CONTRACEPTION UPDATE

Hormonal Contraception Update

2004 WHO Expert Working Group on Missing pill recommendation

Always take a hormonal pill as soon as you remember and continue to take one pill each day.

• Missed 3 or more pills :

1. You must take hormonal pills for 7 days in a row to get back full protection
2. Starting with the first pill you missed, keep taking one pill each day, AND use condoms or avoid sex until you have taken hormonal pills for 7 days in a row.

• if you missed 3 or more hormonal pills in week 3:

Finish only the hormonal pills in that pack, throw away the reminder pills, and then start a new pack the next day.

*These instructions apply to combined oral contraceptive pills containing more than 20 g of the estrogen ethinyl estradiol.

• Advantages of DMPA

o Almost 100% effective

o Does not require day to day motivation

o Non intercourse related

o No oestrogenic side effects or health risks

o Protective against PID & Endometrial Ca

o Does not inhibit lactation

o Protective in sickle cell (SS) disease

• Disadvantages of DMPA

o (Injection cannot be removed once given)

o Menstrual disturbance

o Delay in return of fertility

o Weight gain

o (Androgenic side effects eg. acne - rare)

o osteoporosis

• Depo & osteporosis SUMMARY

o Special Warnings and Precautions etc: Loss of bone mineral density, increasing with length of use.

o A risk: benefit assessment should be performed, especially in young or adolescent women and if use is anticipated to be long term (ie 2 years or longer).

o In adolescents and women with significant lifestyle and/or medical risk factors for osteoporosis, other methods of contraception should be considered before using Depo-Provera.

• Depo Provera and Arterial disease

ü Reduction in HDL (15% approx)

ü Impairment of arterial endothelial function (Sorenson MB et al. Circulation 2002; 106: 1646-1651)

ü WHO Epidemiological study (WHO Contraception 1998; 57: 315-324)

FUTURE HORMONAL CONTRACEPTION

• NuvaRing
  Design, composition and use

1 ring per cycle

Regimen:

ü 3 weeks of ring-use

ü 1 ring-free week

Daily release:

ü 15 µg ethinylestradiol

ü 120 µg etonogestrel

• NuvaRing
  Pharmacokinetics and dynamics
• Irregular bleeding with Nuvaring
  Comparison with a COC

IUD Update

• Re-emergence of the IUD

o Recent research has led to important changes in WHO eligibility criteria

o Risk of upper genital infections is negligible

o Despite many misconceptions, IUD users have higher satisfaction rates than users of many other methods (99% vs 91% for pill users)

• Reducing the Risk of PID

ü Screen women for risk of STIs:

o generally can use if at risk of STIs

o not recommended if at high individual risk of STIs

ü Screen out women with clinical symptoms and signs of an STI

ü Counsel about risk of PID

ü Follow infection prevention procedures during insertion

ü Recommend one-month follow-up visit to check for infection return immediately if any symptoms of PID develop

• If STIs or PID are diagnosed:

o Treat condition

o Leave IUD in place

o Counsel to abstain from sex or use condom until cured to prevent infection transmission

o Encourage partner treatment

• SUMMARY

§ IUDs are:

safe, effective, convenient, reversible, long lasting, cost effective, easy-to-use

§ Providers can ensure safety by:

ü careful screening

ü informative counseling

ü good infection prevention

ü proper follow-up