The Essentials of contraceptive technology: a handbook for clinic staff

Publication date: 1997

The Essentials of Contraceptive Technology Robert A. Hatcher, M.D., M.P.H. Ward Rinehart Richard Blackburn Judith S. Geller James D. Shelton, M.D., M.P.H. Center for Communication Programs The Johns Hopkins Bloomberg School of Public Health March 2003 ;:t\\%¥:f _______ ---":::'u,: deoliveirac Cross-Out Health care providers and programs working in developing countries may obtain additional copies of this book free of charge. See list of local distributors inside back cover or write to the address below. The publisher welcomes orders for multiple copies. In the US and other developed countries, copies are US$5 each. Please send payment in US$ with order to the address below. Published by Population Information Program Center for Communication Programs The Johns Hopkins Bloomberg School of Public Health III Market Place, Baltimore, MD 21202, USA Fax: (410) 659-6266 Suggested citation: Hatcher, R.A., Rinehart, w., Blackburn, R., Geller, ].S., and Shelton, J.D. The Essentials oJContraceptive Technology. Baltimore, lohns Hopkins Bloomberg School of Public Health, Population Information Program, 1997. ISBN: 1-885960-01-8 Fourth Printing, 2003 The Essentials of Contraceptive Technology is made possible through support provided by GH/POP/PEC, Global, United States Agency for International Development, under the terms of Grant No. HRN-A-00-97-00009-00. Johns Hopkins Bloomberg School of Public Health Center for Communication Programs World Health Organization Family Planning and Population Unit 'Iii"-' , .•. ,., "·1·" United States Agency for International Development Office of Population This book was planned, written, and edited by: Robert A. Hatcher, M.D., M.P.H., Professor of Gynecology and Obstetrics, Emory University School of Medicine Ward Rinehart, Project Director, Population Information Program, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health Richard Blackburn, Senior Research Analyst, Population Reports, Population Information Program, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health Judith S. Geller, Research Analyst, Population Reports, Population Information Program, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health James D. Shelton, M.D., M.P.H., Senior Medical Scientist, Office of Population, United States Agency for International Development ©2003 Robert A Hatcher and the Johns Hopkins Center for Communication Programs 1he authors and publisher invite you to reproduce and othetwise use original material in this book to inform health care providers, their clients, and the public and to improve the quality of reproductive health care. There is no charge, and you do not need permission. Please credit the authors and publisher; see suggested citation inside front cover. Also, we would like to receive a copy of any publication based on parts of this handbook:. If, however, you want to use materials in this handbook (including illustrations) that are credited to other sources, you must obtain permission from the original sources. We encourage you to allow others to use your materials free of charge as well, so that information about good reproductive health care can reach as many people as possible. ii Essentials of Contraceptive Technology Contents Forewords from WHO and UNFPA . iv Preface from USAID . vi Introduction and Dedication. . . . . . . . . . . . . . . . . . . . . . . . . . . viii Acknowledgtnents . xi Chapter 1. How to Use This Book . 1-1 Chapter 2. Family Planning Helps Everyone . . . . . . . . 2-1 Chapter 3. Counseling. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1 Chapter 4. Important Information. . . . . . . . . . . . . . . . . . . . 4-1 Chapter 5. Chapter 6. Chapter 7. Chapter 8. Chapter 9. Chapter 10. Chapter 11. Chapter 12. Chapter 13. Chapter 14. Chapter 15. Chapter 16. Who Provides Family Planning and Where? . . . . . . 4-3 How to Tell That a Woman Is Not Pregnant . . . . . 4-6 Family Planning for the Breastfeeding Woman. . . . . 4-8 Infection Prevention in the Clinic . . . . . . . . . . . 4-10 Medical Conditions and Method Choice . . . . . . 4-13 Effectiveness of Family Planning Methods. . . . . . 4-19 How Important Are Various Procedures? . 4-21 Low-Dose Combined Oral Contraceptives . 5-1 Progestin-Only Oral Contraceptives . . . . . . . . . . 6-1 D MP A Injectable Contraceptive. . . . . . . . . . . . . 7-1 Norplant Implants . . . . . . . . . . . . . . . . . . . . . . . 8-1 Female Sterilization . . . . . . . . . . . . . . . . . . . . . . 9-1 Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1 Condoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1 Intrauterine Devices (lUDs) . . . . . . . . . . . . . . . 12-1 Vaginal Methods . . . . . . . . . . . . . . . . . . . . . . . 13-1 Fertility Awareness-Based M.ethods . . . . . . . . . . 14-1 Lactational Amenorrhea Method (LAM). . . . . . 15-1 Sexually Transmitted Diseases Including HIV/AIDS. . . . . . . . . . . . . . . . . . . . 16-1 Table: WHO Medical Eligibility Criteria. . . . . . . . . Appendix: A-I Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . Appendix: A-9 Glossary . Appendix: A-13 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Index: 1-1 List of Handbook Distributors . Inside back cover Hi Foreword from WHO This handbook, The Essentials of Contraceptive Technology, which aims at providing state-of-the-art information on family planning methods to health care providers around the world, is a significant contribution to the reproductive health field. The handbook uses a simple, client-centred approach to the provision of family planning care. It covers a wide range of topics that will help to enable women and men to use the method of their choice effectively and with satisfaction while safeguarding against avoidable negative health effects. It helps health care providers give their clients simple but appropriate information and advice on method use and other reproductive health concerns. Further, it offers guidance for appropriate procedures in offering family planning methods and helping continuing users. This handbook also provides useful guidance to people concerned with improving family planning standards and practices. It is based on growing international consensus on critical medical, epidemiological and clinical research findings and their meaning for reproductive health care providers and clients. The World Health Organization's latest recommendations for revising medical eligibility criteria for contraceptive use are a major contribution to that consensus and a cornerstone of this handbook. These recommendations can lead to major improvements in the way services are provided. The World Health Organization, through the Family Planning and Population Unit of the Division of Reproductive Health, is pleased to have collaborated with the authors and the Population Information Program at the Johns Hopkins Center for Communication Programs in the production of this handbook supported by the US Agency for International Development. This work is an expression of the common aims of all three institutions and, indeed, of family planning providers everywhere, namely, to help all men and women achieve one of their most fundamental freedoms and human rights-the ability to plan their families by choosing freely the number and spacing of their children. Dr. Tomris Tiirmen Executive Director Family and Reproductive Health World Health Organization Geneva iv Essentials of Contraceptive Technology Foreword from UNFPA The International Conference on Population and Development held in Cairo, Egypt, in 1994 was a landmark in that, for the first time, the concept of reproductive health and reproductive rights was cleatly defined. For the first time the concerns of gender equity, equality and women's empowerment were recognized as essential components of reproductive rights. For the first time, the linkages between population, sustained economic growth and sustainable development were articulated. Reproductive health implies that people ate able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition is the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice. Similatly, reproductive rights rest on the recognition of the basic right of all couples to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standatd of sexual and reproductive health. Family planning information and services are therefore a critical means for the articulation and attainment of reproductive rights and reproductive health, and a central component of reproductive health programmes. This handbook will be a valuable resource for clinic-based family planning providers, and will enable them to deliver family planning services from a reproductive health perspective, bearing in mind the differing contraceptive needs of the life cycle. The handbook represents an important tool for the spread of correct and timely information to young people and adults allowing individuals and couples to articulate their reproductive rights and enjoy optimal reproductive health. Sathuramiah L. N. Rao Director Technical and Evaluation Division United Nations Population Fund New York Foreword v Preface from USAID In the 1990s the many people around the world who are committed to improving access and quality of family planning and related reproductive health services are working together more closely than ever. Researchers, program managers, policy-makers, educators, and communicators all are cooperating to help providers everywhere do their jobs more successfully. The United States Agency for International Development (USAID) has been pleased to join in this growing international collaboration. As part of this effort, The Essentials of Contraceptive Technology handbook is designed to provide accurate and up-do-date information that will help clinic-based providers offer readily accessible, good-quality care. This handbook focuses on the major contraceptive methods and how they are provided in clinics and similar settings. It also addresses preventing and treating sexually transmitted diseases. Ready access to good-quality care is key to the success of family planning and related reproductive health services. With ready access, people can easily obtain safe and effective services that meet their needs, free from unreasonable barriers. Good-quality care includes courteous, supportive interactions that help clients express their needs and make informed choices and the technical knowledge and skills to provide fumily planning methods and other reproductive health care effectively and safely. Providers who offer ready access to good-quality care can see their success in terms of healthy, satisfied clients who use family planning longer and more effectively. For more than 30 years of helping providers, USAID has supported a wide range of efforts to improve access and quality of family planning vi Essentials of Contraceptive Technology and related reproductive health services. These efforts have produced new ways to deliver supplies and services conveniently and safely, wider choice of contraceptive methods, providers well-trained in technical and communication skills, more types of providers who offer family planning and other reproductive health care, better communication with clients and the public, accurate and easy-to-use information for providers and policy-makers, and improved program management, research, and evaluation. The Essentials of Contraceptive Technology has been prepared as a collaborative effort involving Dr. Robert A Hatcher of the Emory University School of Medicine and members of the staff of the journal Population Reports, which is published by the Population Information Program at the Johns Hopkins Center for Communication Programs, a part of the Johns Hopkins University School of Public Health. The handbook draws on the work of several international groups dedicated to updating recommendations for family planning guidelines and practices-particularly the scientific working group on medical eligibility criteria, organized by the World Health Organization, and the Technical Guidance/Competence Working Group, begun by USAID and its Cooperating Agencies and now expanded to include many other experts. The authors also had help from a great many expert reviewers and advisors, who contributed their knowledge, the fruits of their work, and the wisdom of their experience in many areas. USAID is pleased to support the development and distribution of this handbook. We hope that it will aid clinic-based providers as they help clients make informed choices and will serve as a useful resource to all concerned with helping women and men around the world achieve their reproductive goals. Elizabeth S. Maguire Director Dr. James D. Shelton Senior Medical Scientist Office of Population, Center for Population, Health and Nutrition United States Agency for International Development, Washington, D. C. Preface vii Introduction and Dedication amily planning is making great progress. During the past several decades we have moved ahead in many ways: • Family planning is now seen as a human right-basic to human dignity. People and governments around the world understand this. • Nearly everyone now knows about family planning. Most people also know of some family planning methods. • Family planning has community support. People expect that most others in their community practice family planning, and they approve. • Most people use family planning. At anyone time, more than half of the world's married couples are family planning users. This handbook covers family planning methods and services. Great progress has been made in these areas, too. As family planning providers, we can offer more choices to more people. People can use family planning more effectively and more safely. • Couples now can choose from more methods. These include injectables, implants, female and male sterilization, new IUDs, oral contraceptives, condoms, various spermicides, diaphragms, and cervical caps. We have a viii Essentials of Contraceptive Technology better understanding of fertility awareness-based methods (modern versions of the rhythm method) and breastfeeding. Now they can be used to prevent pregnancy more effectively. • We have learned that almost everyone can use modern family planning methods safely. At the same time, we are better able to single out the people who should not use certain methods. We also know that, for most methods, most clients do not require physical examinations or laboratory tests. • We have discovered imponant health benefits of some family planning methods, besides preventing unintended pregnancies. For example, combined oral contraceptives help stop anemia, reduce pelvic inflammatory disease, decrease menstrual cramps and pain, and even help prevent several types of cancer. • Condoms help prevent sexually transmitted diseases (STDs) and other infections, especially when used every time. Spermicides, diaphragms, and cervical caps for women also may help somewhat. Many family planning clients need protection from STDs, including HNIAIDS. Family planning providers are seeing that, and they are helping more clients prevent STDs. • Many different types of people now provide family planning supplies, services, and information. For example, many different kinds of health professionals, and not just doctors, provide most methods in clinics and in communities. Shopkeepers sell family planning supplies. Community members distribute supplies and help their neighbors. • We are doing a better job of telling people about family planning and helping them make reproductive health decisions. We are helping them make informed choices. We do this in face-to-face discussion and counseling, through radio, television, and newspapers, and in community events. • We are making it easy for people to get family planning and other reproductive health care. We are removing unnecessary barriers of all kinds. These barriers have included lack of information, not enough service points, limited hours, few methods, not enough Introduction and Dedication ix supplies, restrictions on who can be served, out-of-date medical eligibility criteria ("contraindications"), and required tests or physical exams when these did not help decide on a method or make its use safer, and clients did not want them. To make family planning easy, we are giving people more choices--choices among family planning methods, choices among key reproductive health services, choices among places and times to obtain services and supplies, choices among information sources, and choices among the type of personnel who provide care. The more choices that people have, the better they can find what they need to protect their reproductive health. • We are learning that quality makes a difference. The quality of family planning services affects whether clients can use methods effectively. Quality affects whether clients continue to use family planning. Quality even affects whether people start family planning at all. This handbook is meant to help providers offer good-quality family planning services. Not every issue has been setded, however. New scientific fmdings will keep coming out. Sometimes these findings may cause controversy. They will need to be studied, interpreted, and discussed. Decisions will have to be made about changing family planning services and information. This process will help us to keep improving family planning methods and services. The information in this handbook reflects the latest and most complete scientific understanding. This book represents the thinking of family planning leaders and experts around the world. Many of them helped prepare this book. Their names are listed on the next page. Many people can use this book. Trainers can use it to plan and carry out training. Program managers can use it to update procedures and standards. Most of all, however, this book is meant for-and dedicated to-the providers all over the world who, every day; help people choose and use family planning. The authors x Essentials of Contraceptive Technology Acknowledgments The wisdom, commitment, and effort of many people made this handbook possible. Many people provided valuable comments and contributions: Frank Aivarez, Elliott Austin, Sriani Basnayake, Paul Blumenthal, Patricia Bright, David W. Buchholz, Pierre Buekens, Meena Cabral, Charles S. Carignan, Willard Cates, Jr., Shirley Coly, Anne W. Compton, Joseph deGraft-Johnson, Gina Dallabetta, Grace Ebun Delano, Juan Diaz, Soledad Diaz, Laneta Dorflinger, Gaston Farr, Betty L. Farrell, Paul Feldblum, Monica Gaines, Sally Girvin, Stephen M. Goldstein, Ronald H. Gray, David A. Grimes, Joanne Grossi, Gary S. Grubb, Felicia Guest, Pamela Beyer Harper, Philip D. Harvey, Q.M. Islam, Sarah Keller, Theodore King, Nilgun KircaliogIu, Deborah Kowal, Miriam Labbok, O.A. Ladipo, Virginia Lamprecht, Robert Lande, Ronnie Lovich, Enriquito Lu, T apani Luukkainen, Jill Mathis, Margaret McCann, Noel McIntosh, Grace Mtawali, Elaine Murphy, Emma Ottolenghi, Juan Palmore, Susan Palmore, Bonnie Pedersen, Bert Peterson, Manuel Pina, Phyllis Tilson Piotrow, Linda Potter, Malcolm Potts, Lisa Rarick, Elizabeth Robinson, Ron Roddy, Sharon Rudy, Cynthia Salter, Harshad Sanghvi, Lois Schaefer, Pamela Schwingl, Pramilla Senanayake, Willibrord Shasha, Jennifer Smith, JeffSpieler, Cynthia Steele, Linda Tietjen, James Trussell, Ibrahim TurkmenogIu, Marcel Vekemans, Cynthia Visness, Nancy Williamson, Anne Wdson, Judith Winkler, and Johanna Zacharias. The technical consensus on medical eligibility criteria developed by the World Health Organization scientific working group on Improving Access to Quality Care in Family Planning