Combined hormonal contraception

Define CHCs available in Egypt
Differentiate between side effects and health risks of CHCs.
Discuss non contraceptive benefits of CHCs.
Illustrate MEC for CHCs.
Discuss “When to Start” CHCs in different situations.
Correctly manage missed COC pills.
Correct misunderstandings about CHCs.

Transcript

1. COMBINED HORMONAL CONTRACEPTION Physicians Basic Course Day 3
2. 2 COMBINED HORMONAL CONTRACEPTION
3. OBJECTIVES By the end of this session the participant will be able to: 1) Define CHCs available in Egypt 2) Differentiate between side effects and health risks of CHCs. 3) Discuss non contraceptive benefits of CHCs. 4) Illustrate MEC for CHCs. 5) Discuss “When to Start” CHCs in different situations. 6) Correctly manage missed COC pills. 7) Correct misunderstandings about CHCs. 3
4. 4 Combined Oral Contraceptives
5. Combined injectable contraceptives 5 y
6. 6 Combined Patch
7. 7 Emergency contraception: Yuzpe regimen
8. 8 Combined Vaginal Ring NuvaRing
9. Combined Oral Contraceptives 9
10. KEY POINTS FOR PROVIDERS AND CLIENTS  COC must be taken every day, whether or not a woman has sex that day . And start each new pack of pills on time.  Take any missed pill as soon as possible.  Bleeding changes are common but not harmful.  Can be given to a woman at any time to start now or later. 10
11. WHAT ARE COMBINED ORAL CONTRACEPTIVES? Contain low doses of 2 hormones a progestin and an estrogen Also called “the Pill” low-dose combined pills, OCPs, and OCs. Work primarily by preventing ovulation. 11
12. How Effective? As commonly used, about 7 pregnancies per 100 women over the first year When no pill-taking mistakes are made (3 per 1,000 women) over the first year 12
13. How Effective? Return of fertility after COCs are stopped: No delay Protection against sexually transmitted infections (STIs): None 13
14. Some users report the following: Changes in bleeding patterns, including: Side Effects Bleeding changes are normal and not harmful. If a woman finds them bothersome, counseling and support can help. 14 Lighter bleeding and fewer days of bleeding Irregular bleeding Infrequent bleeding No monthly bleeding X
15. OTHER POSSIBLE PHYSICAL CHANGES:  Blood pressure increases a few points (mm Hg).  When increase is due to COCs, blood pressure declines quickly after use of COCs stops. 15
16. 16 OTHER SIDE EFFECTS
17. 17 Headaches
18. 18 Nausea
19. 19 Weight change
20. 20 Acne
21. 21 Mood changes
22. Breast tenderness
23. 23 KNOWN HEALTH BENEFITS
24. Risks of pregnancy Help protect against: 24
25. Endometrial cancer Help protect against: 25
26. Cancer of the ovary Help protect against: 26
27. PID Help protect against: 27
28. Ovarian cysts May help protect against:
29. Iron-deficiency anemia May help protect against: 29
30. Reduce  Menstrual cramps  Menstrual bleeding problems  Ovulation pain  Excess hair on face or body  Polycystic ovarian syndrome  Symptoms of endometriosis 30 Known Health Benefits
31. Very rare  Blood clot in deep veins of legs or lungs (deep vein thrombosis or pulmonary embolism) 31 Known Health Risks Extremely rare  Stroke  Heart attack
32. 32 CORRECTING MISUNDERSTANDINGS
33.  Make women infertile  Disrupt an existing pregnancy  Collect in the stomach  Build up hormones in a woman’s body  Cause birth defects or multiple births  Change women’s sexual behavior 33 COC DO NOT
34. Nearly all women can use COCs safely and effectively
35. • Women can begin using COCs: • Without a pelvic examination • Without any blood tests or other routine laboratory tests • Without cervical cancer screening • Without a pregnancy test. A woman can begin using COCs at any time, even when she is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant 35 Avoid Unnecessary Procedures
36. NOTE Blood pressure measurement is desirable before starting a hormonal method. However, where the risks of pregnancy are high and few methods are available, a woman should not be denied a hormonal method simply because her blood pressure cannot be measured. If possible, she can have her blood pressure measured later at a time and place convenient for her. 36
37. 37 MEDICAL ELIGIBILITY CRITERIA FOR COMBINED ORAL CONTRACEPTIVES
38. Who CANNOT USE Combined hormonal Contraceptives 1 Breastfeeding a baby less than 6 months 38 2 Not breastfeeding and had a baby in the last 3 weeks 3 More than 35 years and smoke cigarettes 4 Have cirrhosis of the liver, a liver infection, or liver tumor
39. Who CANNOT USE Combined hormonal Contraceptives 39 5 Have high blood pressure (140 /90 or higher) 6 Had diabetes for more than 20 years or complications on arteries, vision, kidneys, or nervous system 7 Have gallbladder disease now or take medication for gallbladder disease
40. Who CANNOT USE Combined hormonal Contraceptives 40 8 Have ever had a stroke, blood clot in the legs or lungs, heart attack, or other serious heart problems 9 Have ever had breast cancer 10 Have ever had migraine with aura 11 Taking medications for seizures or taking rifampicin or rifabutin .
