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  1. 1. Contraception The way to evidence
  2. 2. A 42 year‑old woman P5+1 was wearing an IUD for 6 months ,that was removed 2 months ago because of partial expulsion(2nd expulsion)
  3. 3. <ul><li>She is diabetic for 21 years </li></ul><ul><li>Husbanded refuses condom, coitus interrupts or vaginal tablet </li></ul><ul><li>She is seeking for another effective contraceptive method </li></ul><ul><li>What is the best advice ?? </li></ul>
  4. 4. What Is The Best Advice ?? The most suitable& effective? <ul><li>A- E/P vaginal ring: Nuva Ring </li></ul><ul><li>B- Progestagen implant: Implanon </li></ul><ul><li>C:Levonorgestrel IUD : Mirena </li></ul><ul><li>D: Depoprovera </li></ul><ul><li>E: Progesagen only pills </li></ul>B
  5. 5. Contraceptive Choice above the age of 40 years <ul><li>Choice is influenced by : </li></ul><ul><li>Frequency of intercourse </li></ul><ul><li>Natural decline in fertility </li></ul><ul><li>Menstrual dysfunction </li></ul><ul><li>Concurrent medical disorders </li></ul><ul><li>Wish for non-contraceptive benefits </li></ul><ul><li>Acceptance of the couple. </li></ul><ul><li>Age of the couple. </li></ul>
  6. 6. No contraceptive method is contraindicated by age alone. RCOG FFPRHC Guidance Grade C 2005 Women aged over 40 years can be advised that:
  7. 7. Women should be counseled for the risks and non-contraceptive benefits of all contraceptive methods. Medical eligibility criteria for contraceptive ( MECC ) WHO 2004
  8. 8. The WHO Medical Eligibility Criteria The WHO Medical Eligibility Criteria for Contraceptive Use provides evidence-based recommendations to ensure that women can select the most appropriate method of contraception without unnecessary medical barriers. RCOG FFPRHC Guidance Grade C 2005
  9. 9. WHO Medical Eligibility Criteria for Contraceptive Use (WHOMEC) 2004 / 2008 Eligibility rather than ineligibility (or contraindication) : 4 Categories
  10. 10. Category 1: The use is unrestricted (Used in any circumstances) Category 2: The advantages outweigh the theoretical or proven risks. ( Generally can be used) Category 3: The risks outweigh the benefit. (Not used unless other appropriate methods are not available or acceptable) Category 4: The use an unacceptable health risk (Method not to be used)
  11. 11. A. E/P vaginal ring: Nuva Ring <ul><li>Review 12 RCTs </li></ul><ul><li>Superior cycle control than COC </li></ul><ul><li>Lower incidence of nausea and breast tenderness </li></ul><ul><li>Roumen. Contraception, 2007 </li></ul>
  12. 12. <ul><li>May be more effective than proper COC use. </li></ul><ul><li>Long-term studies is limited: but expected that benefits and risks are similar to COC. </li></ul><ul><li>Evidence-based guidance A WHO Family Planning Cornerstone 2007 </li></ul>
  13. 13. B. Progestagen Implants: Implanon Norplant and Implanon
  14. 14. The Implanon rod <ul><li>Core: 40% EVA Copolymer </li></ul><ul><li>60% Etonogestryl </li></ul><ul><li>Membrane: 100% EVA </li></ul><ul><li>EVA: Ethylene Vinyl Acetate </li></ul>
  15. 15. Applicator Obturator cannula
  16. 16. <ul><li>Alleviate menorrhagia, dysmenorrhea & PMT </li></ul><ul><li>Reduce the size of fibroid </li></ul><ul><li>Regression of endometriosis </li></ul><ul><li>Regression of endometrial hyperplasia </li></ul><ul><li>Endometrial protection in HRT. </li></ul><ul><li>Prevention of PID </li></ul><ul><li>Can be left up to 7 years (Normal = 5 y) </li></ul><ul><li>Particularly useful for the perimenopausal woman </li></ul>C. Mirena®
  17. 17. D. Injectables NET-EN and DMPA
  18. 18. C. Progestin only pills (POP)
  19. 19. WHO Medical Eligibility Criteria: Diabetes IUD Mirena PO Implant PO Injectable POP E+P P - I - R 1 1 1 1 1 History of G. Diabetes 2 2 2 2 2 Uncomplicated Diabetes 2 2 2 2 3 Diabetes + other Risk factor 2 2 3 2 4 1-Vascular Diabetes (Nephropathy, Retinopathy, Neuropathy) 2-Diabetes >20 years
  20. 20. What Is The Best Advice ?? <ul><li>A- E/P vaginal ring: Nuva Ring : Eligibility 4 </li></ul><ul><li>B- Implanon Eligibility 2.& FR 0.0- 0.05HWY </li></ul><ul><li>C:Levonorgestrel IUD : Mirena Previous 2 expulsions </li></ul><ul><li>D: Depoprovera Eligibility 3 </li></ul><ul><li>E: Progesagen only pills E ligibility2 & FR:0.5-5HWY </li></ul>B