Download to read offline
Concepts of contraception updated version
- 1. Cafeteria approach to Contraceptives Dr.M.Mahalakshmi MS.,DNB,MRCOG., Asst. Professor ISO- Govt KGH Dr. A.Geethalakshmi DGO,DNB(OG) Registrar ISO- Govt KGH
- 4. MEDICAL ELIGIBLILITY CRITERIAFOR CONTRACEPTIVES
- 5. Case- 1 19yr old unmarried presents to discuss regarding contraception No significant medical history, Does not take any medications regularly Sexually active with male partners How are u going to approach her? What contraceptive do you recommend?
- 6. 50% adolescents aresexually active but only 22% are aware of safe sex practices Counsel and ensure access to broad range of contraceptives Short-acting methods : oral contraception, injectables and male condoms - most adolescent method use CDC : sexual history taking include the “5Ps”: Partners, Practices, Protection from STIs, Past history of STIs, and Pregnancy Prevention
- 7. LARC (Longacting reversible contraceptives) ? Is it safe to use intrauterine devices in adolescent ? YES: The ACOG, CDC, and the Society of Family Planning support the use of LARC by adolescents
- 8. Is there anycomplication with IUD use ? PID STI Future infertility Uterine perforation Difficult insertion Intrauterine Device Expulsion AUB
- 9. The riskof PID with IUD placement is 0– 2% when no cervical infection is present 0–5% when insertion occurs with an undetected infection With long-term use, levonorgestrel IUDs may lower the subsequent risk of PID by thickening cervical mucus and thinning the endometrium
- 10. STI Screening? CDC: Should be screened for gonorrhea and chlamydial infection at the time of IUD insertion Appropriate to screen for STIs and place an IUD on the same day. Routine antibiotics? Routine antibiotic prophylaxis is not recommended at the time of IUD insertion If an STI is diagnosed after the IUD is in place, it may be treated without removing the IUD Dual method should be practised to avoid STD
- 11. The riskof uterine perforation for adolescents - approximately 0.1% IUD expulsion rates range from 2% to 10% for all IUD users Do Intrauterine Devices Increase an Adolescent’s Risk of Infertility ? Infertility is not more likely to occur after IUD discontinuation than after discontinuation of other reversible methods of contraception Baseline fecundity returns rapidly after IUD removal
- 12. Is it difficultinsert Intrauterine Devices in Adolescents and Nulliparous Women? Not been shown to be more difficult in adolescent or in nulliparous patients compared with parous women. In a cohort of 1,177 adolescents and women aged 13–24 years, successful IUD placement was achieved on first attempt in 96% of patients. Provision of additional analgesia during IUD insertion should be individualized and may include NSAIDs, narcotics, anxiolytics, or paracervical blocks. Misoprostol should not be routinely used before IUD insertion
- 13. The Contraceptive Implant Has minimal or no effect on bone density or weight Changes in bleeding patterns is the most common reason for implant discontinuation
- 14. NACO: ABCapproach in promoting safe sex practices among adolescents A- Abstinence, delay the first sexual activity B- Being faithful, involving with single partner in a monogamous relationship C- Condom, correct and complete use to protect against HIV, STI, unwanted pregnancy
- 15. Patient decideson Depo Provera What about bone density? WHO(2005) : No restriction on the use of DMPA in women aged 18–45 years, including no restriction on the duration of use.
- 16. Adolescent withPCOS COC is the choice
- 17. Case 2 A26yr old married for 5 months wants to postpone her pregnancy for 1-2yr Presently using condoms but she wants more reliable method Frequent traveller and used to have irregular cycles sometimes with heavy flow What additional information do you want Which contraception will you suggest?
