Oral contraception in Hong Kong: Experience and advice

Contraception trends

According to results of the Family Planning Association of Hong Kong’s (FPAHK) 2022 territory-wide survey in 1,502 females aged 15–49 years, 57.3 percent practiced contraception every time they had sex. The male condom was the most common principal contraceptive method used by 75.1 percent of respondents, followed by external ejaculation (8.5 percent), contraceptive pills (6.7 percent), intrauterine contraceptive devices (IUCDs; 3.9 percent), and injectable contraceptives (1.6 percent). [FPAHK, press release 15 August 2023]

In 2015–2019, the estimated average annual number of unintended pregnancies in Hong Kong was 28 per 1,000 women aged 15–49 years, with 13 per 1,000 women (46 percent) ending in abortion. [Guttmacher Institute, 2015–2019 Hong Kong data]

“The number of unintended pregnancies in Hong Kong is unsurprising, as nearly half of all sexual activity is not covered by persistent contraception,” commented Leung. “In Chinese society, people don’t talk about contraception, so many don’t know how to use contraceptive pills or even male condoms properly. Lack of correct and consistent contraception is the main reason behind the high rate of unplanned pregnancies.”

Although contraception is underused in Hong Kong, many choices are readily accessible, including male condoms, IUCDs and oral contraception (OC), such as progesterone-only pills (POPs) and combined OC (COC). Low- or ultra-low-dose (ULD) COC pills typically containing ethinylestradiol 30 mcg or 20 mcg and a progestogen can be purchased at health and beauty retailers, pharmacy stores or online. All OC pills have similar efficacy, with a reported failure rate of 0.3 percent within the first year of perfect use. Lower-dose pills are safer, better tolerated, and have equal or higher efficacy than pills containing ethinylestradiol 50 mcg. [Hong Kong Med J 2016;22:231-236]

“In Hong Kong, we typically use low-dose or ULD oestrogen [30 mcg or 20 mcg] COC, which is available over the counter [OTC], while POPs are usually dispensed through doctors or family planning organizations, as their use requires more prior counselling,” said Leung. “Research shows little difference between third- and fourth-generation ULD COC, with similar contraceptive rates, cycle control and bleeding patterns.” [Contraception 2009;80:445-451]

Raising awareness

WCD takes place on 26 September every year, centering around a vision where every pregnancy is wanted.

“As contraception is seldom discussed in Hong Kong, we want to use WCD to increase awareness of available methods,” explained Leung. “We place a particular focus on OC due to the myths surrounding it, which we try to dispel. We also provide education on proper OC use and potential side effects.” (Table)

 

Practical recommendations

Although it is not required, gynaecologists advise medical assessment before starting OC pills. “Upon commencing OC, there may be minor issues such as spotting or irregular bleeding, which may be of sufficient concern for some women to stop taking the pill, leading to further bleeding and pregnancy risk. Seeing a doctor beforehand ensures awareness of potential side effects and clearer understanding of what to expect, which improves compliance. In addition, doctors provide advice on correct OC use, which is important for preventing unplanned pregnancies,” said Leung. [Open Access J Contracept 2016;7:43-52]

Minor side effects such as breast tenderness, fluid retention, nausea, and vomiting associated with OC are transient and tend to subside after 1–2 cycles, while major health hazards such as myocardial infarction (MI), stroke, venous thromboembolism (VTE), breast and cervical cancer are rare. Although some meta-analyses have identified an increased risk of MI, stroke and VTE, the absolute risk of these vascular complications is very low due to their very low baseline incidence in women of reproductive age (MI: 0.2/100,000 at 30–34 years of age and 2.0/100,000 at 40–44 years of age; stroke: 1/100,000 at 30–34 years of age and 1.6/100,000 at age 40–44 year of age; VTE: 2/10,000 women at reproductive age). [Hong Kong Med J 2016;22:231-236]

“We recommend mild painkillers in case of headaches in the first few cycles of OC, as the body adapts to hormones. If nausea and headaches persist after three cycles of OC, we suggest taking contraceptive pills at night or with meals,” advised Leung. “I also recommend keeping pills at home and taking them at the same time every day, just before bed or first thing in the morning, to foster compliance.”

Apart from potential side effects, COC pills have noncontraceptive benefits, including menstrual regulation and relief of dysmenorrhoea, and lower incidence of gynaecological diseases such as endometriosis, pelvic inflammatory disease, and ectopic pregnancy. [Hong Kong Med J 2016;22:231-236] “As a gynaecologist, I frequently prescribe OC to control heavy menstrual flow, painful periods and endometriosis. In some cases, OC may reduce the risk of iron-deficiency anaemia,” said Leung. [Nutrients 2021;13:2340]

Final thoughts

“As it is rarely discussed in our society, doctors should take every opportunity to educate female patients on contraception, including at routine gynaecological check-ups and HPV vaccinations. The need for contraception to avoid unplanned pregnancy needs to be emphasized, as termination is traumatic to both mind and body,” advised Leung. “When discussing contraceptive methods to facilitate informed choices, we should dispel myths associated with OC pills. I always tell patients that contraceptive pills had to pass many safety tests to be freely available OTC and the benefit they bring outweighs the risk.”