Transcript Contraception in Special Situations Experts Dr Jaya Narendra Dr Arulmozhi Ramarajan Dr Shubha Rao Dr Jayanthy Dr Ashakiran.

Contraception in Special
Situations
Experts
Dr Jaya Narendra
Dr Arulmozhi Ramarajan
Dr Shubha Rao
Dr Jayanthy
Dr Ashakiran
What are special situations for
contraception?





Adolescence
Following pregnancy and lactation
Peri-menopausal women
designated as “special population”
Women with gynaecological problems
Women with medical disorders & others
WHO Recommendation criteria for safe
contraceptive use (2009)
Category1 = no restriction on use
Category2 = Advantages of using the
method generally outweigh the theoretical
or proven risks
Category3 = Theoretical or proven risks
usually outweigh the advantages of using
the method
Category4 = Unacceptable health risk
Case 1
An 18 year old adolescent with irregular
periods and acne comes for treatment.
What are your options?
Choices are

COCs with EE and DSPR

COCs with Cyproterone acetate & EE

COCs with Desogestrel/Norgestrel
Life style modifications of course
Reduction in acne lesions with DSPR
Cycle 11
Cycle 3 3
Cycle 6
DSPR was
associated with a
greater reduction
from baseline in
total lesion counts
versus placebo
Percentage reduction in total lesion
count from baseline
0
-10
-20

-30
-40

50

-60
*p<0.0001 vs. placebo
Koltun W, et al. Int J Gynecol Obstet 2009;107(suppl 2):s620
DSPR
Placebo
Supposing an adolescent with regular
cycles had a medical abortion and comes
to you for contraceptive advice.
What will you give?
When will you start?
The Options
LDOCP
DMPA
IUCD
Ring
The Options
Low dose oral contraceptives: have many
benefits but compliance is an issue
Ring: can be inserted after the abortion is
completed
Contraception in adolescents
Inj. DMPA: It temporarily interferes with
calcium deposition in bones
Both Cu IUD and LNG IUD are
Category 1 for women > 20yrs and
Category 2 for women < 20yrs
Contraception in adolescents
Adolescents are eligible for all
contraceptives which are suitable for adults
Proper counseling regarding use is
important, especially for Emergency
contraception
Dual protection to be stressed upon
Abstinence can be promoted as a method
Contraception after medical abortion
COC on the day of Mifepristone
 Condoms, after bleeding stops
 Sterilization, IUD, POP only after
completion of abortion
 Natural methods, DMPA & Ring, only
after the next period

Case 2

Mrs Just Delivered is being discharged today
after a FTND of a healthy baby 3 days back.
Both the mother and the baby are in good health
and she is breast feeding the baby.

When would you schedule her postpartum visit
for contraceptive advice?
i
3
weeks after delivery
 6 weeks after delivery
 3 months after delivery
 6 months after delivery
Most studies have shown that many
women ovulate before the 6th week (before
the traditional postpartum visit)
A 3 week visit would be ideal for
contraceptive advice
As advised, Mrs. Just Delivered visits after 3
weeks. She is partially breast feeding her
baby
What are her contraceptive options?





COCs
POPs
LNG IUD
Cu IUD
DMPA
Postpartum visit at 3 weeks
Mr J.D. considers Cu IUD and asks
“What would be the ideal time to insert the
Cu IUD, Doctor”

At 4 weeks?

At 6 months?
Postpartum insertion of a Cu IUD is best
done within 48hours or AT or AFTER 4
weeks (Category 1)
It is not inserted between 48 hrs to 4 weeks
(Category 4)
WHO eligibility criteria 2008
What about Breast feeding and COCs?
There are 3 issues here
Risk of Thromboembolism
 Estrogen in doses more than 30 ugm
inhibits lactation and can lead to a shorter
period of breast feeding
 Estrogen can induce reversible increase
in breast size of the mother and the infant,
male or female

The risk for VTE within the first 42 days
postpartum is 22-fold to 84-fold greater than
the risk among non-pregnant, non-postpartum
women.
 The risk is highest immediately after delivery,
declining rapidly during the first 21 days, but
not returning to baseline until 42 days
postpartum.
 Use of COCs, which can cause a small
increased risk for VTE, might theoretically
pose an additional risk if used during this
time.Systematic review, CDC, WHO

