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Contraception in Special Situations
Experts
Dr Jaya Narendra
Dr Arulmozhi Ramarajan
Dr Shubha Rao
Dr Jayanthy
Dr Ashakiran
What are special situations for contraception?
Adolescence Following pregnancy and lactation Peri-menopausal women
designated as “special population” Women with gynaecological
problems Women with medical disorders &
others
WHO Recommendation criteria for safe contraceptive use (2009)
Category1 = no restriction on useCategory2 = Advantages of using the
method generally outweigh the theoretical or proven risks
Category3 = Theoretical or proven risks usually outweigh the advantages of using the method
Category4 = Unacceptable health risk
Case 1
An 18 year old adolescent with irregular periods and acne comes for treatment.
What are your options?
Choices are
COCs with EE and DSPR
COCs with Cyproterone acetate & EE
COCs with Desogestrel/Norgestrel
Life style modifications of course
Reduction in acne lesions with DSPR
*p<0.0001 vs. placebo
Koltun W, et al. Int J Gynecol Obstet 2009;107(suppl 2):s620
-60
50
-40
-30
-20
-10
0Cycle 11 Cycle 3 3 Cycle 6
Per
cen
tag
e re
duct
ion
in t
otal
lesi
on
coun
t fr
om
bas
elin
e
DSPR Placebo
DSPR was associated with a greater reduction from baseline in total lesion counts versus placebo
Supposing an adolescent with regular cycles had a medical abortion and comes to you for contraceptive advice.
What will you give?
When will you start?
The Options
LDOCP
IUCD
DMPA
Ring
The Options
Low dose oral contraceptives: have many
benefits but compliance is an issue
Ring: can be inserted after the abortion is completed
Inj. DMPA: It temporarily interferes with calcium deposition in bones
Both Cu IUD and LNG IUD are
Category 1 for women > 20yrs and
Category 2 for women < 20yrs
Contraception in adolescents
Contraception in adolescents
Adolescents are eligible for all contraceptives which are suitable for adults Proper counseling regarding use is important, especially for Emergency contraception
Dual protection to be stressed upon
Abstinence can be promoted as a method
Contraception after medical abortion
COC on the day of Mifepristone Condoms, after bleeding stops Sterilization, IUD, POP only after
completion of abortion Natural methods, DMPA & Ring, only after
the next period
Mrs Just Delivered is being discharged today
after a FTND of a healthy baby 3 days back.
Both the mother and the baby are in good health
and she is breast feeding the baby.
When would you schedule her postpartum visit
for contraceptive advice?
Case 2
3 weeks after delivery 6 weeks after delivery 3 months after delivery 6 months after delivery
i
Most studies have shown that many
women ovulate before the 6th week (before
the traditional postpartum visit)
A 3 week visit would be ideal for
contraceptive advice
As advised, Mrs. Just Delivered visits after 3 weeks. She is partially breast feeding her baby
What are her contraceptive options?
COCs POPs LNG IUD Cu IUD DMPA
Mr J.D. considers Cu IUD and asks
“What would be the ideal time to insert the
Cu IUD, Doctor”
At 4 weeks?
At 6 months?
Postpartum visit at 3 weeks
Postpartum insertion of a Cu IUD is best
done within 48hours or AT or AFTER 4
weeks (Category 1)
It is not inserted between 48 hrs to 4 weeks
(Category 4)
WHO eligibility criteria 2008
What about Breast feeding and COCs?
There are 3 issues here
Risk of Thromboembolism Estrogen in doses more than 30 ugm
inhibits lactation and can lead to a shorter period of breast feeding
Estrogen can induce reversible increase in breast size of the mother and the infant, male or female
The risk for VTE within the first 42 days postpartum is 22-fold to 84-fold greater than the risk among non-pregnant, non-postpartum women.
The risk is highest immediately after delivery, declining rapidly during the first 21 days, but not returning to baseline until 42 days postpartum.
Use of COCs, which can cause a small increased risk for VTE, might theoretically pose an additional risk if used during this time.
Systematic review, CDC, WHO
Breast-feeding and combined hormonal contraception
COCs have Minor effects on quantity and quality of
breast milk No effect on infant growth
OB-GYNs=obstetricians and gynecologists; WHO=World Health Organization.1. Truitt ST et al. Cochrane Database Syst Rev. 2003;(2):CD003988.
