Dr. Sujata Misra MD , FICOG Associate Professor,OBGYN S.C.B.Medical College; Cuttack; Orissa Chairperson : Medical

1. Dr. Sujata Misra MD , FICOG • Associate Professor,OBGYN • S.C.B.Medical College; Cuttack; Orissa • Chairperson : Medical Education Committee- • FOGSI (2009-2011) • Counselor : PGDMCH course ; IGNOU • Consultant : Mukta ART Centre

2. Contraception for Special Populations Panel Discussion Panelists: Moderator:

3. With reference to contraceptive practices, which women should we consider as –”special population” ? • Do we really need to counsel our teenagers regarding use of • contraceptive practices? • Options for adolescents: Male and female condom . • Further options in females: Oral contraceptives, Patch or Ring?

4. Female condom

5. Take Home Messages • Adolescents, perimenopausal women and following pregnancy and lactation : designated as “special population”. • Long term problems associated with early sexual activity include Pelvic inflammatory disease,infertility,cervical dysplasia, emotional disturbances, as well as criminal prosecution. • Counseling for most teenagers should include the short and long term risks associated with STIs and a realistic assessment of prevention strategies. • A male or female condom used alone or in conjunction with other contraceptive methods is often the best choice for prevention against STI. • Generally, oral contraceptives are options for contraceptive protection in adolescents • Progestin only methods are associated with irregular bleeding. • Diaphragms and cervical caps may provide only limited STI protection.

6. TEDIOUS ?? CONTROVERSIAL ?? BENEFICIAL??

7. Do we really need to address use of contraceptive • practices in perimenopausal women? • Rationale of use of lowest dose OCs and rings in • early menopause • When is it safe to discontinue OCs and switch to hormone therapy? • Reported risk of breast cancer with OCs use – fact • or fiction? • Are they any non contraceptive benefits of Low-Dose • OCs in Perimenopausal women?

8. Take Home Messages • Although fertility is decreased in perimenopausal women, the risk of sporadic ovulation and subsequent pregnancy is always there. • No “fail-safe” method for switch over-but 2 weeks off OC, an increased FSH and/or no change in basal estradiol levels is strong evidence that it is now safe to discontinue OC • OCs use and risk of breast cancer- no reported increased risk • OCs offer important non contraceptive benefits in perimenopausal age group.

9. PREGNANCY: Joyous journey DELIVERY : Exhaustive , Exciting end LACTATION : Dilemma, Debates Debates as to regarding ‘IDEAL CONTRACEPTION’

10. Contraception following pregnancy and during Lactation • Timing of initiation: A million dollar question!! • Contraceptive options for post partum period? • Which one is ‘near’ ideal ? • WHO recommendation for IUD insertion in post partum patients

11. TIMING OF INITIATION

12. WHO Recommendations for IUD Insertion in Postpartum Patients

13. Take Home Messages • Timing of initiation of postpartum contraception is largely dependant on the duration of pregnancy and the breast feeding schedule. • Suppression of ovulation is prolonged following term delivery. • Women who breast feed their baby every four hours will not ovulate until at least 6 wks postpartum and often as long as 6 mths postpartum. • A POP or barrier method may be used till menses resume. • WHO recommends starting DMPA at 6 wks postpartum in breast feeding women, as early as 21days in non breast feeding postpartum women and immediately following a first or second trimester abortion. • Following spontaneous or induced first trimester abortion, ovulation usually occurs within 2-4 weeks.

14. The risk of pregnancy in many women with a chronic medical disease generally far exceeds the risks associated with use of an appropriately selected contraceptive method !!

15. How safe is it for women with medical disorders with respect to cardiovascular disorders to embark on pregnancy ? • Contraceptive counseling of a women with medical disease should include…………. • Ideal contraceptive for a women with a previous history of gestational diabetes? • Is DMPA beneficial in patients on antiepileptic drugs? • Contraceptive advice in malignancy and pre-invasive conditions? • In women with AIDS what would be an ideal contraceptive option?

16. TAKE HOME MESSAGES • In women with complicated cardiac lesions estrogen generally avoided, but POP and progestin implants are safe. • In prediabetics choose lowest acceptable dose of estrogen/progestin formulation • COCs: no risks in thyroid disease but contraindicated in SLE • No restriction of use of hormonal pills in GTD • In CIN and cervical cancer :COC are accepted with risk but POP and progestin implants are safe • In cases with breast cancer both hormonal contraceptive pills and implants are better avoided • No restriction of its use in patients with AIDS. • No restriction in its use in patients with fibroadenosis, endometriosis or past H/O PID

17. Thanks to all contributors. Dr Adarsh Bhargava. Dr Ashwini Bhalerao. Dr Alka Kriplani. Dr. Kalpana Apte. Dr Mala Arora. Dr.Meenakshi Bharath. Dr. Mandakini Parihar. Dr.Nozer Sheriar. Dr.Parikshit Tank. Dr. Roza Olyai. Dr.Sasikala Kola. Dr.Sujata Mishra.