Breast-feeding and combined hormonal
contraception


COCs have
Minor effects on quantity and quality of
breast milk
No effect on infant growth
OB-GYNs=obstetricians and gynecologists; WHO=World Health Organization.
1. Truitt ST et al. Cochrane Database Syst Rev. 2003;(2):CD003988.
Special Situations - Postpartum
Contraception
COC POP INJ
IMP
Cu IUD
LNG IUS
Breastfeeding
<3weeks postpartum
4
3
3
3
> 48 hr
3
> 48 hr
3
3 weeks - < 6 weeks
postpartum if risks for
VTE present
3
1
1
1
> 4 wks
1
> 4 wks
1
> 6 months postpartum
2
1
1
1
1
1
< 21 days
3
1
1
1
> 48 hr
3
> 48 hr
3
> 21 days
1
1
1
1
> 4 wks
1
> 4 wks
1
Non Breastfeeding
She chooses to use Inj DMPA
What would you counsel her about?
She takes Inj DMPA and is quite happy with it.
Her periods are irregular with spotting on & off
but since she has been counseled, she is not
unduly disturbed by it and the bleeding settles
down
Following the second injection, she returns to
the clinic only after 4 months
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
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
What are the demerits of DMPA?

Irregular bleeding in the 1st 3-4 months

Interferes with Calcium deposition in bones

Fertility returns 8-10 mths after the last dose
Case 3
F, 32yrs, P2 L2
 Regular heavy periods
 Clinical Examination – 14wks size uterus
 Ultrasound examination – Bulky uterus with
multiple intramural fibroids, largest measuring
4cmX4cm.
 Endometrial thickness 11mm, contour - normal

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 women with fibroids & troublesome bleeding,
the size of the uterus and the largest individual
tumors diminished slightly with LNG-IUS.
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
Special Situations - Genital & Breast
Conditions
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Cavity non distorting
1
1
1
1
1
1
Cavity distorting
1
1
1
1
4
4
Endometriosis
1
1
1
1
2
1
Benign Ovarian
Tumors
1
1
1
1
1
1
Benign Breast
Disease
1
1
1
1
1
1
Ectropion
1
1
1
1
1
1
Fibroids
Mrs F chooses to get an LNG IUS inserted. She
comes back after 3yrs for a check up. She
reveals that she was recently hospitalized for a
bad lung infection and is presently undergoing
treatment for tuberculosis with a 4 drug regime.
Would you like to suggest a change in her
contraceptive method?
LNG IUS and Anti-TB Drugs
Data shows no reduction in the efficacy of LNGIUS 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
Special Situations - Miscellaneous
Issues
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Iron deficiency anemia
& thalessemia
1
1
1
1
2
1
Sickle cell
2
1
1
1
2
1
4
3
3
3
1
3
3
3
2
3
1
1
Anemias
Liver Tumors
Benign adenoma
Malignant hepatoma
Liver Enzyme
Affecting Drugs
Rifampicin, phenytoin,
barbiturate,
carbamezipine
33yr old with a BP of 150/100 needs
contraception. She is on medication for
Hypertension and does not have any other
medical problem. What contraceptives would be
safe for her?
Oral contraceptives (including newer agents), increase
systolic BP by 8 mm Hg and diastolic by 6 mm Hg
Special Situations - Hypertensive
Conditions
COC
R/P
POP
DM
PA
IMP
Cu IUD
LNG IUS
3/4
2
3
2
1
2
Adequate control
3
1
2
1
1
1
140 – 159 / 90 – 99
mm Hg
3
1
2
1
1
1
> 160 / > 100 mm Hg
4
1
3
2
1
2
Vascular disease
4
2
3
2
1
2
History of HT during
pregnancy
2
1
1
1
1
1
Arterial CVD Risk
Age, smoking, DM, HT
Hypertension
35yr old woman with 3 children and diabetic
since 1yr needs contraception. Her BMI is
28 and she is not hypertensive.
COC & Diabetes…

COC in type I DM – Studies find no change in HbA1c,
development or progression of nephropathy or
retinopathy