and the consensus on updating practices for providing family planning Acknowledgments xi developed by the Technical Guidance/Competence Working Group, organized by the US Agency for International Development and its Cooperating Agencies, are foundation stones of this handbook. So is the work of many other organizations and agencies that have addressed the needs of family planning professionals for practical technical guidance. Valuable publications from some of these groups are listed in the Suggested Reading at the end of this book. In particular, Contraceptive Technowgy, 16th edition, by RobenA Hatcher, James Trussell, Felicia Stewart, Gary K Stewart, Deborah Kowal, Felicia Guest, Willard Cates, Jr., and Michael S. Policar, was the starting point for this handbook. Throughout the development of the handbook, Marcia Angle, Douglas Huber, Roy Jacobstein, and Roberto Rivera offered helpful guidance and assistance. Under its Maximizing Access and Quality (MAQ) initiative, the US Agency for International Development is playing a leading role in improving family planning and other reproductive health care services. The MAQ initiative has focused attention on services that both respond to the needs of clients and meet scientifically valid criteria for technical quality. This handbook is both a product of that initiative and a contribution to it. This handbook was made possible through suppon provided by GH/POP/PEC, Global, United States Agency for International Development, under the terms of Grant No. HRN-A-00-97-00009-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the US Agency for International Development. xii Essentials of Contraceptive Technology Chapter 1 How to Use This Book This handbook is for family planning and reproductive health care providers who work in clinics and other health care facilities. It contains practical information about family planning methods, how to provide them, and how to help clients use them. You can use this book: • To look up information in order to serve your clients, • For background information and study on your own, • In training courses, • "When you talk to community groups, • "When you prepare information materials for the public or clients, • To help develop policies, guidelines, procedures, and training materials. Carry it with you, and consult it oftenl Many different people can learn from this book. Please share it with clients, policy-makers, journalists, and volunteers as well as with other health care providers. The more people who have this book, the more useful it will be. If you have extra copies, please share them with co-workers. You can order How to Use This Book 1-1 more copies, too. This handbook is free of charge to health care providers and programs in developing countries. See the list of distributors inside the back cover. Also, you are welcome to photocopy pages of this book and give the copies to others. You can adapt and add to this handbook The handbook has been written for family planning providers all over the world. The situation in your area or your program may call fOr special information and guidance. Please tell us how you are using this handbook Tell us what is helpful and what causes problems. Tell us what should be clearer, what should be changed, and what should be added. With your help, we will be able to make this handbook better in the future. How to Find Information in This Book Finding the right chapter. There are 16 chapters in this book, including one chapter for each major family planning method. These methods are listed on the back cover. You can line up the name of the method on the back cover with the ink on the edge of the pages. That way you can turn quickly to the chapter on that method. Finding information in the chapter. Most chapters about family planning methods have the same sections in them. There are major sections in each chapter and then some subsections. These sections and subsections are always in the same order. The standard sections and subsections are listed below, and their contents are described: Key Points-On page 1 of each chapter, a short list of the most important information about the method. Table of Contents-On page 2 of each chapter. (Note that page numbers are made up of the chapter number and then a page number. For example, this is page 1-2-that is, Chapter 1, page 2.) 1-2 Essentials of Contraceptive Technology ~ ~ntroduction-Brief description of the method and some of ~ Its common names. [] Deciding About the Method-Information to help decide if the method suits the specific client. • How Does It Worla-How the method prevents pregnancy. • Advantages and Disadvantages-The client may want to consider these. Lists of disadvantages begin with common side effects, if there are any; these are printed in brown. • Medical Eligibility Checklist-After the client has freely chosen a method, this checklist helps make sure that no medical conditions prevent or restrict use of that method. ~ Starting the Method-Information on providing a new It.IiI method and explaining how to use it. • When to Start?-When a client can start using the method. This may depend on her or his situation. • Providing the Method-Procedures for providing the new method. • Explaining How to Use the Method-Instructions for the new user. These inst~ctions often include what to do about side effects and reasons to see a doctor or nurse. These pages have brown borders. 11I Following Up-Information on what to ask and do during later visits. • Helping Clients at Any Routine Return Visit-Procedures when a returning client has no problems. • Managing Any Problems-Suggestions for helping when a returning client has problems with the method. H Important Information for the User to Remember-Brief information to help the client. This information can be copied or adapted and then given to clients. How to Use This Book 1-3 r,-, ~ues~ions and An~wers-Answers to providers' and . clients common questions. In each chapter the main sections are marked with the same small symbols shown above and on page 1-3. The name of the section and method and the symbol for that section are printed at the bottom of each righthand page. Decision tables appear throughout the chapters. The example below shows how to use these tables: First look in this column Find here the client's situation, condition, or problem. Then look in this column Find here the appropriate information or recommended action that fits the client's situation, condition, or problem. Besides the chapters on family planning methods (Chapters 5 to 15), this book contains several other chapters. Chapter 2 summarizes benefits of family planning. Chapter 3 briefly describes family planning counseling. Chapter 4 covers various information that applies to many different clients and various family planning methods. Other chapters often refer to information in Chapter 4. Chapter 16 covers sexually transmitted diseases includlng HNI AIDS. A wall chart about family planning methods is available from the Johns Hopkins Population Information Program OHU/PIP). (If you would like copies, write to JHU IPIP at the address on the inside front cover of this book. Please include shipping address and number of copies you require.) You can hang the wall chart in a client waiting area. Clients can look at the chart and see for themselves which methods may suit them best. Then they will be better prepared to talk with a provider. You are welcome to translate this wall chart and any other text into the languages of your area. You also may want to add or change text to suit your clients' needs and situations. At the back of the book are a table of medical eligibility criteria, a list of suggested reading, a glossary of medical terms, and an index. 1-4 Essentials of Contraceptive Technology Special Notes on Certain Standard Features of Each Chapter DECIDING ABOUT THE METHOD: How EHective? This handbook describes the effectiveness of most family planning methods in terms of the likelihood of pregnancy in the first year of using the method. The likelihood of pregnancy is often reported in two ways: Effectiveness as commonly used. This is the typical, or average likelihood of pregnancy for all users taken together, whether or not they use the method correctly and consistently. Effectiveness when used correctly and consistently. This is the lowest likelihood of pregnancy reported in reliable studies. This figure is about the best that a client could hope for. If the user's behavior has little or no effect on the likelihood of pregnancy-as with Norplant implants or female sterilization, for example-only one pregnancy rate is reported. Most estimates of the likelihood of pregnancy in this book were made by James Trussell for publication in Hatcher et al. 1998. They are based on scientific reports. Most of these reports come from developed countries. Estimates for combined oral contraceptives (Chapter 5), various IUDs other than the TCu-380A (Chapter 12), and fertility awareness-based methods (Chapter 14) as commonly used come from Moreno and Goldman 1991. They are based on findings of Demographic and Health Surveys in developing countries. Estimates for female sterilization come from a large US study by Peterson et al. published in 1996. Except for fertility awareness-based methods, these estimates are the same or nearly the same as T russell's. Estimates for progestin- only oral contraceptives (Chapter 6) come from McCann and Potter 1994. Estimates for lAM (Chapter 15) come from Labboket al. 1994.1 How to Use This Book 1-5 DECIDING ABOUT THE METHOD: Advantages and Disadvantages Advantages and disadvantages are listed for each family planning method. These lists cover the most important characteristics and effects of the method. Common side effects are printed in brown under "Disadvantages." With the provider's help, the client considers how these advantages and disadvantages apply to her or his own situation. Then the client can make an informed choice about whether the method meets her or his needs. Not all advantages and disadvantages apply to every client. Also, a disadvantage to one person may be an advantage to another person. Still, with these lists, a provider can help a client choose whether or not to use that method. In the Advantages and Disadvantages lists, the word "may" means that the statement is based on theories or on similarity with another family planning method. There is no conclusive evidence from studies of people using this method, however. For example, "progestin-only injectables may help prevent ovarian cancer." (They are similar to combined oral contraceptives.) When the word "may" is not used, it means that there is direct evidence from studies of users. For example, "progestin-only injectables help prevent endometrial cancer." DECIDING ABOUT THE METHOD: Medical Eligibility Checklist Medical Eligibility Checklists appear in most chapters. They list the most important questions for medical screening of clients. These questions are based on recent recommendations from a World Health Organization (WHO) Scientific Working Group.2 This WHO Scientific Working Group reviewed the latest scientific information and then made its recommendations. The checklist asks clients about characteristics-for example, whether a woman is breastfeeding-and about known medical conditions-for example, heart disease. 1-6 Essentials of Contraceptive Technology Considering the client's answers, the provider decides whether any medical conditions prevent or restrict the client's use of the method. The Working Group called these characteristics and conditions "medical eligibility criteria." Medical eligibility criteria often have been called "contraindications" when they limit use of a method. The questions in each medical eligibility checklist are examples. Each program can decide what questions are most important in its own area. Also, the WHO Working Group expects each program to choose the most suitable means of screening for these conditions. Information from the client (client history) will often be the best approach, according to the Working Group. Generally, clinical and laboratory tests are not routinely needed for safe use of methods. On occasion, a client's medical history may call for specific tests. A detailed table covering WHO medical eligibility criteria for major family planning methods appears in the Appendix after Chapter 16. Information about when to start hormonal methods and IUDs, about what to do about missed pills and late injections, about handling menstrual changes caused by injectables and IUDs, on the importance of selected procedures (page 4-22), and on several other topics comes from recommendations of the Technical Meeting to Develop Consensus on Evidence-Based Guidance for Family Planning, convened by WHO in October 2001. 1. Trussell. J. ContraceptM: efficacy. In: Hatcher et al. Con=ptive technology (l7th revised edition). New York, Irvington. 1998. Labbok. M., Cooney, K. and Coly, S. Guidelines; Br=r:fi:eding, family planning, and the lactational amenorthea method-lAM. Washington, D.e., Georget<>Wn University, Institute fOr RJoptoductive Health, 1994. 18 p. McCann, M.F. and Potter, L.S. Progestin-only oral contraception: A comprehensive review. Contraception 50(6) (Supplement 1): SI-5195. December 1994. Moreno, L. and Goldman, N. Conttac<:ptive f.illure rares in developing countries: Evidence from the Demngraphic and Health Surveys. International Family Planning Perspectives 17(2); 44-49. June 1991. Petetron, H.B., Xi., 1., Hugbes, J.M., Wdrox, l.S., Tylor, LR, and T!'tlSIdl, J. The risk of p~ alter rubal srerilizarion: F~ fiom the U.S. CoIlaborarive Review of Stt:rilization. Am<rican Journal of OIJstetrk:, and Gyoo:aIogy 174: 1161-1170. 1996. 2. World Health Organization (WHO). Improving access ro quality care in family planning: Medical eligibility criteria for contraceptive use. Geneva, WHO, Family and RJoproducrive Health. 1996. How to Use This Book 1-7 The Essentials of Contraceptive Technology Wall Chart Free for readers in developing countries To order copies, please remit your complete mailing address, telephone number, fax number, and number of copies required to: Population Information Program, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland, 21202, USA; Fax: (410) 659-6266; E-mail: orders@jhuccp.org or order online at http://www.jhuccp.org/wallchart/index.stm Chapter 2 Family Planning Helps Everyone Family planning providers can be proud of their work because family planning helps everyone. Here are some of the ways: Women. Family planning helps women protect themselves from unwanted pregnancies. Since the 1960s family planning programs have helped women around the world avoid 400 million unwanted pregnancies. As a result, many women's lives have been saved from high-risk pregnancies or unsafe abortions. If all women could avoid high-risk pregnancies, the number of maternal deaths could fall by one-quarter. Also, many family planning methods have other health benefits. For example, some hormonal methods help prevent certain cancers, and condoms help prevent sexually transmitted diseases, including HNIAIDS. Children. Family planning saves the lives of children by helping women space births. Between 13 and 15 million children under age 5 die each year. If all children were born at least 2 years apart, 3 to 4 million of these deaths would be avoided. Men. Family planning helps men-and women--care for their families. Men around the world say that planning their families helps them to provide a better life for their families. Families. Family planning improves family well-being. Couples with fewer children are better able to provide them with enough food, clothing, housing, and schooling. Family Planning Helps Everyone 2-1 Nations. Family planning helps nations develop. In countries where women are having far fewer children than their mothers did, people's economic situations are improving faster than in most other countries. The earth. If couples have fewer children in the future, the world's current population of 6.1 billion people will avoid doubling in less than 50 years. Future demands on natural resources such as water and fertile soil will be less. Everyone will have a better opportunity for a good life. ~'DPlJlatiDFI ="""'"""=~~ Reports P . ""Oe<;~ . ) G' ATHER cu,·-Ie _a.o;c., . 15 rt. I UI ;;r,.~~~~'~ . ~~ T.o Counsel,·n1o Post8r\O~CI/ent$ . 32 •• 0 GATKft.,. ~Connedion . ,4 Counseling is one person helping another ~::::i:'';:':~:''::::~ as they talk person-to-person. When you Cat\ You Talk About Sexl . ~'.H6 =:::SL=~~.::::i~ help a client make a decision or solve a Couno!<I . , . _ . .28 problem, you are counseling. 'ld-Ta,Uored & PetSOnlli.tocL . 7 T,nCIIettlsAbotJt~.,,8&25 Through counseling. you help clients make choices that suit them. ~~~~3: For example. some clients are choosing family planning methods. HeJp~L~ . '''~ . ''.M9 ~~=:~~~~~g~~~~i~~~:~::a~iS-~he Presnant1 . :·:::::.:~.~! activity. All these clients can make better decisions with your help. ~~~::~~~~i&~~ """'_""'1 . " . 22 ~Attenrion . M,_13 R«umina Helps Continuing C1~ . "' .•• '" . , . 14&19 SpedoI ~ SpedoI Tepia ~~t.~:!:~ =~~.~.~:::::::j; _ . ~ . 'O -"TIpo 'TeachyClOtMft . ,." . _ •.• ~ . 18 T!pSfor~ .• ~ . M •••.•• M~ . 18 ~~~:::~:::::::::~: PIlbI_bylhe"",,-,_ . ,'"""""'~ lion Prosrams. The Johns Hot*ini Univemty School 01 Pubii<:Htalih. 111 Matftet Place, Suke 310, BaJti. mcwe, MMyland 21202. tJSA. VoIUn'It XXVI, Number . ~1998 Competent, Caring Counseling Everyone can leam gO<Xl counseling. You counsel clients well when you: • Show that you understand and care about them. Build trust. • Give clients useful, accurate information. Help them under- stand what this information means to them. • Help clients to make their own choices, based on clear information and their own feelings, situation, and needs. • Help them remember what to do. If you offer good counseling, more clients will make healthy choices. Clients will use family planning longer and more effec- tively. More clients will be happy with their care. They will come back when they need help. They will tell other people good things about you andu G - Greet aix>ut family planning. A - Ask Counseling often has 6 elements, or :. T - le" steps. Each letter in the word GATHER H - Help stands for one of these elements. Good E - Expbin counseling is more than covering the R - Retum For this free, 32-page Popul4tion Reports issue "GATHER Guide To Coumeling, "please write to the Population Information Program at the address imide the front cover. (For more on GATHER, see page 3 - 6.) 2-2 Essentials of Contraceptive Technology Chapter 3 Counseling Counseling is crucial. Through counseling, providers help clients make and carry out their own choices about reproductive health and family planning. Good counseling makes clients more satisfied. Good counseling also helps clients use family planning longer and more successfully. "What is needed for good counseling? Particularly for new clients who are choosing a new family planning method, there are 6 principles, topics to cover~ and steps in the counseling process. Although these are described separately here, during counseling all are woven together. Good counseling does not have to take a lot of time, especially if information is tailored to the client's needs. Good counseling does take training and an attitude of caring and respect for clients. 6 Principles 1. Treat each client well. The provider is polite, shows respect for every client, and creates a feeling of trust. The provider shows the client that she or he can speak openly, even about sensitive matters. The provider, too, speaks openly and answers questions patiently and fully. Also, the provider assures the client that nothing she or he says will be discussed with others inside or outside the clinic. 