Contraceptives for Special Contraceptives for Special SituationsSituations

Dr.Suma Natarajan Dr.Suma Natarajan MD DGO FAGEMD DGO FAGE

HOD,Ganga Women & Child HOD,Ganga Women & Child CentreCentre

“ “ Family Planning alone could bring more benefits to more Family Planning alone could bring more benefits to more people at less cost than any other single technology now people at less cost than any other single technology now

available to the human race.” available to the human race.”

UNICEFUNICEF

Need for contraception….Need for contraception….

World’s population expected to reach 9 billion World’s population expected to reach 9 billion by 2050.by 2050.

India accounts for 17% of world’s population.India accounts for 17% of world’s population.

Wikipedia, The Free EncyclopediaWikipedia, The Free Encyclopedia

Need for contraception….Need for contraception….

Annually, 529,000 maternal deaths & 50 million morbidity.Annually, 529,000 maternal deaths & 50 million morbidity.

In India, contraceptive prevalence is 48.3%In India, contraceptive prevalence is 48.3% 21% of all pregnancies resulting live births are unplanned.21% of all pregnancies resulting live births are unplanned.

If unmet need for contraceptionIf unmet need for contraception was met, we can avoidwas met, we can avoid

52 million unwanted pregnancies52 million unwanted pregnancies

25-50% of maternal deaths25-50% of maternal deaths

Hindin MJ, Lancet. 2007;370:1297-8Hindin MJ, Lancet. 2007;370:1297-8..

Contraceptive measures would…Contraceptive measures would…

Slow the pace of population growthSlow the pace of population growth Decrease abortion related complications and deathsDecrease abortion related complications and deaths Cut down maternal care costsCut down maternal care costs Promote better maternal healthPromote better maternal health Improve the health of children through provision of better Improve the health of children through provision of better

nutrition and other carenutrition and other care

…………..beneficial to the society at large!!!..beneficial to the society at large!!! Population reference bureau, Washington, USA, Nov Population reference bureau, Washington, USA, Nov

20042004

Importance of Contraceptive “Fit”Importance of Contraceptive “Fit”

Contraceptive “fit” – the safest, most effective Contraceptive “fit” – the safest, most effective birth control method that will birth control method that will work well for the userwork well for the user

A good fit depends upon a woman’sA good fit depends upon a woman’s– Individual health profileIndividual health profile– LifestyleLifestyle– Reproductive stageReproductive stage– PreferencesPreferences

What are special situationsWhat are special situations

AdolescentsAdolescents Following pregnancy and lactation Following pregnancy and lactation Perimenopausal women designated asPerimenopausal women designated as

“ “Special population”Special population” Women with gynaecological problemsWomen with gynaecological problems Women with medical disordersWomen with medical disorders

Moderator :Moderator : Dr .Suma NatarajanDr .Suma Natarajan Panelists:Panelists: Dr. SUNDAR NARAYANAN  M.D.(O&G)Dr. SUNDAR NARAYANAN  M.D.(O&G) Dr. SUSAN  D.G.O. D.N.B (O&G)Dr. SUSAN  D.G.O. D.N.B (O&G) Dr. RASHMI  M.D.  (O&G) Dr. RASHMI  M.D.  (O&G)

Dr. DHANALEKSHMI  D.G.ODr. DHANALEKSHMI  D.G.O

Case 1Case 1

An 18 year old adolescent wants An 18 year old adolescent wants contraception contraception same oral contraceptive as same oral contraceptive as her friend (a COC)her friend (a COC)

Has moderate acne lesions on faceHas moderate acne lesions on face Overweight BMI – 30Overweight BMI – 30 Has Irregular cycles 6 – 7 days/ 2 -3 monthsHas Irregular cycles 6 – 7 days/ 2 -3 months

Given that she has asked for a specific Given that she has asked for a specific contraceptive type, what would you do?contraceptive type, what would you do?

1.1. Give her the contraceptive she’s asking forGive her the contraceptive she’s asking for

2. Offer several options for discussion2. Offer several options for discussion

3. Have a dialog to better understand her needs/life context 3. Have a dialog to better understand her needs/life context before choosing which options to discuss with herbefore choosing which options to discuss with her

4. Offer her one option (not the one she 4. Offer her one option (not the one she originally requested)originally requested)

What subject would you discuss? What subject would you discuss?

