28. Contraception Flashcards
Why is family planning considered a critical health intervention?
Family planning is essential for achieving long-term sustainable development goals, combating HIV/AIDS, and improving the health and development of women, men, and children by allowing women to plan, space, and delay pregnancies.
What guidelines is the South African National Contraception and Fertility Regulation Policy based on?
It is based on the 2012 SA National Contraception and Fertility Regulation Policy and Service Delivery Guidelines, which align with WHO recommendations.
What are the cornerstones of family planning according to WHO?
The cornerstones include:
- Medical Eligibility Criteria (MEC) for Contraceptive Use
- Selected Practice Recommendations for Contraceptive Use
Both are evidence-based recommendations developed by WHO to improve quality and safety in family planning and undergo periodic expert reviews.
What is the purpose of the WHO Medical Eligibility Criteria (MEC)?
MEC provides guidance on the safety of contraceptive methods in the context of specific health conditions and characteristics, such as HIV and tuberculosis.
What are the four WHO MEC classification categories?
Category 1: No restriction; the method can be used in any circumstance.
Category 2: Advantages generally outweigh theoretical or proven risks; method can generally be used.
Category 3: Risks usually outweigh advantages; use is not recommended unless no other acceptable methods are available.
Category 4: Unacceptable health risk; method should not be used.
What is the purpose of WHO’s Selected Practice Recommendations for Contraceptive Use?
It provides guidance on how to use contraceptives safely and effectively.
What does “informed choice” mean in the context of family planning?
Informed choice means clients are provided with accurate, unbiased information about all available contraceptive methods to make a decision. They should receive their chosen method, subject to availability and meeting medical eligibility criteria.
How does expanding contraceptive method choices impact family planning?
Expanding method choices improves satisfaction, increases acceptance, and raises the prevalence of contraceptive use (WHO MEC 2009).
What aspects should be assessed prior to initiating contraception?
- Medical history
- Future fertility plans
- Contraceptive history
- STI/HIV risk assessment
- Promotion of dual protection/dual method use
- Blood pressure (BP)
- Pelvic exam (only for IUS/IUD fitting or female sterilization)
- Breast and cervical screening is not essential
- Pap smears per national guidelines or clinical indication
When is it essential to measure blood pressure before initiating contraception?
- Essential prior to sterilization surgery
- Recommended before and during hormonal contraceptive use
- If not possible, hormonal methods can still be provided if there is no history of high BP, with BP measurement deferred to the next visit.
When is a pelvic exam required before contraception use?
A pelvic exam is only required before:
- Fitting an intrauterine system (IUS) or intrauterine device (IUD)
- Performing female sterilization
What is “dual protection” in the context of contraception?
Dual protection refers to using male or female condoms in combination with another contraceptive method to prevent both pregnancy and STI/HIV transmission.
Why should correct and consistent condom use be emphasized?
Because condoms alone have a higher pregnancy rate compared to combined methods, and they provide protection against STIs and HIV.
What is the current WHO classification for progestogen-only injectables among women at high risk of HIV?
Category 2: Women can use progestogen-only injectables but must be informed about:
- Potential increased risk of HIV acquisition
- Uncertainty of a causal relationship
- Ways to minimize HIV risk
What findings have been observed about hormonal contraception and HIV acquisition risk?
- Injectable DMPA-IM increases the likelihood of HIV-1 acquisition in women.
- NET-EN and COCs containing LNG do not show the same risk.
- Differences arise from the biological effects of individual progestins and the protective effects of estrogen.
Why is the relationship between DMPA-IM and HIV acquisition particularly important in sub-Saharan Africa?
Sub-Saharan Africa has high rates of both HIV and usage of DMPA injectable contraception, making this a critical public health concern.
How does WHO stay updated on the evidence regarding hormonal contraception and HIV?
WHO continuously monitors evidence and commissions systematic reviews, such as the 2016 update, to provide the most accurate guidelines.
Why might different progestins have varying effects on HIV risk?
Different progestins act via specific steroid receptors, and estrogen may have a protective anti-viral effect, leading to differential biological outcomes.zz
What is a low-dose Combined Oral Contraceptive (COC)?
