed is known as a hysterectomy with bilateral salpingo-oophorectomy or a radical hysterectomy. The latter is typically only performed when patients have other complications which require removal of the ovaries or tubes.

Both procedures provide a high level of contraceptive protection, however both are invasive surgical procedures which carry additional risks associated with surgery (e.g. from anaesthetic or infection). As the method is permanent, it is not suitable for women who wish to have children in the future.

Male sterilisation (vasectomy)

Vasectomy is a surgical procedure in which the vas deferens (the tube which links the testicles to the ejaculatory ducts in the penis) is severed. In most cases one or both of the severed ends of the vas are ligated (tied off). This blocks the path by which sperm leave the testes and therefore makes a man permanently sterile.

For more information see Vasectomy.

Coitus interruptus or withdrawal

Coitus interruptus is a contraceptive method in which the male withdraws his penis from his partner's vagina prior to ejaculation. It is the least reliable of all contraceptive methods, however it is also a method which is always available to all couples.

For more information see?Coitus Interruptus.

Spermicides

Spermicides are chemical substances which kill sperm by breaking the membrane of the sperm cell. Spermicides are available in a range of preparations which include foaming tablets, creams, jellies, suppositories, sponges and foams. They are inserted deep into the vagina shortly before sexual intercourse. As spermicides used alone are one of the least effective contraceptive methods, they are often used in conjunction with either a condom, cervical cap or diaphragm.

Monthly hormonal contraceptive pills

Pills are the most effective contraceptive method available. When used correctly combined hormonal contraceptives are 99% effective, progesterone only contraceptives are 99% effective in lactating women and 91-97% effective in non-lactating women.The woman must remember to take one pill every day at the same time to ensure effectiveness.

Hormonal contraceptive injections

Injections are less effective than pill methods.Requires administration by a health professional so requires more regular clinic visits than pill methods.They are unsuitable for some women.Requires less user input than pills, as injections need only be administered once every two or three months.Provides more user privacy as the medication does not need to be stored at home.The only method which can be used after sex.They provide women with an opportunity to prevent pregnancy after a sexual encounter which may have resulted in pregnancy.Are much less effective than permanent contraceptive methods.They should only be used as an emergency measure.

Combined hormonal contraceptives

Provide highly effective contraceptive protection when used correctly (99% for pill and injection).Side effects are more common than with other methods.Some women cannot use them including those who are breastfeeding, those with high blood pressure and those who have multiple risk factors for cardiovascular disease.

Progesterone-only hormonal contraceptives

Suitable for breastfeeding women.99% effective in breastfeeding women.Side effects are less common than with combined methods.In non-breastfeeding women, progesterone-only pills provide much less effective protection (91-97%).Unsuitable for some women.

Hormonal contraceptive patch or vaginal ring

Initial evidence suggests that they may be more effective than combined oral contraceptive pills.Applied weekly.New technology so evidence regarding their effectiveness is limited.Both have been associated with vaginal irritation.

Hormonal contraceptive implants

99% effective.Provide long term contraceptive protection (up to 7 years).Suitable for breastfeeding women.Must be fitted and removed by a trained health professional.

Intrauterine devices and systems

>99% effective.Provides long term contraceptive protection (up to 12 years for IUDs and 5 years for IUSs).IUSs tend to make menstrual bleeding lighter and reduce menstrual cramps.IUDs are associated with heavier menstrual bleeding.Provides permanent contraceptive protection.Permanent and so only suitable for individuals who do not wish to have any more children.Risks are associated with surgery.Unsuitable for a number of patients.Only contraceptive method which provides protection against STIs.Easily accessible and do not require a prescription like many other methods.High level of contraceptive protection when used correctly (98% for male condoms and 95% for female condoms).In practice, condoms are far less effective (85% for males and 79% for females) due to user error.Negotiating condom use can be difficult for some women.

Spermicides, diaphragms, caps and withdrawal method

Can be kept on hand for use when needed.Side effects can thus be avoided in periods of sexual abstinence.Spermicides, diaphragms, caps and withdrawal methods are all far less effective than other contraceptive methods.Can be used by women who do not wish to take contraceptives for religious or other reasons.Only around 75% effective in preventing pregnancy.Lactational amenorrhoea is a highly effective method.Only suitable for women who are breastfeeding regularly as the baby's main source of food and have given birth in the previous 6 months.

For more information on different types of contraception, male and female anatomy and?related health issues, see?Contraception.

