Transcript Slide 1
Contraceptives for Special Situations
Dr.Suma Natarajan
MD DGO FAGE
HOD,Ganga Women & Child Centre
“ Family Planning alone could bring more benefits to more people at less cost than any other single technology now available to the human race.” UNICEF
Need for contraception….
World’s population expected to reach 9 billion by 2050.
India accounts for 17% of world’s population.
Wikipedia, The Free Encyclopedia
Need for contraception….
Annually, 529,000 maternal deaths & 50 million morbidity.
In India, contraceptive prevalence is 48.3% 21% of all pregnancies resulting live births are unplanned.
If unmet need for contraception was met, we can avoid 52 million unwanted pregnancies 25-50% of maternal deaths
Hindin MJ, Lancet. 2007;370:1297-8
.
Contraceptive measures would…
Slow the pace of population growth Decrease abortion related complications and deaths Cut down maternal care costs Promote better maternal health Improve the health of children through provision of better nutrition and other care ……..beneficial to the society at large!!!
Population reference bureau, Washington, USA, Nov 2004
Importance of Contraceptive “Fit”
Contraceptive “fit” – the safest, most effective birth control method that will work well for the user A good fit depends upon a woman’s – Individual health profile – Lifestyle – Reproductive stage – Preferences
What are special situations
Adolescents
Following pregnancy and lactation
Perimenopausal women designated as “Special population”
Women with gynaecological problems
Women with medical disorders
Moderator : Dr .Suma Natarajan Panelists: Dr. SUNDAR NARAYANAN M.D.(O&G) Dr. SUSAN D.G.O. D.N.B (O&G) Dr. RASHMI M.D. (O&G) Dr. DHANALEKSHMI D.G.O
Case 1
An 18 year old adolescent wants contraception same oral contraceptive as her friend (a COC)
Has moderate acne lesions on face
Overweight BMI – 30
Has Irregular cycles 6 – 7 days/ 2 -3 months
Given that she has asked for a specific contraceptive type, what would you do?
1.
Give her the contraceptive she’s asking for 2. Offer several options for discussion 3. Have a dialog to better understand her needs/life context before choosing which options to discuss with her 4. Offer her one option (not the one she originally requested)
What subject would you discuss?
Relationship status
Life context (how important is work/education to her)
Her contraceptive history
Her health risks as they relate to contraceptive options
Based on all information which contraceptive option do you think would best suit ?
1.
Same COC as her friend 2.
Newer COC with Drospirenone , Cyproterone acetate 3.
POP 4.
Copper IUD 5.
IUS (Mirena) 6.
Vaginal ring
From the clinical presentation of patient she can be prescribed a COC containing drosperionone
24/4 regimen OC will give adequate contraception benefit
Drosperinone component antiandrogenic effect help counteract androgen induced hyperactivity of Pilosebaceous glands
Other choices
COC
Vaginal ring
Cyproterone acetate
In combination with ethinyl estradiol
Should be prescribed for ~ 6 -12 months
Excellent results in
– – –
Acne Hirsutism PCOS
Case 2
Miss K,18yrs, student, has irregular periods, 4days /2-3 months. She has undergone medical TOP 6months back. She seeks consultation for irregular bleeding since 18days She gives history of having used ‘I’ pills twice since her LMP You find her 6weeks pregnant and have provided medical TOP What contraceptive advice would you now give her?
What would you discuss with her?
Health risks due to repeated abortions Emphasize on proper usage of contraceptive method Stress on importance on single partner – Risk of STI Dual protection Educate regarding other choice of contraception
You educate her about the correct method of use of Emergency Contraception. You advice…
Abstinence
COCs
POPs
IUD
Injectable contraception
Vaginal ring
She does not want to take OCs because she fears she may forget taking during her exams & also fears that her parents will find out.She is not sure if she can abstain from SI
What would you advice?
This girl needs regular contraception. Long acting Injectable Progesterones need to be used with caution in adolescents because of possible effect on Bone mineral density Both CuIUD and LNG IUD are Category 1 for women >20yrs and Category 2 ( benefits of contraception outweigh the risks) for women <20yrs
Contraception for adolescents
Adolescents are eligible for all contraceptives which are suitable for adults.
Proper counseling regarding its use is important.
DMPA – can interfere with bone growth Dual protection be stressed upon Abstinence can be promoted as a method.