Low-dose COCs are pills containing 35 µg or less of synthetic estrogen (ethinyl estradiol) and a synthetic progestogen (e.g., levonorgestrel, desogestrel, gestodene). They are highly effective at preventing pregnancy when taken regularly and are safe for most healthy women.
synthetic estrogen
ethinyl estradiol
synthetic progestogen
levonorgestrel,
desogestrel,
gestodene
List three examples of synthetic progestogens found in low-dose COCs.
Synthetic progestogens include:
Levonorgestrel
Desogestrel
Gestodene
What is the main condition for the effectiveness of low-dose COCs?
They must be taken regularly to be highly effective at preventing pregnancy.
Can breastfeeding women use COCs?
Breastfeeding women should avoid using COCs if they are less than 6 weeks postpartum (WHO Category 3/4).
Why should women who smoke more than 10-15 cigarettes per day and are over 35 years old avoid COCs?
Smoking combined with COCs significantly increases the risk of cardiovascular conditions, making it unsuitable for this group (WHO Category 3/4).
Which types of migraines are contraindications for COC use?
- Migraine with aura (any age)
- Simple migraines in women over 35 years
Name three cardiovascular-related conditions that are contraindications for COCs.
- Ischemic heart disease
- Stroke
- Complicated valvular heart disease
Why are women with VTE or known thrombogenic mutations advised against using COCs?
COCs increase the risk of blood clot formation, making them unsuitable for women with VTE or thrombogenic mutations.
Why are COCs contraindicated in women with diabetes lasting over 20 years or with vascular complications?
Long-term diabetes or vascular complications increase the risk of cardiovascular disease, which is exacerbated by COCs.
Which liver condition is a contraindication for COCs?
Liver tumors are a contraindication for COC use.
Why are enzyme-inducing drugs like rifampicin and ritonavir contraindicated with COCs?
These drugs reduce the effectiveness of COCs by increasing their metabolism.
Name a chronic autoimmune condition that is a contraindication for COCs.
Systemic lupus erythematosus (SLE) with positive or unknown antiphospholipid antibodies.
Why is prolonged immobilization a contraindication for COCs?
It increases the risk of venous thromboembolism (VTE), which is already a concern with COCs.
Mnemonic for contraindications of COC
“Breastfeeding Mothers Should Call Hypertension Clinics Before Liver Doctors See Acute Cases.”
B - Breastfeeding (<6 weeks postpartum)
M - Migraine (with aura or simple migraine >35 years)
S - Smokers (>10-15 per day aged over 35)
C - Cardiovascular conditions / Complicated valvular heart disease
H - Hypertension
C - Cancer (breast)
B - Blood clots (VTE, thrombogenic mutations)
L - Liver tumors or severe liver disease
D - Diabetes (>20 years or with vascular complications)
S - SLE with antiphospholipid antibodies
A - Acute porphyria
C - CVD-related conditions (stroke, IHD, prolonged immobilization, etc.)
What should you do if one pill is missed (24–48 hours late)?
Take the missed pill as soon as it is remembered.
Continue taking the remaining pills at the usual time.
Key Point: No additional contraception is required.
What should you do if two or more pills are missed (>48 hours late)?
Take the most recent missed pill as soon as possible.
Discard any other missed pills.
Continue taking the remaining pills at the usual time.
Precaution: Use condoms or avoid sexual intercourse until seven consecutive active pills have been taken.
What should you do if two or more pills are missed in Week 1 (Pills 1–7)?
Use emergency contraception if unprotected sex occurred during the missed pill window or the first week of pill-taking.
Resume taking pills as usual.
Use additional contraception (e.g., condoms) for seven days.
What should you do if two or more pills are missed in Week 2 (Pills 8–14)?
No emergency contraception is needed if pills were taken correctly before the missed days.
Resume taking pills as usual.
Ensure seven consecutive active pills are taken.
What should you do if two or more pills are missed in Week 3 (Pills 15–21)?
Omit the pill-free interval.
Finish the active pills in the current pack and discard all the placebos and start the next pack the following day without a break.
What is the effectiveness of COCs?
92% during the first year as commonly used.
Up to 99.7% effective when used correctly and consistently.
Are there any age or parity limitations for COC use?