2. Interact. The provider listens, learns, and responds to the client. Each client is a different person. A provider can hdp best by understanding *The 6 principle. and 6 topics are adapted from: Mwphy, E.M. and Sreele, C. Client-provider interactiOn> in family planning .ervices. In; Teehnkal Guidance/Competenee Working Group. Reeomroendations mr updating .e1ected practiees in conrraeeprive use. Vo!. 2. Chapel Hill, NC, INTRAH, 1997. p. 187-194. Counseling 3-1 that person's needs, concerns, and situation. Therefore the provider encourages clients to talk and ask questions. 3. Tailor information to the client. Listening to the client, the provider learns what information each client needs. Also, the stage of a person's life suggests what information may be most important. For example, a young, newly married woman may want to know more about temporary methods for birth spacing. An older woman may want to know more about female sterilization and vasectomy. A young, unmarried man or woman may need to know more about avoiding sexually transmitted diseases (STDs). The provider gives the information accurately in language that the client understands. Also, the provider helps the client understand how information applies to his or her own personal situation and daily life. This personalizing of information bridges the gap between the provider's knowledge and the client's understanding. 4. Avoid too much information. Clients need information to make informed choices (see page 3-3). But no client can use all information about every family planning method. Too much information makes it hard to remember really important information. This has been called "information overload." Also, when the provider spends all the time giving information, little time is left for discussion or for the client's questions, concerns, and opinions. 5. Provide the method that the client wants. The provider helps clients make their own informed choices (see page 3-3), and the provider respects those choices--even if a client decides against using family planning or puts off a decision. Most new clients already have a family planning method in mind. Good counseling about method choice starts with that method. Then, in the course of counseling, the provider checks whether the client has conditions that might make use of the method not medically appropriate as well as whether the client understands the method and how it is used. Counseling also addresses advantages and disadvantages, health benefits, risks, and side effects. The provider also may help the client think about other, similar methods and compare them. In this way the provider makes sure that the client is (Continued on page 3-4.) 3-2 Essentials of Contraceptive Technology What Does Illnformed Choice" Mean? When a person freely makes a thought-out decision based on accurate, useful information, this is an informed choice. One important purpose of family planning counseling is to help the client make informed choices about reproductive health and family planning. "Informed" means that: • Clients have the clear, accurate, and specific information that they need to make their own reproductive choices including a choice among family planning methods. Good-quality family planning programs can explain each family planning method as needed-without information overload-and can help clients use each method effectively and safely. • Clients understand their own needs because they have thought about their own situations. Through person-to-person discussions and counseling and through mass-media messages, good-quality family planning programs help clients match family planning methods with their needs. "Ch'" th Olce means at: • Clients have a range of family planning methods to choose from. Good-quality family planning services offer different methods to suit people's differing needs-not just 1 or 2 methods. If programs cannot provide a method or service, they refer clients somewhere else for that method. • Clients make their own decisions. Family planning providers help clients think through their decisions, but they do not pressure clients to make a certain choice or to use a certain method. Counseling 3-3 making an informed choice. If there is no medical reason against it, clients should have the methods that they want. When clients get the methods they want, they use them longer and more effectively. 6. Help the client understand and remember. The provider shows sample family planning materials, encourages the client to handle them, and shows how they are used. Also, the provider shows and explains flip charts, posters, or simple pamphlets or printed pages with pictures. From time to time, the provider checks that the client understands. If the client can be given print materials to take home, they help remind clients what to do. They can be shared with others, too. 6 Topics Counseling should be tailored to each client. At the same time, most counseling about method choice covers 6 topics. Information on these 6 topics can be found in chapters 5 through 15 of this handbook. Information on these topics also should reach clients in many other ways-for example, on radio and television, in posters and pamphlets, and in community meetings. When clients have accurate information even before they see a provider, the provider's work is easier, and the client can make better decisions. Of course, it is important that information from different sources be as consistent as possible. 1. Effectiveness. How well a family planning method prevents pregnancy depends more on the user for some methods than for others (see page 4-19). Pregnancy rates for methods as commonly used give clients a rough idea of what they can expect. Still, their own experience may be better or worse--sometimes much better or much worse. Pregnancy rates for methods used consistently and correctly give an idea of the best possible effectiveness. Providers can help clients consider whether and how they can use a specific method consistendy and correcdy. For some clients, effectiveness is the most important reason for choosing a method. Other clients have other reasons for their choices. 3-4 Essentials of Contraceptive Technology 2. Advantages and disadvantages. Clients need to understand both advantages and disadvantages of a method for them (tailored information). It is important to remember that disadvantages for some people are advantages for others. For example, some women prefer injections. Others want to avoid injections. 3. Side effects and complications. If methods have side effects, clients need to know about them before they choose and start a method. Clients who learn about side effects ahead of time tend to be more satisfied with their methods and use them longer. Clients need to know which side effects may be bothersome but are not signs of danger or symptoms of a serious condition. With some methods, such side effects may be fairly common. Also, clients need to know what symptoms, if any, are reasons to see a doctor or nurse or to return to the clinic. These symptoms may point to a rare but serious side effect. Clients need to understand the difference. If a method hardly ever has any side effects or complications, clients need to know that, too. (Side effects and complications are covered under "Disadvantages" in the "Deciding About" sections of chapters 5 through 15.) 4. How to use. Clear, practical instructions are important. Instructions should cover what clients can do if they make a mistake with the method (such as forgetting to take a pill) and also what clients and providers can do if problems come up (such as bothersome side effects). Also, clients may need special help on matters such as remembering to take a pill each day or discussing condoms with a sex partner. 5. STD prevention. Some STDs, including HIV/AIDS, are spreading in many countries. With sensitivity, family planning providers can help clients understand and measure their risk of getting STDs. Family planning clients should know to use condoms if they might get STDs-even if they are using another family planning method. Providers can explain the ABCs of safe behavior: Abstinence, Being mutually faithful, Condom use. (See Chapter 16.) Counseling 3-5 6. When to return. There are many good reasons to return to the clinic. Some methods require return visits for more supplies. Clients should be told of several places to get more supplies, if possible. In contrast, some methods--for example, IUDs, female sterilization, and vasectomy-require at most one routine return visit. Clients should not be asked to make unnecessary visits. Still, the provider always makes clear that the client is always welcome back any time for any reason-for example, if she or he wants information, advice, or another method or wants to stop using an IUD or Norplant implants. Providers make clear that changing methods is normal and welcome. 6 Steps in Counseling New Clients Deciding on a family planning method and using it involve a step-by-step process. The process includes learning, weighing choices, making decisions, and carrying them out. Therefore counseling new clients about family planning usually is a process, too. The process can consist of 6 steps. These steps can be remembered with the word GATHER. Good counseling is flexible, however. It changes to meet the special needs of the client and situation. Not every new client needs all 6 steps. Some clients need more attention to one step than another. Some steps can be carried out in group presentations or group discussions. Other steps usually need one-on-one discussion. THE GATHER STEPS G - Greet clients in an open, respectful manner. Give them full attention. Talk in a private place if possible. Assure the client of confidentiality. Ask the client how you can help, and explain what the clinic can offer in response. A - Ask clients about themselves. Help clients talk about their family planning and reproductive health experiences, their intentions, concerns, wishes, and current health and family life. Ask if the client has a particular family planning method in 3-6 Essentials of Contraceptive Technology mind. Pay attention to what clients express with their words and their gestures and expressions. Try to put yourself in the client's place. Express your understanding. Find out the client's knowledge, needs, and concerns so you can respond helpfully. T - Tell clients about choices. Depending on the client's needs, tell the client what reproductive health choices she or he might make, including the choice among family planning methods or to use no method at all. Focus on methods that most interest the client, but also briefly mention other available methods. Also, explain any other available services that the client may want. H - Help clients make an informed choice. Help the client think about what course of action best suits his or her situation and plans. Encourage the client to express opinions and ask questions. Respond fully and openly. Consider medical eligibility criteria for the family planning method or methods that interest the client. Also, ask if the client's sex partner will support the client's decisions. If possible, discuss choices with both partners. In the end, make sure that the client has made a clear decision. The provider can ask, "What have you decided to do?" or perhaps, "What method have you decided to use?" E - Explain fully how to use the chosen method. After a client chooses a family planning method, give her or him the supplies, if appropriate. Explain how the supplies are used or how the procedure will be performed. Again encourage questions, and answer them openly and fully. Give condoms to anyone at risk for sexually transmitted diseases (STDs), and encourage him or her to use condoms along with any other family planning method. Check that clients understand how to use their method. R - Return visits should be welcomed. Discuss and agree when the client will return for follow-up or more supplies, if needed. Also, always invite the client to come back any time for any reason. Counseling 3-7 Counseling Continuing Clients Continuing clients are just as important as new clients. They deserve just as much attention as new clients. Counseling continuing clients usually focuses on talking with clients about their experience and needs. Tests and examinations generally are not needed unless a special situation calls for them. Like counseling new clients, counseling continuing clients can be flexible. It should change to meet the client's needs. For example, returning clients may need more supplies, answers to questions, help with problems, a new method, removal of Norplant implants or an IUD, or help with another reproductive health problem such as STDs or unexplained vaginal bleeding. Usually, counseling the continuing client involves finding out what the client wants and then responding: • If the client has problems, resolve them. This can include offering a new method or referring the client elsewhere if needed. • If the client has questions, answer them. • If the client needs more supplies, provide them--generously. • Make sure the client is using her or his method correctly, and offer help if not. See also the "Following Up" sections in chapters 5 through 15. For a more detailed provider's guide to family planning counseling, see Population Reports, GATHER Guide to Counseling, available from the J ohns Hopkins Population Information Program at the address inside the front cover. 3-8 Essentials of Contraceptive Technology Chapter 4 Important Infonnation for Providing Family Planning 4-1 Chapter 4 Important Information for Providing Family Planning Note: This chapter contains various information important to family planning providers. The sections in this chapter apply to various family planning methods. They are often referred to in Chapters 5 through 15, each of which covers a specific method. Contents Who Provides Family Planning and Where? How To Tell That a Woman Is Not Pregnant . Family Planning for the Breastfeeding Woman Infection Prevention in the Clinic . . . . Medical Conditions and Method Choice . Effectiveness of Family Planning Methods How Important Are Various Procedures? . 4-2 Essentials of Contraceptive Technology .4-3 .4-6 .4-8 4-10 4-13 4-19 4-21 Who Provides Family Planning and Where? Many different people can learn to inform and advise people about family planning. Many different people can provide family planning methods. Countries and programs have various rules about who can offer which methods and where. Still, in countdes around the world these people commonly provide family planning: • Nurses, nurse-midwives, nurse-practitioners, • Auxiliary nurse-midwives, • Midwives, • Physicians, including gynecologists, obstetricians, • Physicians' assistants, physicians' associates, • Pharmacists, pharmacists' assistants, chemists, • Primary health care workers, community health workers, • Specially trained traditional birth attendants, • • Shopkeepers and vendors, • Community members serving as community+based distributors, • Volunteers, experienced users of family planning, peer educators, and community leaders. Specific training helps all these people do a better job at providing family planning. Training needs to cover skills in. informing and counseling clients about choosing and using specific methods and in screening for medical eligibility criteria as well as any specific technical skills such as how to give injections or insert an [UD. Method Who Can Provide? Where? Combined oral All those listed. Anywhere. contraceptives . _- Progestin-only All those listed. Anywhere. oral contraceptives Injectables Anyone trained to give Anywhere sterile injections and to handle needles and needles and syringes syringes can be properly. handled safely. Who Can Provide? 4-3 Method Who Can Provide? Where? Norplant implants Anyone with training in Wherever medical procedures and appropriate specific training in insertion infection- of Norplant implants, prevention including physicians, nurses, procedures can nurse-midwives, nurse- be followed. practitioners, midwives, physicians' assistants and associates. Female With specific training, general In facilities sterilization physicians, specialized where surgery physicians such as obstetricians, can be done. gynecologists, and surgeons, Laparoscopy and and medical assistants or certain medical students under supervision. conditions have Laparoscopy is best performed additional by experienced and requirements. specifically trained surgeons. See page 9-6. Vasectomy With specific training, Almost any physicians, medical officers, health facility, nurse-midwives, nurse- including practitioners, midwives, physicians , physicians' assistants and offices, clinics, associates. hospitals, temporary and mobile clinics. See page 10-7. Condoms All those listed. Anywhere, including shops and vending machines. 4-4 Essentials of Contraceptive Technology Method Who Can Provide? Where? IUDs Anyone with training in Wherever medical procedures and approprIate specific training in IUD infection- screening, insertion, and prevention removal, including procedures can physicians, nurses, nurse- be followed, midwives, midwives, nurse- including clinics, practitioners, physicians' hospitals, and assistants and associates. In physicians' some countries pharmacis~s offices. sell IUDs; the woman takes the IUD to a health care provider, who inserts it. Spermicides All those listed. Anywhere. Diaphragms and Any provider specifically Anywhere pelvic cervical caps trained to perform pelvic exam can be examinations and to choose done and client the right size diaphragm or has privacy to cervical cap for each woman. practice putting in diaphragm or cap. Fertility Anyone specifically trained Anywhere. awareness-based to teach fertility awareness~ methods Couples experienced with these techniques often make the best teachers. Lactational The breastfeeding woman Anywhere. amenorrhea herself provides the method. method (LAM) Knowledgeable and supportive health care providers can help her use it most effectively. Who Con Provide? 4-5 How To Tell That a Woman Is Not Pregnant A woman should not start certain family planning methods while she is pregnant. These methods are combined and progestin-only oral contraceptives, injectables, Norplant implants, IUDs, and female sterilization. In contrast, condoms and vaginal methods can and should be used when protection against sexually transmitted diseases is needed during pregnancy. Although pregnant women should not use some contraceptives, methods other than the IUD probably are not harmful to the mother or the fetus. (See page 12-21.) The best evidence shows that hormonal methods such as oral contraceptives and injectables are not harmful. A health care provider usually can tell if a woman is not pregnant by asking her questions. Pregnancy tests and physical examinations usually are not needed, they waste resources, and they discourage clients. ~ It is reasonably certain that a woman is not pregnant if: • Her menstrual period started within the last 7 days, OR • She gave birth within the last 4 weeks, OR • She had an abortion or miscarriage within the last 7 days, OR • She gave birth within the last 6 months, is breastfeeding often, and has not yet had a menstrual period. ~ If a woman does not fit any of these categories, it is still reasonably certain that she is not pregnant if: • She has not had vaginal sex since her last menstrual period, OR • If she has had sex since her last menstrual period, she used family planning correcdy* and her last menstrual period was less than 5 weeks ago. *Note: Appropriate methods include injecrables, Norplant implants, IUDs, and, if properry used, combined or progestin-only oral contraceptives, condoms, Lacrational Amenorrhea Method (LAM), spermicide, diaphragm, cervical cap, and fenility awareness-based methods except calendat rhythm. 