High blood pressure and how to lower it

Hypertension is common, but in some cases it is caused by other conditions such as kidney disease, for which investigations are needed to confirm the diagnosis.

Hypertension is one of the most modifiable and undertreated risk factors for preventable deaths. This editorial highlights the need for improved measurement standards, lower treatment targets and greater use of combination therapy, all anticipated in Australian guidelines currently being updated and expected in 2026.

High blood pressure during pregnancy may be due to pre-eclampsia. Management requires balancing the risk of harm for the mother with the welfare of the fetus.

Accurately measuring blood pressure is imperative for the diagnosis and management of hypertension. This article summarises different methods and devices for measuring blood pressure, and factors that influence measurement accuracy.

Amputations are caused by both medical conditions and trauma. Medical conditions resulting in amputation are often those that restrict blood flow to extremities, usually by atherosclerosis forming in the arteries. This can be from conditions such as diabetes, hypertension, hypercholesterolaemia and renal failure.

Download: Diagnosing Menopause | Information Sheet Key PointsMenopause is the final period in a woman’s life.Perimenopause is usually diagnosed clinically on the basis of new onset vasomotor or other symptoms and a change in the pattern of menstrual bleeding. Menopause is diagnosed 12 months after the final menstrual period.The average age of menopause is 51. Early menopause is defined as menopause occurring between 40-45years and premature ovarian insufficiency (POI) prior to age 40.Measuring oestradiol or FSH is generally not indicated because of marked daily fluctuations.A symptom score sheet can be helpful in measuring the severity and impact of symptoms and assessing response to any intervention.DON’TMeasure FSH, LH, AMH (anti-Müllerian hormone), oestradiol or testosterone, inhibin A or B (which inhibit FSH production) levels and antral count or ovarian volume in a woman with symptoms at the normal age for menopause (over 45 years) because these results are unlikely to change your management. The indications for intervention are clinical.BUT for premature menopauseWhich is defined as occurring before the age of 40 and is designated as ‘Premature Ovarian Insufficiency’ (POI).Measurement of FSH is indicated in women under 40 and 40-45 with menopausal symptoms. Premature menopause is diagnosed by elevated FSH levels on two occasions, 4-6 weeks apart.DO take a historyMenopausal symptoms – the multiplicity of which are identified in the Greene scale below is a useful standardised symptom measurement system.Vasomotor symptoms cause sleep disturbance. Ask about severity and number.Sleep disturbance is a major factor affecting quality of life. Identify the impact of sleep disturbance.Record personal medical history and risk factors for breast cancer, cardiovascular disease, thromboembolic disease and osteoporosis.Ask about absolute or relative contraindications to MHT: uncontrolled hypertension, undiagnosed abnormal bleeding, previous breast or endometrial cancer and personal history or high inherited risk of thrombo-embolic diseaseEnsure that screening (breast, cervical) is up to dateIntroductionFrequently, the woman herself has already made the diagnosis of menopause. She attends her doctor with symptoms such as hot flushes or night sweats interrupting her sleep, together with changes in her menstrual cycle. Not all women with menopausal symptoms will need treatment. Most women will be glad of information about menopause and about the safe and effective treatment options available. The questions we should be asking her are "Why did you come to see me", and "What do you hope to get out of this consultation?"Common questions are:How long does menopause last?When will I be through it?What are the pros and cons of taking menopause hormone therapy (MHT) for me?Can I treat my symptoms naturally?If I do decide to take MHT, for how long should I take it?When am I no longer fertile and when should I stop using contraception?There is a lot of information to give, and even if a menopause information sheet is given, a long appointment will be required to give all the information required and answer questions. Menopausal women often have multiple health issues that need addressing and they may be anxious and tired due to