Age Limitations: No restrictions from menarche to age 40; after 40, more careful follow-up may be required.
Parity Limitations: No restrictions
What is the primary mode of action of COCs?
COCs primarily prevent ovulation. Secondary mechanisms include thickening cervical mucus and altering the endometrium.
What are the common side effects of COCs?
Nausea and inter-menstrual spotting/bleeding (common in the first 3 months).
Mild headaches, dizziness, breast tenderness, light periods, breakthrough bleeding, or occasional amenorrhea may occur.
Usually, no medical management is required, but side effects should be discussed.
What are the non-contraceptive benefits of COCs?
COCs offer several non-contraceptive benefits, including:
- Regular, lighter, and less painful menstruation.
- Prevention or improvement of iron-deficiency anemia.
- Decreased incidence of PID, ectopic pregnancy, ovarian and endometrial cancers, and benign breast disease.
- Reduced symptoms of endometriosis and PCOS.
- Acne improvement, especially with preparations containing cyproterone acetate or drospirenone.
- Protection from risks associated with pregnancy.
Do COCs provide protection against HIV/STIs?
No, COCs do not protect against HIV or other STIs.
How long can COCs be used, and is there any delay in fertility return after discontinuation?
COCs can be safely used throughout the reproductive years; periodic discontinuation is not necessary.
Fertility returns without delay after discontinuation.
When can COCs be initiated, and is extra protection required?
If started on Day 1–5 of the cycle, protection is immediate.
If initiated at any other time, ensure the client is not pregnant and use extra protection for 7 days.
How should nausea, dizziness, moodiness, mild headaches, or tender breasts be managed in COC users?
- Exclude pregnancy.
- Reassure that these side effects are common and usually diminish within 3 months.
- Advise to take pills with meals or before bed.
- If problems persist:
- Try a different pill.
- Switch to a COC with less than 35 micrograms of oestrogen (if available).
- Help her choose another contraceptive method. - For cyclical pre-menstrual mood swings or breast tenderness with triphasic pills, consider switching to a monophasic pill.
What is the management for breakthrough bleeding or spotting that persists beyond 3 months of COC use?
- Ask about missed pills.
- Exclude concomitant drug use and severe diarrhea or vomiting (D&V).
- Examine to exclude pregnancy or genital tract pathology (e.g., infection or cancer).
- If pathology is identified, manage appropriately. - Switch to a different brand of low-dose pills.
- If low-dose pills fail:
- Switch to a higher-dose pill (if available) for 3 cycles for better cycle control, then revert to a low-dose pill.
- Alternatively, help her choose another contraceptive method.
What are the severe adverse events associated with COCs?
- Venous Thromboembolism (VTE):
- Rare but occurs more frequently in COC users than non-users (though less frequently than during pregnancy). - Arterial Events:
- Myocardial infarction, haemorrhagic stroke, and ischaemic stroke are extremely rare during reproductive years.
- Associated with risk factors such as hypertension, smoking, diabetes, and migraine with aura.
How can the risk of severe adverse events with COCs be minimized?
- Apply the Medical Eligibility Criteria (MEC) carefully to screen users.
- Identify and address risk factors such as smoking, hypertension, diabetes, and migraine with aura.
What do progestogen-only pills (POPs) contain?
POPs contain very low doses of synthetic progestogen.
How should POPs be taken?
A POP should be taken approximately at the same time every day. There are no inactive pills in the POP pack, and no break is required between packs.
Are POPs suitable for breastfeeding women?
Yes, POPs are appropriate for breastfeeding women as they do not affect breastfeeding.
Why are POPs used in women who experience side effects from COCs (combined oral contraceptives)?
POPs are used in women who experience oestrogen-related side effects with COCs or have health conditions that preclude safe use of COCs.
How effective are POPs in preventing pregnancy compared to COCs?
POPs are slightly less effective than COCs in non-breastfeeding women, but when compliance is good, they are highly effective. They are also highly effective in breastfeeding women.
Are POPs safe for most women?
Yes, POPs are safe for most women.
What conditions preclude the use of POPs?
Conditions that preclude the use of POPs include current breast cancer, acute porphyria, and the use of enzyme-inducing drugs.