4-6 Essentials of Contraceptive Technology If she has had sex and her last period was 5 wee~ ago or more, pregnancy cannot be ruled out, even if she used effective contraception. Has she noticed early signs of pregnancy? If more than 12 weeks since her last menstrual period, has she noticed later signs of pregnancy? Signs of Pregnancy Early signs of pregnancy Later signs: of pregnancy • Late menstrual period • Larger breasts • Breast tenderness • Darker nipples • Nausea • More vaginal discharge • Vomiting • Enlarged abdomen • Weight change • Movements of a baby • Always tired • Mood changes • Changed eating habits • Urinating more often If she has had several of these signs, she may be pregnant. Try to confirm by physical examination. 11-- If her answers cannot rule out pregnancy, she should either have a laboratory pregnancy test, if available, or wait until her next menstrual period before starting a method that should not be used during pregnancy. A provider can give her condoms or spermicide to use until then, with instructions and advice on how to use them. How To Tell That a Woman Is Not Pregnant 4-7 Family Planning for the Breastfeeding Woman Breastfeeding has important health benefits: • Provides the best nutrition for the child. • Protects the baby from life-threatening diarrhea that other foods or contaminated water might cause. • Passes the mother's immunities to the child, which helps protect the baby from life-threatening infectious diseases such as measles. • Helps develop a close relationship between mother and child. • May help protect the mother against breast cancer later in life. Breast milk is the best food for nearly all babies. In some situations the baby's life depends on continuing to breastfeed. Therefore it is very important to delay another pregnancy. Delaying pregnancy avoids early weaning and the many health problems that often result. Breastfeeding itself helps to prevent pregnancy. Breastfeeding alone, without another family planning method, can provide effective protection against pregnancy for the first 6 months after delivery. It does so if. • The woman has not had her first menstrual period since childbirth (bleeding in the first 56 days-8 weeks--after childbirth is not considered menstrual bleeding), and • The woman is fully or nearly fully breastfeeding-at least 85% of the baby's feedings are breast milk. This is called the Lactational Amenorrhea Method (LAM). (See Chapter 15.) By definition, a woman is not using LAM if the baby gets substantial food other than breast milk OR the mother's menstrual periods return OR the baby reaches 6 months of age. To protect herself from pregnancy, she should then: 4-8 Essentials of Contraceptive Technology • Choose another effective family planning method that does not interfere with breastfeeding (not combined oral contraceptives before her baby is 6 months old). • Continue to breastfeed her baby if possible, even while beginning to give the baby other food. Breast milk is the healthiest food for most babies during the first 2 years of life. She should breastfeed before giving other food, if possible. If the baby's hunger is satisfied first by breast milk, this will help ensure good nutrition and will encourage production of breast milk. All breastfeeding women, whether or not they are using lAM, should be counseled on: • When they can and should start particular family planning methods. • The advantages and disadvantages of each method, including any effects on breastfeeding. If a breastfeeding woman needs or wants more protection from pregnancy, she should first consider nonhormonal methods (IUDs, condoms, female sterilization, vasectomy, or vaginal methods). She also can consider fertility awareness-based methods, although these may be hard to use. None of these methods affects breastfeeding or poses any danger to the baby. Women who are breastfeeding can start progestin-only methods- progestin-only oral contraceptives, long-acting injectables, or Norplant implants-as early as 6 weeks after childbirth. The estrogen hormone in combined oral contraceptives may reduce the quantity and quality of breast milk. Therefore the World Health Organization recommends that breastfeeding women wait at least 6 months after childbirth to start using them. Another method, if needed, can be used until then. Family Planning for the Breastfeeding Woman 4-9 Infection Prevention in the Clinic Infection-prevention procedures protect both clients and providers from the spread of infectious disease. Infection-prevention procedures are simple, easy, effective, and inexpensive. It is not possible to tell easily which client may have an infectious disease that could be passed in a health clinic. Therefore infection- prevention procedures must be followed with every client. Making infection-prevention procedures a habit-a part of every family planning procedure-will protect both health care providers and clients. The Principle of Infection Prevention Infection prevention means stopping the passage of infectious organisms (germs) between people by always (I) making a barrier to body fluids-- for example, by wearing gloves-and (2) removing infectious organisms-- for example, by processing of instruments and by waste disposal. Blood, semen, vaginal secretions, and body fluids containing blood can carry infectious organisms. These organisms include HN (the virus that causes AIDS), hepatitis B virus, staphylococcus bacteria ("staph"), and many others. Infections can be passed from one person to another when infection-prevention procedures are not followed and these fluids pass from one person to another. In the clinic, infectious organisms can be passed between clients and health workers through needle sticks (with used needles) or similar puncture wounds or through broken skin (such as an open cut or scratch). Infectious organisms can be passed from one client to another by surgical instruments, needles, syringes, and other equipment if it has not been properly decontaminated, cleaned, and high-level disinfected or sterilized between clients. For detailed instructions on infection-prevention procedures, see Tietjen et al. Infection prevention for family planning service programs. Baltimore, JHPIEGO, 1992. 4-10 Essentials of Contraceptive Technology Basic Rules of Infection Prevention • Wash hands. Hand washing may be the single most important infection-prevention procedure. Wash hands before and after contact with each client. Use soap and clean running water from a tap or bucket. Also wash before putting on gloves and whenever hands get dirty. • Wear gloves. Wear gloves when there is any chance of contact with blood or other body fluids. Before any procedures with each client, put on a new pair of single-use or processed reusable gloves if possible. For surgical procedures, gloves should be sterile. • Do vaginal examinations only when needed! or requested. Vaginal or pelvic exams generally are not needed for most contraceptive methods-only for female sterilization and IUDs (see page 4--22). For vaginal exams, wear either a new pair of single-use gloves or reusable, processed high-level disinfected or sterile gloves. Vaginal exams should be done only when there is a reason-such as a Pap smear or suspicion of disease when the exam could help with diagnosis or treatment. • Clean the client's skin appropriately before an injection or insertion of Norplant implants. Use a locally available antiseptic. • Clean the cervix with antiseptic as a part of· "no touch" technique for IUD insertion. • For each injection, use a new, single-use needle and syringe or a sterilized reusable needle and syringe. (If reusable needle and syringe cannot be sterilized, use high-level diSinfection.) • After use with each client, reusable instruments, equipment, and supplies should be: (1) decontaminated (soaked in 0.5% chlorine solution (bleach) or another disinfectant), (2) cleaned with soap and water, and (3) either high-level disinfected (by boiling or steaming) or sterilized (by steam or dry heat), - Vaginal specula, uterine sounds, gloves for pelvic exams, and other equipment and instruments that touch mucous membranes should be decontaminated, cleaned, and then either high-level disinfected or sterilized, as appropriate. - Needles and syringes, scalpels, troears for Norplant implants, and other equipment and instruments that touch human tissue beneath the skin should be decontaminated, cleaned, and then sterilized. - Disinfected or sterilized objects should not be touched with bare hands. - Wear gloves when cleaning instruments and equipment. - Wash linens in warm, soapy water and line-dry. - After each client, exam tables, bench tops, and other surfaces that will come in contact with unbroken skin should be wiped with 0.5% chlorine solution. • Dispose of single-use equipment and supplies properly. - Needles and syringes meant for single use must not be reused. (See page 7-13.) - Used needles should not be broken, bent, or recapped. They should be put at once into a puncture-proof container. The container should be burned or buried when three-quarters fulL - Dressings and other soiled solid waste should be burned, if possible, or else put in a pit latrine. Do not put dressings in a flush toilet. Liquid wastes should be put in a pit latrine. 4-12 Essentials of Contraceptive Technology Safe and Effective Temporary Pregnancy Condition or Temporary Methods Not To Especially Characteristic Methods Be Used Dangerous? Breastfeeding Progestin-only (continued) methods if started at least 6 weeks after childbirth. Fertility awareness- based but may be hard to use. CO Cs after 6 COCs until months since 6 months after childbirth. childbirth. Smoking COCs if uncler COCs if age 35 age 35. or older. All other methods No children All methods None High blood COCsifBP COCs if systolic Dangerous pressure (BP) less than BP 140 or higher especially 140190. or diastolic BP 90 when BP or higher, or if 160/100 history of high BP or higher. but BP cannot be taken. DMPAand DMPAand NET EN if BP NET EN if BP less than 180/1 1 O. 1801110 or higher. All other methods 4-14 Essentials of Contraceptive Technology Safe and EHective Temporary Pregnancy Condition or Temporary Methods Not To Especially Characteristic Methods Be Used Dangerous? Diabetes COCs,DMPA COCs,DMPA Dangerous and NET EN in and NET EN if ifwith most cases. diabetes for 20 vascular All other years or more or if disease. methods vascular disease. Ordinary All methods headache (not migraines) Migraine COCs if under COCs if (1) age headache age 35 and no 35 or older or (recurring distortion of (2) at any age, severe head vision (aura) or vision is distorted pain, often on one side or trouble speaking (aura) or woman pulsating, that or moving before has trouble can cause or during these speaking or nausea and headaches. moving before or often is made Progestin-only during these worse by light headaches. and noise or methods moving about) Copper IUDs Barrier methods LAM Fertility awareness- based 4-16 Essentials of Contraceptive Technology Safe and Effective Temporary Pregnancy Condition or Temporary Methods Not To Especially Characteristic Methods Be Used Dangerous? Current viral Copper IUDs COCsand hepatitis or COCsand progestin-only hepatitis progestin-only methods if camer current disease. methods if camer only. lAM, but breastfeeding may not be recommended. Barrier methods Fertility awareness- based Obesity All methods, but None diaphragm or cap placement may be difficult. Tuberculosis Copper IUDs IUDs if (TB) except if pelvic TB. pelvic TB. lAM, but breastfeeding may not be recommended. All other methods 4-1 8 Essentials of Contraceptive Technology EHectiveness of Family Planning Methods The table on the next page reports rates of unintended pregnancies among users of various family planning methods in the first 12 months (1 year) of using that method. Two rates are reponed for each method. One is the pregnancy rate for the method as commonly used. This is a typical, or average rate. A specific couple may be more successful or less successful than this-sometimes much more or much less. The other rate is the pregnancy rate when the method is used correctly and consistently. This is about the best rate that a user can expect from the method. The effectiveness of family planning methods can be divided into 3 groups, as shown in the left column of the table. *LAM is used for no more than 6 months after childbirth. Doubling these rates would give I-year rates for comparison with other methods. **When abstinence is used to avoid pregnancy. Effectiveness when used correctly and consistently depends on which fertility signs anqi abstinence rules are used. Sources of effectiveness data: Trussell, J. Contraceptive efficacy. In: Hatcher et al Contraceptive technology (I7th revised edition). Except progestin-only oral contraceptives during breastfeeding as commonly used, from McCann, M.P. and Potter, 1.S. Progestin-only oral contraception: A comprehensive review. Contraception 50(6)(Supplement 1): S1-S195. December 1994; LAM from Labbok, M., Cooney, K., and Coly, S. Guidelines: Breastfeeding, family planning, and the lactational amenorrhea method-LAM. Wasqington, D.e, Georgetown University, Institute for Reproductive Health, 1994; aJ!ld combined oral contraceptives and fertility awareness-based methods as commonly used from Moreno, 1. and Goldman, N. Contraceptive fuilure rards in developing countries: Evidence from the Demographic and Health Surveys. International Family Planning Perspectives 17(2): 44-49. June 1991. Estimates by Ttussell and by Moreno and Goldman are similar for combined oral contraceptives; as commonly used. Table concept developed by Jill Mathis. Effectiveness of Family Planning Methods 4-19 Pregnancies per 100 Women in First 12 Months of Use Key to As Used shading in Effectiveness Family Planning Commonly Correctly & See table: Group Method Used Consistendy Chapter NorplAnt Ch. 8 implants Vasectomy Ch.l0 DMPA and NET Ch. 7 Always very EN injectables effective. Female Ch. 9 sterilization TCu-380A IUD Ch. 12 Progestin-only Ch. 6 i effective oral conttacept:ives during breastfeeding Effective as LAM (for 6 Ch. IS commonly months only") used. ~ry Combined oral Ch.S effective when used contraceptives correctly and consistently. Condoms Ch. 11 Only somewhat Diaphragm with Ch. 13 effective as spermicide commonly used. Fertility Ch. 14 Effective awareness-based when used methods** correctly and Female condoms Ch. 11 consistently. Spermicides Ch. 13 No method 4-20 Essentials of Contraceptive Technology How Important Are Various Procedures? What procedures should family planning providers regularly perform when giving clients a method that is new to them? A group of experts named the Technical Guidance/Competence Working Group has rated the importance of selected procedures to providing family planning methods. For each major family planning method, they put each procedure into 1 of 4 categories, as shown IOn the next page. This list is not a complete list of all possible procedures. Instead, it is meant to offer examples. The chart on the next page shows that expensive or difficult procedures are not needed to decide about most methods. Some procedures or tests may provide other useful health information, however. Counseling about family planning methods is important with every method. How Important Are Various Procedures? 4-21 t N m ~ ::l a- . Q. () o ::l a 2 '" tl ~ ~ ::r ::l o c8 '< Im po rt an ce o f S el ec te d Pr oc ed ur es fo r Pr ov id in g Fa m ily P la nn in g M et ho ds Cl ass B = Co nll ibu tes su bs tan tia lly Cl ass A = Es se nti al an d m an da tor y i n all ci rcu ms tan ce s f or sa fe an d e ffe cti ve us e of the co ntr ac ep tiv e m etf 1o d. to sa fe an d e ffe cti ve us e, bu t im ple me flla lio n m ay be co ns ide red w tth in the pu bli c h ea lth a nd /or se rv ice co nte xt. Th e r isk of no t p erf orm ing an IO OI mi na lion or te st sh ou ld be ba lan ce d ag ain st 111 e b en eft ts of m ak ing th e co ntr ac ep live m efh od av ail ab le. I1 11 Is Pr oc ed ure Pe lvic ex am (sp ecu lum an d b im an ua l) fo r w om en ; ge nit al ex am fo r m en . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C Blo od pr es su re re ad ing •• • • .• • .• • • • . . • • • • • .• . .• • • .• • • . .• • 2 Br ea st ex am by pr ov ide r . . . . . . • • • .• • . • • .• • • • .• . . • • . . . • C He mo glo bln te st . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C sr n ris k a ss es sm en t m ed ica l h ist or y a nd ph ys ica l e xa m . • • . .• . . • • • • .• . .• . • • .• • .• • • . .• .• • • • • • . . • C sr n sc re en ing by la b t es ts (fo r pe rso ns w ith ou t sy mp tom s) . . . . . • • . . . .• • • • . . • • • • • • . . .• • • • .• .• . • • . . .• . C Ce rvi ca l c an ce r s cr ee nin g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C Ro uti ne , m an da tor y l ab te sts (fo r e xa m ple , ch ole ste ro l, g luc os e, liv er fu nc tio n t es ts) . . . . . . . . . . . . . . . . . C Pr op er Inf ec tiD n-p rev en tlo n p roc ed ure s . • . . . . .• • • • • . . C Sp ec ific co un se lin g p oin ts for fa m ily pl an nin g A7 m et ho d·* * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co un se llng ab ou t c ha ng e i n m en se s, In clu din g Irr eg ula r o r a bs en t m en str ua l b lee din g • . . • . .• • . . . . . A Cl as s C = D oe s n ot co ntr ibu te su bs tan tia lly to sa fe an d e ffe cti ve us e of the co ntr ac ep tiv e m eth Od . :Il l . t I ~i as ~ .- If fl i! I SI i!!i :. ~ If C C C A 2 2 2 A C C C C C C C B C C C C C C C C C C C C C C C rf C A A A A7 A A AS A A A - f J A C NA C C C NA C A AS NA C las s D = No t m ate ria lly re lat ed to eil he r g oo d r ou tin e pre ve nti ve he alt h ca re o r t o lh e s afe an d e ffe cti ve us e of the fa mi ly pla nn ing m eth od . I- . 'I . . . '8 I s -~ a il! _ 1:& 115 I 11 fJ 'E 011 Cl A C C C C C C C C C C C B C C ca A C C C g4 C C C C C C C C - - ca A C C B9 A1 0 Al l A1 2 - A - - - = No t a dd res se d NA = No t a pp lica ble 'Cl as sif lca tlo n i s f or bo II1 ge ne rnl an d l oc al an es 1h esi a. • 'C las slf ica lio n i s f or co nd om s, sp erm icid es , a nd di ap hra gm . " 'S pe ci fic co un se lin g p oin ts: ef fic ac y, co m m on s ide eI Ill ds , c or re ct us e of m eti 1o d. sig ns an d s ym pto ms fo r w hic h to se e a he alt h c ar e pro vid er, ST D pr oiJ lcI ion (w hen las ap pro pri all l) . 1 Cla ss A f ur di ap hra gm . , De sir ab le bu t, w he te riS ks 01 pr eg na nc y ar e hig h, w om en s ho uld no t b e d en ied hO lTl lon al m eti 10 ds si mp ly be ca us e b loo d pI !IS SU fli c an no t b e m ea su re d. , W om en at hi gh ris k f or HI VlA lD S s hO uld av oid pr od uc ts co nta ini ng no no xy no l-9 . Th es e I nc lud e m os t s pe rm icid es , w f1e !h< lr US od Wi th dia ph rag m Of c eM ca l c ap or us ed af on e, an d a lso co nd om s l ub ric ate d Wi th sp erm icid e. • ST D sc re en ing I< Y Il isI wy is Cla ss A. ho we ve r. 5 He mo glo bin le ve l te sti ng an d u rin e s ug ar tes tin g a re Cl as s e , - . . . , Ci ass A for di ap hre gm fi1 1in g. ) Inc lud ing irls truC 1io I1s !o r m iss ed pi lls. • Po int s f ll i nc lod e: pe nn an en t m elh od , pre op era t1o n a nd re co ve lYJ po sto pe rat ion ins tru cti on s. 9 Co un se ling is a go od id ea bU l c an no t a lw ay s be do ne W ith ov er -th e-c ou nts r s ale s 0 1 co nd om s a nd sp erm icid es . C las s A for dia ph rag m, ho we ve r. 10 Po int s t o inc lud e: hig h-r isk bo h.v ior ; co nd om us e for w om en w ho , u nd er ce rta in Cir Cu ms Jan ces , m igh t b ec om e a t h igh ris k for ST Os . NO Te : W om en w ho ar e cu rre ntl y a t hig h r isk fu r S TD s in ge na nd sh ou ld no t re ce ive IU Ds 11 Po int s t o inc lod e: LA M cr iJB ria, be st bre aS tf1 led ing be ha vio r, a nd w he n an d w he re to ge t fo llo w- up m eth od . 