- 18. Details ofM/H Assessment of medical eligibility Assessment of medical history & life style factors Hypertension ? or VTE ? H/O of migraines with aura A drug history Family H/o thrombotic disorder General & Pelvic examination Her BMI is 24kg/m2. She has mild asthma not on any medication and has family h/o of HTN
- 19. Perfect use:(following directions for use) the failure rate is 0.3% Typical use: (actual use including inconsistent or incorrect use) is 9%. FSRH 2020
- 20. How do youprescribe CHC? Do you think all the regimens are equally efficacious? FSRH Guideline CHC 2019
- 21. What are theadvantage of this tailored regimen? Reduced frequency of menses Control HMB & dysmenorrhoea Decrease in frequency of withdrawal bleeds and associated symptoms (e.g. headache, mood change) is reduced
- 22. If she isobese or overweight? Intrauterine IUD/IUS and ENG implant recommended first line if BMI >25 Combined Hormonal contraception MEC 2 if BMI 30-34 MEC 3 if BMI >34
- 23. Case 3 26 yrNulligravida desires contraception Not planning childbearing in near future Currently using condoms P/H: SLE, anemia, dysmenorrhea,PE, sickle trait Meds: HCQ ,immunosupressant, prednisolone, lisinopril, atorvastatin, omeprazole What contraceptive would you recommend?
- 24.
- 26. CHC use andRisk of VTE
- 27. Case 4 30yr Primigravida at 36 weeks gestation seen for routine prenatal care Would like to discuss postpartum contraception Plans to breastfeed Desires future fertility What are your recommendations?
- 28.
- 29. IMPLANON (etonogestrel implant)is a progestin-only, soft, flexible implant preloaded in a sterile, disposable applicator for subdermal use. The implant is off-white, non-biodegradable and 4 cm in length with a diameter of 2 mm (see Figure 22). Each implant consists of an ethylene vinylacetate (EVA) copolymer core, containing 68 mg of the synthetic progestin etonogestrel, surrounded by an EVA copolymer skin. Once inserted subdermally, the release rate is 60 to 70 mcg/day in Week 5 to 6 and decreases to approximately 35 to 45 mcg/day at the end of the first year, to approximately 30 to 40 mcg/day at the end of the second year, and then to approximately 25 to 30 mcg/day at the end of the third year.IMPLANON is a progestin-only contraceptive and does not contain estrogen. IMPLANON does not contain latex and is not radio-opaque.
- 31. Case 5 23yr married 3months ago comes in to get emergency contraception. She had unprotected intercourse last night. Her LMP started 12 days ago she has a regular monthly cycle. She doesn’t take any medications. Her BMI is 32kg/m2 What if she presents 4 days later? How do you follow her up?
- 32.
- 33. No restrictionsfor the medical eligibility of who can use ECPs ECPs were found to be less effective in obese women (BMI> 30 kg/m2) Should not be used repeatedly do not harm future fertility no delay in the return to fertility MEC category 3 or 4 (with current PID, puerperal sepsis, unexplained vaginal bleeding, cervical cancer, or severe thrombocytopenia) should not use a copper IUD as EC IUCD can be inserted upto 4 days after ovulation i.e. day 19 in 28 days cycle FOLLOWUP: 3-4weeks after or anytime in between in case of abdominal pain/bleeding P/V
- 34. Case 6 43-year-old womanpresented with complaints of heavy and irregular menstrual periods 10 kg weight gain in the past year, and acne She was not using any contraceptive method. Biopsy revealed a disordered proliferative endometrium
- 35. Which methodsof contraception are safe and suitable for her When contraception should be stopped If she wants MHT ?
- 36. Counselling ? Naturaldecline in fertility with age Should be counselled about effective contraception until menopause or age 55 years, whichever occurs first She needs contraception with non-contraceptive benefits Age-related increased background risk of cardiovascular disease, obesity and of breast and most gynaecological cancers which may affect choice of contraceptive method.
- 37. Combined hormonalcontraception ? CHC (pill, patch and vaginal ring) are suitable until the age of 50, so long as there are no health risks (e.g. smoking, obesity, high blood pressure) FSRH 2020
- 38. Pros & Consof CHC after age of 40 yr ?
- 39. Cu IUD?/ LNG IUS? How long as contraception 5yrs. HMB — highly effective in reducing HMB and menstrual pain.
- 40. Progestogen-only implant ? No age restriction and it can be used safely until a woman no longer requires contraception, licensed for 3 years and extended use is not supported, regardless of age. Not licensed for use as endometrial protection and should not be used as the progestogen component of HRT
- 41. Progestogen-only injectable contraceptives? DMPA is not licensed for use as endometrial protection with oestrogen replacement and should not be used as the progestogen component of HRT
- 42. Progestogen-only pill (POP)? No age restriction for the POP and it can be used safely until a woman no longer requires contraception. The POP is not licensed for use as endometrial protection with oestrogen replacement and should not be used as the progestogen component of HRT
- 43. When is contraceptionno longer needed?
