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Depot medroxyprogesterone acetate. most commonly used injectable a 150 mg dose at 12 week intervals. released slowly from the injection site into the circulation. DMPA is more than 99% effective. Prolonged spotting common side-effect in the first year but amenorrhoea in long-term use.
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most commonly used injectable a 150 mg dose at 12 week intervals. released slowly from the injection site into the circulation. DMPA is more than 99% effective. Prolonged spotting common side-effect in the first year but amenorrhoea in long-term use. other side-effects such as breast discomfort, nausea, vomiting, weight gain, seborrhoea, acne and mood swings. amenorrhoea for more than two years with DMPA is associated with chronic low serum oestrogen and reduced bone density. All women choosing DMPA should be aware of this information.
bone density assessed with dual X-ray absorptiometry (DEXA) scan. reduced bone mineral density (BMD) The BMD returns to normal after discontinuation • Teenagers, not have peak bone mass, should be advised to use other methods. The peak bone mass is attained around the age of 30 years. Women who have been amenorrhea for more than three years receiving DMPA should have their
Depot medroxyprogesterone acetate can offer additional health benefits for women with homozygous sickle cell haemoglobinopathy by reducing haemolytic and bone pain crises • After discontinuation of DMPA, there may be a delay in the return of fertility for up to 18 months.
Norethisterone enanthate (NET-EN) • Noristerat, • injectable contraceptive is given intramuscularly in a 200 mg • dose at 8 week intervals. • Noristerat is more than 99% effective and its side-effects are similar to DMPA.
Using injectable progestogens • If the initial injection is given within the firstfive days of the menstrual period (preferably days 1 to 3), the contraceptive effect is immediate. • If given at any other timeadditional contraceptive cover is required for the next seven days
Specific considerations • This method is irreversible from the time of action, any side-effects may be present until the injection wears off. • The efficacy of DMPA and NET-EN is not affected by concurrent use of liver enzyme-inducing medications. • Preconception considerations • Injectable progestogen is not recommended as contraception for women who plan to conceive soon.
Postpartum considerations • Injectable progestogen contraceptives can be given prior to the 21st day postpartum, thus preventing the earliest ovulation • however, the woman must be warned about the increased risk of bleeding. • can be used by women who are breastfeeding their baby • delaying commencement until 6 weeks postpartum is often advised to ensure lactation is well established and reduce bleeding problems.
Subdermal contraceptive implants • Norplant was used 1993 • Implanon from 1999. • Nexplanon, 2010. • more recent implant are that the rod is radio-opaque, containing barium in order to locate it on X-ray • has a pre-loaded applicator which has been designed to reduce insertion errors.
Using implants • capsules containing progestogen, which are inserted under local anaesthetic into the inner aspect of the non-dominant upper arm ( • The steroid is released into the circulation, producing a change in the cervical mucus which prevents spermatozoa penetration, disturbance of the maturation of the endometrium and suppression of ovulation.
Norplant, six capsules containing levonorgestrel, has been replaced by Norplant 2 (also marketed as Jadelle) two capsules. Jadelle is effective for 5 years Nexplanon and Implanonare single contraceptive rods containing 68 mg of etonogestrel. inserted during the firstfive days of the menstrual cycle and no additional contraceptive cover is required. Ovulation is suppressed within 24 hours. effective for 3 years but can be removed at any time if the woman wishes. After removal, the serum is cleared of etonogestrel within 1 week and fertility is promptly regained.
Efficacy • Norplant is more than 99% effective. Nexplanon and Implanon have practically zero failure rates if instructions are carefully followed • implant failures due to interaction with enzyme-inducing medications, the implant has been incorrectly inserted
Specific considerations • Irregular bleeding is the most common problem for women using subdermal contraceptive implants. Only 20–30% of users become amenorrhoeic, headache, seborrhoea, acne and mood swings • Insertion and removal require a minor surgical procedure, risks of bleeding and infection. • These aspects should be discussed prior to the woman making her decision. • Counselling before fitting and during use appears to be the only way to reduce premature discontinuation due to the side-effects.
Preconception considerations • The action of the implant is quickly reversible and ovulation can return within 21 days of removal in 94% of women • This makes it suitable also for women wishingto ‘space’ pregnancies.
Postpartum considerations • If the implant is inserted up to or at 21 days postpartum it is effective immediately • inserted after the 21st day postpartum, additional contraception, such as a condom, • The implant is safe for women who are breastfeeding their babies. • can also be inserted immediately after miscarriages or induced terminations of pregnancy. • No extra contraceptive precautions need to be taken.
Intrauterine contraceptive device (IUCD) • These devices are inserted into the uterus • They contain copper, which increases contraceptive efficacy. • the use of IUCDs and progestogen-releasing intrauterine systems (IUS) • The IUCD is the most popular method • 150 million women worldwide use IUCDs, of which 60 million are in China.
Mode of action • an inflammatory response in the endometrium. • Leucocytes are capable of destroying spermatozoa and ova. • Gamete viability is also impaired by alteration of uterine and tubal fluids. • Copper affects endometrial enzymes, glycogen metabolism and oestrogen uptake, thus rendering the endometrium hostile to implantation, consequently IUCDs are more than 99% effective
Using the IUCD • A copper IUCD can be inserted any time during the menstrual cycle if it is certain that the woman is not pregnant, or up to 5 days following the earliest estimated date ofovulation • day 19 in a 28-day cycle, when it will be effective immediately. • The woman may experience some discomfort during the procedure, which should be performed using aseptic techniques.
left in place from 5–10 years and longer in some instances; e.g. if a woman aged 40 years or over has an IUCD fitted, it may remain in place until one year after the menopause, if this occurs after the age of 50. Once in situ, the device requires no action of the user and it does not interfere with sexual intercourse. Women are usually taught to feel the threads
attached to the IUCD on a regular basis as reassurance that it remains in place. A follow-up appointment in 3–6 weeks following insertion is recommended to assess for any infection, translocation or expulsion. Subsequently the woman requires further follow-up appointments only if she has any concerns. The traditional routine annual review is no longer recommended
Side-effects of using the IUCD include menorrhagia, dysmenorrhoea, bacterial vaginosis and colonization by Actinomycetes-like organisms. When the lafer is reported in a routine cervical smear, the woman should be counselled about the options of either changing the IUCD or retaining it and being reviewed periodically to ensure there is no pelvic infection. Removal of the IUCD whenever desired is easy and painless, and fertility is promptly restored.
The suggestion that IUCDs promote pelvic inflammatory disease (PID) has been refuted. Clinical risk assessment for sexually transmifed infection (STI) is recommended • Routine or selective screening for chlamydia and gonorrhoea may be appropriate in some cases, where prompt treatment and contact tracing will be offered. Intrauterine contraceptive devices are
associated with a decreased risk of ectopic pregnancies because of their effectiveness. However, in the unlikely event that a pregnancy should occur, the ratio of ectopic to intrauterine pregnancies is greater among women using IUCDs, as in general the device prevents more intrauterine pregnancies than ectopic pregnancies. Thus a woman who has an IUCD fifed should be advised to seek early
medical advice, should she suspect that she is pregnant. • If uterine pregnancy occurs, there is an increased risk of spontaneous miscarriage, therefore gentle removal of the device is preferred, to prevent infection and premature labour. If removal is not possible, it is reassuring to know there is no evidence of teratogenicity in the fetus.
A newer frameless device, GyneFix, as shown in Fig. 27.4(B), comprising six copper sleeves crimped onto a polypropylene monofilament thread, is fifed with one end embedded into the fundal myometrium of the uterus. This device is associated with lower expulsion rates and less dysmenorrhoea.