12 Po int to in cio de : Im po l1il J1 ce of pa rtn er' s co op .nd ion . Chapter 5 Low-Dose Combined Oral Contraceptives Contents = Introduction to Combined Oral Contraceptives . 5-3 [] Deciding About Combined Oral Contraceptives . 5-3 How Do They Work? . . . . . . . . . . . . 5-3 How Effective? . . . . . . . . . 5-3 Advantages and Disadvantages . 5-4 Medical Eligibility Checklist. . . 5-6 ~ Starting Low-Dose Combined Oral Contraceptives . . 5-9 When to Start. . . . . . . . . . . . . . . . . . 5-9 Providing Combined Oral Contraceptives . 5-10 Explaining How to Use . . . . . . . . . . 5-12 [jJ Following Up . 5-16 Helping Clients at Any Routine Return Visit 5-16 Managing Any Problems . . . 5-17 H Important Points for the User to Remember 5-19 Emergency Oral Contraception 5-20 t!1 Questions and Answers. . . . . . . . . . . 5-26 5-2 Essentials of Contraceptive Technology ~ Introduction to Combined ~ Oral Contraceptives • Women who use oral contraceptives swallow a pill each day to prevent pregnancy. Combined oral contraceptives contain two hormones similar to the natural hormones in a woman's body-an estrogen and a progestin. Also called combined pills, COCs, OCs, the Pill, and birth control pills. • Present-day combined oral contraceptives contain very low doses of hormones. They are often called low-dose combined oral contraceptives. • There are two types of pill packets. Some packets have 28 pills. These contain 21 "active" pills, which contain hormones, followed by 7 "reminder" pills of a different d:olor that do not contain hormones. Other packets have only the 21 "active" pills. See Chapter 6 for information on progestin-only oral contraceptives for breastfeeding women. [] Deciding About Combined Oral Contraceptives . How Do They Work? • Stop ovulation (release of eggs from ovaries). • Also thicken cervical mucus, making it difficult for sperm to pass through. They do NOT work by disrupting existing pregnancy. How EHective? I Effective as commonly used--6 to 8 pregnancies per 100 women in first year of use (1 in every 17 to 1 in every 12). Very effective when used correctly and consistently~.l pregnancies per 100 women in first year of use (1 in every 1,000). INTRODUCTION to Combined Oral Contraceptives 5-3 IMPORTANT: Should be taken every day to be most effective. Many women may not take pills correctly and thus risk becoming pregnant. The most common mistakes are starting new packets late and running out of pills. Advantages and Disadvantages ADVANTAGES • Very effective when used correctly. • No need to do anything at time of sexual intercourse. • Increased sexual enjoyment because no need to worry about pregnancy. • Monthly periods are regular; lighter monthly bleeding and fewer days of bleeding; milder and fewer menstrual cramps. • Can be used as long as a woman wants to prevent pregnancy. No rest period needed. • Can be used at any age from adolescence to menopause. • Can be used by women who have children and by women who do not. • User can stop taking pills at any time. • Fertility returns soon after stopping. • Can be used as an emergency contraceptive after unprotected sex (see page 5-20). • Can prevent or decrease iron deficiency anemia. • Help prevent: - Ectopic pregnancies, - Ovarian cysts, - Endometrial cancer, - Pelvic inflammatory disease, - Ovarian cancer, - Benign breast disease. DISADVANTAGES • Common side effects (not signs of sickness): - Nausea (most common in first 3 months), - Spotting or bleeding between menstrual periods, especially if a woman forgets to take her pills or takes them late (most common in first 3 months), - Mild headaches, - Breast tenderness, - Slight weight gain (some women see weight gain as an advantage), - Amenorrhea (some women see amenorrhea as an advantage), 5-4 Essentials of Contraceptive Technology • Not highly effective unless taken every day. Difficult for some women to remember every day. • New packet of pills must be at hand every 28 days. • Not recommended for breastfeeding women because they affect quality and quantity of milk. • In a few women, may cause mood changes including depression, less interest in sex. • Very rarely can cause stroke, blood clots in deep veins of the legs, or heart attack. Those at highest risk are women with high blood pressure and women who are age 35 or older and at the same time smoke 15 or more cigarettes per day. • Do not protect against sexually transmitted diseases (STDs) including AIDS. IMPORTANT: Ask the client if she might have or get a sexually transmitted disease (STD). (Has more than orite sex panner? Parmer has more than one panner? Could this happen in future?) If she has or might get an STD, urge her to use condoms regularly. Give her condoms. She can still use combined oral contraceptives. Using the Medical Eligibility Checklist The list on the next 2 pages checks whether the client has any known medical conditions that prevent use of combined oral contraceptives. It is not meant to replace counseling. The questions in the checklist refer to known conditions. Generally, you can learn of these conditions by asking the client. IOu do not usually have to pe'iform laboratory tests or physiu,al examinations. IMPORTANT: Low-dose oral contraceptives contain only small . amounts of hormone. Many conditions that limited use of oral ""'11IIIIIIII contraceptives with high doses of estrogen do not apply to low-dose combined oral contraceptives. DECIDING About Combihed Oral Contraceptives 5-5 MEDICAL ELIGIBILITY CHECKLIST FOR Combined Oral Contraceptives (COCS) Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use low-dose combined oral contraceptives if she wants. If she answers YES to a below, follow the instructions. ONo 0 Yes . If you cannot check blood pressure (BP) and she reports high BP, do not provide COCs. Refer fur BP check if feasible or help her choose a method without estrogen. If no report of high BP, okay to provide COCS. Check BP if feasible: If BP below 140190, okay to give COCs without further BP readings. If systolic BP 140 or higher or diastolic BP 90 or higher, do not provide COCs. Help her choose another method. (One BP reading in the range of 140-159/90-99 is not enough to diagnose high BP. Offer condoms or spermicide for use until she can return for another BP check, or help her choose another method if she prefers. If BP reading at next check is below 140/90, she can use COCs and further BP readings are not necessary.) If systolic BP 160 or higher or diastolic BP 100 or higher, she also should not use DMPA or NET EN. DYes . Can provide COCs now with instruction to start when she stops breastfeeding or 6 months after childbirth-whichever comes first. If she is not fully or almost fully breastfeeding, also give her condoms or spermicide to use until her baby is 6 months old. Other effective methods are better choices than COCs when a woman is breastfeeding, whatever her DYes . Do not provide COCs if she reports heart attack or heart disease due to blocked arteries, stroke, blood clots (except superficial clots), severe chest pain with unusual shortness of breath, diabetes for more than 20 years, or damage to vision, kidneys, or nervous system caused by diabetes. Help her choose another effective method. 5-6 Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FOR COCs (continued) Dyes . If she is 35 or older, do not provide COCs. Hdp her choose another method. If she is under age 35, but her vision is distorted or she has trouble speaking or moving before or during these headaches, do not provide COCS. Hdp her choose another meth6d. If she is under age 35 and has migraine headaches without distortion of vi$ion or trouble speaking or rno!v]·ml!. she can use COCs. . D No DYes . If she is takingphenytoin, carbamezapine, barbiturates, or primidone for seizures or rifompin or griseofolvin, provide condoms or spermicide to use along with COCs or, if she: prefers, help her choose another effective method if she is on long-term treatment. DYes . If she has gallbladder disease now oir takes medicine for gallbladder disease, or if she has had jaundice! while using COCs, do not provide COCS. Hdp her choose a method without estrogen. If planning surgery or just had a baby, can provide COCs ~ith instruction on when to start them later (see pages 5-9 and 5-10). Be sure to explain the health benefits and risks and the ~ide effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable when relevant to the client. ! DECIDING About Combined Oral Contraceptives 5-7 Most Women Can Use Combined Oral Contraceptives In general, most women CAN use low-dose combined oral contraceptives safely and effectively. * Low-dose combined oral contraceptives can be used in any circwnstances by women who: • Have no children, • Smoke cigarettes but are • Are fat** or thin, under age 35, • Are any age, including • Have just had abortion adolescents and over 40 or mlScarnage. (except women who are age 35 or older and who smoke), Also, women with these conditions CAN use low-dose combined oral contraceptives in any circwnstances: • Heavy, painful menstrual • Schistosomiasis, periods or iron deficiency • Thyroid disease, anemia (condition may improve), • Irregular menstrual periods, • Benign breast disease, • Diabetes without vascular, kidney, eye, or nerve disease, • Mild headaches, • Varicose veins, • Malaria, • Pelvic inflammatory disease, • Endometriosis, • Benign ovarian tumors, • Uterine fibroids, • Past ectopic pregnancy; • Tuberculosis (unless taking rifampin; see checklist question 8 on page 5-7). IMPORTANT: Nonmedical providers can safely offer low-dose combined oral contraceptives. Nonmedical providers include shopkeepers and community-based distributors. These providers do not need to obtain medical consultation or approval to provide pills to a woman unless she has a condition that requires it. *Characteristics and conditions listed in this box are in WHO Eligibility Criteria category 1. Women with characteristics and conditions in WHO category 2 also can use this method. See Appendix, page A-I. **Yery fat is WHO category 2. 5-8 Essentials of Contraceptive Technology ~ Starting Low-Dose Combined I.Ii Oral Contraceptives When to Start IMPORTANT: A woman can be given combined oral contraceptives . at any time and told when to start taking them. The following table ~ shows when to start. Woman's situation Having menstrual cycles (including switching from a nonhormonal method or progestin-only pills) When switching from injectables or implants After childbirth if breast- feeding and has no monthly bleeding period . When to start • Any of the first 5 days after her menstrual bleeding starts, if she is cycling normally. The first day of menstrual bleeding may be easiest to remember. • Any other time it is reasonably certain that she is not pregnant. (See page 4-6.) If more than 5 days since menstrual bleeding started, she can begin combined oral contraceptives but should. avoid sex or also use condoms or spermicide for the next 7 days. Her usual bleeding pattern may change temporarily. • Immediately, if it is reasonably certain she is not pregnant. (See page 4-6.) No need to wait for a first period after using injectables or implants. • After she stops breastfeeding or 6 months after child- birth-whichever comes firstj (See page 4--8.) i Note: Can give her pills now. Make sure she knows when to start taking memo STARTING Combin~d Oral Contraceptives 5-9 Woman's situation After childbirth if not breastfeeding After nuscarnage oraborUon When to start • 3 to 6 weeks after childbirth. No need to wait for menstrual periods to return to be certain that she is not pregnant. • After 6 weeks, any time it is reasonably certain that she is not pregnant. Note: If not reasonably certain, she should avoid sex or use condoms or spermicide until her first period starts, and then begin combined oral contraceptives. • In the first 7 days after first- or second-trimester miscarriage or abortion. • Later, any time it is reasonably certain that she is not pregnant. Providing Combined Oral Contraceptives IMPORTANT: A woman who chooses low-dose combined oral contraceptives benefits from good counseling. A friendly provider who listens to a woman's concerns, answers her questions, and gives clear, practical information about side effects, especially nausea and vomiting, and about proper use will help the woman use combined oral contraceptives with success and satisfaction. You can follow these steps to provide combined oral contraceptives: 1. Give her plenty of pills-a year's supply, if possible. Running out of pills is a major reason for unintended pregnancies. 2. Explain how to use combined oral contraceptives (see page 5-12). 3. If possible, give her condoms or spermicide to use: • Until she can stnt taking her pills (if needed) (see page 5-9 and above); • If she starts a packet of pills late, if she forgets several pills in a row, or if she stops taking oral contraceptives for any reason; • If she thinks she or her partner could get AIDS or any other STD. Show her how to use condoms or spermicide. 5-10 Essentials of Contraceptive Technology 4. Plan a return visit in time to give her mor(j: pills before her supply runs out. 5. Invite the client to come back any time she has questions, problems, or wants another method. This drawing can help explain what to do when a client misses pills. Describe the pills by their colors. (See page 5-13 for details.) What to do if you miss one or more pills Every time you miss one or more active pills (days 1-21): In these special cases ALSO foUow these special rules: Started pack Z 4ys late or more? Avoid sex or use another method fot7days. Missed\ any 2 to 4 pills of firSt 7 pills (days 1-7)? Missed any S or more active pills in a rqw (daysl.;,21~? Missed any % ro4piDsof last 7 ;i~ive pills (da}'$ lS.:.21)? STARTING Combined Oral Contraceptives 5-11 Explaining How to Use FOllOW THIS PROCEDURE 1. Hand her at least one packet of the same pills that she will use, even if she will be getting her pills elsewhere later. 2. Show her: • Which kind of pill packet you are giving her-21 pills or 28 pills. IMPORTANT:With 28-pill packets, explain that the last 7 pills ~ do not contain hormones. They are inactive or "reminder" ~ pills. Point out that they are a different color from the first 21 pills. Explain that, if she forgets to take reminder pills, she is still protected from pregnancy. If she forgets to take active, hormonal pills, however, she risks pregnancy. • How to take the first pill out of the packet. • How to follow directions or arrows on the packet to take the rest of the pills, one each day (first hormonal pills, then any reminder pills). 3. Give her instructions on starting the first packet, starting the next packet, and what to do after missing pills (see below and next page). 4. Ask her to repeat the most important instructions and show how she will take her pills, using the pill packet. 5. Ask her if she has any questions, fears, or concerns, and answer her concerns respectfully and caringly. GIVE SPECIFIC INSTRUCTIONS IMPORTANT: The dient should always TAKE ONE PILL EACH ~ DAY-until the pill packet is empty. The more pills she misses, the ~ greater her risk of becoming pregnant. The greatest risk of pregnancy comes from going more than 7 days without taking an active pill. Therefore starting each new pack on time is very important . . Starting the first packet: - See pages 5-9 and 5-10 for when to start. - If she starts beyond day 7 after the start of her menstrual period, she may have irregular menstrual bleeding for a few days. - Taking pill at the same time each day may help her remember them. 5-12 Essentials of Contraceptive Technology . Starting the next packet: If you provide: 28-pill packets 21-pill packets Give this instrudion: When she finishes one packet, she should take the first pill from the next packet on the very next day. After she takes the last pill from one packet, she should wait 7 days and then take the first pill from the next packet. Note: She must NOT wait MORE than 7 days between cycles of 21-pill packets. (Some providers may tell women to wait only 4 or 5 days to reduce the chance of pregnancy.) . Instructions if a woman forgets to take a piU or pills: Missed an active pill or pills (days 1-21), including startingpack I4te? ALWAYS: 1. Take a pill as soon as you remember. 2. Take the next pill at the usual time. This may mean taking 2 pills on the same day or even at the same time. 3. Continue taking active pills as usual, one each day. ALSO follow these steps when you have missed more than one pill or started late: When pills How pills are are missed: missed: First 7 days • Started pack 2 or more days late OR • Missed any 2 to 4 pills Days 8-14 • Missed any 2 to 4 pills Days 15-21 • Missed any 2 to 4 pills Follow the 3 rules above and also do this: • Avoid sex or use additional contraception for the next 7 days. • Oust follow the 3 "Always" rules above.) • Go straight to the next pack. Throwaway inactive pills from a 28-day pack (days 22-28); do not wait 7 days before starting a 21-pill pack. STARTING Combin$d Oral Contraceptives 5-13 When pills are missed: First 3 weeks (days 1-21) How pills are missed: • 5 or more days in a row Follow the 3 rules above and also do this: • Avoid sex or use additional contraception for the next 7 days. • Go straight to the next pack. Throwaway inactive pills from a 28-day pack (days 22-28); do not wait 7 days before starting a 21-pill pack. Missed any inactive pills (klst 7) in a 2B-pill pack? (The 7 inactive pills may be a different color from the 21 active pills.) 1. Throwaway missed pills. 2. Keep taking one pill each day. 3. Start a new pack as usual. Note: These instructions can be hard to remember. Invite the woman to come in or telephone, if convenient for her, any time she is uncertain of what to do. Also, printed copies of these instructions can be given to clients. GIVE ADVICE ON COMMON PROBLEMS 1. Mention the most common side effects-for instance, nausea, mild headaches, tender breasts, spotting between periods, irregular bleeding, mood changes (see page 5-4). Explain about these side effects: • Not signs of serious sickness. • Usually become less or stop within 3 months after starting combined oral contraceptives. • Many women never have them. 2. Explain how she can deal with some common problems. Give these instructions: 5-14 Essentials of Contraceptive Technology If the client experiences: Common side effects such as nausea, mild headaches, mood changes, tender breasts, spotting between periods, irregular bleeding. Vomiting (for any reason) within 2 hours after taking a hormonal pill. Severe diarrhea or vomiting for more than 24 hours. (Probably not caused by low-dose combined oral contraceptives.) Then she should: Keep taking her pills. Skipping pills may make these side effects worse. Also, skipping pills risks pregnancy. For spotting or irregular bleeding, she can try taking each pill at the same time of day. Reassure her that these are not signs of more serious problems, and thq usually go away. Take another hormonal pill from a separate packet. (Give her extra pills to take if she vomits.) Follow the instructions for missed pills. (See page 5-13.) Diarrhea or vomiting may reduce effectiveness.in the same way as missing pills. 