Contraceptives for Special Situations

1. Contraceptives for Special Situations Dr.Suma Natarajan MD DGO FAGE HOD,Ganga Women & Child Centre

2. “ 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

3. 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

4. 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.

5. 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

6. 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

8. What are special situations • Adolescents • Following pregnancy and lactation • Perimenopausal women designated as “Special population” • Women with gynaecological problems • Women with medical disorders

10. 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

11. 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

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

13. 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

14. Based on all information which contraceptive option do you think would best suit ? • Same COC as her friend • Newer COC with Drospirenone , Cyproterone acetate • POP • Copper IUD • IUS (Mirena) • Vaginal ring

15. 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

16. Cyproterone acetate • In combination with ethinyl estradiol • Should be prescribed for ~ 6 -12 months • Excellent results in • Acne • Hirsutism • PCOS

17. 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?

18. 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

19. You educate her about the correct method of use of Emergency Contraception. You advice… • Abstinence • COCs • POPs • IUD • Injectable contraception • Vaginal ring

20. 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?

21. 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

22. 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.

23. Case 3 • Mrs G 32yrs, P2 L2 • Regular periods with moderate flow • Clinical Examination – Uterus normal size mobile, fornices free

24. Among contraceptives, which one of these is the most cost - effective • Condoms • IUD • OCs • DMPA • Vaginal Ring

25. Pt requests for a Cu IUCD However, examination reveals vulvovaginitis suggestive of candidal infection Would you still go ahead with with the insertion?

26. 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?

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

28. 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

29. 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

30. 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

31. Patient is asymptomatic & not keen on surgery

32. Perforated IUD • Is it best left alone if the woman is asymptomatic? • Is it best removed soon after it is located?

33. 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

34. 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?

35. 6 weeks after delivery • 4 months after delivery • 3 months after delivery • 3 weeks after delivery i

36. Most studies have shown that half the women ovulate before the 6th week (before the traditional postpartum visit) . A 3 week visit would be ideal

37. Rule of 3’s Beginning of postpartum contraceptive use • Full breast feeding – 3rd month • Partial or No breast feeding – 3rd week

38. 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

39. 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

40. 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. WHO eligibility criteria 2008

41. 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?

42. She chooses to use Inj DMPA. When would you start her on the injection? • Immediately • Later….if so when?

43. 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?

44. 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

45. 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

46. 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

47. 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

48. 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

49. Issues • When to start using contraception. • When to use IUD after LSCS • Sterilization with second CS

50. TIMING OF INITIATION