sleep disturbance. Allowing adequate time for the consultation allows her to discuss the issues she is concerned about without feeling rushed.Perimenopause, Menopause or Postmenopause?Perimenopause refers to the time from the onset of menopausal symptoms (some or all of symptoms such as irregular periods, hot flushes, night sweats or sleep disturbance) to 12 months after the last menstrual period1. This can last on average 4 to 8 years. Menopause is the last menstrual period. One year after the last menstrual period the woman is considered "postmenopausal". Peri-menopausal symptoms can occur when periods are still regular, but typically the symptoms worsen in the premenstrual days. The symptoms experienced during the perimenopause are often the most distressing. Menstrual changes are common and it is normal to have periods that are less frequent or irregular. More frequent periods or those that are very heavy may not be normal and suggest that there may be pelvic or systemic pathology.Women older than 40 years with more frequent or heavy bleeding, or intermenstrual bleeding require investigation by their doctor. Hormone levels may fluctuate during this time and measurement of sex steroids is rarely clinically helpful once the diagnosis has been made2. At this time of hormone fluctuation, oestradiol can actually briefly be higher than normal, giving symptoms of excess oestrogen, such as breast tenderness. Explaining to women that, at a time when their body is running out of oestrogen, they may get brief periods of high oestrogen symptoms is useful. (Some women are told that because of these brief periods of high oestrogen they need progesterone treatment but there is no evidence that this is needed). Eventually, symptoms of oestrogen deficiency predominate.Menopause is said to have occurred when there has been no menstruation for one year. If a woman has taken MHT since she was peri-menopausal, it may not be possible to assess the exact age at which she became menopausal. This may also impact on the advice provided about perimenopausal contraception (see AMS information sheet Contraception) If a woman has required peri-menopausal MHT for symptoms, it is a reasonable guess to expect her to be post-menopausal after 4-5 years.PostmenopauseThis starts one year after the last menstrual period. There is no reliable way of predicting how long menopausal symptoms will continue. For many women they resolve within 2-5 years. Ten to 20% of women will have symptoms for up to 12 years. Vaginal dryness and urinary frequency may start during the peri-menopause and tend not to resolve naturally with time. Some women only experience vaginal dryness during sexual activity and others are aware of uncomfortable vaginal symptoms at other times.For those symptomatic women who elect to use MHT, we advise that they be reviewed annually to evaluate ongoing care and the need to continue MHT.Premature menopausePremature menopause is considered to have occurred if a woman is younger than 40 when she becomes menopausal. About 1% of women experience a spontaneous premature menopause (POI or premature ovarian insufficiency) and around another 6% have premature menopause due to surgery, chemotherapy or radiation. There has been relatively little research on symptoms in these women, but it seems that their menopausal symptoms may be more severe than in older women, particularly when menopause occurs due to surgery or chemotherapy. There are also distinct personal, sexual, social and psychological issues for younger women, particularly for those women who wish to have children but have not yet started or completed their families. These women need extra counselling, and time to come to terms with their situation. This is the one time that measuring and finding a high FSH and a low oestradiol is helpful to differentiate between menopause and other causes of secondary amenorrhoea.POI is a pathological condition associated with an increased risk of osteoporosis and fracture, an increased risk of cardiovascular disease, possible cognitive impairment, Parkinson’s disease and reduced life expectancy. It is conventional to treat with MHT at least until the average age of the menopause.There are 3 main identifiable causes of POI: genetic, autoimmune and iatrogenic3Genetic conditions include a strong maternal family history, 45,X, 46,XX and46,XY POI.POI is associated with galactosemia and FMR premutations (e.g., Fragile X)Women with an autoimmune predisposition