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No 329-Consensus canadien sur la contraception (4e partie de 4) : chapitre 9 – contraception hormonale combinée

      Résumé

      Objectif

      Mettre à la disposition des fournisseurs de soins des lignes directrices concernant le recours à des méthodes contraceptives pour prévenir la grossesse et la promotion d’une sexualité saine.

      Issues

      Efficacité globale des méthodes contraceptives citées : évaluation de l’innocuité, des effets indésirables et de la baisse du taux de grossesse; effet des méthodes contraceptives citées sur la santé sexuelle et le bien-être général; disponibilité des méthodes contraceptives citées au Canada.

      Résultats

      Des recherches ont été effectuées dans MEDLINE et la base de données Cochrane afin d’en tirer les articles en anglais publiés entre janvier 1994 et décembre 2015 traitant de sujets liés à la contraception, à la sexualité et à la santé sexuelle, dans le but de mettre à jour le consensus canadien sur la contraception paru de février à avril 2004. Nous avons également passé en revue les publications pertinentes du gouvernement canadien, ainsi que les déclarations de principes issues d’organisations compétentes vouées à la santé et à la planification familiale.

      Valeurs

      La qualité des résultats a été évaluée au moyen des critères décrits par le Groupe d’étude canadien sur les soins de santé préventifs. Les recommandations quant à la pratique sont classées en fonction de la méthode décrite dans le rapport du Groupe.