What is the effectiveness of POPs in non-breastfeeding women?
In non-breastfeeding women, POPs are 90-97% effective as commonly used. When used consistently and correctly, they are more than 99% effective.
How effective are POPs in fully breastfeeding women?
POPs are ≥99% effective in fully breastfeeding women.
Are there age restrictions for using POPs?
No, there are no age restrictions for women from menarche to menopause.
Are there any parity restrictions for using POPs?
No, there are no parity restrictions.
What is the primary mode of action of POPs?
POPs primarily thicken cervical mucus to prevent sperm penetration (after 2 days of use) and also inhibit ovulation in 60% of cycles.
What are the common side effects of POPs?
ommon side effects include changes in menstrual bleeding (irregular bleeding, spotting, or amenorrhoea), mild headaches, nausea, dizziness, mood changes, and breast tenderness.
Do POPs offer non-contraceptive benefits?
POPs provide no non-contraceptive benefits other than protection from risks associated with pregnancy.
Does using POPs protect against HIV or other STIs?
No, POPs do not provide protection against HIV or other STIs.
How long can POPs be used?
POPs can be used throughout the reproductive years.
How quickly does fertility return after stopping POPs?
Fertility returns without delay once POPs are discontinued
When can POPs be started?
POPs can be started at any time, provided it is reasonably certain that the client is not pregnant. If pregnancy is a possibility, a pregnancy test must be done, or the client should avoid sex or use condoms until her next period, and then begin taking the pills from Day 1.
What should a client do if she is more than 3 hours late in taking a POP?
If more than 3 hours late, take the missed pill as soon as possible, continue taking one pill each day as usual, and use condoms or avoid sex for the next 48 hours.
What should be done if a client experiences irregular bleeding or spotting while using POPs?
Reassure the client that irregular bleeding or spotting is common with POPs. Ask if she takes the pills on time, had vomiting or diarrhea, or started any medications that could affect POP effectiveness. If necessary, exclude pregnancy or other conditions. If no pathology is found, reassure the client and advise continuing with POPs. For short-term relief, offer ibuprofen 800 mg three times a day for 5 days. If bleeding persists and is unacceptable, consider changing methods.
What should be done if a client using POPs experiences amenorrhoea (absence of menstruation)?
Reassure the client that amenorrhoea is not uncommon with POPs. If pregnancy is suspected, perform a pregnancy test. If pregnant, stop the POPs and discuss management options, including termination of pregnancy (TOP). If not pregnant, continue using POPs with reassurance.
What is a Long Acting Reversible Contraceptive (LARC)?
LARCs are contraceptive methods that require administration less than once per cycle, offering high effectiveness without relying on daily compliance or correct use like pills or barrier methods
What are the different types of LARC methods?
LARC methods include:
- Intrauterine Contraception (IUD/IUS):
- Copper T 380 IUD (10 years)
*Nova T IUD (5 years)
*Levonorgestrel releasing Intrauterine System (LNG-IUS) (5 years)
- Copper T 380 IUD (10 years)
- Progestogen-only Injections:
- DMPA (12 weekly)
*NET-EN (8 weekly) - Sub-dermal Progestogen Implants:
*Single rod (3 years)
*Two rods (4 or 5 years depending on type)
How do LARCs compare to short-term contraceptive methods?
LARCs generally have superior continuation rates compared to short-term methods because they don’t rely on user compliance. They are highly effective and cost-effective, even though the initial costs are higher.
Are LARCs cost-effective?
Yes, despite their higher initial costs, LARCs are more cost-effective within one to two years. Male and female sterilization only become more cost-effective than LARCs after 15 years.
What are progestogen-only injectables?
Progestogen-only injectables are highly effective, reversible contraception methods containing synthetic progestogens administered by deep intramuscular injection. The two main types are depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN).
How effective are progestogen-only injectables?
When used as commonly prescribed, progestogen-only injectables are 93% effective. However, if used correctly (e.g., reinjection on time), their effectiveness can be as high as 99.7%.
Are there any age restrictions for using progestogen-only injectables?
There are no strict age restrictions. However, caution is advised for adolescents under 18 and women over 45 due to concerns about bone mineral density. There is no data supporting the choice of injectable based on age alone.