41. Who CANNOT USE Combined hormonal Contraceptives 41 12 Planning for major surgery that will keep women from walking for one week or more. 13 Have several conditions that could increase the chances of heart disease (coronary artery disease) or stroke, such as older age, smoking, high blood pressure, or diabetes.
42. 42 WHEN TO START IMPORTANT A woman can start using COCs any time she wants if it is reasonably certain she is not pregnant.
44. WOMAN’S 44 2-Switching from a hormonal method 3-Fully or nearly fully breastfeeding 4-Partially breastfeeding 5-Not breastfeeding 6-No monthly bleeding 7-After miscarriage or abortion 8-After taking emergency contraceptive pills (ECPs) 1-Having menstrual cycles or switching from a non hormonal method
45. 1- HAVING MENSTRUAL CYCLES OR SWITCHING FROM A NON HORMONAL METHOD When to start Additional contraceptive Protection required ? Any time of the month If within 5 days after the start of her monthly bleeding. no need for a backup method. If more than 5 days after the start of her monthly bleeding, start COCs any time if no pregnancy If switching from an IUD, COCs start immediately a backup method for the first 7 days of taking pills. 45
46. 2- SWITCHING FROM A HORMONAL METHOD When to start Additional contraceptive Protection required ? Immediately, No need to wait for her next monthly bleeding. no need for a backup method. 46
47. 3- FULLY OR NEARLY FULLY BREASTFEEDING When to start Additional contraceptive Protection required ? 1- Less than 6 months after giving birth Give COCs and tell her to start taking them 6 months after giving birth or when breast milk feeding was stopped No need for a backup method. 47
48. 3- FULLY OR NEARLY FULLY BREASTFEEDING When to start Additional contraceptive Protection required ? 2-More than 6 months after giving birth No monthly bleeding ,start COCs any time if she is not pregnant If her monthly bleeding has returned, she can start COCs as advised for women having menstrual cycles She will need a backup method for the first 7 days of taking pills 48
49. 4- PARTIALLY BREASTFEEDING When to start Additional contraceptive Protection required ? Less than 6 weeks after giving birth Give her COCs and tell her to start taking them 6 weeks after giving birth. Give her a backup method to use until 6 weeks since giving birth if her monthly bleeding returns 49
50. 4- PARTIALLY BREASTFEEDING When to start Additional contraceptive Protection required ? More than 6 weeks after giving birth If her monthly bleeding has not returned, she can start COCs any time it is reasonably certain she is not pregnant If her monthly bleeding has returned, she can start COCs as advised for women having menstrual cycles She will need a backup method for the first 7 days of taking pills. 50
51. 5- NOT BREASTFEEDING When to start Additional contraceptive Protection required ? Less than 4 weeks after giving birth start COCs at any time on days 21–28 after giving birth. Give her pills any time to start during these 7 days. No need for a backup method. 51
52. 5- NOT BREASTFEEDING When to start Additional contraceptive Protection required ? More than 4 weeks after giving birth If her monthly bleeding has not returned, she can start COCs any time it is reasonably certain she is not pregnant If her monthly bleeding has returned, she can start COCs as advised for women having menstrual cycles She will need a backup method for the first 7 days of taking pills. 52
53. 6- NO MONTHLY BLEEDING When to start Additional contraceptive Protection required ? (not related to childbirth or breastfeeding) She can start COCs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days of taking pills. 53
54. 7- AFTER MISCARRIAGE OR ABORTION When to start Additional contraceptive Protection required ? Immediately. If she is starting within 7 days after first- or second-trimester miscarriage or abortion. no need for a backup method. If it is more than 7 days after first- or second trimester miscarriage or abortion, she can start COCs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days of taking pills. 54