World Health Organisation. Family Planning: A global handbook for providers [online]. 31 August 2007 [cited 20 June 2009]. Available from URL:?http://www.who.int/ entity/ reproductivehealth/ publications/ family_planning/ en/ Richters J, Grulich AE, de Visser RO, Smith AM, Rissel CE. Sex in Australia: Contraceptive practices in a representative sample of women. Aust NZ J Public Health. 2003; 27(2): 210-6.Smith AM, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: Reproductive experiences and reproductive health among a representative sample of women. Aust NZ J Public Health. 2003; 27(2): 204-9.World Health Organisation. Health benefits of family planning [online]. 1995 [cited 24 June 2009]. Available from URL: http://www.who.int/ reproductivehealth/ publications/ family_planning/ HRP_FHE_FPP_95_15/ en/ index.html ? Gollub E, Warren M.?The female condom:?A guide for planning and programming [online]. World Health Organisation. 2005 [cited 24 June 2009].?Available from URL: http://www.who.int/ hiv/ topics/ vct/ sw_toolkit/ The_female_condom2.pdfJohn Hopkins Bloomberg School of Public Health. Focus on improving hormonal method continuation. 5 April 2007 [cited 24 June 2009]. Available from URL: http://www.infoforhealth.org/ inforeports/ hormonal_methods/ hormonal.pdf ?Lesnewski R, Prine L. Initiating hormonal contraception. Am Fam Physician. 2006; 74(1): 105-12.Williams H. Adolescent sexual and reproductive health: Practical implications for clinical practice in Victoria [online]. Family Planning Victoria. 3 August 2006 [cited 29 June 2009]. Available from URL: http://www.fpv.org.au/ pdfs/ Bulletin_2.pdf?Callabretto, H. Emergency contraception - knowledge and attitudes in a group of Australian university students. Aust NZ J Public Health. 2009; 33(3): 234-9.World Health Organisation. Progesterone-only contraceptive use during lactation and its effects on the neonate. 6 June 2009 [cited 20 June 2009]. Available from URL: http://www.who.int/ reproductivehealth/ publications/ family_planning/ en/ ?Family Planning New South Wales. The male condom fact sheet [online]. 31 March 2008 [cited 20 June?2009]. Available from URL: http://www.fpnsw.org.au/ fs.020_male_condom08.pdfMarie Stopes International Australia. Contraception: A guide to help you choose [online]. 30 January 2008 [cited 28 July 2009]. Available from URL: http://www.mariestopes.com.au/ contents/ Contraception Info Sheet.pdf ?Family Planning New South Wales. The female condom factsheet [online].?26 March 2008 [cited 20 June 2009]. Available from URL: http://www.fpnsw.org.au/ fs.003female_con_08.pdfFarmer L, Everett S. Non-hormonal contraception. Obstet Gynaecol?Reprod Med. 2008; 18(2): 33-8.Torpy JM, Lynm C, Glass RM. JAMA patient page: Hysterectomy. JAMA. 2004; 291(12): 1526.Royal College of Obstetricians and Gynaecologists. Male and female sterilisation. Evidence-based clinical guidelines no.?4 [online]. London: RCOG Press. 2004 [cited 27 July 2009]. Available from URL: http://www.guideline.gov/ summary/ summary.aspx?ss=15&doc_id=7669&nbr=4468

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Cervical Mucus Monitoring Methods of Birth Control

The cervical mucus monitoring methods of contraception are methods for preventing pregnancy which rely on a woman monitoring changes in her cervical mucus throughout the menstrual cycle. As the presence and nature of cervical mucus varies at different stages of the menstrual cycle, in response to changing hormone and fertility levels, women can determine when they are and are not fertile, based on the changes in their cervical mucus.

In order for the method to work effectively as a contraceptive, women must then abstain from vaginal intercourse during the fertile period of the cycle or use alternative methods of contraception if they have sex.

The cervical mucus method, like other fertility awareness methods, works by enabling women to avoid sex in periods when they are fertile. In doing this, it prevents sperm coming into contact with a live egg and thus prevents pregnancy.

Cervical mucus monitoring methods of contraception are suitable for all women who experience menstrual cycles and are able to monitor changes in their cervical mucus on a daily basis (e.g. they are comfortable to touch their bodies and insert their fingers into their vagina). Use of these methods should be delayed however for women who have:

Recently used emergency contraceptive pills - These women should delay use until normal vaginal secretions return, usually at the start of the next menstrual cycle;Who have recently given birth - These women should delay until regular menstrual cycles return, typically six months for breastfeeding and four weeks for non-breastfeeding women; orWho have an unusual vaginal discharge - These women should have the discharge checked by a health professional, as it may indicate a serious condition such as a sexually transmitted infections. They should delay use of cervical mucus monitoring methods until the discharge has resolved.

There are several contraceptive methods based on monitoring cervical mucus changes. All methods require women to abstain from vaginal sex or use an alternative contraceptive method during the fertile period. Women should consider whether it is realistic for them to do this before choosing this method.