Relationship statusRelationship status

Life context (how important is work/education Life context (how important is work/education to her)to her)

Her contraceptive historyHer contraceptive history

Her health risks as they relate to contraceptive Her health risks as they relate to contraceptive optionsoptions

Based on all information which contraceptive option do Based on all information which contraceptive option do you think would best suit ?you think would best suit ?

1.1. Same COC as her friendSame COC as her friend

2.2. Newer COC with Drospirenone , Cyproterone acetate Newer COC with Drospirenone , Cyproterone acetate

3.3. POPPOP

4.4. Copper IUDCopper IUD

5.5. IUS (Mirena)IUS (Mirena)

6.6. Vaginal ringVaginal ring

From the clinical presentation of patient she From the clinical presentation of patient she can be prescribed a COC containing can be prescribed a COC containing drosperionone drosperionone

24/4 regimen OC will give adequate 24/4 regimen OC will give adequate contraception benefit contraception benefit

Drosperinone component antiandrogenic Drosperinone component antiandrogenic effect help counteract androgen induced effect help counteract androgen induced hyperactivity of Pilosebaceous glandshyperactivity of Pilosebaceous glands

Other choices Other choices COCCOC Vaginal ringVaginal ring

Cyproterone acetateCyproterone acetate

In combination with ethinyl estradiolIn combination with ethinyl estradiol Should be prescribed for ~ 6 -12 monthsShould be prescribed for ~ 6 -12 months Excellent results inExcellent results in

– AcneAcne– HirsutismHirsutism– PCOSPCOS

Case 2Case 2 Miss K,18yrs, student, has irregular periods, Miss K,18yrs, student, has irregular periods,

4days /2-3 months. She has undergone medical TOP 4days /2-3 months. She has undergone medical TOP 6months back. 6months back.

She seeks consultation for irregular bleeding since She seeks consultation for irregular bleeding since 18days18days

She gives history of having used ‘I’ pills twice since She gives history of having used ‘I’ pills twice since her LMP her LMP

You find her 6weeks pregnant and have provided You find her 6weeks pregnant and have provided medical TOPmedical TOP

What contraceptive advice would you now give her?What contraceptive advice would you now give her?

What would you discuss with her? What would you discuss with her?

Health risks due to repeated abortions Health risks due to repeated abortions Emphasize on proper usage of contraceptive Emphasize on proper usage of contraceptive

method method Stress on importance on single partner – Risk Stress on importance on single partner – Risk

of STIof STI Dual protectionDual protection Educate regarding other choice of Educate regarding other choice of

contraceptioncontraception

AbstinenceAbstinence COCsCOCs POPsPOPs IUDIUD Injectable contraceptionInjectable contraception Vaginal ringVaginal ring

You educate her about the correct method of use of You educate her about the correct method of use of Emergency Contraception. You advice…Emergency Contraception. You advice…

She does not want to take OCs because she She does not want to take OCs because she fears she may forget taking during her fears she may forget taking during her exams & also fears that her parents will find exams & also fears that her parents will find out.She is not sure if she can abstain from SIout.She is not sure if she can abstain from SI

What would you advice? What would you advice?

This girl needs regular contraception. This girl needs regular contraception.

Long acting Injectable Progesterones need to be used Long acting Injectable Progesterones need to be used

with caution in adolescents because of possible effect on with caution in adolescents because of possible effect on

Bone mineral densityBone mineral density

Both CuIUD and LNG IUD are Category 1 for women Both CuIUD and LNG IUD are Category 1 for women

>20yrs and Category 2 ( benefits of contraception >20yrs and Category 2 ( benefits of contraception

outweigh the risks) for women <20yrsoutweigh the risks) for women <20yrs

Contraception for Contraception for adolescentsadolescents

Adolescents are eligible for all contraceptives Adolescents are eligible for all contraceptives which are suitable for adults.which are suitable for adults.

Proper counseling regarding its use is Proper counseling regarding its use is important.important.

DMPA – can interfere with bone growthDMPA – can interfere with bone growth Dual protection be stressed uponDual protection be stressed upon Abstinence can be promoted as a method.Abstinence can be promoted as a method.