- 44. Contraceptive options in conjunctionwith hormone replacement therapy
- 45. Case 7 MRS.X ,29YEAR OLD,P1L1,FORGETS TO TAKE PROGESTERONE ONLY PILL SCHEDULED THAT MORNING, AS SHE WAS BUSY TAKING HER BABY FOR THE FIRST PENTAVALENT VACCINATION. SHE REALISED THE MISSED PILL ON RETURNING HOME BY LATE NIGHT. SHE SEEKS YOUR ADVICE To take 1 pill ASAP. To use additional contraception for next 48 hours.
- 46. POPS steady levels ofprogestogen are acheived in 4-5 days. MOA: 1.cervical mucus effect 2.inhibition of ovulation 3.acclerated tubal motility 4.endometrial alteration optimal cervical mucus effect :begins after 2hours and lasts for 23hours.
- 47. Case 8 30 YRSOLD,MRS.ANTARA,P1L1A1,USING DMPA INJECTION FOR CONTRACEPTION FOR PAST ONE YEAR,PLANS FOR EUROPE TOUR WITH FAMILY. HER CONCERN IS THAT HER TRIP DATE COMES 1 WEEK PRIOR TO THE SCHEDULED DATE OF DMPA INJECTION. HELP HER. GIVE THE USUAL DOSE OF INJECTION DMPA can be safely given 2 weeks before or upto 1 month after the scheduled date.
- 48. DMPA Micro crystals ofprogestin a single 150mg inj can suppress ovulation for 14weeks. Return of fertility: 70% conceive in 12months 90% conceive in 24months Does not impair lactation bone mineral loss with recovery of bone mass after discontinuation benefits women with SICKLE CELL DISEASE.
- 49. Case 9 33 YEAROLD MRS.CHHAYA,EVENT MANAGER,ON ORMELOXIFENE SINCE TWO MONTHS BACK, MISSES THE SECOND PILL SCHEDULED FOR THAT WEEK BY 2 DAYS. SHE SEEKS YOUR ADVICE take the pill ASAP Maximum serum concentrations are achieved in 3-8 hours of administration Mean residence time : 128 days.
- 50. CENTCHROMAN Ormeloxifene,nonsteroidal selective estrogenmodulator. Has weak estrogen agonistic activity in bones and potent anti estrogenic activity in uterus and breast. MOA : asynchrony in menstrual cycle between endometrium and developing embryo resulting in implantation failure. dose: 30 mg twice weekly for 1st 3 months followed by once weekly. other uses: AUB, mastalgia
- 51. Case 10 A 28/fMrs Mirena P1L1 /Immediate postpartum,wants to delay her next child birth. Not willing to take any oral medication/ injections How would you help her?
- 52. CONTRACEPTION IN LACTATING MOTHER Barriermethods,spermicides,the copper T380A good options. Progestin only OCs,implants and injectable contraceptives do not effect milk quality/quantity progestin only pills/ Implants can be started immediate postpartum DMPA can begin at 6 weeks.
- 53. Case 11 Mrs ssss,28years/P2L2/previous normal delivery with cuT375, LCB 8months,was on regular follow up has now come to your OPD with C/O not able to feel the CuT thread and amenorrhoea for 1 month. how do you manage?
- 54. do UPT andUSG pelvis. if UPT -NEG ,USG CuT Insitu--REASSURE if UPT -neg,USG displaced CuT --usg guided/hysteroscopic removal If UPT -POSITIVE, 1.Therapeutic abortion 2.USG guided intra uterine removal of the IUD 3.Continuation of pregnancy with device left in situ
- 55.
Editor's Notes
- #10 It is appropriate to screen for STIs and place an IUD on the same day. Screening and awaiting results before IUD insertion do not decrease the risk of postinsertion PID but could delay initiation of highly effective contraception and increase the risk of unintended pregnancy.