may develop autoimmune POI, with or without other autoimmune diseases (diabetes mellitus, Addison's, thyroid).Women with iatrogenic menopause includes women with benign disease and those having treatment for cancer (hormonal, chemotherapy and/or radiotherapy) which has brought about an early menopause. In most women the cause of an early menopause is unknown.Early menopause affects 3.7% of African-American women, 2.9% of white women, 2.2% of Chinese women and 0.8% of Japanese women4. About 1 in 1000 women are affected under the age of 305.Lower socioeconomic status has been associated with POI.The measurement of FSH and oestradiol should be repeated at least once (See AMS information sheets Early Menopause Due to Chemotherapy and Spontaneous Premature Ovarian Insufficiency).Symptom assessment and diagnosis at Perimenopause and MenopauseThe time when most women are trying to understand what is happening to them is during the peri- menopause. During this time of hormonal fluctuation women may experience some, but not all of the symptoms listed in the table. For instance, she may come with severe joint aches and tiredness, which may be suggestive of a rheumatological disease. Checking a symptom score will often reveal many more unreported menopausal symptoms.In most cases, recording a symptom score helps to make the diagnosis, at the same time educates the woman and is a basis for assessing efficacy of treatment. Checking FSH or AMH levels or serum oestradiol and progesterone are unnecessary tests in diagnosing menopause for most women.  Checking an androgen profile as a routine on all peri-menopausal women is also unnecessary and costly. Many women come to the consultation expecting a blood test to diagnose menopause, and it is important to explain to them why we use the symptom score rather than a blood test in establishing a diagnosis. It is important to explain to women that the blood tests of FSH/oestradiol can fluctuate on a daily basis and therefore are not useful or necessary. It is especially unhelpful to do hormone blood tests while women are on MHT/OCP – symptoms, not blood levels, guide therapy. Treat the symptoms, not the biochemistry.Symptom score sheetThe Modified Greene Scale6 (see below) can be completed together with the woman, or she can do it herself in the waiting room. The woman judges the severity of her own symptoms and records the score - 1 for mild, 2 for moderate, 3 for severe and 0 if she does not have that particular symptom. A score of 15 or over usually indicates oestrogen deficiency that is intrusive enough to require treatment, but this is only a guide. Women are very variable in their tolerance of discomfort, often tolerating quite severe symptoms before they will even consider taking MHT. Scores of 20-50 are common in symptomatic women, and with adequate treatment tailored to the individual, the score will reduce to 10 or under in 3-6 months.Using the symptom score sheet at subsequent follow-up visits is a useful method of judging whether adequate oestrogen is being taken to alleviate symptoms. Generally, there is a halving of the symptom score after 2-3 months on MHT and if the woman is still experiencing a lot of symptoms, she may require a dose increase. If symptoms still persist, changing from the oral route to transdermal may help if the problem is oestrogen malabsorption.If it's not menopause, what is it?Depression, anaemia and thyroid disorders are the most common conditions that may occur concurrently. Unstable diabetes and hyperthyroidism may cause hot flushes. Medication, such as the SSRI family of anti-depressants, may also cause hot flushes.Doing a blood count, ferritin and/or a TSH level will usually establish the diagnosis. However, if a woman presents with low mood or anxiety, there is a need to evaluate whether this is a primary anxiety/depression or one aggravated by the lack of oestrogen. A previous history of depression or an elevated FSH may help to differentiate between the two. Hair loss may be a sign of iron deficiency or hypothyroidism rather than menopause.Need more information?Diagnosing menopause is something that most GPs are skilled at doing and helping women at this difficult stage of their life can be very rewarding. If you are reading this information sheet because you have inadequate knowledge on how to counsel menopausal women, then consider joining the Australasian Menopause Society and receiving its monthly newsletter, called eChanges. Attend one of our annual meetings, which aim to be of interest to a wide range of doctors, nurses, psychologists and physiotherapists.ReferencesMcKinlay SM et al. The normal menopause transition. Maturitas 1992;14:103.Burger HG. Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications. Menopause Int 2011;17:153.?ükür, Y[anuz]. E., K?vançl?, ?. B., & Özmen, B. Ovarian aging and premature ovarian failure. Journal of the Turkish German Gynecological Association, 2014;15(3):190.Green R et al. Menopausal Symptoms and Ethnicity: the Study of Women’s Health across the Nation. Womens Health (Lond). 2009;5(2):127-33Coulam CB et al. Incidence of Premature Ovarian Failure. Obstet Gynecol 1986;67(4):604-606Greene JG. Constructing a standard climacteric standard. Maturitas 1998;29:25-31 Symptom Score (Modified Greene Scale)

Contraception | Information Sheet  Download: Contraception | Information Sheet Key PointsContraception is required for 12 months after the final menstrual period (FMP) if the FMP occurs after the age of 50. If the FMP occurs before the age of 50, 24 months of contraception is required.Oestrogen - based methods are not recommended over the age of 50 due to cardiovascular risks.The Levonorgestrel IUD (Mirena®) provides effective management of heavy menstrual bleeding as well as contraception and can also be used as part of an MHT regimenWomen in a new relationship should be advised about the use of condoms to prevent sexually transmitted infections.Women should be informed about the availability of the Emergency Contraceptive Pill without a prescription at pharmacies.Fertility declines with age and available data suggest that spontaneous conception for women over age 50 is very rare (1). Pregnancy at the age of 45-49 results in a live birth rate of less than 2 per 1000, while over the age of 50 it is less than 1 per 2000. Despite the low risk in this age group, women should be counselled about the possibility of unintended pregnancy and advised about appropriate contraception.Contraception is required for 12 months after the final menstrual period (FMP) if the FMP occurs after the age of 50 (2). If the FMP occurs before the age of 50, 24 months contraception is required.Amenorrhea is common in perimenopausal women using progesterone-only contraception making it difficult to determine the date of her FMP. In this situation, for women age 50 or older, a single FSH measurement ?30mI U/L will indicate that contraception will be required for a further 12 months, and can then be ceased. If the FSH is ?30mIU/L, contraception should be continued for the next 12 months and FSH to be repeated to check if ?30 at that time (3).The choice of contraception is determined by several factors including the woman’s age, medical eligibility criteria (4), comorbid medical conditions, affordability, and personal choice. Oestrogen-containing methods are not recommended for women over the age of 50. Women of any age with contraindications to oestrogen, such as a history of breast cancer, thromboembolic disorders, complex migraines and heavy smokers should be offered non-hormonal or progestogen-only methods.1.  LONG-ACTING REVERSIBLE CONTRACEPTIVE METHODS (LARC)(a) Levonorgestrel Intrauterine System (hormonal IUS)(i) The Mirena IUD® is inserted into the uterus. It releases levonorgestrel (LNG) 52mg over 5 years (with extended use for contraception up to 10 years if inserted after age 45) (3). It works primarily by thinning the endometrium and thickening of the cervical mucus. It is a highly effective form of contraception (>99% efficacy) (4) and suitable for women with contraindications to oestrogen–containing methods.Women should be warned of possible spotting and bleeding for the first few months. Some women experience progestogen side effects such as acne and mood changes.The Mirena IUD is an excellent option for women around the perimenopause particularly if they are experiencing irregular heavy periods. It also provides endometrial protection for women using MHT; use should not be extended beyond 5 years at any age for this indication.(ii) The Kyleena IUD® is similar to the Mirena® but releases a smaller dose of LNG (19.5mg) over 5 years. The IUD device itself is smaller than the Mirena and is most suitable for nulliparous women who don’t mind having a regular lighter period. Importantly it does NOT provide adequate endometrial protection for women on MHT and is not suitable for women experiencing heavy menstrual bleeding around the time of menopause.In New Zealand, Jaydess® is the lower dose IUS, releasing 13.5mg of levonorgestrel over its use in 3 years.