Case 3

Mrs G 32yrs, P2 L2 Mrs G 32yrs, P2 L2 Regular periods with moderate flowRegular periods with moderate flow Clinical Examination – Uterus normal size mobile, Clinical Examination – Uterus normal size mobile,

fornices freefornices free

Among contraceptives, which one of these is the most Among contraceptives, which one of these is the most cost - effective cost - effective

CondomsCondoms IUDIUD OCsOCs DMPADMPA Vaginal RingVaginal Ring

Pt requests for a Cu IUCDPt requests for a Cu IUCD

However, examination reveals vulvo vaginitis suggestive of candidal infectionHowever, examination reveals vulvo vaginitis suggestive of candidal infection

Would you still go ahead with with the insertion?Would you still go ahead with with the insertion?

You are ready for insertion. While the patient is lying You are ready for insertion. While the patient is lying

on the couch she gives history of gestational diabetes. on the couch she gives history of gestational diabetes.

Would you still insert the IUCD? Would you still insert the IUCD?

Would you give prophylactic antibiotic? If so, Would you give prophylactic antibiotic? If so, what drug and what dosage?what drug and what dosage?

IUD & prophylactic antibiotics

Low risk women Low risk women

No benefitNo benefit

High risk women –High risk women –

Single dose ofSingle dose of

Doxycycline 200mg PO or Azithromycin 500mg PODoxycycline 200mg PO or Azithromycin 500mg PO

When an old IUCD is replaced with a new oneWhen an old IUCD is replaced with a new one

Is it true?IUD use Cleaning the vagina with Povidone Iodine before insertion

decreases the risk of infection.

Iodine preparation is of little benefit. No touch technique is more important

Increased risk of infection is related only to the insertion process and not to IUD

True Doubles the incidence of tubal infertility

No increased incidence Increases the risk of ectopic pregnancy

No increased incidence

Patient comes back within 3 days saying that she Patient comes back within 3 days saying that she

cannot feel the threads. Ultrasound reveals an empty cannot feel the threads. Ultrasound reveals an empty

uterus. IUCD on the antero superior surface of uterusuterus. IUCD on the antero superior surface of uterus

Patient is asymptomatic & not keen on surgeryPatient is asymptomatic & not keen on surgery

Perforated IUD

Is it best left alone if the woman is asymptomatic?Is it best left alone if the woman is asymptomatic? Is it best removed soon after it is located? Is it best removed soon after it is located?

Perforated IUD

Copper can lead to adhesion formation. Copper can lead to adhesion formation. It is best removed soon after it is located – before It is best removed soon after it is located – before

adhesion formation can occuradhesion formation can occur It is left alone ONLY if the risk of surgery is high It is left alone ONLY if the risk of surgery is high

AND if the woman is asymptomaticAND if the woman is asymptomatic

Case 4Case 4

Mrs C is being discharged today after a Mrs C is being discharged today after a

FTND of a healthy boy baby 3 days back. FTND of a healthy boy baby 3 days back.

Both mother and the baby are in good Both mother and the baby are in good

health and she is breast feeding the baby.health and she is breast feeding the baby.

When would you schedule her postpartum When would you schedule her postpartum

visit to provide contraception?visit to provide contraception?

6 weeks after delivery6 weeks after delivery

4 months after delivery4 months after delivery

3 months after delivery3 months after delivery

3 weeks after delivery3 weeks after delivery

i

Most studies have shown that half the women Most studies have shown that half the women

ovulate before the 6ovulate before the 6thth week week (before the (before the

traditional postpartum visit) . traditional postpartum visit) . A 3 week visit A 3 week visit

would be idealwould be ideal

Rule of 3’sRule of 3’s

Beginning of postpartum contraceptive useBeginning of postpartum contraceptive use

Full breast feeding – 3Full breast feeding – 3rdrd month month

Partial or No breast feeding – 3Partial or No breast feeding – 3rdrd week week

Mrs C visits after 3weeks. She is partially Mrs C visits after 3weeks. She is partially breast feeding her baby.breast feeding her baby.

What are her contraceptive options?What are her contraceptive options? COCsCOCs POPsPOPs LNG IUDLNG IUD Cu IUD Cu IUD Injectable progesteronesInjectable progesterones

Postpartum visit at 3 weeksPostpartum visit at 3 weeks

Mr C considers Cu IUD and asks Mr C considers Cu IUD and asks

“ “What would be the ideal time to insert What would be the ideal time to insert

CuIUD?”CuIUD?”