3. Invite the client to come back if she needs more help with any problems. (See pages 5-17 and 5-18.) Let her know that she can switch to another method any time she wishes. EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR Describe the symptoms of problems that require medical attention. Serious complications of pill use are rare. Still, a woman should see a doctor or nurse or return to the clinic if she has questions or problems or any of these possible symptoms of more serious problems. Combined oral contraceptives mayor may not cause these problems: • Severe, constant pain in belly, chest, or legs. • Any very bad headaches that start or become worse after she I begins to take combined oral contraceptives. i • Briefloss of vision, seeing flashing lights or zigzag lines (with or without bad headache); brief trouble speaking or moving arm or leg. • Jaundice (skin and eyes look yellow). STARTING Combined Oral Contraceptives [j] Following Up IMPORTANT: The client can return for more pills at her convenience, any time before her supply runs out. A scheduled return visit is not necessary. Helping Clients at Any Routine Return Visit ASK QUESTIONS At any return visit: 1. Ask if the client has any questions or anything to discuss. 2. Ask the client about her experience with the method, whether she is satisfied, and whether she has any problems. Give her any information or help that she needs and invite her to return again any time she has questions or concerns. If she has problems that cannot be resolved, help her choose another method. 3. Ask if she has had any health problems since her last visit. • Check blood pressure once a year if possible. • If she has developed high blood pressure, heart disease due to blocked arteries, stroke, breast cancer, active liver disease, or gallbladder disease or she is taking medicines for seizures, rifampin, or griseofolvin, see pages 5-6 and 5-7 for instructions. If appropriate, help her choose another method. • If she has developed very bad hettddches, see page 5-18 for instructions. PLAN FOR HER NEXT VISIT If she has not developed any condition that means she should not use combined oral contraceptives, provide more supplies if needed. Plan for her next visit before she will need more pills. 5-16 Essentials of Contraceptive Technology Managing Any Problems If the client reports any of the common side effects of low-dose combined oral contraceptives: 1. Do not dismiss the woman's concerns or take them lightly. 2. If the woman is worried, reassure her that such side effects are not usually dangerous or signs of danger. Ifshe has just started the method, tell her that these side effects usually become less or go away within 3 months. 3. Urge her to keep taking a pill each day even ifshe has these side effects. Skipping pills can risk pregnancy. 4. If she is not satisfied after treatment and counseling, help her choose another method if she wishes. For this problem: Nausea Minor headaches Amenorrhea (no monthly bleeding period). Common. Not usually a sign of pregnancy. Try this suggestion: • Suggest taking the pill at night or with food. • Suggest taking ibuprofen, aspirin, paracetamol, or other nonsteroidal anti- inflammatory drug (NSAID). • Ask if she is having any bleeding at all. (She may have just a small stain on her underclothing and not recognize it as vaginal bleeding.) If so, reassure her. • Ask if she is sure she ~ been taking a pill every day. If she has, reassure her that she is not likely to be pregnant. She should start the next packet of pills: on time. Ifshe is not sure: - Ask if she might have missed the 7 -day break between 21-day packets. This may cause a missed period. Reassure her that she probably is not pregnant. - Ask if she might have missed 2 or more active, honnonal pill$ in a row. If so, assess whether pregnant (see page 4-6). If she FOUOWING UP on CombinEkl Oral Contraceptives 5-17 For this problem: Amenorrhea (no monthly bleeding period) {continued} Spotting or bleeding between monthly periods over several months that bothers the client. Common. Very bad headaches (migraines) - that . . IS, recurrmg severe head pain, often on one side or pulsating, that can cause nausea and often is made worse by light and noise or moving about Minor side effects that last more than 3 months Try this suggestion: may be pregnant, tell her. Ask her to stop taking oral contraceptives. Offer her condoms and/or spermicide. She can use them until her next period comes or until it is otherwise clear whether or not she is pregnant. • Ask if she has recently stopped taking oral contraceptives. - If she is not pregnant, her periods may take a few months to return. Ask if she had irregular periods before she took combined oral contraceptives. If so, her periods may be irregular again after she stops the pills. • Ask if she has missed any pills. Explain that missing pills can cause bleeding between periods. (Can occur even when taking pills every day, however.) • Ask if she has had vomiting or diarrhea. This may cause the problem. (See page 5-15.) • Ask if she is taking rifampin or medicines for seizures (except valproic acid). These medicines may make oral contraceptives less effective. Encourage her to use condoms and/or spermicide. • A woman who develops migraines while using COCs should switch to another method. She should not choose a progestin-only method if she has blurred vision or brief loss of vision, sees flashing lights or zigzag lines, or has brief trouble speaking or moving before or during these headaches. • Refer for care as appropriate. • If the client prefers pills, consider offering another low-dose combined oral contraceptive or progestin-only oral contraceptives (see Chapter 6). 5-1 8 Essentials of Contraceptive Technology IMPORTANT POINTS About Combined Oral Contraceptives 5-19 Emergency Oral Contraception: Oral Contraceptives for Postcoital Contraception ~ Introduction to Emergency ~ Oral Contracep,tion What Is Emergency Oral Contraception? After unprotected sex, emergency oral contraception can prevent pregnancy. Sometimes called postcoital or "morning after" contraception. [] Deciding About Emergency Oral Contraception How Does It Work? Mainly stops ovulation (release of egg from ovary) but perhaps also works in other ways. Does NOT disrupt existing pregnancy. How Effective? Seems to prevent at least three-fourths of pregnancies that would otherwise have occurred. (Average chance of pregnancy due to one act of unprotected intercourse in the second or third week of the menstrual cycle is 8%; after emergency oral contraception, 1-2%.) The sooner emergency oral contraceptives are used, the better they prevent pregnancy. IMPORTANT: Emergency oral contraception does not prevent sexually transmitted diseases. Medical Eligibility Criteria for Emergency Oral Contraception Any woman can use emergency oral contraception if she is not already pregnant. 5-20 Essentials of Contraceptive Technology IMPORTANT: Emergency oral contraception should not be used in ~ place of family planning methods. It should be wied only in an ~ emergency-for example: • A woman has had sex against her will or has been forced to have sex (rape). • A condom has broken. • An IUD has come out of place. • A woman has run out of oral contraceptives, has missed 2 or more progestin- only oral contraceptives, or is more than a few weeks late fOr a DMPA injection and has had sex without using other family planning. • Sex took place without contraception, and the woman wants to avoid pregnancy. ~ Using Emergen~ l.1li Oral Contraception When to Start Up to 72 hours after unprotected sex. Family planning providers at Grady Memorial Hospital in Atlanta, USA, make up emergency contraceptive kits for clients. Each kit contains 8 low-dose combined oral contraceptive tablets, some condoms, and printed materials about emergency oral contraception and continuing oral contraceptives. USING Emergency Oral Contraception 5-21 Explaining How to Use Emergency Oral Contraception FOllOW THIS PROCEDURE 1. Ask careful questions to determine likelihood of pregnancy. (See page 4-6.) If she is dearly already pregnant, do not provide emergency oral contraceptives. 2. Explain emergency oral contraception, its side effects, and effectiveness. (See advice on page 5-23.) 3. Provide the pills for emergency oral contraception. GIVE SPECIFIC INSTRUCTIONS 1. Up to 72 hours after unprotected sex, the woman should take 4 low-dose or 2 "standard-dose" combined oral contraceptives, or else take 20 or 25 progestin-only oral contraceptives, and then take another equal dose 12 hours later. (See table on next page.) IMPORTANT: If she takes pills from a 28-day packet of combined oral contraceptives, she must be sure to take hormone-containing pills. Show her which pills contain hormones. 2. If willing, she should start another method immediately, such as condoms and/or spermicide, or she should avoid sex until she can start her preferred method. (See page 5-24.) Progestin-Only Pills Better for Emergency Contraception A large WHO study has found that progestin-only pills are better than combined oral contraceptives (progestin + estrogen) for emergency contraception. Used for emergency contraception, progestin-only pills were more effective and caused less nausea and less vomiting. Dosage: Either 20 or 25 progestin-only oral contraceptive tablets up to 72 hours after unprotected sex. Then 20 or 25 more tablets 12 hours later. (See table on next page.) Note: Special-purpose pills, each containing 0.75 milligrams levonorgestrel, may be available in some places. 5-22 Essentials of Contraceptive Technology The following table tells how many pills to take according to their formulation: I Number I Number . of pills to· of pills to Formulation (examples 0' brands) Progestin-only oral contraceptives containing 0.075 milligrams (75 micrograms) of norgestrel (Ovrette, Neogest, Norgeal) Progestin-only oral contraceptives containing 0.03 milligra,rrjs (30 micrograms) oflevonorgesrrel (Fol1istrel Microva!, Micro/ut; Micro/uton, Mikro-30 \f:5reth, Mikro-30, Norgeston, Nortre~ Low-dose eoCs containing 0.15 or 0.25 milligrams of levonorgestrel or 0.5 milligrams of norgestrel plus 0.03 milligrams (30 micrograms) of ethinyl e~tradiol (Lo-Femenal Lo-Ovral Mala-D (India), Nordette, Microgynon-30) "Standard-dose" eoCs containing 0.125 or 0.25 milligrams oflevonorgestrel or 0.5 milligrams of nor~trel plus 0.05 milligrams (50 micrograms) of ethinyl estradiol (Eugynon 50, Nordiol Ovral Microgynon-50, Nordette 50) Levonorgestrel 0.75 mg (Postinor-2) . swallaw swallow within 12 hours 72 hours later 20 25 25 4 4 2 2 1 1 IMPORTANT: Other combined oral contraceptive pills may work, too, but . their effectiveness for emergency contraception has nOt been tested. ~ (Note that equal weights of different hormones do not mean equal strength.) GIVE ADVICE ON COMMON PROBLEMS • Nausea. Suggest that she eat .something soon after taking the pills to reduce any nausea. Nonprescription anti-I¥usea medicines such as Dramamine® and MarezintfFJ can reduce the risk of nausea when taken one half-hour before taking emeligency contraceptive pills and every 4 to 6 hours thereafter. • Vomiting. If the woman vomits within 2 hours after taking the pills, she needs to take another dose. Otherwise, she should NOT take any extra pills. Extra pills will not make the method more effective, and they may increase nausea. If vomiting continues, she can take the repeat dose by placing the pills high in her vagina. • Her next monthly period may start a few days earlier or later than expected. Reassure her that this is not a bad sign. EXPLAIN SPECIFIC REASONS TO RETURN TO THE HEALTH CARE PROVIDER 1. Advise her to return or see another health care provider if her next period is quite different from usual for her, especially if it is: • Unusually light (possible pregnancy). • Does not start within 4 weeks (possible pregnancy). • Unusually painful. (Possible ectopic pregnancy. But emergency oral contraception does not cause ectopic pregnancy.) 2. Describe the symptoms of sexually transmitted diseases-- for example, unusual vaginal discharge, pain or burning on urination. Advise her to see a health care provider if any of these symptoms occurs. (See Chapter 16.) PLAN CONTINUING CONTRACEPTION AND STD PROTECTION IMPORTANT: Emergency oral contraception is not as effective as most other contraceptive methods. It should not be used regularly in place of another method. If: The woman is likely to have sex again . She does not start any other method immediately . Then: Urge her to start using an effective contra- ceptive. Help her do so or plan to do so. Give her condoms or spermicide to use at least until she chooses another ongoing method of contraception. 5-24 Essentials of Contraceptive Technology Along with emergency oral contraception, a woman can start any of various ongoing contraceptive methods. These include combined oral contraceptives, condoms, and vaginal methods. • For example, if she wants low-dose combined oral contraceptives and no medical conditions prevent their use, give her several months' supply of pills and instructions. (See pages 5-12 to 5-15.) She should start these pills on the next day after she finishes the emergency oral contraceptives. Help the woman decide if she needs ongoing protection from sexually transmitted diseases (STDs): For example, does she have more than one sexual partner? Does her partner have any other partners? Does he have symptoms of STDs? If so, discuss condorris for STD protection. Give her condoms. USING Emergency Oral Contraception 5-25 1. Do combined oral contraceptives cause cancer? Oral contraceptives have not been proved to cause any common cancer. Oral contraceptives help to prevent two kinds of cancer-cancer of the ovaries and cancer of the endometrium (lining of the womb). For breast and cervical cancer: Some studies find that these cancers are more common among certain women who have used oral contraceptives. Other studies do not find this. More research is taking place. 2. Should a woman take a break from oral contraceptives after a rime? No. There is no evidence that "taking a rest" from oral contraceptives is helpful. This practice can lead to unplanned pregnancy. 3. Does the Pill cause deformed babies? Will the fetus be harmed if a woman takes the Pill while she is pregnant? Good evidence shows that a child conceived after a woman stops taking oral contraceptives will not be deformed because of the Pill. Also, even if a woman takes some pills accidentally while pregnant, they will not make the baby deformed or cause abortion. 4. Can the Pill make a woman sterile? No. Women who could get pregnant before taking the Pill will be able to get pregnant when they stop taking it. Some Pill users have to wait a few months for normal menstrual periods to return. 5. Can a woman take the Pill throughout her reproductive years? Yes. There is no minimum or maximum age. Oral contraceptives can be an appropriate method for most women from menarche to menopause. Women age 35 or older who smoke should not use combined oral contraceptives, however, unless they stop smoking. 5-26 Essentials of Contraceptive Technology 6. Can a woman take the Pill if she has not had any babies? Yes. Both women with children and women without children can safely take the Pill. 7. Must a woman have a pelvic examinatio.p. before she can start or continue using the Pill? No. Instead, asking the right questions can help to find out whether pregnancy is likely. (See page 4-6.) A woman should not be refused oral contraceptives because a pelvic exam cannot be done or because she does not want one. If a woman has symptoms of a gynecologital. problem, however, a pelvic exam might help find the reason. S. Will the Pill make a woman weak? No. The Pill does not cause weakness. In fact, it helps some women feel stronger by preventing anemia (not enough iron in the blood). Women using the Pill lose much less menstrual blood than other women. That is how the Pill prevents anemia. A woman may feel different because of the Pill and describe this as weakness, or she may have some other problem that makes her feel weak. She should keep taking het pills. She can go to a doctor or nurse to find out why she feels weak. 9. If a woman has been using the Pill for a long time, will she still be protected from pregnancy after she stops taking the Pill? No. A woman is protected only as long as she takes her pills regularly. 10. Can a woman who smokes take the Pill? Women less than age 35 who smoke cani be offered low-dose combined oral contraceptives. Older women who smoke should choose another method. Older women who cannot stop smoking can take the progestin-only pill if they prefer pills. All women who smoke should be urged to stop smoking. QUESTIONS & ANSWERS About CombIned Oral Contraceptives 5-27 11. For emergency contraception, can a woman use combined oral contraceptives from family planning programs, pharmacies, social marketing programs, retail stores, or other oudets? Yes, if necessary. It would be better for her to see a health care provider who can counsel her about emergency contraception and future family planning. If she will not be able to reach a provider within 72 hours after unprotected intercourse, she can obtain combined oral contraceptives herself. (See pages 5-20 to 5-25.) 12. Can older women who smoke use the Pill for emergency contraception? Yes. Because of the short treatment, even women age 35 or older who are heavy smokers can take emergency oral contraceptives. Preventing pregnancy is important, since pregnancy can be especially dangerous for such women. 5-28 Essentials of Contraceptive Technology Chapter 6 Progestin-Only Oral Contraceptives 6-1 Chapter 6 Progestin-Only Oral Contraceptives Progestin-only oral contraceptives differ from combined oral contraceptives in some important ways. This chapter describes those differences. Otherwise, see Chapter S. Contents = Introduction to Progestin-Only Oral Contraceptives . 6-3 [] Deciding About Progestin-Only Oral Contraceptives . . 6-4 How Do They Work? . . . . . . . . . . . . . . . 6-4 How Effective? . . . . . . . . . 6-4 Advantages and Disadvantages . 6-S Medical Eligibility Checklist. . . 6-7 ~ Starting Progestin-Only Oral Contraceptives . 6-9 When to Start. . . . . . . . . . . . . . 6-9 Providing Progestin-Only Oral Contraceptives 6-10 Explaining How to Use . . . . . . . . . . . 6-11 [iJ Following Up . . . . . . . . . . . . . 6-13 Helping Clients at Any Routine Return Visit 6-13 Managing Any Problems . . . . . . . 6-13 H Important Points for the User to Remember 6-16 [!1 Questions and Answers. . . . . . . . . . . 