- #11 A retrospective review of 2,138 adolescents and women aged 13–35 years with an IUD showed that younger females (aged 13–19 years) and nulliparous women were not more likely to experience expulsion than older or parous women A prospective study that compared 12-month pregnancy rates of 69 participants aged 18–35 years from the CHOICE project who had discontinued their IUD with 42 former non-IUD users found no difference in pregnancy rates or time to pregnancy between the groups
- #13 etonogestrel implant users, The CDC recommends consideration of the following two treatment options: 1) NSAIDs for short-term treatment (5–7 days), and 2) hormonal treatment (if medically eligible) with low-dose combined oral contraceptives or estrogen for short-term treatment (10–20 days)
- #15 use of DMPA is associated with loss of bone mineral density (BMD), current longitudinal and cross-sectional evidence suggests that recovery of BMD occurs after discontinuation of DMPA. No high-quality data answer the important clinical question of whether DMPA affects fracture risk in adolescents or adults later in life. “black box” warning to DMPA labeling about the potential loss of BMD. The potential health risks associated with the bone effects of DMPA must be balanced against a woman’s likelihood of pregnancy using other methods or no method, and the known negative health and social consequences associated with unintended pregnancy, particularly among adolescents
- #18 BMI should be documented for all women prior to CHC prescription. Pelvic examination is not required prior to initiation of CHC. Breast examination, cervical screening, testing for thrombophilia, hyperlipidaemia or diabetes mellitus and liver function tests are not routinely required prior to initiation of CHC.
- #19 CP- s 33.9 micrograms ethinylestradiol and 203 micrograms norelgestromin per 24 hours (Evra®). One patch to be applied once weekly for three weeks, followed by a 7 day patch free interval. CVR: f ethylene vinylacetate (latex-free) and releases 15 micrograms ethinylestradiol and 120 micrograms etonogestrel daily. One ring should be inserted vaginally for 3 weeks of use per cycle. Rings must be kept refrigerated prior to dispensing to the client. Thereafter, they can be stored at room temperature and used within 4 months
- #20 combined hormonal contraception (CHC) is as safe and at least as effective for contraception if it is taken as an extended or continuous regimen
- #32 single dose of 1.5 mg, or alternatively in 2 doses of 0.75 mg each, 12 hrs apart). UPA had a pregnancy rate of 1.2%. LNG had a pregnancy rate of 1.2% to 2.1% . Yuzpe regimen (one dose of 100 μg of ethinyl estradiol & 0.50 mg of LNG, followed by a second dose of same 12 hrs later).
- #36 Women aged over 40 years have a distinct set of needs regarding contraception. Perimenopausal symptoms (e.g. vasomotor symptoms, mood changes, irregular and/or heavy bleeding) combined with increased background risks of certain health conditions (e.g. cardiovascular disease, obesity, breast cancer, most gynaecological cancers) mean that the benefits and risks of contraception for this population are different from those relevant to younger women.
- #37 The risk of venous thromboembolism (VTE) increases sharply over the age of 40 years, which means that consideration of other risk factors for VTE is essential when considering CHC in this age group. Weight is an important risk factor; body mass index should be reviewed on a regular basis.1 The risk of VTE is highest on initiation of CHC and this increased risk recurs if CHC is stopped and restarted.1 The guideline therefore advises against repeated episodes of stopping/starting CHC, for example, to measure follicle stimulating hormone (FSH) levels. Pills containing higher doses of oestrogen are linked to greater risk of VTE, stroke, and cardiovascular disease.1 When prescribing COC for women over 40, first choice should be a preparation with ≤30 mcg ethinylestradiol. This should be combined with either levonorgestrel or norethisterone as this combination confers the lowest VTE risk. Women aged over 35 who smoke and all women aged over 50 (regardless of smoking status) should be advised to stop CHC as risks outweigh benefits
- #39 If only being used for HMB and/or menstrual pain (not contraception or endometrial protection), can remain in situ for as long as it controls symptoms, regardless of age at insertion.
- #41 Depot medroxyprogesterone acetate (DMPA) is associated with a reduction in bone mineral density (BMD) in women of all ages.1 Reassuringly, studies looking at women over 40 who use DMPA have shown that although users experience an initial loss in BMD with use, this is not repeated or worsened by menopause.1 Women over 40 with additional risk factors for osteoporosis are advised to consider alternative methods.