ImmediatelyImmediately

At 4weeksAt 4weeks

At 6weeksAt 6weeks

Postpartum visit at 3 weeksPostpartum visit at 3 weeks

Postpartum insertion of either a Cu IUD or Postpartum insertion of either a Cu IUD or

LNG IUD is best done AFTER 4 weeks or LNG IUD is best done AFTER 4 weeks or

within 48hours within 48hours

It is not inserted between 48hrs to 4weeks. It is not inserted between 48hrs to 4weeks.

WHO eligibility criteria 2008WHO eligibility criteria 2008

Despite allaying her fears of IUD, Mrs C is Despite allaying her fears of IUD, Mrs C is

unwilling to consider it. She is doubtful of unwilling to consider it. She is doubtful of

taking pills regularly. What are her options taking pills regularly. What are her options

now?now?

She chooses to use Inj DMPA. When would She chooses to use Inj DMPA. When would

you start her on the injection?you start her on the injection?

ImmediatelyImmediately

Later….if so when?Later….if so when?

She takes Inj DMPA. Her periods are She takes Inj DMPA. Her periods are

irregular with spotting on & off despite the irregular with spotting on & off despite the

non steroidal anti- inflammatory/ non steroidal anti- inflammatory/

antifibrinolytics drugs prescribed. She is antifibrinolytics drugs prescribed. She is

disturbed by it because she cannot say her disturbed by it because she cannot say her

prayers when she has bleeding. prayers when she has bleeding.

What would you do now? What would you do now?

Discontinue using further injectablesDiscontinue using further injectables

If no gynaec problems are found treat with If no gynaec problems are found treat with

NSAID’s, Antifibrinolytics, ethinyl NSAID’s, Antifibrinolytics, ethinyl

estradiol, or Conjugated equine estrogen estradiol, or Conjugated equine estrogen

or low dose OC short term (7-21 days)or low dose OC short term (7-21 days)

Evaluate for unexplained vaginal bleeding Evaluate for unexplained vaginal bleeding

She takes Inj DMPA and is quite happy with it. She takes Inj DMPA and is quite happy with it.

Her periods are irregular with spotting on & Her periods are irregular with spotting on &

off but since she has been counselled, she is not off but since she has been counselled, she is not

unduly disturbed by it and the bleeding settles. unduly disturbed by it and the bleeding settles.

Following the second injection, she returns to Following the second injection, she returns to

the clinic only after 4months the clinic only after 4months

What would you do now?What would you do now?

Check for pregnancy. If negative give the injection and ask Check for pregnancy. If negative give the injection and ask

her to use additional method for the next 7days her to use additional method for the next 7days

Check for pregnancy and if negative give the injection Check for pregnancy and if negative give the injection

without any additional advice about contraceptionwithout any additional advice about contraception

Give the injection without any additional advice Give the injection without any additional advice

about contraception about contraception

Late for an injection??Late for an injection?? grace period extended! grace period extended!

The repeat injection of The repeat injection of

DMPA can be given up to 4 weeks lateDMPA can be given up to 4 weeks late

NET-EN can be given up to 2 weeks late NET-EN can be given up to 2 weeks late

without requiring additional contraceptive without requiring additional contraceptive

protectionprotection

Selected Practice Recommendations for Contraceptive Use 2008 updateSelected Practice Recommendations for Contraceptive Use 2008 update

Case 5Case 5

22 yr old girl22 yr old girl Delivered a female child by caesarean Delivered a female child by caesarean

section 6 weeks agosection 6 weeks ago Lactating Lactating Came for pain in breastCame for pain in breast O/E Breast engorgementO/E Breast engorgement Contraceptive counselingContraceptive counseling

Issues Issues

When to start using contraception.When to start using contraception.

When to use IUD after LSCSWhen to use IUD after LSCS

Sterilization with second CSSterilization with second CS

Condition Start date Contraceptive method

POSTPARTUM

Non-breastfeeding 3-4 weeks postpartum

COCs, ring, DMPA, POP, barrier methods, progestin implant IUD

Fully breastfeeding 6 months postpartum

POP. barrier method. DMPA, progestin implant IUD

Partial breast feeding 6 weeks postpartum POP, barrier method. DMPA, ring , COCs progestin implant IUD