Nonsmoking, <35yrs, otherwise healthy diabetics, no
end-organ disease – COC safe

LNG-IUS – Safe in diabetics

Past h/o GDM – COC does not accelerate or precipitate
development of type II DM
ACOG Practice bulletin no:18, Obst & Gynecol. 2006
Case 4
A 24-year old woman, with no concomitant
diseases, was admitted with epigastric pain and
vomiting. A provisional diagnosis of Acute
Pancreatitis was made. On further questioning, she
gave a h/o having taken Diane 35 in the previous 4
months. Her LMP was 5 days back.
Is there a connection between the OC Pill and
Acute Pancreatitis?
Facts in favour of a connection
 Acute pancreatitis occurred within 3months
of starting estrogen therapy in most cases
 Abdominal pain and pancreatitis ceased
within 10 days of stopping estrogen
 S Triglycerides, Cholesterol and FBS are
increased when on the pill
 Estrogen increases fasting Triglycerides by
increasing the hepatic production of
Triglycerides.
 Estrogen also increases HD Lipoproteins and
decreases LD Lipoproteins
 Primary Dyslipidemia is a relative
contraindication for Estrogen therapy
Take Home message
In young, healthy women taking oral
contraceptives and presenting with acute
abdominal pain, consider the diagnosis of Acute
Pancreatitis
 Lipid profile before starting OCPs not
recommended
 With no pre-existing Hyperlipidemia, S
triglycerides increase is usually mild and does not
lead to pancreatitis
 If obese, with a family history of hyperlipidemia,
lipid profile checked to prevent acute
pancreatitis

Knehtl M, Journal of Disease Markers, Nov 2014
Case 5
A 28-year-old woman, P2+1, developed
jaundice, pruritus, fatigue and anorexia. She
gave a history of a single 28 day cycle of oral
contraceptives (Ovral L), started shortly after a
first trimester abortion. She was on no other
medication and did not drink alcohol
Because of persistent jaundice, she
underwent endoscopic retrograde cholangiopancreatography which was normal. A liver
biopsy showed intrahepatic cholestasis with
minimal inflammation and bile duct
proliferation
What could be the problem? Do you want
to elicit any other history?
She gives a history of having pruritus and
jaundice in her 2 previous pregnancies
In the 5th month of her 1st and the 6th week
of her 2nd pregnancy
Bilirubin values of 3.5 and 3.8 mg/dl
Severe pruritus
Cause of jaundice not identified
What type of jaundice did she suffer from?
Is there a connection between the jaundice
she had in her 2 prior pregnancies and what
she is suffering from now?
What are the features of Cholestatic jaundice?
Bland Cholestasis
Time of onset: 4 to 24 wks after starting pill
Jaundice: mild, S Bil never > 7mgs%
Pruritus: severe
ALT: <200 U/L (<5 times ULN)
Alkaline phosphatase: <230 U/L (<2 times
elevated) Both may be normal too
Resolves in 1-2 mths, rarely 6 mths
Never associated with fatal liver disease
To avoid it, should you do a LFT for all women
before prescribing the pill?
Can happen in men too after Anabolic steroids
Take home message
Take a proper history before starting the pill
 If woman complains of pruritus when on the
pill, discontinue it
 Do LFT. If elevated, treat symptomatically
 Repeat LFT after 6 weeks
 Use only those hormonal contraceptives
that bypass the liver like LNG-IUS, Vaginal
Ring, etc
 Reassure the woman that it is not a serious
condition

Special Situations - Gastrointestinal
Conditions
COC POP
INJ
IMP
Cu IUD
LNG IUS
Gall Bladder Disease
Symptomatic
Asymptomatic
3
2
2
2
2
2
2
2
1
1
2
2
Cholestasis
Pregnancy / COC
related
2
3
1
2
1
2
1
2
1
1
1
2
4
1
3
1
3
1
3
1
1
1
3
1
3
4
2
3
2
3
2
3
1
1
2
3
Viral Hepatitis
Active disease
Carrier state
Cirrhosis
Mild – compensated
Severe decompensated
Is it true?
 Women
who use oral contraceptives have
an increased risk of developing cervical
cancer
 The new analysis of data from 24
worldwide studies is one of the most
rigorous examinations of cervical cancer
risk in oral contraceptive users ever
conducted
Lancet, Nov 2010
 16,500
cervical cancer patients and
35,500 women without the disease studied
to quantify the risk associated with oral
contraceptive use worldwide.
 It was found that women who used the pill
for 5 years or less had a 10% increased
risk of cervical cancer when compared
with women who had never taken it. This
increased risk rose to 60% with 5-9 years
of use and doubled with 10 years of use or
over
Epidemiologist Jane Green, MD, who led
the study team…
 The risk starts to fall pretty quickly and has
gone away 10 years later

Lancet, Nov 2010
The reasons for this risk from OC use are
not entirely clear.
 less likely to use a diaphragm, condoms,
or other methods that offer some
protection against STDs including HPV.
 hormones in OCs might help the virus
enter the genetic material of cervical cells.
 "Regular
screening is important for all
women, but especially for those taking oral
contraceptives," Sasieni says.
 "A woman who has regular screenings can
basically forget about the increase in risk.“
 Based on the most recent evaluation of
several studies, the IARC has concluded
that HC can be classified as carcinogenic
to the cervix as well as to the breast.
When women who had used DMPA were
compared to women who had never used this
method, there were also significant differences
in presence of and severity of disease
 There are several studies which have reported
that hormonal contraception (HC) - pills and
injectables - moderately increase the risk of
cervical cancer as well as being a risk for all
stages of cervical cancer particularly in human
papilloma virus (HPV)-positive women thus
suggesting that oral contraceptives may act as a
promoter for HPV-induced carcinogenesis.