      Déclarations sommaires

      • 1.
        Bien que très efficace en utilisation parfaite, la contraception hormonale combinée, qui comprend les contraceptifs oraux combinés, est associée à un taux d’échec pouvant atteindre 9 % dans le contexte d’une utilisation typique (II-2).
      • 2.
        Selon la majorité des études retenues, l’efficacité des contraceptifs oraux combinés ne serait pas inférieure chez les femmes obèses; on ne peut toutefois pas écarter la possibilité d’une légère hausse des échecs contraceptifs chez les femmes ayant un indice de masse corporelle supérieur à 30 (II-2).
      • 3.
        Les contraceptifs oraux combinés sont associés à plusieurs avantages non liés à la contraception, notamment une diminution des saignements menstruels, de l’acné, des symptômes associés à l’endométriose ainsi que des risques de cancer de l’ovaire et de l’endomètre (II-2).
      • 4.
        Les contraceptifs oraux combinés (COC) sont associés à un risque accru de thromboembolie veineuse (II-2). Les différences potentielles entre les risques de thromboembolie veineuse associés aux différents types de progestatif et à la dose d’œstrogène dans les COC à faible dose ne suffisent actuellement pas pour appuyer un traitement préférentiel (III).
      • 5.
        Les contraceptifs oraux combinés à faible dose (contenant moins de 50 μg d’éthinylestradiol) ne sont pas associés à un risque accru d’infarctus du myocarde ou d’accident vasculaire cérébral chez les femmes n’affichant aucun autre facteur de risque (II-2).
      • 6.
        Selon de récentes études épidémiologiques, le risque de cancer du sein et de mortalité due au cancer du sein n’est pas plus élevé chez les utilisatrices de contraceptifs oraux combinés (COC) que chez les non-utilisatrices (II-2). L’incidence du cancer du sein pourrait être légèrement plus élevée parmi les utilisatrices de COC actuelles ou récentes (II-2). L’utilisation de COC par les porteuses du gène BRCA1 ou BRCA2 est controversée, mais elle semblerait être associée à une diminution du risque de cancer de l’ovaire et ne pas augmenter pas le risque de cancer du sein (II-2).
      • 7.
        Les contraceptifs oraux combinés (COC) sont associés à une diminution du risque de cancer de l’ovaire, de cancer de l’endomètre et de cancer colorectal (II-2). Une association potentielle a été observée entre l’utilisation de COC et le risque de cancer du col de l’utérus (II-2), mais aucun lien de causalité n’a été établi.
      • 8.
        La prise de la tension artérielle est le seul examen nécessaire avant l’instauration d’une contraception hormonale combinée (CHC) chez les femmes en bonne santé (II-2). La mesure du poids et de l’indice de masse corporelle de départ peut aider à suivre les changements chez les utilisatrices. Il n’est pas nécessaire de procéder à un examen pelvien, à un test Pap, à un dépistage des infections transmissibles sexuellement ou à un dépistage de la thrombophilie avant l’instauration d’une CHC (III).
      • 9.
        Les contraceptifs oraux combinés et les autres méthodes de contraception hormonale combinée (CHC) peuvent être instaurés à n’importe quel moment durant le cycle menstruel, à condition qu’on puisse exclure raisonnablement toute grossesse ou possibilité de grossesse. En cas d’incertitude, il est tout de même probable que les avantages de l’instauration de la CHC surpassent les risques (III).
      • 10.
        L’instauration immédiate de la contraception hormonale combinée (méthode dite du « démarrage rapide ») peut favoriser l’observance à court terme et n’est pas associée à une augmentation des saignements non prévus ou d’autres effets indésirables (I).
      • 11.
        Le risque d’ovulation est à son maximum lorsque l’ISH se prolonge au-delà de sept jours en raison d’un report de la prise de la contraception hormonale combinée (CHC) ou de l’oubli de doses actives durant la première ou la troisième semaine (I). L’ovulation se produit rarement après l’utilisation d’une CHC pendant sept jours consécutifs (II-2).
      • 12.
        Le recours à une contraception d’urgence (CU) et à une contraception d’appoint peut être nécessaire dans certains cas d’oubli de doses de contraception hormonale combinée (CHC), en particulier si l’intervalle sans hormone se prolonge au-delà de sept jours. Une CU est rarement indiquée lorsque l’oubli se produit durant la deuxième ou la troisième semaine du cycle, sauf en cas d’oublis répétés ou de l’omission d’utiliser une contraception d’appoint après l’oubli de doses (III).
      • 13.
        L’exposition à des contraceptifs oraux combinés juste avant ou durant la grossesse n’est pas associée à une augmentation du risque d’anomalies congénitales majeures (II-2).
      • 14.
        L’efficacité de la contraception hormonale combinée (CHC), notamment des contraceptifs oraux combinés, peut être affectée par d’autres médicaments, notamment certains anticonvulsivants, certains antirétroviraux, la rifampicine et la griséofulvine. De même, les médicaments de CHC peuvent avoir un effet sur le taux sérique d’autres substances, notamment de certains anticonvulsivants et antirétroviraux (II-2).
      • 15.
        Le timbre contraceptif pourrait être moins efficace chez les femmes de ≥90 kg (II-2).
      • 16.
        En comparaison avec les contraceptifs oraux combinés, le timbre contraceptif transdermique est associé à moins de métrorragie et de microrragie, mais à davantage d’inconfort et de douleurs mammaires, de nausées et de vomissements ainsi que de dysménorrhée (I).
      • 17.
        Selon des études pharmacocinétiques, le timbre contraceptif transdermique maintient les concentrations sériques d’éthinylestradiol et de norelgestromine à des niveaux permettant d’inhiber l’ovulation pendant au moins neuf jours d’utilisation continue (II-2).
      • 18.
        L’anneau vaginal contraceptif est associé à moins de saignements non prévus que les contraceptifs oraux combinés ainsi qu’à des saignements menstruels de durée significativement plus courte que le timbre contraceptif (I).
      • 19.
        Les taux sériques d’éthinylestradiol et d’étonogestrel sont maintenus à des niveaux permettant d’inhiber l’ovulation pendant au moins 28 jours après l’insertion de l’anneau vaginal contraceptif (II-2).
      • 20.
        Les schémas de contraception hormonale combinée (CHC) continus et de longue durée sont associés à des taux d’observance et d’efficacité semblables à ceux des schémas cycliques de 28 jours (I).
      • 21.
        Les schémas de contraception hormonale combinée (CHC) continus et de longue durée sont associés à une diminution significative des symptômes de menstruations par rapport aux schémas cycliques (I). Avec les schémas C/LD, les saignements et la microrragie diminuent à chaque cycle; leur incidence est semblable ou inférieure à celle associée aux schémas cycliques (I).