Are there any restrictions for women based on parity (number of children) when using progestogen-only injectables?
No, there are no restrictions related to parity.
How do progestogen-only injectables work?
Progestogen-only injectables primarily inhibit ovulation, but they also thicken cervical mucus, which prevents sperm penetration.
What are common side effects of progestogen-only injectables?
Common side effects include changes in menstrual bleeding (irregular, prolonged, heavy bleeding, or amenorrhoea), weight gain, headaches, dizziness, mood changes, and decreased sex drive.
What non-contraceptive benefits do progestogen-only injectables offer?
Non-contraceptive benefits include:
- Prevention or improvement of iron deficiency anaemia
- Decrease in ectopic pregnancy, pelvic inflammatory disease (PID), uterine fibroids, and endometrial cancer
- Reduction in sickle cell crises in women with sickle cell anaemia
- Reduction in severity of endometriosis symptoms
Do progestogen-only injectables protect against HIV or STIs?
No, they do not protect against HIV or STIs. Some studies suggest that DMPA might increase the risk of HIV acquisition. It’s important to emphasize the use of condoms along with hormonal or non-hormonal contraception for HIV prevention. Alternatives like Cu IUDs or lower-dose hormonal options should be explored with clients.
How long can progestogen-only injectables be used?
Progestogen-only injectables can be used throughout the reproductive years. However, for perimenopausal women, switching methods after age 45 may be considered to allow time for bone density recovery.
How long does it take for fertility to return after using progestogen-only injectables?
Fertility typically returns within 4-6 months, depending on the injectable type. There is no permanent damage to fertility.
When can progestogen-only injectables be initiated?
- If the first injection is given within the first 7 days of the menstrual cycle, protection is immediate, and no backup contraception is needed.
- If started after day 7, avoid sex or use condoms for 7 days.
- Injectables can be given immediately after childbirth, miscarriage, or termination of pregnancy (TOP). For breastfeeding women, initiation is suggested to be delayed until 6 weeks post-delivery.
What are common side effects of progestogen-only injectables?
Common side effects include:
- Irregular bleeding, prolonged spotting, or heavy bleeding: Especially in the first few months of use. Frequency decreases with duration.
- Amenorrhoea (absence of menstruation): Increases with use; about 80% of users experience it by the end of the second year.
- Weight gain: Caused mainly by increased appetite. Monitoring diet can help manage this.
- Acne, headaches, mood changes, bloating, and dizziness may also occur.
How long does it take for fertility to return after stopping progestogen-only injectables?
After discontinuation, the average delay in return to fertility is about:
4 to 6 months for NET-EN and DMPA, respectively.
It’s important to discuss this delay with clients when they plan to stop the method.
What should be done if a NET-EN injection is late?
A NET-EN injection can be safely given if it is less than 2 weeks late. If more than 2 weeks have passed:
- If pregnancy can be reasonably excluded (e.g., no sex since the grace period, consistent condom use, or LAM), the injection can be given.
- If pregnancy cannot be excluded, use condoms, abstain, or use POP for 3 weeks. If a pregnancy test is still negative, give the injection and advise continued protection for 7 days after the injection.
What should be done if a DMPA injection is late?
A DMPA injection can be safely given if it is less than 4 weeks late. If more than 4 weeks have passed:
- If pregnancy can be reasonably excluded (e.g., no sex since the grace period, consistent condom use, or LAM), the injection can be given.
- If pregnancy cannot be excluded, use condoms, abstain, or use POP for 3 weeks. If a pregnancy test is still negative, give the injection and advise continued protection for 7 days after the injection.
What should be done if the possibility of pregnancy cannot be excluded after a late injection?
If pregnancy cannot be excluded, the injection may still be given with the understanding that it will not harm an existing pregnancy. Advise the following:
- Use condoms or abstain from sex for the first 7 days after the injection.
- Schedule an early follow-up appointment in 4-6 weeks to confirm there is no pregnancy.
- Do not simply tell the client to wait for their next period; ensure they are given a method to use until their next period.
Are there any significant drug interactions with progestogen-only injectables?