55. 8 - AFTER TAKING EMERGENCY CONTRACEPTIVE PILLS (ECPS) When to start Additional contraceptive Protection required ? After taking progestin- only or combined ECPs: immediately after she takes the ECPs. No need to wait for her next monthly bleeding. – ECPs due to pill-taking errors can continue where woman left off with her current pack. – If she does not start immediately but returns for COCs, she can start at any time if it is reasonably certain she is not pregnant. All women will need to use a backup method for the first 7 days of taking pills. 55
56. 8 - AFTER TAKING EMERGENCY CONTRACEPTIVE PILLS (ECPS) When to start Additional contraceptive Protection required ? After taking ulipristal acetate (UPA) ECPs: on the 6th day after taking UPA- ECPs. No need to wait for the next monthly bleeding. ---COCs and UPA interact. one or both may be less effective. Give a supply of pills and tell to start them on the 6th day after taking the UPA-ECPs. A backup method from the time she takes the UPA-ECPs until she has been taking COCs for 7 days. 56
57. 8 - AFTER TAKING EMERGENCY CONTRACEPTIVE PILLS (ECPS) When to start Additional contraceptive Protection required ? After taking ulipristal acetate (UPA) ECPs: -If the client not start on the 6th day but returns later for COCs, she may start at any time if it is reasonably certain she is not pregnant. A backup method from the time she takes the UPA-ECPs until she has been taking COCs for 7 days. 57
58. 58 EXPLAINING HOW TO USE
59. 1 - Give pills Give as many packs as possible 2. Explain pill pack Show which kind of pack—21 pills or 28 pills. With 28-pill packs, last 7 pills do not contain hormones 3 - Give key Instruction one pill at the same time each day. 4. Explain starting next pack take the first pill from the 21-pill packs: After she takes the last pill from one pack, she should wait 7 days 5- Provide backup method and explain use when she misses pills or is late taking a pill. 59
60. Managing Missed Pills “Come Back Any Time”: Reasons to Return Planning the Next Visit 60 Supporting the User Helping Continuing Users
61. 61 MAKING UP MISSED PILLS WITH 30–35 ΜG ESTROGEN
62. Key message Take a missed hormonal pill as soon as possible. Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on the same day.) Missed 1 or 2 pills? Started new pack1 or 2 days late? Take a hormonal pill as soon as possible Little or no risk of pregnancy. Missed pills 3 or more days in a row in the first or second week? Take a hormonal pill as soon as possible. Use a backup method for the next 7 days. Also, if she had sex in the past 5 days, she can consider ECPs 62
63. Missed 3 or more pills in the third week? Take a hormonal pill as soon as possible. Finish all hormonal pills in the pack. Throw away the 7 non hormonal pills in a 28-pill pack. Start a new pack the next day. Use a backup method for the next 7 days. Also, if she had sex in the past 5 days, she can consider ECPs 63
64. Missed any non hormonal pills? (last 7 pills in 28-pill pack) Discard the missed non hormonal pill(s). Keep taking COCs, one each day. Start the new pack as usual. 64 Severe vomiting or diarrhea If she vomits within 2 hours after taking a pill, she should take another pill from her pack as soon as possible, then keep taking pills as usual. If she has vomiting or diarrhea for more than 2 days, follow instructions for 3 or more missed pills, above..
65. 65 If You Miss Pills Always take a pill as soon as you remember, and continue taking pills, one each day . Also...
69. 69 “COME BACK ANY TIME”: REASONS TO RETURN Assure every client that she is welcome to come back any time , if
70. 70 She has QUESTIONS
71. 71 Has Major change in health status
72. 72 Thinks she might be pregnant
73. 73 She wants ECPs
74. 74 She has PROBLEMS
75. 75 Wants another method
76. 76 Needs more pills.
77. 77 General health advice Anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor.
78. Planning the Next Visit 1 Encourage her to come back for more pills before she uses up her supply of pills. An annual visit is recommended 78 2