(b) The Contraceptive ImplantThe Implanon NXT® is available in Australia and is a 4cm single rod inserted under the skin of the inner non-dominant arm under local anaesthetic. It releases the progestogen etonorgestrel over a three-year period but can be removed earlier if required. It inhibits ovulation, thickens the cervical mucus and thins the endometrium. The Implanon is available on PBS in Australia.In New Zealand the Jadelle® implant is fully funded. It consists of 2 small flexible silicon rods, each containing levonorgestrel 75mg.The contraceptive implants provide highly >99% effective (5) and are cost-effective. Side effects can include irregular bleeding along with common progestogenic side effects (6). Contraceptive implants should not be used for endometrial protection in an MHT regimen.(c) Copper-bearing IUDThe copper IUD is >99% effective. It is toxic to sperm and can prevent implantation of the fertilized egg. In Australia, three types of Copper IUD are available, Load375® and Copper TT380 Short® which last for 5 years and Copper TT380 Standard®, which is effective for 10 years. As there are no hormones, it is suitable for women concerned about hormone side effects or those with contraindications to hormonal methods.The Copper IUD can cause heavier, longer and more painful periods. In Australia Copper IUDs are not PBS listed with a higher upfront cost that the hormonal IUDs. In New Zealand, Copper IUDs are subsidised and less expensive than the hormonal IUD.2.  MEDIUM ACTING CONTRACEPTION(a) Depomedroxyprogesterone acetate (DMPA) injectionsDMPA injections (Depo-Provera® and Depo-Ralovera®) are progestogen-only injections administered every 3 months into the gluteal or deltoid muscle. It prevents ovulation and is 99.8% (5) effective when used correctly. Most women are amenorrhoeic so it may be helpful for women with heavy menstrual bleeding. As it also suppresses oestrogen production, long term use may result in low bone density or osteoporosis (7). For this reason, it is also less preferred in women over age 45 (7, 8).(b) The Vaginal RingThe vaginal ring (NuvaRing®) is a soft silastic ring containing ethinyl oestradiol and etonorgestrel. It is inserted by the woman herself and left in place for 3 weeks, then removed for a week before a new ring is inserted. Women must remember to remove and replace the ring for it to be effective.The vaginal ring works in a similar principle to the oral contraceptive pill but obviates the need for daily tablet taking.  In perfect use the risk of pregnancy is <1% per year (5). The vaginal rings can be used ‘back-to-back’ for 3 months at a time, to prevent withdrawal bleeding. It can also provide better regulation of the menstrual cycle for women who experience breakthrough bleeding with combined oral contraceptive pill (COCP).The vaginal ring has the same contraindications as COCP (see below). It is not PBS listed so the cost may be a deterrent for some women. 3.  SHORT ACTING CONTRACEPTION(a) The Combined Oral Contraceptive Pill (COCP)The COCP contains both oestrogen and progestogen hormones. It works primarily by inhibiting ovulation but also thickens cervical mucus and thins the endometrium with >99% efficacy with perfect use (93% in typical use) (5). Active hormone pills can be taken continuously for up to 12 months to reduce menstrual blood loss. There is some data that suggest a reduction in the risk of ovarian and endometrial cancer with COCP use.The COCP should not be used in women with contraindications to oestrogen (e.g. women with a history of breast cancer, VTE, migraine with aura and smokers over the age of 35 year). The COCP is associated with an increased risk of VTE by approximately 2-fold (8) (although the absolute risk for most women is very low). The COCP is not recommended for women over the age of 50 because of increased cardiovascular risk. For women with additional risk factors such an elevated BMI, a history of diabetes or hypertension, consideration should be given to cease the use of COCP at an earlier age.