The effectiveness of cervical mucus monitoring methods in preventing pregnancy is highly dependent on the cooperation of male sexual partner, to abstain or use alternate contraception while the woman is fertile. It may therefore be useful for a woman who chooses to use cervical mucus monitoring methods to visit a family planning clinic with her sexual partner, so that both can learn about the method from a health professional.

Patients who wish to use an alternative method (usually a barrier method rather than abstain during the fertile period, should discuss their options with a health professional. Numerous methods which can be used on demand are available, for example condoms and diaphragms. It is also recommended that women discuss how to use cervical mucus monitoring methods (two of which are outlined below) with a health professional.

Ovulation method

The ovulation method (also called the Billings method) requires a woman wishing to prevent pregnancy to monitor both the presence or absence and nature of her cervical mucus. Women using this method should:

Avoid vaginal intercourse on days of heavy menstrual bleeding, as cervical mucus may appear (indicating fertility) on these days but be difficult to detect. Many women believe, incorrectly, that they cannot become pregnant during menstrual bleeding. While the risk is very slight, particularly for women who have regular menstrual cycles, for those who have short cycles or experience extended periods of bleeding, menstrual bleeding can overlap with the fertile period, which begins five days prior to ovulation. This is because sperm can survive in the uterus for as many as five days following ejaculation;Check for cervical secretions every day, in the afternoon, after a period of being upright;Have sex only in the evening, as the presence of semen may make it difficult to detect cervical secretions;Avoid having sex two days in a row in the period between menstrual bleeding and cervical secretions;Consider herself fertile on the day that she notices cervical secretions of any colour or consistency;Continue monitoring cervical secretions from the time they appear, until after the "peak" day. On the peak day cervical mucus will be clear, wet and slippery and after the peak day it will become drier and stickier;Consider herself fertile for three days after the peak day;Avoid unprotected intercourse on fertile days.

Two days methods

The two days method is a simplified cervical mucus monitoring method, which, unlike the ovulation method, does not require a woman to be aware of changes in the nature of her cervical mucus (e.g. colour, consistency). Rather, a woman need only monitor when cervical mucus first appears in her menstrual cycle. Women using this method should:

Monitor their cervical secretions on a daily basis. This can be done using fingers, checking for secretions on underwear, or using a tissue. Women should be aware that the presence of semen or menstrual blood may make assessing the presence of cervical mucus more difficult; Consider themselves fertile when they find cervical secretions on two consecutive days;Consider themselves fertile until they have not experienced cervical secretions for two consecutive days (that is, until they have two dry days);Use an alternative contraceptive method or abstain from intercourse in the fertile period.

When used correctly, the two days cervical monitoring method is 96% effective in preventing pregnancy in the first year of use, while the ovulation method is 97% effective. In addition, research indicates that women become more confident with the monitoring process over time, and this may increase effectiveness in the long term. The effectiveness of both methods decreases if they are not used correctly (e.g. if unprotected intercourse occurs in the fertile period).

The benefits of cervical monitoring methods include:

They are natural and do not cause side effects;They do not require any special devices or procedures and do not cost anything;Women become more knowledgeable about their menstrual cycle when they use the method;The are suitable for women with irregular cycle lengths (cycle <26 days or >32 days) who cannot used calendar based methods;The two days method is simple and requires minimal monitoring of cervical mucus changes.

The limitations of cervical mucus monitoring methods include:

Women must monitor changes in their cervical mucus on a daily basis in order to use the methods effectively. This makes the methods inappropriate for some women (e.g. those who have unusual vaginal discharge or are not comfortable checking for secretions or, for the ovulation method, those who are unable to check at certain times of the day) and difficult to use during some stages of the menstrual cycle (e.g. days of heavy menstrual bleeding);The ovulation method requires women not only to monitor for the presence of cervical mucus but also to note changes in its consistency, and is therefore more difficult than the two days method to use;The ovulation method may require changes to sexual practice (e.g. not having sex two days in a row in the first half of the menstrual cycle and only having sex in the evenings);Additional contraceptive methods or abstinence are required if couples wish to have vaginal intercourse in the fertile period;The methods do not protect against sexually transmitted infections (STIs), Women who have sexual partners of unknown STI status should, whenever possible, use male or female condoms?to protect against STIs.

For more information on different types of contraception, male and female anatomy and?related health issues, see?Contraception.

World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from:? www.who.int/entity/reproductivehealth/publications/family_planning/en/Germano, E. Jenning, V. New approaches to fertility awareness based methods: incorporating the standard days and two days methods into practice. J Midwifery Women’s Health. 2006;51:471-7.International Planned Parenting Federation. Fertility Awareness. 2009. [cited 2009, November 5] Available from: http://www.plannedparenthood.org/health-topics/birth-control/fertility-awareness-4217.htm

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