Special Situations - Postpartum Contraception
COC POP
INJ IMP Cu IUD
LNG IUS
Breastfeeding
<3weeks postpartum
4 3 3 3 > 48 hr3
> 48 hr3
3 weeks - < 6 weeks postpartum if risks for VTE present
3 1 1 1 > 4 wks
1
> 4 wks1
> 6 months postpartum
2 1 1 1 1 1
Non Breastfeeding< 21 days 3 1 1 1 > 48
hr3
> 48 hr3
> 21 days 1 1 1 1 > 4 wks
1
> 4 wks1
She chooses to use Inj DMPA
What would you counsel her about?
She takes Inj DMPA and is quite happy with it.
Her periods are irregular with spotting on & off
but since she has been counseled, she is not
unduly disturbed by it and the bleeding settles
down
Following the second injection, she returns to
the clinic only after 4 months
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
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
What are the demerits of DMPA?
Irregular bleeding in the 1st 3-4 months
Interferes with Calcium deposition in bones
Fertility returns 8-10 mths after the last dose
Case 3
F, 32yrs, P2 L2 Regular heavy periods Clinical Examination – 14wks size uterus Ultrasound examination – Bulky uterus with
multiple intramural fibroids, largest measuring 4cmX4cm.
Endometrial thickness 11mm, contour - normal
OC pills & Fibroids
The administration of low dose OC pills to women with leiomyomas does not stimulate fibroid growth and is associated with decreased bleeding
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995
LNG IUS & Fibroids
In women with fibroids & troublesome bleeding, the size of the uterus and the largest individual tumors diminished slightly with LNG-IUS.
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995
Special Situations - Genital & Breast ConditionsCOC POP INJ IMP Cu
IUDLNG IUS
Fibroids
Cavity non distorting
1 1 1 1 1 1
Cavity distorting 1 1 1 1 4 4
Endometriosis
1 1 1 1 2 1
Benign Ovarian Tumors
1 1 1 1 1 1
Benign Breast Disease
1 1 1 1 1 1
Ectropion 1 1 1 1 1 1
Mrs F chooses to get an LNG IUS inserted. She
comes back after 3yrs for a check up. She
reveals that she was recently hospitalized for a
bad lung infection and is presently undergoing
treatment for tuberculosis with a 4 drug regime.
Would you like to suggest a change in her contraceptive method?
Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugs
Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver enzymes, such as rifampicin and anti-epileptic drugs
LNG IUS and Anti-TB Drugs
Special Situations - Miscellaneous Issues
COC POP
INJ IMP Cu IUD
LNG IUS
Anemias Iron deficiency anemia & thalessemia
1 1 1 1 2 1
Sickle cell 2 1 1 1 2 1
Liver TumorsBenign adenoma Malignant hepatoma
4 3 3 3 1 3
Liver Enzyme Affecting Drugs
Rifampicin, phenytoin, barbiturate, carbamezipine
3 3 2 3 1 1
33yr old with a BP of 150/100 needs contraception. She is on medication for Hypertension and does not have any other medical problem. What contraceptives would be safe for her?
Oral contraceptives (including newer agents), increase
systolic BP by 8 mm Hg and diastolic by 6 mm Hg
Special Situations - Hypertensive Conditions
COCR/P
POP DMPA
IMP Cu IUD
LNG IUS
Arterial CVD Risk Age, smoking, DM, HT
3/4 2 3 2 1 2
Hypertension
Adequate control 3 1 2 1 1 1
140 – 159 / 90 – 99 mm Hg
3 1 2 1 1 1
> 160 / > 100 mm Hg
4 1 3 2 1 2
Vascular disease 4 2 3 2 1 2
History of HT during pregnancy
2 1 1 1 1 1
35yr old woman with 3 children and diabetic since 1yr needs contraception. Her BMI is 28 and she is not hypertensive.
COC & Diabetes… COC in type I DM – Studies find no change in
HbA1c, development or progression of nephropathy or retinopathy
Nonsmoking, <35yrs, otherwise healthy diabetics, no end-organ disease – COC safe
LNG-IUS – Safe in diabetics
Past h/o GDM – COC does not accelerate or precipitate development of type II DM
ACOG Practice bulletin no:18, Obst & Gynecol. 2006
A 24-year old woman, with no concomitant diseases, was admitted with epigastric pain and vomiting. A provisional diagnosis of Acute Pancreatitis was made. On further questioning, she gave a h/o having taken Diane 35 in the previous 4 months. Her LMP was 5 days back.
Is there a connection between the OC Pill and Acute Pancreatitis?