There are few significant drug interactions. It is not necessary to shorten injection intervals when using enzyme-inducing drugs.
How should amenorrhoea (absence of menstruation) be managed in users of progestogen-only injectables?
Explain to the client that amenorrhoea is common and normal with progestogen-only methods and is not harmful.
Reassure the client that it does not indicate a problem, and it is a typical side effect of the method.
What should be done if a client experiences spotting or light irregular bleeding while using progestogen-only injectables?
Reassure the client that spotting or light bleeding is very common during the first few months of use, and it is usually not harmful.
Examine the client to exclude any underlying gynaecological pathology.
For light bleeding, a low-dose combined oral contraceptive (COC) for 7 days may help control it.
If oestrogen is contraindicated, consider using a non-steroidal anti-inflammatory drug (NSAID) like ibuprofen (400 mg three times a day for 3 days).
How should very heavy, prolonged, or frequent bleeding be managed in users of progestogen-only injectables?
- Examine to rule out any underlying gynaecological pathology.
- Reassure the client that some injectable users experience heavy or prolonged bleeding, but it usually diminishes over time and is not harmful.
- However, it may require attention, especially in women with anaemia.
- If pathology is excluded and oestrogen is not contraindicated, prescribe a high-dose COC, such as Biphasil®, to be taken daily for 21 days, followed by 7 placebo pills to allow for a normal withdrawal bleed (this can be repeated for up to two cycles if needed).
- If oestrogen is contraindicated, consider using an NSAID or Tranexamic acid to help reduce bleeding.
What should be done if bleeding remains unacceptable or persists despite treatment?
If bleeding remains unacceptable or continues after the prescribed treatments, advise the client to switch to another contraceptive method.
What are progestogen subdermal implants?
Progestogen subdermal implants are long-acting, highly effective, and safe contraceptives. The most common type, Implanon Next, consists of a single rod containing etonorgestrel, and it can be used for 3 years. The small rod, about the size of a matchstick, is inserted just under the skin of the upper arm, releasing a small amount of progestogen into the body.
How effective are progestogen subdermal implants?
Progestogen implants are the most effective form of contraception with extremely low failure rates and good continuation rates. They are highly reliable for contraception.
What are the non-contraceptive benefits of progestogen implants?
In addition to providing effective contraception, progestogen implants offer some non-contraceptive benefits, although these were not specified in the provided information. They also do not affect bone mineral density, unlike some other hormonal methods.
How do the hormone levels from implants compare to other methods, and what side effects might occur?
The hormone levels from implants are constant and much lower than with injections. As a result, side effects, while similar to those of other progestogen methods, are generally less frequent, less pronounced, and rapidly reversible once the implant is removed.
Are progestogen implants cost-effective?
Despite high initial costs, progestogen implants are cost-effective compared to pills and injections, especially after one year of use.
Are there any women who should not use progestogen subdermal implants?
Women who should not use progestogen implants are those with the same contraindications as for injections, such as certain health conditions like severe cardiovascular disease, acute porphyria, and current breast cancer.
How effective are progestogen-only implants?
Progestogen-only implants are almost 100% effective. For example, with Implanon®, only 1 pregnancy occurs in 1,000 women over a 3-year period.
Are there age restrictions for using progestogen-only implants?
No, there are no age restrictions for progestogen-only implants, from menarche to menopause. Additionally, they do not affect bone mineral density (BMD).
Are there any restrictions based on parity (number of children) for using progestogen-only implants?
No, there are no parity limitations for using progestogen-only implants.
How do progestogen-only implants work?
Progestogen-only implants primarily inhibit ovulation and thicken cervical mucus, preventing sperm from penetrating the cervix.
What are common side effects of progestogen-only implants?
A: Common side effects include:
Changes in menstrual bleeding: Lighter bleeding, irregular bleeding, infrequent bleeding, and amenorrhoea.
Other side effects: Headaches, nausea, dizziness, breast tenderness, mood changes, and abdominal pain due to enlarged ovarian follicles.
What are the non-contraceptive benefits of progestogen-only implants?
Progestogen-only implants provide the following non-contraceptive benefits:
-Prevention of symptomatic pelvic inflammatory disease (PID)
- Prevention of iron-deficiency anaemia