      Recommandations

      • 1.
        Dans l’offre de counseling aux patientes, les fournisseurs de soins devraient fournir des instructions claires concernant la contraception hormonale, notamment sur la marche à suivre en cas d’oubli de doses. Il faut offrir aux femmes des ressources à consulter en cas d’oubli ou de retard dans la prise de doses de contraceptif hormonal, ou encore de signes d’incident thérapeutique grave (III-A).
      • 2.
        Les fournisseurs de soins devraient envisager de conseiller aux femmes de commencer immédiatement (méthode dite du « démarrage rapide ») la contraception hormonale combinée (CHC), à condition qu’ils puissent exclure raisonnablement toute possibilité de grossesse. Les femmes doivent avoir recours à une contraception d’appoint (méthode de barrière) ou à l’abstinence pendant les sept premiers jours d’utilisation de la CHC, à moins que le traitement ait été instauré au premier jour des menstruations (I-A).
      • 3.
        Si une utilisatrice de COC se présente avec des saignements non prévus persistants, les fournisseurs de soins devraient envisager les possibilités suivantes : manque de régularité dans la prise des pilules, utilisation concomitante de médicaments, malabsorption, pathologies de l’utérus ou du col, grossesse ou infection à chlamydia (III-A).
      • 4.
        En cas d’oubli d’une dose de contraceptifs oraux combinés ou de toute autre méthode de contraception hormonale combinée (CHC) durant la première semaine d’utilisation, il faut avoir recours à une contraception d’appoint ou à l’abstinence jusqu’à ce que la CHC ait été utilisée pendant sept jours consécutifs. Si l’oubli survient au cours de la deuxième ou de la troisième semaine du cycle de contraception hormonale, l’intervalle sans hormones devrait être éliminé. (III-A)
      • 5.
        Une contraception d’appoint devrait être utilisée à la suite de l’oubli de trois doses consécutives de contraception hormonale combinée ou plus au cours de la deuxième ou de la troisième semaine du cycle de contraception, et ce, jusqu’à ce que sept jours consécutifs d’utilisation correcte du contraceptif hormonal se soient écoulés. Pour des raisons pratiques, l’intervalle sans hormones prévu devrait être éliminé de ces cycles. (I-A)
      • 6.
        Les fournisseurs de soins devraient être au courant des autres médicaments pris par les utilisatrices d’une contraception hormonale combinée ainsi que des interactions médicamenteuses potentielles qui pourraient affecter les taux sériques et l’efficacité d’un de ces médicaments (II-2A).
      • 7.
        Les professionnels de la santé devraient savoir qu’il est possible d’administrer une contraception selon un schéma continu ou de longue durée et envisager de proposer ce type de schémas aux femmes selon leurs besoins de contraception et leurs préférences personnelles, ou pour des raisons médicales (III-A).
      • 8.
        Il faut renseigner les femmes utilisant un schéma de contraception hormonale combinée continu ou de longue durée à propos des saignements prévus et de la façon de prendre en charge les saignements non prévus et la microrragie (III-A).
      • 9.
        Lorsqu'une femme se fait prescrire un médicament donné, elle devrait être avisée si une substitution par un produit générique est envisagée, et son fournisseur de soins de santé devrait être mis au courant de la substitution, le cas échéant. La patiente devrait avoir le choix d'accepter ou non cette substitution et être informée de toute différence de prix entre les produits considérés (III-B).

      Mots clés

      Sigles:

      AUP (Acétate d’ulipristal), C/LD (Continu et/ou de longue durée), CDC (Centres pour le contrôle et la prévention des maladies), CHC (Contraception hormonale combinée), CIU (Contraceptif intra-utérin), COC (Contraceptif oral combiné), CU (Contraception d’urgence), CYP3A4 (Cytochrome P450-3A4), DIU (Dispositif intra-utérin), DIU de cuivre (Dispositif intra-utérin de cuivre), E2 (17-bêta-œstradiol), E2V (Valérate d’estradiol), ECR (Essai clinique randomisé), EE (Éthinylestradiol), ENG (Étonogestrel), EP (Embolie pulmonaire), FA (Femmes-années), FPV (Fosamprénavir), HDL (Lipoprotéine de haute densité), IDM (Infarctus du myocarde), IMC (Indice de masse corporelle), IP (Indice de Pearl (nombre d’échecs contraceptifs par 100 femmes-années d’utilisation)), ISH (Intervalle sans hormones), ITS (Infection transmissible sexuellement), LNG (Lévonorgestrel), MAE (Médicament antiépileptique), OMS (Organisation mondiale de la santé), PC (Pharmacocinétique), PPS (Pilule de progestatif seul), RSNP (Relation sexuelle non protégée), SHBG (Globuline de liaison aux hormones sexuelles), SIU (sysème intra-utérine), SOGC (Société des obstétriciens et gynécologues du Canada), TARV (Traitement antirétroviral), TEV (Thromboembolie veineuse), TVP (Thrombose veineuse profonde), VIH (Virus de l’immunodéficience humaine), VPH (Virus du papillome humain)
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