After 1st ,2nd trimester pregnancy loss or ectopic

pregnancy

immediately COCs, ring, DMPA,IUD, implant, progestin-only Ocs, barrier methods

TIMING OF INITIATION

Post partum Copper IUD LNG-IUS

<48hrs Can be used Increased risk of expulsion / benefits outweigh risks

48hrs - <6wks Risks outweigh benefits Risks outweigh benefits

> 6 wks Recommended Recommended

Peurperal sepsis Do not use Do not use

Post abortion

Immediately after 1st TM Recommended Recommended

Immediately after 2nd TM > risk of expulsion > risk of expulsion

Immediately post septic abortion Do not use Do not use

WHO Recommendations for IUD Insertion in Postpartum Patients

Breast-feeding and combined hormonal Breast-feeding and combined hormonal contraception contraception

OB-GYNs have been comfortable recommending nonhormonal OB-GYNs have been comfortable recommending nonhormonal or progestin-only contraceptives to breast-feeding mothersor progestin-only contraceptives to breast-feeding mothers

WHO studies in early 1980s regarding use of combined oral WHO studies in early 1980s regarding use of combined oral contraceptivescontraceptives11

- Minor effects on quantity and quality of breast milk- Minor effects on quantity and quality of breast milk- No effect on infant growth was seen - No effect on infant growth was seen

No problem offering any of the nonhormonal or progestin-only No problem offering any of the nonhormonal or progestin-only methodsmethods

OB-GYNs=obstetricians and gynecologists; WHO=World Health Organization.1. Truitt ST et al. Cochrane Database Syst Rev. 2003;(2):CD003988.

Case 6Case 6

Busy 29 years old lawyer with a 6 months old child.Busy 29 years old lawyer with a 6 months old child. c/o heavy menstrual flow prior to child birthc/o heavy menstrual flow prior to child birth p/v- 12wks enlarged uterus.p/v- 12wks enlarged uterus. Ultrasound reveals small intramural fibroids.Ultrasound reveals small intramural fibroids. Does not desire pregnancy in the near future.Does not desire pregnancy in the near future. Wants a contraceptive that reduces her bleeding Wants a contraceptive that reduces her bleeding

Contraceptive Options That Reduce MenorrhagiaContraceptive Options That Reduce Menorrhagia

Oral Contraceptives – COC , POPOral Contraceptives – COC , POP

DMPADMPA

Extended-cycle ring or pillsExtended-cycle ring or pills

Implant- characterized by erratic spotting & bleeding.Implant- characterized by erratic spotting & bleeding.

LNG-IUS for a women with baseline menorrhagia.LNG-IUS for a women with baseline menorrhagia.

Bleeding reduction with Bleeding reduction with LNG-IUS vs NSAID vs tranexamic acidLNG-IUS vs NSAID vs tranexamic acid

LNG-IUS=levonorgestrel-releasing intrauterine system; NSAID=nonsteroidal anti-inflammatory. Reproduced with permission of Milsom I et al. Am J Obstet Gynecol 1991;164:882.

Contraception after medical abortionContraception after medical abortion

COC on the day of misoprostolCOC on the day of misoprostol Sterilization, IUD, Progesterone only method Sterilization, IUD, Progesterone only method

only after completion of abortiononly after completion of abortion Condoms, Vaginal tablets after bleeding stopsCondoms, Vaginal tablets after bleeding stops Natural methods, DMPA, Ring only after next Natural methods, DMPA, Ring only after next

mensesmenses

Case 7Case 7 A 42 years old patient, who has completed her family, referred A 42 years old patient, who has completed her family, referred

for sterilization by primary care physician.for sterilization by primary care physician.

3 FTCS , LCB 3 yrs ago.3 FTCS , LCB 3 yrs ago.

Known hypertensive, Abnormal lipids on Rx, Diabetic on trtKnown hypertensive, Abnormal lipids on Rx, Diabetic on trt

On examination:On examination:

- Height- 5’5’’ - Weight- 100 kg- Height- 5’5’’ - Weight- 100 kg

- BP 162/104 mmHg- BP 162/104 mmHg

O/E uterus bulky, regular, mobility restrictedO/E uterus bulky, regular, mobility restricted

What issues would you discussWhat issues would you discuss

Laparoscopic sterilization presents technical issues in obese Laparoscopic sterilization presents technical issues in obese

womenwomen

- Thick abdominal walls- Thick abdominal walls

- Anesthesia risks- Anesthesia risks

- Other surgical risks- Other surgical risks Convenience of sterilization is appealing….Convenience of sterilization is appealing….