Case 3
Mrs G 32yrs, P2 L2 Regular periods with moderate flow Clinical Examination – Uterus normal size mobile, fornices free
Among contraceptives, which one of these is the most
cost - effective
Condoms IUD OCs DMPA Vaginal Ring
Pt requests for a Cu IUCD However, examination reveals vulvo vaginitis suggestive of candidal infection Would you still go ahead with with the insertion?
You are ready for insertion. While the patient is lying on the couch she gives history of gestational diabetes. Would you still insert the IUCD?
Would you give prophylactic antibiotic? If so, what drug and what dosage?
IUD & prophylactic antibiotics
Low risk women No benefit High risk women – Single dose of Doxycycline 200mg PO or Azithromycin 500mg PO When 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 cannot feel the threads. Ultrasound reveals an empty uterus. IUCD on the antero superior surface of uterus
Patient is asymptomatic & not keen on surgery
Perforated IUD
Is it best left alone if the woman is asymptomatic?
Is it best removed soon after it is located?
Perforated IUD
Copper can lead to adhesion formation. It is best removed soon after it is located – before adhesion formation can occur It is left alone ONLY if the risk of surgery is high AND if the woman is asymptomatic
Case 4
Mrs C is being discharged today after a FTND of a healthy boy baby 3 days back. Both mother and the baby are in good health and she is breast feeding the baby.
When would you schedule her postpartum visit to provide contraception?
6 weeks after delivery
4 months after delivery
3 months after delivery
3 weeks after delivery
i
Most studies have shown that half the women ovulate before the 6 th week (before the traditional postpartum visit) . A 3 week visit would be ideal
Rule of 3’s
Beginning of postpartum contraceptive use
Full breast feeding – 3 rd month
Partial or No breast feeding – 3 rd week
Mrs C visits after 3weeks. She is partially breast feeding her baby.
What are her contraceptive options?
COCs
POPs
LNG IUD
Cu IUD
Injectable progesterones
Postpartum visit at 3 weeks
Mr C considers Cu IUD and asks “What would be the ideal time to insert CuIUD?”
Immediately
At 4weeks
At 6weeks
Postpartum visit at 3 weeks
Postpartum insertion of either a Cu IUD or LNG IUD is best done AFTER 4 weeks or within 48hours
It is not inserted between 48hrs to 4weeks.
Despite allaying her fears of IUD, Mrs C is unwilling to consider it. She is doubtful of taking pills regularly. What are her options now?
She chooses to use Inj DMPA. When would you start her on the injection?
Immediately
Later….if so when?
She takes Inj DMPA. Her periods are irregular with spotting on & off despite the non steroidal anti- inflammatory/ antifibrinolytics drugs prescribed. She is disturbed by it because she cannot say her prayers when she has bleeding. What would you do now?
Discontinue using further injectables
If no gynaec problems are found treat with NSAID’s, Antifibrinolytics, ethinyl estradiol, or Conjugated equine estrogen or low dose OC short term (7-21 days)
Evaluate for unexplained vaginal bleeding
She takes Inj DMPA and is quite happy with it. Her periods are irregular with spotting on & off but since she has been counselled, she is not unduly disturbed by it and the bleeding settles. Following the second injection, she returns to the clinic only after 4months
What would you do now?
Check for pregnancy. If negative give the injection and ask her to use additional method for the next 7days Check for pregnancy and if negative give the injection without any additional advice about contraception Give the injection without any additional advice about contraception
Late for an injection??
grace period extended!
The repeat injection of
DMPA can be given up to 4 weeks late
NET-EN can be given up to 2 weeks late without requiring additional contraceptive protection
Selected Practice Recommendations for Contraceptive Use 2008 update
Case 5
22 yr old girl
Delivered a female child by caesarean section 6 weeks ago
Lactating
Came for pain in breast
O/E Breast engorgement
Contraceptive counseling
Issues
When to start using contraception.