(b) The progestogen-only pill (POP) or “minipill”The progestogen-only pill contains a small dose of progestogen and primarily works by thickening cervical mucus. It can be used by women with contraindications to the use of oestrogen who prefer an oral method. There is no increased risk of thromboembolic events.Most POPs must be taken within a three-hour time frame each day for it to be effective, although the newer Drospirenone-containing Mini-Pill (Slinda®) has a 24-hour window (10).In New Zealand, Cerazette® is the only POP available and has a 12-hour window of use.Similar to contraceptive implants, POPs should not be used for endometrial protection in an MHT regimen.4.  COITALLY DEPENDENT BARRIER METHODSThe barrier methods require ‘action’ with every act of sexual intercourse, which results in lower effectiveness in typical use than other contraceptive methods. Condoms, both male and female (now also referred to “external” and “internal” condoms respectively), are the only method of contraception that can prevent STIs.(a) Contraceptive DiaphragmThe diaphragm Caya® is a barrier method which the woman inserts herself, to cover the cervix to prevent sperm reaching the uterus. It must be left in place for a minimum of 6 hours after intercourse to allow sperm to be killed off by the vaginal acidity. The single size diaphragm has a lifespan of two years; the manufacturer recommends the use of a lactic acid buffer gel with the diaphragm (note that spermicide is not available in Australia).The diaphragm may be associated with urethal irritation and a risk of urinary tract infection (10). Some women find it difficult to insert and there is a risk of incorrect placement.(b) Male CondomThe male condom is a fine latex or polyurethane sheath, worn on the erect penis. It can be used with a water-based lubricant which may be useful for women experiencing perimenopausal vaginal dryness.  Condoms have a relatively high failure rate in typical use (especially in ‘new users’) due to the need for consistent use and the risk of breakage, slippage or leakage (98% effective in perfect use and 88% in typical use) (4). Some men and some women believe they interfere with sexual pleasure.(c) Female CondomThe female condom is a polyurethane sheath inserted into the vagina prior to intercourse. It is less commonly used than other forms of contraception. They are more expensive than male condoms and have a slightly higher failure rate. They can be purchased online at family planning clinics and also at some pharmacies. More information here: here5.  EMERGENCY CONTRACEPTIONEmergency contraception (previously known as “the morning after pill”) is used to prevent pregnancy after unprotected intercourse or contraceptive failure.(a) Single 1.5mg levonorgestrel emergency contraceptive (LNG-ECP) tabletThe LNG-ECP contains 1.5mg levonorgestrel and is recommended for use up to 72 hours after unprotected intercourse; it has some effectiveness if taken up to 120 hours after unprotected intercourse.   It is available over the counter without a prescription. It acts by preventing or delaying ovulation.  It can be used by breastfeeding women and can be used multiple times in a cycle if needed.(b) Single 30mg ulipristal acetate (UPA) tabletUlipristal acetate is a selective progesterone receptor modulator (SPRM) which works to prevent or delay ovulation even when the LH surge has begun.   It can be used up to 120 hours after unprotected intercourse with superior efficacy to LNG-EC. Breastfeeding women are advised to express and discard breastmilk for one week after taking UPA. Women using progestogen containing contraception should seek medical advice on when to start or re-start the method after taking UPA as UPA can reduce the effectiveness of hormonal contraception.(c) Copper IUDIf inserted within five days of unprotected intercourse, the copper IUD provides highly effective ongoing long-term contraception. However, it can be difficult to access within the appropriate time frame.6.  PERMANENT(a) Tubal ligation or Salpingectomy (female sterilization)Tubal ligation or salpingectomy are carried out under general anaesthetic either laparoscopically or during laparotomy.  It may be appropriate for women undergoing laparoscopy for other reasons or at the time of a Caesarian Section.  It may be appealing for women concerned about side effects of other contraceptive methods.  (b)Vasectomy (male sterilization)Vasectomy is a surgical procedure, usually performed under local anaesthetic, during which the vas deferens is cut so that no sperm will enter the ejaculate. It allows the male partner to take responsibility for contraception. Couples should be advised ongoing contraception is required for 3 months after the procedure, at which time a follow-up semen analysis is performed to confirm azoospermia. There is a small risk of haematoma, infection, sperm granuloma and rarely post-vasectomy pain syndrome.ReferencesTrussell J et al. Sterility in a population with natural fertility. Population Studies 2010;39(2):269–86Sauer MV. Reproduction at a advanced maternal age. Fertility Sterility. 