6-17 6-2 Essentials of Contraceptive Technology IIIJII!I'II Introduction to Progestin-Only ~ Oral Contraceptives • Women who use progestin-only oral contrac~ptives swallow a pill every day to prevent pregnancy. Progestin-only oral contraceptives contain very small amounts of only one kind of hormone, a progestin. Progestin-only oral contraceptives contain one-half to one-tenth as much progestin as combined oral contraceptives. They do not contain estfogen. Also called progestin-only pills (POPs), POCs, and minipills. • Progestin-only oral contraceptives are the best oral contraceptive for breastfeeding women. They do not seem ~o reduce milk production. This chapter looks mainly at progestin-only oral contraceptives for breastfeeding women. Women who are not breastfeeding also can use progestin-only oral contraceptives. INTRODUCTION to Progestin-Only Oral Contraceptives 6-3 [] Deciding About Progestin-Only Oral Contraceptives How Do They Work? • Thicken cervical mucus, making it difficult for sperm to pass through. • Stops ovulation (release of eggs from ovaries) in about half of menstrual cycles. (Breastfeeding prevents pregnancy in the same ways.) Progestin-only oral contraceptives do NOT work by disrupting existing pregnancy. How EHective? For breastfeeding women: Very eJfoctive as commonly used-About 1 pregnancy per 100 women in first year of use. (More effective than combined oral contraceptives as commonly used because breastfeeding itself provides much protection against pregnancy.) (Pregnancy rate for progestin-only oral contraceptives as commonly used by women not breastfeeding is not available. Mistakes in pill-taking lead to pregnancy more often than with combined oral contraceptives. But pill-taking may be easier because a woman takes the same pill every day without breaks.) For all women: '[,fry eJfoctive when used correctly and consistently-- 0.5 pregnancies per 100 women in first year of use (1 in every 200) (not quite as effective as combined oral contraceptives used correctly and consistendy). IMPORTANT: Most effective when taken at about the same time . everyday. . 6-4 Essentials of Contraceptive Technology Advantages and Disadvantages ADVANTAGES • Can be used by nursing mothers starting 6 weeks after childbirth. Quantity and quality of breast milk do not seem harmed. (In contrast, combined oral contraceptives am slightly reduce milk production.) • No estrogen side effects. Do not increase risk of estrogen-related complications such as heart attack or stroke. • Women take one pill every day with no break. Easier to understand than taking 2 I-day combined pills. • Can be very effective during breastfeeding. • Even less risk of progestin-related side effects, such as acne and weight gain, than with combined oral contraceptives. • May help prevent: - Benign breast disease, - Endometrial and ovarian cancer, - Pelvic inflammatory disease. DECIDING About Progestir'l-Only Oral Contraceptives 6-5 DISADVANTAGES • For women who are not breastfteding--common side effects (not signs of sickness): Changes in menstrual bleeding are normal, including irregular periods, spotting or bleeding between periods (common), and amenorrhea (missed periods), possibly for several months (less common). (Some women see amenorrhea as an advantage.) A few women may have prolonged or heavy menstrual bleeding. (Breastfeeding women normally do not have regular periods for some months, whether or not they use progestin-only oral contraceptives. Therefore menstrual changes due to progestin-only oral contraceptives generally are not noticed or bothersome. Progestin-only oral contraceptives may lengthen amenorrhea during breastfeeding.) • Less common side effects include headaches and breast tenderness. • Should be taken at about the same time each day to work best. For women who are not breastfeeding, even taking a pill more than a few hours late increases the risk of pregnancy, and missing 2 or more pills increases the risk greatly. • Do not prevent ectopic pregnancy. Using the Medical Eligibility Checklist The list on the next page checks whether the client has any known medical conditions that prevent use of progestin-only oral contraceptives. It is not meant to replace counseling. The questions in the checklist refer to known conditions. Generally, you can learn of these conditions by asking the client. }0u do not usually have to perform laboratory tests or physical examinations. IMPORTANT: Progestin-only oral contraceptives contain no ~ estrogen. Many of the criteria that restrict use of combined ~ oral contraceptives, which contain estrogen, do not apply to progestin-only oral contraceptives. 6-6 Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FOR Progestin-Only Oral Contraceptives Ask the client the questions below. If she answers NO to All of the questions, then she CAN use progestin-only oral contraceptives (POCs) if she wants. If she answers YES to a question below, fpllow the instructions. In some cases she can still use progestin-only oral cqntraceptives. o No DYes ~ If she is taking phenytoin, carbamezapine, barbiturates, or primidIJne for seizures or rifompin or griseofolvin, provide condoms or spermicide to use along with POCs. If she prefers, or if she is on long-term treatment, help her choose another effective method. ONo 0 Yes ~ Assess whether pregnant (see page 4-6). If she might be pregnant, also give her condoms or spermicide to use until reasonably sure that she is not pregnant. Then she can start POCs. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any: conditions that would make the method inadvisable when relevant to the Client. DECIDING About Progestin-Only Oral Contraceptives 6-7 Most Women Can Use Progestin-Only Oral Contraceptives In general, most women CAN use progestin-only oral contraceptives safely and effectively. * Progestin-only oral contraceptives can be used in any circumstances by women who: • Are breastfeeding (starting as • Are any age, including soon as 6 weeks after adolescents and over 40, childbirth), • Smoke cigarettes, • Have no children, • Are fat or thin, • Have just had abortion or miscarrIage. Also, women with these conditions CAN use progestin-only oral contraceptives in any circumstances: • Benign breast disease, • Heavy, painful menstrual • Headaches, periods, • Iron deficiency anemia, • Varicose veins, • Valvular heart disease, • Malaria, • Sickle cell disease, • Schistosomiasis, • Pelvic inflammatory disease, • Sexually transmitted diseases, • Irregular menstrual periods, • Endometriosis, • Thyroid disease, • Benign ovarian tumors, • Uterine fibroids, • Epilepsy, • Tuberculosis (unless taking rifampin; see checklist question 5 on page 6-7). *Characteristics and conditions listed in this box are in WHO Eligibility Criteria category 1. Women with characteristics and conditions in WHO category 2 also can use this method. See Appendix, page A-I. 6-8 Essentials of Contraceptive Technology ~ Starting Progestin-Only I.IIi Oral Contraceptives When to Start IMPORTANT: A woman can be given progestin-only oral contraceptives at any time and told when to start' taking them. Woman's situation When to start Breastfeeding • As early as 6 weeks after childbirth. After childbirth if not breastfeeding • Fully or nearly folly breastfeeding effectively prevents pregnancy for at le~t 6 months or until she has a menstrual period, whichever comes first (see Chapter 15). Progestin-only oral contraceptives can give her extra protection if she wants it. • If only partially breastfeeding and child receives much other food or drink, 6 weeks after childbirth is the best time to start progestin-only pills. If she waits longer, fertility may return. • If menstrual periods have returned, she can start progestin-only oral contraceptives any time it is reasonably certain that she is not pregnant (see page 4-6 and "Having menstrual cycles," page 6-10). • Immediately or at any time in the first 4 weeks after childbirth. No need tQ wait for her menstrual period to return.' • After 4 weeks, any time it is reasonably certain that she is not pregnant (see page 4-6). If not reasonably certain, she should avoid sex or use condoms or spermicide until her first period begins and then start progestin-only oral contraceptives. STARTING Progestin-Only Oral Contraceptives 6-9 Woman's situation After miscarriage or abortion Having menstrual cycles (including switching from a nonhonnonal method) When switching from injectables, implants, or combined oral oontraceptives When to start • Immediately or in the first 7 days after either first- or second-trimester miscarriage or abortion. • Later, any time it is reasonably certain that she is not pregnant (see page 4-6). • Any time it is reasonably certain that she is not pregnant (see page 4-6). • In the first 5 days of menstrual bleeding. The first day of menstrual bleeding may be easiest to remember. No backup method is needed for extra protection. • If not starting in the first 5 days of her menstrual period, she should also use condoms or spermicide or avoid sex for at least the next 48 hours. If possible, give her condoms or spermicide. • Immediately. No need to wait for a first period after using injectables. Providing Progestin-Only Oral Contraceptives Same as for combined oral contraceptives (see page 5-10). Also can be used for emergency contraception (see pages 5-22 and 5-23). 6-1 0 Essentials of Contraceptive Technology Explaining How to Use Same as for combined oral contraceptives (see pages 5-12 to 5-15) EXCEPT: GIVE SPECIFIC INSTRUCTIONS IMPORTANT: The client should always TAKE ONE PILL EVERY . DAY. If not breastfeeding, it is best to take the pill at the same time . each day if possible; even taking a pill more than a few hours late increases the risk of pregnancy, and missing 2 or:more pills in a row gready increases the risk. ~ Starting the next packet: When she finishes one packet, she should take the first pill from the next packet on the very next day. All pills are active, hormonal pills. There is no wait between packets. 28 or 35 pills of the same color: These are progestin-only oral contraceptives. STARTING Progestin-Only Oral Contraceptives 6-11 ~ If a woman missed one or more pills by 3 hours or more: She needs to take 1 as soon as she remembers and then keep taking 1 pill each day as usual. If she is having menstrual cycles, she also needs to avoid sex or use condoms or spermicides for at least 48 hours. GIVE ADVICE ON COMMON PROBLEMS Same as for combined oral contraceptives (see page 5-14) EXCEPT, for women not breastfeeding, especially mention spotting or bleeding between periods and mention amenorrhea. These changes are common, normal, and not harmful. EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR Describe the symptoms of problems that require medical attention. Serious complications of progestin-only pill use are rare. Still, a woman should see a doctor or nurse or return to the clinic if she has questions or problems or any of the following possible symptoms of more serious problems. Progestin-only oral contraceptives mayor may not cause these problems. • Extremely heavy bleeding (twice as long or as much as usual for her). • Any very bad headaches that start or become worse after she begins to take progestin-only oral contraceptives. • Skin or eyes become unusually yellow. • Might be pregnant (for example, missed period after several regular cycles), especially if she also has signs of ectopic pregnancy-abdominal pain or tenderness, or faintness. A woman who develops these signs must seek care at once. Note on ectopic pregnancy: Pregnancies among consistent users of progestin-only oral contraceptives are few, especially during breastfeeding. When pregnancy occurs, however, as many as 1 in every 10 may occur outside the uterus (ectopic pregnancy). Ectopic pregnancy is life-threatening and requires treatment at once. 6-1 2 Essentials of Contraceptive Technology [j] Following Up Helping Clients at Any Routine Return Visit Same as for combined oral contraceptives (see page 5-16) EXCEPT: If the client has developed breast cancer or active liver disease or she is taking medicine for seizures, rifampin, or griseofolvin, see page 6-7 for instructions. If appropriate, help her choose another method. If the client has developed any of the following conditions, see "Managing Any Problems," this page through 6-15. • Unexplained abnormal vaginal bleeding that may suggest pregnancy or an underlying medical condition. • Heart disease due to blocked arteries, or stroke. • Very bad headaches. Managing Any Problems Same as for combined oral contraceptives (see p~e 5-17 and 5-18) EXCEPT the following: For this problem: Amenorrhea (no monthly bleeding period) or irregular bleeding and spotting in a breastfeeding woman Try this suggestion: • Reassure the woman that this is normal during breastfeeding, whether or not a woman is using progestin-only oral contraceptives. FOLLOWING UP on Progestin-Oily Oral Contraceptives 6-13 For this problem: Amenorrhea or irregular bleeding and spotting that bothers the client who is not breastfeeding Unexplained abnonnal vaginal bleeding that suggests pregnancy or underlying medical condition Heart disease due to blocked arteries (ischemic heart disease) or stroke Try this suggestion: • Ask if she has been having regular monthly periods while taking progestin-only pills and then suddenly had no period. She may have been ovulating (producing eggs). Rule out pregnancy (see page 4--6). • If not likely that she is pregnant, tell the client that these bleeding patterns are normal with progestin-only oral contraceptives. They are not harmful. She is losing less blood than she would if she were not using family planning. Explain that this can improve her health. It helps prevent anemla. • She can continue using progestin-only oral contraceptives while her condition is being evaluated. • Explain that progestin-only oral contraceptives sometimes change vaginal bleeding patterns. This is not harmful. • Evaluate and treat any underlying medical condition, including ectopic pregnancy, or refer for care. • A woman who has this condition can safely start using progestin-only oral contraceptives. If, however, the condition develops after she starts using them, she should switch to a method without hormones. • Refer for care as appropriate. 6-14 Essentials of Contraceptive Technology For this problem: Very bad headaches (migraines) with blurred VIsIon Try this suggestion: • A woman who gets migraine headaches can safely start using progestin-only oral contraceptives. She should switch to a method without hormones, however, if these headaches start or become worse after she begins using progestin-only oral contraceptives and these headaches involve blurred vision, temporary loss of vision, seeing flashing lights or zigzag lines, or trouble speaking or movmg. • Refer for care as appropriate. IMPORTANT: If the woman is not satisfied after :treatment and counseling, help her choose another method if she wishes. FOLLOWING UP on Progestin-Only Oral Contraceptives 6-15 6-16 Essentials of Contraceptive Technology 1. Can a woman who is breastfeeding a baby take progestin-only pills? Yes. This is a good choice for a breastfeeding mother who wants a hormonal method. Progestin-only pills are safe for both the mother and the baby starting as early as 6 weeks after childbirth. 2. If a woman does not have her monthly period while taking progestin-only oral contraceptives, does this mean that she is pregnant? Probably not, especially if she is breastfeeding. If she has been taking her pills every day and has no other signs of pregnancy (including ectopic pregnancy), she is very probably not pregnant and can keep taking her pills. If she is still worried about being pregnant after being reassured, she can be offered a pregnancy test, if available, or referred for one. If she is not breastfeeding and not having her period bothers her, she may want to choose another family planning method. 3. Does it matter what time of day a woman takes her pill? Ifbreastfeeding, no. If not breastfeeding, yes. Because the progestin-only pill contains very little hormone, a woman who is not breastfeeding should try to take her pill at the same time each day. If she is more than 3 hours late taking her pill, she should take the missed pill as soon as she remembers and take the next pill at the usual time of day. Then for added protection, she should either use condoms or spermicide or else avoid sex for the next 2 days. If a woman often misses pills, she may want ito consider another family planning method. On a return visit, the provider should ask the client if she has missed pills. If she has missed several pills in a row, the provider may want to assess whether the woman might be pregnant (see page 4-6), especially if she is not breastfeeding. QUESTIONS & ANSWERS About Progestin-Only Oral Contraceptives 6-17 4. Must the progestin-only pill be taken every day? Yes. All of the pills contain the hormone that prevents pregnancy. If a woman does not take a pill every day, she may become pregnant. (In contrast, the last 7 pills in a 28-pill packet of combined oral contraceptive are not active. They contain no hormones.) 5. Are ovarian cysts more common with progestin-only pills? Yes. So-called ovarian cysts are more common among women taking progestin-only pills than among women using combined pills or using no contraception at all. What are often called ovarian cysts are really follicles (small fluid-611ed strucrures in the ovary) that continue to grow beyond the usual size in a normal menstrual cycle. They are not very common and usually disappear on their own. They may cause some abdominal pain but rarely require treatment. 6. Is it hard to get pregnant after using progestin-only pills? No. Women who have used progestin-only pills can become pregnant as quicldy as women stopping barrier methods and sooner than women stopping combined pills. 7. Can progestin-only pills be used for emergency contraception after unprotected sex? Yes. (See pages 5-20 to 5-25.) Up to 72 hours after unprotected sex, the woman should take 20 or 25 progestin-only oral contraceptive tablets containing the progestin levonorgestrel or norgestrel. Then 12 hours later she should take another 20 or 25 progestin-only tablets. Whether she takes 20 + 20 or 25 + 25 depends on the formulation, or brand. Either of these doses will amount to about the same total dose as 4 + 4 low-dose combined oral contraceptives containing levonorgrestrel or norgestreL In some areas progestin-only formulations may be available especially for emergency use. Each tablet contains 0.75 milligrams oflevonorgestreL A woman takes one tablet within 72 hours after unprotected sex, and she takes a second tablet 12 hours after the first tablet. 6-1 8 Essentials of Contraceptive Technology Chapter 7 DMPA Injectable Contraceptive 7-1 Chapter 7 DMPA Injectable Contraceptive Contents = Introduction to Injectable Contraceptives [] Deciding About DMPA . . How Does It Work? . . . . . . How Effective? . . . . . . . . Advantages and Disadvantages Medical Eligibility Checklist. ~ StartingDMPA . . When to Start. . . . . Providing DMPA . . . Explaining How to Use Giving the Injection. . Proper Handling of Needles and Syringes [[I Following Up . . Helping Clients at Routine Return Visits Managing Any Problems . . Comparing DMPA and NET EN . . . . . H Important Points for the User to Remember tIl Questions and Answers. . . . . . . . . . . 