When to use IUD after LSCS
Sterilization with second CS
Condition POSTPARTUM
TIMING OF INITIATION
Start date Contraceptive method Non-breastfeeding Fully breastfeeding 3-4 weeks postpartum 6 months postpartum COCs, ring, DMPA, POP, barrier methods, progestin implant IUD POP. barrier method. DMPA, progestin implant IUD Partial breast feeding After 1 st ,2 nd trimester pregnancy loss or ectopic pregnancy 6 weeks postpartum POP, barrier method. DMPA, ring , COCs progestin implant IUD immediately COCs, ring, DMPA,IUD, implant, progestin-only Ocs, barrier methods
WHO Recommendations for IUD Insertion in Postpartum Patients Post partum Copper IUD LNG-IUS <48hrs 48hrs - <6wks > 6 wks Peurperal sepsis Post abortion Immediately after 1 st TM Immediately after 2 nd TM Immediately post septic abortion Can be used Increased risk of expulsion / benefits outweigh risks Risks outweigh benefits Risks outweigh benefits Recommended Do not use Recommended > risk of expulsion Do not use Recommended Do not use Recommended > risk of expulsion Do not use
Breast-feeding and combined hormonal contraception
OB-GYNs have been comfortable recommending nonhormonal or progestin-only contraceptives to breast-feeding mothers WHO studies in early 1980s regarding use of combined oral contraceptives 1 - Minor effects on quantity and quality of breast milk - No effect on infant growth was seen No problem offering any of the nonhormonal or progestin-only methods OB-GYNs=obstetricians and gynecologists; WHO=World Health Organization.
1. Truitt ST et al. Cochrane Database Syst Rev. 2003;(2):CD003988.
Case 6
Busy 29 years old lawyer with a 6 months old child.
c/o heavy menstrual flow prior to child birth p/v- 12wks enlarged uterus.
Ultrasound reveals small intramural fibroids.
Does not desire pregnancy in the near future.
Wants a contraceptive that reduces her bleeding
Contraceptive Options That Reduce Menorrhagia
Oral Contraceptives – COC , POP DMPA Extended-cycle ring or pills Implant- characterized by erratic spotting & bleeding.
LNG-IUS for a women with baseline menorrhagia.
Bleeding reduction with LNG-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 abortion
COC on the day of misoprostol Sterilization, IUD, Progesterone only method only after completion of abortion Condoms, Vaginal tablets after bleeding stops Natural methods, DMPA, Ring only after next menses
Case 7
A 42 years old patient, who has completed her family, referred for sterilization by primary care physician.
3 FTCS , LCB 3 yrs ago.
Known hypertensive, Abnormal lipids on Rx, Diabetic on trt On examination: - Height- 5’5’’ - Weight- 100 kg - BP 162/104 mmHg O/E uterus bulky, regular, mobility restricted
What issues would you discuss
Laparoscopic sterilization presents technical issues in obese women - Thick abdominal walls - Anesthesia risks - Other surgical risks Convenience of sterilization is appealing….
Effective non-surgical methods exist
Options
Cu 380 A LNG-IUS Vasectomy – No scalpel Vasectomy – OPD procedure – Client walks in OT & walks out in 10 min.
– Special instruments- ring forceps/ dissector/ scissors – No stitches – Contraception x 3 months – Semen analysis ensure azoospermia – No effect on sexuality
Hypertension and OC pills
Low dose OC pills can be used in women less than 35yrs with HT.
Progesterone only pills are better Low dose OC pills have negligible impact on the lipoprotein level However, BP & lipid levels need to be closely monitored
DVT risk & recommended therapy
Combination hormone contraception is associated with elevated DVT risk Age and obesity are also independent risk factors Recently updated ACOG guidelines 1 - Obesity in women >35 years suggests use of progestin-only and/or intrauterine contraceptives - Discourages use of combination contraceptives Neither 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 resolution
Patient chose the copper T IUD 10 years later at age 52, she has irregular cycles; should the IUD be removed? Studies from the United Nations and Brazil indicate high efficacy of copper T IUD after the 10-year window 1,2 Spontaneous fertility beyond age 45 is rare and the IUD becomes even more effective Keeping 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 8
Mrs. G 38yrs, P2 L2 Irregular heavy periods Clinical Examination – 10wks size uterus Ultrasound examination – Bulky uterus with multiple intramural fibroids, largest measuring 4cmX4cm. Endometrial thickness 11mm, contour - normal
Which one of these would be appropriate?