Effective non-surgical methods existEffective non-surgical methods exist

OptionsOptions Cu 380 ACu 380 A LNG-IUSLNG-IUS Vasectomy – No scalpel Vasectomy Vasectomy – No scalpel Vasectomy

– OPD procedureOPD procedure– Client walks in OT & walks out in 10 min.Client walks in OT & walks out in 10 min.– Special instruments- ring forceps/ dissector/ scissorsSpecial instruments- ring forceps/ dissector/ scissors– No stitchesNo stitches– Contraception x 3 monthsContraception x 3 months– Semen analysis Semen analysis ensure azoospermia ensure azoospermia– No effect on sexualityNo effect on sexuality

Hypertension and OC pillsHypertension and OC pills

Low dose OC pills can be used in women less Low dose OC pills can be used in women less than 35yrs with HT.than 35yrs with HT.

Progesterone only pills are betterProgesterone only pills are better Low dose OC pills have negligible impact on Low dose OC pills have negligible impact on

the lipoprotein levelthe lipoprotein level However, BP & lipid levels need to be closely However, BP & lipid levels need to be closely

monitoredmonitored

DVT risk & recommended therapyDVT risk & recommended therapy

Combination hormone contraception is associated with elevated Combination hormone contraception is associated with elevated DVT riskDVT risk

Age and obesity are also independent risk factorsAge and obesity are also independent risk factors Recently updated ACOG guidelinesRecently updated ACOG guidelines11

- Obesity in women >35 years suggests use of - Obesity in women >35 years suggests use of progestin-only and/or intrauterine contraceptivesprogestin-only and/or intrauterine contraceptives

- Discourages use of combination contraceptives- Discourages use of combination contraceptives Neither Copper T IUD or LNG IUS is contraindicatedNeither Copper T IUD or LNG IUS is contraindicated

ACOG=American College of Obstetricians and Gynecologists; DVT=deep venous thrombosis.1. ACOG, Committee on Practice Bulletins-Gynecology. Obstet Gynecol. 2006;107:1453-1472.

10-year follow-up and resolution10-year follow-up and resolution Patient chose the copper T IUDPatient chose the copper T IUD 10 years later at age 52, she has irregular cycles; 10 years later at age 52, she has irregular cycles;

should the IUD be removed? should the IUD be removed? Studies from the United Nations and Brazil indicate Studies from the United Nations and Brazil indicate

high efficacy of copper T IUD after the 10-year high efficacy of copper T IUD after the 10-year windowwindow1,21,2

Spontaneous fertility beyond age 45 is rare and the Spontaneous fertility beyond age 45 is rare and the IUD becomes even more effectiveIUD becomes even more effective

Keeping IUD for a few more years may be indicatedKeeping IUD for a few more years may be indicated

1. Bahamondes L et al. Contraception. 2005;72:337-341. 2. United Nations (UN) Development Programme, UN Population Fund, WHO and World Bank, Special Programme of Research, Development and Research Training in Human Reproduction. Contraception. 1997;56:341-352.

Case 8Case 8

Mrs. G 38yrs, P2 L2 Mrs. G 38yrs, P2 L2 Irregular heavy periodsIrregular heavy periods Clinical Examination – 10wks size uterusClinical Examination – 10wks size uterus Ultrasound examination – Bulky uterus with Ultrasound examination – Bulky uterus with

multiple intramural fibroids, largest measuring multiple intramural fibroids, largest measuring 4cmX4cm. 4cmX4cm.

Endometrial thickness 11mm, contour - Endometrial thickness 11mm, contour - normal normal

Which one of these would be appropriate? Which one of these would be appropriate?

IUDIUD

OCsOCs

DMPADMPA

LNG IUD LNG IUD

OC pills & FibroidsOC pills & Fibroids

The administration of low dose OC pills to The administration of low dose OC pills to women with leiomyomas does not stimulate women with leiomyomas does not stimulate fibroid growth and is associated with decreased fibroid growth and is associated with decreased bleedingbleeding

Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

LNG IUS & FibroidsLNG IUS & Fibroids

In studies of the levonorgestrel device in In studies of the levonorgestrel device in women with troublesome bleeding associated women with troublesome bleeding associated with fibroids, the size of the uterus and the with fibroids, the size of the uterus and the largest individual tumors diminished slightly. largest individual tumors diminished slightly.

Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

Mrs G chooses to get an LNG IUS inserted. Mrs G chooses to get an LNG IUS inserted.

She comes back to you after 3yrs for a She comes back to you after 3yrs for a

check up. She reveals that she was recently check up. She reveals that she was recently

hospitalized for a bad lung infection. She is hospitalized for a bad lung infection. She is

presently undergoing treatment for presently undergoing treatment for

tuberculosis and is on a 4 drug regime. tuberculosis and is on a 4 drug regime.

Would you like to suggest a change in her Would you like to suggest a change in her contraceptive method?contraceptive method?

Data shows no reduction in the efficacy of Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugsLNG-IUS with liver enzyme-inducing drugs

Current WHO-MEC recommendations Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver prescribed drugs which affect liver enzymes, such as rifampicin and anti-enzymes, such as rifampicin and anti-epileptic drugsepileptic drugs

Case 9Case 9

Mrs D 38yrs, P3 L3 TOP 3, is planning to Mrs D 38yrs, P3 L3 TOP 3, is planning to

undergo Incisional hernia repair and undergo Incisional hernia repair and

Tubectomy. She is on low dose OC pills for Tubectomy. She is on low dose OC pills for

contraception. contraception.

When would you ask her to stop the OC pill?When would you ask her to stop the OC pill?

4weeks before the planned surgery 4weeks before the planned surgery

2weeks before the planned surgery2weeks before the planned surgery

The day before the planned surgeryThe day before the planned surgery

Data shows that high dose OC pills carry a Data shows that high dose OC pills carry a

risk of postoperative thrombosis risk of postoperative thrombosis

Low dose OC pills have not shown similar Low dose OC pills have not shown similar

riskrisk

Stopping OC pills well before the procedure is Stopping OC pills well before the procedure is

recommended only when prolonged recommended only when prolonged

immobilization is required following surgeryimmobilization is required following surgery

What can a woman do if she vomits and / or What can a woman do if she vomits and / or

has severe diarrhoea while using COCs or has severe diarrhoea while using COCs or

progestogen-only pills (POPs)?progestogen-only pills (POPs)?

Continue taking it orally despite her discomfort Continue taking it orally despite her discomfort (consider like missing pills)(consider like missing pills)

Use the vaginal route at the same dosage as oralUse the vaginal route at the same dosage as oral

Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive pills Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive pills

administered vaginally, an international multicentrer clinical trial. Clinical Pharamacoladministered vaginally, an international multicentrer clinical trial. Clinical Pharamacol

Ziaei et al, Compartive study and evaluation of side effects of low dose OC pills adminsrtered by the oral Ziaei et al, Compartive study and evaluation of side effects of low dose OC pills adminsrtered by the oral and vaginal route, Contraception 2002and vaginal route, Contraception 2002

Case 10Case 10 28 yrs Mrs.A 28 yrs Mrs.A 80 kgs with well controlled DM with no 80 kgs with well controlled DM with no

complications no DVT,HT,Breast cancer, migraine complications no DVT,HT,Breast cancer, migraine request ring and desires pregnancy with in a yearrequest ring and desires pregnancy with in a year

What would you recommend ?What would you recommend ? Ring - highly effective Ring - highly effective < 35 yrs ,DM well controlled, desires fertility in a < 35 yrs ,DM well controlled, desires fertility in a

yr.yr. Patch or pill copper IUD ,LNG IUS are also good Patch or pill copper IUD ,LNG IUS are also good

choicechoice

COC & DiabetesCOC & Diabetes COC in type I DM – Studies find no change in HbA1c, no COC in type I DM – Studies find no change in HbA1c, no

change in development or progression of nephropathy or change in development or progression of nephropathy or retinopathyretinopathy

Nonsmoking, <35yrs, otherwise healthy diabetics, no end-Nonsmoking, <35yrs, otherwise healthy diabetics, no end-organ disease – COC safeorgan disease – COC safe

Mirena – Safe in diabeticsMirena – Safe in diabetics

Past h/o GDM – COC do not accelerate or precipitate Past h/o GDM – COC do not accelerate or precipitate development of type II DMdevelopment of type II DM

ACOG Practice bulletin no:18, Obst & Gynecol. 2006ACOG Practice bulletin no:18, Obst & Gynecol. 2006