Case 4
Acute pancreatitis occurred within 3months of starting estrogen therapy in most cases
Abdominal pain and pancreatitis ceased within 10 days of stopping estrogen
S Triglycerides, Cholesterol and FBS are increased when on the pill
Facts in favour of a connection
Estrogen increases fasting Triglycerides by increasing the hepatic production of Triglycerides.
Estrogen also increases HD Lipoproteins and decreases LD Lipoproteins
Primary Dyslipidemia is a relative contraindication for Estrogen therapy
In young, healthy women taking oral contraceptives and presenting with acute abdominal pain, consider the diagnosis of Acute Pancreatitis
Lipid profile before starting OCPs not recommended
With no pre-existing Hyperlipidemia, S triglycerides increase is usually mild and does not lead to pancreatitis
If obese, with a family history of hyperlipidemia, lipid profile checked to prevent acute pancreatitis
Take Home message
Knehtl M, Journal of Disease Markers, Nov 2014
Case 5
A 28-year-old woman, P2+1, developed jaundice, pruritus, fatigue and anorexia. She gave a history of a single 28 day cycle of oral contraceptives (Ovral L), started shortly after a first trimester abortion. She was on no other medication and did not drink alcohol
Because of persistent jaundice, she underwent endoscopic retrograde cholangio-pancreatography which was normal. A liver biopsy showed intrahepatic cholestasis with minimal inflammation and bile duct proliferation
What could be the problem? Do you want to elicit any other history?
She gives a history of having pruritus and jaundice in her 2 previous pregnancies
In the 5th month of her 1st and the 6th week of her 2nd pregnancy
Bilirubin values of 3.5 and 3.8 mg/dl
Severe pruritus
Cause of jaundice not identified
What type of jaundice did she suffer from?
Is there a connection between the jaundice she had in her 2 prior pregnancies and what she is suffering from now?
What are the features of Cholestatic jaundice?
Bland Cholestasis
Time of onset: 4 to 24 wks after starting pill
Jaundice: mild, S Bil never > 7mgs%
Pruritus: severe
ALT: <200 U/L (<5 times ULN)
Alkaline phosphatase: <230 U/L (<2 times elevated) Both may be normal too
Resolves in 1-2 mths, rarely 6 mths
Never associated with fatal liver disease
To avoid it, should you do a LFT for all women before prescribing the pill?
Can happen in men too after Anabolic steroids
Take home message Take a proper history before starting the pill If woman complains of pruritus when on the
pill, discontinue it Do LFT. If elevated, treat symptomatically Repeat LFT after 6 weeks Use only those hormonal contraceptives
that bypass the liver like LNG-IUS, Vaginal Ring, etc
Reassure the woman that it is not a serious condition
Special Situations - Gastrointestinal ConditionsCOC PO
PINJ IMP Cu
IUDLNG IUS
Gall Bladder Disease
SymptomaticAsymptomatic
32
22
22
22
11
22
Cholestasis Pregnancy / COC related
23
12
12
12
11
12
Viral Hepatitis
Active diseaseCarrier state
41
31
31
31
11
31
Cirrhosis
Mild – compensatedSevere - decompensated
34
23
23
23
11
23
Taking oral contraceptives for five or more years is
associated with a doubling of cervical cancer risk
Is it true?
Women who use oral contraceptives have an increased risk of developing cervical cancer
The new analysis of data from 24 worldwide studies is one of the most rigorous examinations of cervical cancer risk in oral contraceptive users ever conducted
Lancet, Nov 2010
16,500 cervical cancer patients and 35,500 women without the disease studied to quantify the risk associated with oral contraceptive use worldwide.
It was found that women who used the pill for 5 years or less had a 10% increased risk of cervical cancer when compared with women who had never taken it. This increased risk rose to 60% with 5-9 years of use and doubled with 10 years of use or over
Epidemiologist Jane Green, MD, who led the study team…
The risk starts to fall pretty quickly and has gone away 10 years later
Lancet, Nov 2010
The reasons for this risk from OC use are not entirely clear. less likely to use a diaphragm, condoms,
or other methods that offer some protection against STDs including HPV.
hormones in OCs might help the virus enter the genetic material of cervical cells.
"Regular screening is important for all women, but especially for those taking oral contraceptives," Sasieni says.
"A woman who has regular screenings can basically forget about the increase in risk.“
Based on the most recent evaluation of several studies, the IARC has concluded that HC can be classified as carcinogenic to the cervix as well as to the breast.