Norma McFarlane-Anderson etal, BMC Womens Health, 2008
No more
Surprise periods
No more
Surprise Babies
No more
Hot Flushes
No more
Diaper duty
Issues with Peri-Menopause
 Need
for effective contraception
 Menstrual cycle abnormalities
 Vasomotor instability
 Need for osteoporosis and cardiovascular
disease prevention
 Increased risk of gynecological cancer
Kailas NA, Reprod Health Eur J Contracept Care. 2005
The choices are
Oral Contraceptives-highly effective
contraception, non-contraceptive benefits,
improve QOL
 POPs.. Excellent safety profile
 IUCDs
 DMPA.. No evidence about # due to bone loss
 Barrier
 Combined Vaginal Ring, Skin Patches.. Risks
same as OCPs
 Natural Estrogens.. safer

A woman had a Cu 380 A inserted at 38
years. 10 years later, at the age of 48, she
has irregular cycles. Should the IUD be
removed?
Studies from the United Nations and Brazil
indicate high efficacy of copper IUD after the 10year window
Spontaneous fertility beyond age 45 is rare and
the IUD becomes even more effective
Keeping the 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.
When on COC, how does a woman know
that she has reached menopause?
Stop the pills for a month or more
Check her FSH
Testing FSH a second time one month
later will provide a more reliable result
Case 6
Mrs M, just married, had an open heart
surgery for ASD repair 2months back. She is
on oral anticoagulants. Wants contraception
for at lease one year.
Women on anticoagulant Rx
↑
Menorrhagia, corpus luteum hematoma,
hemoperitoneum
 COC, DMPA, Mirena - Appropriate
 COC – Do not ↑ risk of thrombosis if well
anticoagulated
 DMPA – Not much injection site problems
Special Situations - Heart Disease
COC
POP
INJ
IMP
Cu IUD
LNG IUS
History of IHD
4
I-2
C-3
3
I-2
C-3
1
I-2
C-3
Current IHD
4
I-2
C-3
3
I-2
C-3
1
I-2
C-3
Uncomplicated
2
1
1
1
1
1
Complicated Pulmonary HT & atrial
fibrillation
4
1
1
1
2
2
Complicated - SBE
4
1
1
1
2
2
Ischemic Heart
Disease
Valvular Heart Disease
Ideal Contraceptive in a woman with
Hypertension
If < 35 years
Non-smoking
No end organ disease
Well controlled Hypertension
Low dose COC ..OK
If not POPs or LNG-IUS
Oral contraceptives (including newer agents), increase systolic
blood pressure by 8 mm Hg and diastolic by 6 mm Hg
Ideal contraceptive in a woman with
Dyslipidemia
If dyslipidaemia is well controlled,
COCs with <35 ugms of EE can be used
Serum lipids monitored regularly
If LDL > 160 mgs%- POPs safer
Type of Progesterone is the deciding factor
Estrogens increase HDL, Triglycerides and lower LDL
Progesterone opposes this action. Androgenic Progestogens like Norethisterone,
LNG, increase LDL, lower HDL and Triglycerides.
Ideal contraceptive in a woman with Diabetes
COCs do not increase a woman's risk of
developing type 2 diabetes
In type 1 diabetes, COCs do not impair
metabolic control or accelerate the
development of vascular disease
BUT, ACOG recommends COCs only
If <35 yrs
No HT, Nephropathy, Retinopathy or other
vascular disease
LNG IUS.. safe
What about in Obesity?
COCs and Transdermal patch less effective
Obesity and COCs independent risk factors
for VTE
DUB and Endo Ca more common in obese
LNG-IUS safe and effective
A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload
375 inserted this time. When does she need to come for removal?
A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload
375 inserted this time. When does she need to come for removal?
She need not get it removed till after menopause.
Women 40 years or older at the time of IUD insertion may retain the
device until they no longer require contraception, even if this is beyond
the duration