Contraception in special situationsContraception in special situations

Epilepsy Epilepsy

– Enzyme inducers- Studies observe ↓ serum levels of Enzyme inducers- Studies observe ↓ serum levels of COCP, ↑ BTB, but no ovulation or accidental COCP, ↑ BTB, but no ovulation or accidental pregnancypregnancy

– No published data to support role of COCP with No published data to support role of COCP with 50μg EE50μg EE

– Efficacy of mirena remains highEfficacy of mirena remains high– Use IUCD or COCP + condomsUse IUCD or COCP + condoms

Inflammatory bowel diseaseInflammatory bowel disease

– Disease exacerbation – Immobilisation – Stop COCPDisease exacerbation – Immobilisation – Stop COCP– No special recommendations in stable diseaseNo special recommendations in stable disease

Contraception in special situationsContraception in special situations SLESLE

– H/o vascular disease, nephritis or presence of antiphospholipid H/o vascular disease, nephritis or presence of antiphospholipid antibody – Avoid COCPantibody – Avoid COCP

– Stable disease, no antiphospholipid antibodies – Use COCPStable disease, no antiphospholipid antibodies – Use COCP

– Progesterone only methods – SafeProgesterone only methods – Safe

– IUCD IUCD Safe, effective` Safe, effective` Women on anticoagulant RxWomen on anticoagulant Rx

– ↑ ↑ Menorrhagia, corpus luteum hematoma, hemoperitoneumMenorrhagia, corpus luteum hematoma, hemoperitoneum

– COCP, DMPA, Mirena - AppropriateCOCP, DMPA, Mirena - Appropriate

– COCP – Do not ↑ risk of thrombosis if well anticoagulatedCOCP – Do not ↑ risk of thrombosis if well anticoagulated

– DMPA – Not much injection site problemsDMPA – Not much injection site problems

Rapid fireRapid fire

IUD in HIV + ve woman IUD in HIV + ve woman Yes, can be used Yes, can be used IUD in previous Ectopic pregnancyIUD in previous Ectopic pregnancy YesYes IUD causes PIDIUD causes PID NoNo IUD in Endocarditis / Rheumatic Heart IUD in Endocarditis / Rheumatic Heart

Disease / Prosthetic heart valves Disease / Prosthetic heart valves YesYes

Rapid fireRapid fire

Contraceptive for endometriosisContraceptive for endometriosis POP, LNG IUS, DMPA, COC POP, LNG IUS, DMPA, COC Contraceptive for woman with adenomyosisContraceptive for woman with adenomyosis LNG IUSLNG IUS Contraception for woman with DUBContraception for woman with DUB COC, LNG IUS vaginal ring COC, LNG IUS vaginal ring 35 yr old woman on anticoagulant Rx35 yr old woman on anticoagulant Rx LNG IUS / COC/vaginal ringLNG IUS / COC/vaginal ring

Rapid fireRapid fire

Hormonal contraception for heart diseaseHormonal contraception for heart disease POP, Progestin implants safe, NO COC POP, Progestin implants safe, NO COC Hormonal contraception for woman with Hormonal contraception for woman with

Cervical dysplasia/ cancerCervical dysplasia/ cancer POP, DMPA, Prog Implants; NO COCPOP, DMPA, Prog Implants; NO COC COCs in SLECOCs in SLE Not recommendedNot recommended COC in Thyroid disordersCOC in Thyroid disorders Can be usedCan be used

SexualSexual

andand

reproductivereproductive

healthhealth

Environmental Environmental sustainability sustainability

Global partnership Global partnership for development for development

Combatting Combatting HIV/AIDS, HIV/AIDS, malaria, TBmalaria, TB

Improved Improved maternal healthmaternal health

Reduced child Reduced child mortality mortality

Gender equity Gender equity

Universal Universal primary primary education education

Eradication of Eradication of poverty poverty

Source: Dr. Wang Yifei; Former Staff of RHR/WHO; Shanghai Second Medical UniversityDepartment of reproductive health and research

Good Sexual and Reproductive Health Contributes to Good Sexual and Reproductive Health Contributes to Achievement of MDGsAchievement of MDGs

“ “ No woman is No woman is completely free unless completely free unless

she has control over her she has control over her own reproductive own reproductive

destiny “destiny “

Thank YouThank You