IUD
OCs
DMPA
LNG IUD
OC pills & Fibroids
The administration of low dose OC pills to women with leiomyomas does not stimulate fibroid growth and is associated with decreased bleeding
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995
LNG IUS & Fibroids
In studies of the levonorgestrel device in women with troublesome bleeding associated with fibroids, the size of the uterus and the largest individual tumors diminished slightly.
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995
Mrs G chooses to get an LNG IUS inserted. She comes back to you after 3yrs for a check up. She reveals that she was recently hospitalized for a bad lung infection. She is presently undergoing treatment for tuberculosis and is on a 4 drug regime.
Would you like to suggest a change in her contraceptive method?
Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugs Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver enzymes, such as rifampicin and anti epileptic drugs
Case 9
Mrs D 38yrs, P3 L3 TOP 3, is planning to undergo Incisional hernia repair and Tubectomy. She is on low dose OC pills for contraception.
When would you ask her to stop the OC pill?
4weeks before the planned surgery
2weeks before the planned surgery
The day before the planned surgery
Data shows that high dose OC pills carry a risk of postoperative thrombosis
Low dose OC pills have not shown similar risk
Stopping OC pills well before the procedure is recommended only when prolonged immobilization is required following surgery
What can a woman do if she vomits and / or has severe diarrhoea while using COCs or progestogen-only pills (POPs)?
Continue taking it orally despite her discomfort (consider like missing pills)
Use the vaginal route at the same dosage as oral
Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive pills administered 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 and vaginal route, Contraception 2002
Case 10
28 yrs Mrs.A 80 kgs with well controlled DM with no complications no DVT,HT,Breast cancer, migraine request ring and desires pregnancy with in a year What would you recommend ?
Ring - highly effective < 35 yrs ,DM well controlled, desires fertility in a yr.
Patch or pill copper IUD ,LNG IUS are also good choice
COC & Diabetes
COC in type I DM – Studies find no change in HbA1c, no change in development or progression of nephropathy or retinopathy
Nonsmoking, <35yrs, otherwise healthy diabetics, no end organ disease – COC safe
Mirena – Safe in diabetics
Past h/o GDM – COC do not accelerate or precipitate development of type II DM
ACOG Practice bulletin no:18, Obst & Gynecol. 2006
Contraception in special situations
Epilepsy
–
Enzyme inducers- Studies observe ↓ serum levels of COCP, ↑ BTB, but no ovulation or accidental pregnancy
–
No published data to support role of COCP with 50μg EE
–
Efficacy of mirena remains high
–
Use IUCD or COCP + condoms
Inflammatory bowel disease
–
Disease exacerbation – Immobilisation – Stop COCP
–
No special recommendations in stable disease
Contraception in special situations
SLE
– H/o vascular disease, nephritis or presence of antiphospholipid antibody – Avoid COCP – Stable disease, no antiphospholipid antibodies – Use COCP – Progesterone only methods – Safe – IUCD Safe, effective`
Women on anticoagulant Rx
– ↑ Menorrhagia, corpus luteum hematoma, hemoperitoneum – COCP, DMPA, Mirena - Appropriate – COCP – Do not ↑ risk of thrombosis if well anticoagulated – DMPA – Not much injection site problems
Rapid fire
IUD in HIV + ve woman
Yes, can be used
IUD in previous Ectopic pregnancy
Yes
IUD causes PID
No
IUD in Endocarditis / Rheumatic Heart Disease / Prosthetic heart valves
Yes
Rapid fire
Contraceptive for endometriosis
POP, LNG IUS, DMPA, COC
Contraceptive for woman with adenomyosis
LNG IUS
Contraception for woman with DUB
COC, LNG IUS vaginal ring
35 yr old woman on anticoagulant Rx
LNG IUS / COC/vaginal ring
Rapid fire
Hormonal contraception for heart disease
POP, Progestin implants safe, NO COC
Hormonal contraception for woman with Cervical dysplasia/ cancer
POP, DMPA, Prog Implants; NO COC
COCs in SLE
Not recommended
COC in Thyroid disorders
Can be used
Good Sexual and Reproductive Health Contributes to Achievement of MDGs Gender equity Reduced child mortality Improved maternal health
Universal primary education
Combatting HIV/AIDS, malaria, TB Environmental sustainability Eradication of poverty Sexual and reproductive health Source: Dr. Wang Yifei; Former Staff of RHR/WHO; Shanghai Second Medical University Department of reproductive health and research Global partnership for development