When women who had used DMPA were compared to women who had never used this method, there were also significant differences in presence of and severity of disease
There are several studies which have reported that hormonal contraception (HC) - pills and injectables - moderately increase the risk of cervical cancer as well as being a risk for all stages of cervical cancer particularly in human papilloma virus (HPV)-positive women thus suggesting that oral contraceptives may act as a promoter for HPV-induced carcinogenesis. Norma McFarlane-Anderson etal, BMC Womens Health, 2008
Contraception in the peri-menopausal period
Do we need it?
No more Surprise periods
No more Surprise Babies
No more Diaper duty
No more Hot Flushes
Issues with Peri-Menopause
Need for effective contraception Menstrual cycle abnormalities Vasomotor instability Need for osteoporosis and cardiovascular
disease prevention Increased risk of gynecological cancer
Kailas NA, Reprod Health Eur J Contracept Care. 2005
The choices are
Oral Contraceptives-highly effective contraception, non-contraceptive benefits, improve QOL
POPs.. Excellent safety profile IUCDs DMPA.. No evidence about # due to bone loss Barrier Combined Vaginal Ring, Skin Patches.. Risks
same as OCPs Natural Estrogens.. safer
A woman had a Cu 380 A inserted at 38 years. 10 years later, at the age of 48, she has irregular cycles. Should the IUD be removed?
Studies from the United Nations and Brazil indicate high efficacy of copper IUD after the 10-year windowSpontaneous fertility beyond age 45 is rare and the IUD becomes even more effectiveKeeping the IUD for a few more years may be indicated
1. Bahamondes L et al. Contraception. 2005;72:337-341. 2. United Nations (UN) Development Programme, UN Population Fund, WHO and World Bank, Special Programme of Research, Development and Research Training in Human Reproduction. Contraception. 1997;56:341-352.
When on COC, how does a woman know that she has reached menopause?
Stop the pills for a month or more Check her FSHTesting FSH a second time one month later will provide a more reliable result
Case 6
Mrs M, just married, had an open heart surgery for ASD repair 2months back. She is on oral anticoagulants. Wants contraception for at lease one year.
Women on anticoagulant Rx
↑ Menorrhagia, corpus luteum hematoma, hemoperitoneum
COC, DMPA, Mirena - Appropriate COC – Do not ↑ risk of thrombosis if well
anticoagulated DMPA – Not much injection site problems
Special Situations - Heart Disease
COC POP INJ IMP Cu IUD
LNG IUS
Ischemic Heart Disease
History of IHD 4 I - 2C - 3
3 I - 2C - 3
1 I - 2C - 3
Current IHD 4 I - 2C - 3
3 I - 2C - 3
1 I - 2C - 3
Valvular Heart Disease
Uncomplicated 2 1 1 1 1 1
Complicated - Pulmonary HT & atrial fibrillation
4 1 1 1 2 2
Complicated - SBE 4 1 1 1 2 2
To sum up
Ideal Contraceptive in a woman with Hypertension
If < 35 years
Non-smoking
No end organ disease
Well controlled Hypertension
Low dose COC ..OK
If not POPs or LNG-IUS
Oral contraceptives (including newer agents), increase systolic blood pressure by 8 mm Hg and diastolic by 6 mm Hg
Ideal contraceptive in a woman with
Dyslipidemia
If dyslipidaemia is well controlled,
COCs with <35 ugms of EE can be used
Serum lipids monitored regularly
If LDL > 160 mgs%- POPs safer
Type of Progesterone is the deciding factor
Estrogens increase HDL, Triglycerides and lower LDLProgesterone opposes this action. Androgenic Progestogens like Norethisterone,LNG, increase LDL, lower HDL and Triglycerides.
Ideal contraceptive in a woman with Diabetes
COCs do not increase a woman's risk of developing type 2 diabetes
In type 1 diabetes, COCs do not impair metabolic control or accelerate the development of vascular disease
BUT, ACOG recommends COCs only
If <35 yrs
No HT, Nephropathy, Retinopathy or other vascular disease
LNG IUS.. safe
What about in Obesity?
COCs and Transdermal patch less effective
Obesity and COCs independent risk factors for VTE
DUB and Endo Ca more common in obese
LNG-IUS safe and effective
A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload
375 inserted this time. When does she need to come for removal?
A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload
375 inserted this time. When does she need to come for removal?
She need not get it removed till after menopause.
Women 40 years or older at the time of IUD insertion may retain the
device until they no longer require contraception, even if this is beyond
the duration