2015; 103(5):1136-43Faculty or Sexual and Reproductive Healthcare. FSRH Guideline for women aged over 40 years. Contraception for Women aged over 40 years. FSRH Clinical Effectiveness Unit; 2017(Amended 2019). https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/Pearson S et al. Long Acting Reversible Contraceptives. AJGP 2022;51(4)Faculty of Sexual & Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. FSRH, 2019.Sexual and Reproductive Health Experts Group. In: Therapeutic Guidelines.  Melbourne: Therapeutic Guidelines Limited;2020.   Available online at:https://tgldcdp.tg.org.au/guideLine?guidelinePage=Sexual+and+Reproductive+Health&frompage=etgcomplete (subscription required) (accessed March 2022)Rocca ML et al. Safety and Benefits of Contraceptive Implants: A Systematic Review Pharmaceuticals (Basel). 2021; 14(6): 548Albertazzi P et al. Bone Mineral Density and Depot medroxyprogesterone acetate. Contraception 2006; 73(6):577-83Royal College of Obstetricians and Gynaecologists. Contraception for Women Aged Over 40 Years. In: Faculty of Sexual & Reproductive Healthcare Clinical Guidance, editor. 2010Dragoman MV et al. A systematic review and meta?analysis of venous thrombosis risk among users of combined oral contraception. Int J Gynaecol Obstet.2018 Jun; 141(3): 287–294 https://doi.org/10.1002/ijgo.12455.Bateson D et al. Drospirenone 4mg: A new progestogen only pill. Medicine Today 2021; 22(12):56-59Allen RE. Diaphragm Fitting. Am Fam Physician. 2004 Jan 1;69(1):97-100  Table 1:   Contraceptive methods Effectiveness (%)HormonesAdvantagesDisadvantagesOther comments Perfect useTypical use    Tubal ligation>99.5>99.5NilImmediate effectRequires hospital admission and surgery Vasectomy99.599.5NilPerformed under local anaestheticSmall risk of infection and sperm granulomaNeed semen analysis at 3 months to ensure azoospermiaMirena® IUD>99>99Progestogen onlyReduces menstrual loss.Cost effective.Suitable for women with contraindications to oestrogen.Irregular bleeding or spotting may occur in first few months.Some women have progestogenic side effectsProvides endometrial protection for women on MHT. Kyleena® IUD>99>99Progestogen onlySmaller dose of progestogen than Mirena®.Cost effective.  Suitable for women with contraindications to oestrogen Does not provide endometrial protection for women on MHT.Not suitable for women with heavy bleeding around time of menopause.Implant>99>99Progestogen onlyCost effective.Suitable for women with contraindications to oestrogen.20% of women have prolonged or heavy bleeding.  Copper IUD>99>99NilHormone free.Cost effective.Periods may be heavier and more painful DMPA injections>9996Progestogen onlyUseful for women with heavy mensesReduces bone densityNot recommended for women > 45Combined oral contraceptive pill(COCP)>9993Oestrogen and progestogenConvenienceNot suitable for women with VTE of complex migraines.Not recommended for women > 50.Consider ceasing by age 45 if cardiovascular risk factors.Vaginal ringNuvaRing®>9993Oestrogen and progestogenWorks same as the COCP but no tablet takingSame as for COCPSame as for COCPProgestogen only Mini Pill>9993Progestogen onlySuitable for women with contraindications to oestrogenMust be taken daily within a 3 hour time frame Diaphragm8682NilHormone free.Prevents STI’sRisks of urethral irritation, UTI and incorrect placement Male condom9888NilHormone free.Prevents STI’sWidely available.Some feel it interferes with sexual pleasure Female condom9579NilHormone freePrevents STI’sDifficult to find; purchased onlinenot commonly used in Australia (? NZ) Table 2:   Emergency contraception HormonesAdvantagesDisadvantagesOther commentsLevonorgestrel (LNG- EC)ProgestogenReadily available at pharmacies without a prescription.Very safe with few side effectsDoes not provide ongoing contraceptionIdeally take within 72 hours of intercourseUlipristal acetate(EllaOne®)Progesterone receptor modulator Does not provide ongoing contraceptionCan be used for up to 120 hours after intercourse.  Don’t use with LNG-EC within the same cycle.Superior efficacy to LNG-EC. Copper IUDNilHighly effectiveContraceptive effect is ongoingDifficult to access within appropriate time frame