7-2 Essentials of Contraceptive Technology .7-3 .7-3 .7-3 .7-4 .7-4 . .7-6 .7-7 . .7-7 .7-9 7-10 7-12 7-13 7-14 7-14 7-15 7-18 7-19 7-20 ~ Introduction to ~ Iniectable Contraceptives • Women who use this method receive injections to prevent pregnancy. • This chapter describes the most common type of injectable contraceptive, DMPA. DMPA is given every 3 months. It contains a progestin, similar to the natural hormone that a woman's body makes. The hormone is released slowly into the bloodstream. Also known as depot-medroxyprogesterone acetate, Depo-Provera®, Depo, and Megestron®. • There are other injectable contraceptives. NET EN-also called Noristerat®, norethindrone enanthate, and norethisterone enanthate--is given every 2 months. Much of the information that applies to DMPA also applies to NET EN. (For differences between DMPA and NET EN, see page 7-18.) Also, monthly injectable contraceptives are available in some countries. Monthly injectables include Cyclofem™, Cycloprovera™, and Mesigyna®. Monthly injectables contain estrogen and progestin. Therefore they are different from DMPA and NET EN. Monthly injectables are not discussed in this chapter. [] Deciding About DMPA How Does It Work? • Mainly stops ovulation (release of eggs from ovaries). • Also thickens cervical mucus, making it difficult for sperm to pass through. DMPA does NOT work by disrupting existing pregnancy. INTRODUCTION to Injectable Contraceptives 7-3 How EHective? Very effective-O.3 pregnancies per 100 women in first year of use (1 in every 333) when injections are regularly spaced 3 months apart. Pregnancy rates may be higher for women who are late for an injection or who miss an injection or if providers run out of supplies. Advantages and Disadvantages ADVANTAGES • Very effective. • Private. No one else can tell that a woman is using it. • Long-term pregnancy prevention but reversible. One injection prevents pregnancy for at least 3 months. • Does not interfere with sex. • Increased sexual enjoyment because no need to worry about pregnancy. • No daily pill-taking. • Allows some flexibility in return visits. Client can return as much as 2 weeks early or 2 weeks late for next injection. • Can be used at any age. • Quantity and quality of breast milk do not seem harmed. Can be used by nursing mothers as soon as 6 weeks after childbirth. • No estrogen side effects. Does not increase the risk of estrogen-related complications such as heart attack. • Helps prevent ectopic pregnancies. • Helps prevent endometrial cancer. • Helps prevent uterine fibroids. • May help prevent ovarian cancer. • Special advantages for some women: - May help prevent iron-deficiency anemia. - May make seizures less frequent in women with epilepsy. - Makes sickle cell crises less frequent and less painful. 7-4 Essentials of Contraceptive Technology DISADVANTAGES • Common side effects (not signs of sickness): - Changes in menstrual bleeding are likely, including: • Light spotting or bleeding. Most common at first. • Heavy bleeding. Can occur at first. Rare. • Arnenorrhea. Normal, especially after first year of use. (Some women see amenorrhea as an advantage.) - May cause weight gain (average of 1-2 kilo, or 2-41bs., each year). (Changes in diet can help control or prevent weight gain. Some women see weight gain as an advantage.) • Delayed return of fertility (until DMPA levels in the body drop). About 4 months longer wait before pregnancy than for women who had been using combined oral contraceptives, IUDs, condoms, or a vaginal method. • Requires another injection every 3 months. • May cause headaches, breast tenderness, moodiness, nausea, hair loss, less sex drive, and/or acne in some women. • Does not protect against sexually transmitted diseases including HIV/AIDS. IMPORTANT: Ask the client if she might have or get a sexually . transmitted disease (STD). (Has more than one sexual partner? "IIIIIIIIIIIII Partner has more than one partner? Could this happen in future?) If she has or might get an STD, urge her to use condoms regularly. Give her condoms. She can still use DMPA Using the Medical Eligibility Checklist The list on the next page checks whether the client has any known medical conditions that prevent use of DMPA. It is not meant to replace counseling. The questions in the checklist refer to known conditions. Generally, you can learn of these conditions by asking the client. You do not usually have to peif'onn laboratory tests or physical examinations. IMPORTANT: DMPA contains no estrogen. Many of the criteria . that restrict use of combined oral contraceptives, which contain "IIIIIIIIIIIII estrogen, do not apply to DMPA DECIDING About DMPA 7-5 MEDICAL ELIGIBILITY CHECKLIST fOR DMPA Iniectable Ask the client the questions below. If she answers NO to AlL of the questions, then she CAN use DMPA.lf she answers YES to a question below, follow the instructions. o No OYes'" She can start using DMPA beginning 6 weeks after childbirth. If she is fully or almost fully breastfeeding, however, she is protected &om pregnancy for 6 months after childbirth or until her menstrual period rerurns--whichever comes first. Then she must begin contraception at once to avoid pregnancy. Encourage her to continue breastfeeding. ONo 0 yes . Do not provide DMPA if she reports heart attack, heart disease due to blocked arteries, stroke, blood clots (except superficial clots), severe chest pain with unusual shortness of breath, severe high blood pressure, diabetes for more than 20 years, or damage to vision, kidneys, or nervous system caused by diabetes. Help her choose another effective method. ONo 0 yes . If you cannot check blood pressure (BP) and she reports high BP, can provide DMPA. Refer for BP check. ONo Check BP if feasible: Ifsystolic BP below 160 and diastolic BP below 100, okay to give DMPA. Ifsystolic BP over 160 or diastolic BP over 100, do not provide DMPA. Help her choose another method except not COCs. OYes'" If she is not likely to be pregnant but has unexplained vaginal bleeding that suggests an underlying medical condition, can provide DMPA. Assess and treat any underlying condition as apptopriate, or refer. Reassess DMPA use based on findings. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable when relevant to the client. 7-6 Essentials of Contraceptive Technology Most Women Can Use DMPA In general, most women CAN use DMPA injectable contraceptive safely and effectively. * DMPA injectable can be used in any circwnstances by women who: • Are breastfeeding (starting • Are any age, including as soon as 6 weeks after adolescents and over 40, childbirth), • Are fat** or thin, • Smoke cigarettes, • Have just had abonion or • Have no children, miscarriage. Also, women with these conditions CAN use DMPA in any circwnstances: • Benign breast disease, • Malaria, • Mild headaches, • Schistosomiasis, • Mild or moderate high blood pressure, • Iron deficiency anemia, • Sickle cell disease, • Thyroid disease, • Uterine fibroids, • Varicose veins, • Valvular heart disease, • Epilepsy, • Tuberculosis. • Irregular menstrual periods, *Cbaracteristics and conditions listed in this box are in WHO Eligibility Criteria category 1. Women with charncreristics and ronditions in WHO category 2 aOO cm use this method. SreAppendix, pageA-1. **Very fat is WHO category 2. 1::::::1 Starting DMPA When to Start Woman's situation Having menstrual cycles (including switching from a nonhormonal method or progestin-only pills) When to start • Any time it is reasonably cenain that she is not pregnant. (See page 4-6.) IMPORTANT: If she is not at risk of ~ pregnancy (for example, has not had sex since last menstrUal period), she may statt DMPA at any time she wants. STARnNG DMPA 7-7 Woman's situation Having menstrual cycles {continued} When switching from combined pills or implants Breastfeeding When to start • If starting during the first 7 days after menstrual bleeding starts, no back-up method is needed for extra protection. • If she is starting on or after day 8 of her menstrual period, she should use condoms or spermicide or avoid sex for the next 7 days. If possible, give her condoms or spermicide. • Immediately. • As early as 6 weeks after childbirth. • Fully or nearly funy breastfeeding effectively prevents pregnancy for at least 6 months or until she has a menstrual period, whichever comes first (see Chapter 15). DMPA can give her extra protection if she wants it. • If only partially breastfeeding and child receives much other food or drink, 6 weeks after childbirth is the best time to start DMPA. If she waits longer, fertility may return. • If menstrual periods have returned, she can start DMPA any time it is reasonably certain that she is not pregnant (see page 4-6). See "Having menstrual cycles,» above. 7-8 Essentials of Contraceptive Technology Woman's situation After childbirth if not breastfeeding After miscarriage or abortion When to start • Immediately or at any time in the first 6 weeks after childbirth. No need to wait for her menstrual period to return. • After 6 weeks, any time it is reasonably certain that she is not pregnant. (See page 4-6.) If not reasonably certain, she should avoid sex or use condoms or spermicide until her first period begins and then start DMPA • Immediately or in the first 7 days after either first-- or second-trimester miscarriage or abortion. • Later, any time it is reasonably certain that she is not pregnant. Providing DMPA IMPORTANT: A woman who chooses DMPA benefits &om good counseling. A friendly provider who listens to a woman's concerns, answers her questions, and gives clear, practical information about side effects, especially probable bleeding change including amenorrhea (no bleeding at all), will help the woman use DMPA with success and satisfaction. You can follow these steps to provide DMPA: 1. Explain how to use DMPA (see page 7-10). 2. Give the injection (see pages 7-12 and 7-13). 3. Plan with the woman for her return visit in 3 months for her next injection. Discuss how to remember the date, perhaps tying it to a holiday or change of season. 4. Invite the client to come back any time she has questions or problems or wants another method. STARTING DMPA 7-9 Explaining How to Use GIVE SPECIFIC INSTRUCTIONS 1. The client should try to come back on time for the next injection. She may come as much as 2 weeks early or 2 weeks late. 2. If more than 2 weeks late for her next injection, she should use condoms or spermicide or else avoid sex until the next injection. 3. She should come back no matter how late she is. The provider can ask questions to see if she might be pregnant (see page 4-6). She still may be able to get her injection. (See "Managing Any Problems," page 7-15.) GIVE ADVICE ON COMMON PROBLEMS 1. Mention the most common side effects-in particular, she can expect changes in menstrual bleeding and possibly weight gain. 2. Explain about these side effects: • At first she probably will have bleeding at unexpected times. The amount of bleeding usually decreases over time. After 6 to 12 months of use, she probably will have little vaginal bleeding or none at all. • These changes are common, normal, and not harmful. They do not mean that she is pregnant or sick or that bad blood is building up inside her. Little or no bleeding can make some women healthier. It helps prevent anemia. • She may gain weight. This also is common, normal, and not harmful. 3. Invite the client to come back any time she needs more help with any problem or wants a different method. (See pages 7-15 through 7-17.) 7-10 Essentials of Contraceptive Technology EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR Describe the symptoms of problems that require medical attention. Serious complications ofDMPA are rare. Still, a woman should see a doctor or nurse or return to the clinic if she has questions or problems or any of the following possible symptoms of more serious problems. DMPA mayor may not cause these problems. • Bothersome extremely heavy bleeding (twice as long or twice as much as usual for her). • Very bad headaches that start or become worse after she begins DMPA. • Skin or eyes become unusually yellow. STARnNG DMPA 7-11 Giving the Iniection Equipment and Supplies Needed: • One dose ofDMPA (150 mg), • An antiseptic and cotton wool, • A 2 or 5 ml syringe and a 21- to 23-gauge intramuscular needle. Syringe and needle should be sterile, or high-level disinfected if sterilization is not possible. Steps: 1. Wash hands or else wash hands and wear clean gloves. 2. Wash injection site with soap and water if needed and wipe with antiseptic, if available. Use a circular motion from the injection site outward. 3. Shake vial gendy, wipe top of vial and stopper with antiseptic, and fill syringe with proper dose. 4. Insert sterile needle deep into the upper arm (deltoid muscle) or into buttocks (gluteal muscle, upper outer portion). For DMPA the upper arm is more convenient. Inject the contents of the syringe. 5. Do NOT massage the injection site. Tell client not to massage or rub the site. Explain that this could cause DMPA to be absorbed too fast. 7-12 Essentials of Contraceptive Technology Proper Handling of Needles and Syringes IMPORTANT: Use DISPOSABLE syringes and needles if available. ~ They do not transmit infections if disposed of properly. ~ Disposable Needles and Syringes • Place used disposable syringes and needles in a puncture-proof container. • Burn or bury the container when three-quarters full. • Do not put disposable needles in the trash (even if decontaminated). Do not recap them before disposal. Do not bend or break needles before disposal. • Do not reuse disposable syringes and needles. They are meant to be destroyed after one use. Because of their shape, they are very difficult to disinfect. Therefore, they might transmit diseases such as HIV/AIDS. Reusable Needles and Syringes • If disposable syringes are not available, use reusable needles and syringes that have been properly sterilized or high-level disinfected if sterilization is not possible. • These needles and syringes must be sterilized or high-level disinfected again after each use. (See page 4-10.) STARTING DMPA 7-13 []I Following Up Helping Clients at Routine Return Visits ASK QUESTIONS At any return visit: 1. Ask if the client has any questions or anything to discuss. 2. Ask the client about her experience with the method, whether she is satisfied, and whether she has any problems. Give her any information or help that she needs and invite her to return any time she has questions or concerns. If she has problems that cannot be resolved, help her choose another method. 3. Ask about her bleeding patterns. 4. Ask if she has had any health problems since her last visit. • If the client has developed heart disease due to blocked arteries, stroke, blood clots (except supeificial clots), breast cancer, severe high blood pressure, or active liver disease, help her choose a method without hormones (see page 7-6). • If the client has developed very bad head4ches, see "Managing Any Problems" (page 7-17). PLAN FOR HER NEXT VISIT If she has not developed any condition that means she should not use DMPA and she wants to continue this method, give her the injection and plan for her next visit in 3 months. 7-14 Essentials of Contraceptive Technology Managing Any Problems If the client reports any of the common side effects ofDMPA: 1. Do not dismiss the woman's concerns or take them lightly. 2. If the woman is worried, reassure her that such side effects are not usually dangerous or signs of danger. 3. If the woman is not satisfied after treatment and counseling, help her choose another method if she wishes. For this problem: More th.an 2 weeks late for her injection and has been sexually active Amenorrhea. (no monthly bleeding period) Try this suggestion: • If she might be pregnant, assess for pregnancy. (See page 4--6.) Remember that women using DMPA often have no monthly bleeding period (amenorrhea). • If she is not likely to be pregnant, she can continue using DMPA if she prefers it. • She needs to use condoms or spermicide or avoid sex for 7 days after her injection. • Reassure her that amenorrhea is normal among DMPA users and not harmful. She is not sterile. She is not pregnant. Menstrual blood is not building up inside her. Instead, her body is not producing blood. Explain that this can improve her health. It helps to prevent anemia. • Reassure her that amenorrhea does not mean she cannot become pregnant after stopping DMPA. It does not mean she has reached menopause early. (If the woman reaches age 50--usual age of menopause--discontinue DMPA for 9 months to see ifher period returns. She should use a nonhormonal method during this time.) FOLLOWING UP on DMPA 7-15 For this problem: Spotting or bleeding between monthly periods that bothers the client Very heavy or very prolonged bleeding (more than 8 days long or twice as much as her usual menstrual period) Try this suggestion: • Reassure her that spotting or bleeding between periods is normal and very common during the first months ofDMPA use. It is not harmful. She loses less blood than if she did not use DMPA. • If spotting or bleeding persists or follows a period of amenorrhea, rule out gynecologic problems when clinically warranted. If a gynecologic problem is found, treat or refer. If irregular bleeding is caused by sexually transmitted disease or pelvic inflammatory disease, she can continue her injections. Treat or refer. • Rare, but requires attention. Heavy bleeding soon after the injection, but now stopped? • If the woman wants to continue injections, reassure her and give the next injection. Heavy bleeding continues? • Ifbleeding persists or follows a period of amenorrhea, rule out gynecologic problems when clinically warranted. If a gynecologic problem is found, treat or refer. • Ifbleeding becomes a health threat or if the woman wants, help her choose another method. • Give her iron supplements and! or name foods containing iron, and advise the woman to eat more of them if possible. Note: Uterine evacuation is not necessary unless a medical condition that requires it is suspected. 7-16 Essentials of Contraceptive Technology For this problem: Unexplained abnormal vaginal bleeding that suggests pregnancy or an underlying medical condition Very bad headaches (migraines) with blurred vision Try this suggestion: • If her bleeding began after she started using DMPA, she can continue using it while her condition is being evaluated. • Explain that DMPA normally changes vaginal bleeding patterns and that usually these changes are not harmfuL • Evaluate and treat any underlying medical condition, or refer for care. • A woman who gets migraine headaches can safely start using DMPA. She should switch to a method without hormones, however, if these headaches start or become worse after she begins using D MPA and these headaches involve blurred vision, temporary loss of vision, seeing flashing lights or zigzag lines, or trouble speaking or moving. • Refer for care as appropriate. FOUOWlNGUPo,DMPA 7-~ Comparing DMPA and NET EN Characteristic DMPA I NET EN Time between 3 months • 2 months injections Latest that client 2 weeks 2 weeks can return for next injection without need to check for pregnancy Injection Deep intramuscular Deep intramuscular technique injection into the deltoid injection into the (upper arm muscle). deltoid (upper arm) Gluteal (buttock) muscle or gluteal (buttock) also okay. muscle. May be more painfuL Amenorrhea i 55% of women by end of 30% of women by (no menstrual . first year of use. end of first year of bleeding) use. T ical r yp p egnancy About 0.3 women in eve • About 0.4 women ryl rate if on time for injections Return of fertility (ability to become pregnant again) 100 in first year (1 in every 333). Average delay: 4 months longer than for women who had been using combined oral contraceptives, IUDs, condoms, or a vaginal method. Effect on diabetes Causes some mild glucose (sugar) intolerance but often is used with good results by diabetic women who do not have accompanying vascular disease. 7-1 8 Essentials of Contraceptive Technology in every 100 in first year (1 in every 250). Probably less delay. No effecron glucose tolerance. IMPORTANT POINTS About DMPA 7-19 1. Can a woman who is breastfeeding use DMPA? Yes. While nonhormonal methods are better, DMPA is a reasonable choice for a breastfeeding mother who wants a hormonal method. It can be started as early as 6 weeks after delivery. She is protected from pregnancy without DMPA for the first 6 months after delivery, however, if she is fully or almost fully breastfeeding (at least 85% of the baby's food is breast milk) and her monthly period has not resumed. 2. Should a woman stop using DMPA because she has no menstrual bleeding for a long time (amenorrhea)? No. This is normal. There is no medical reason to stop because of amenorrhea. Reassure her that this is common and not harmful. Absence of bleeding can make some women healthier because it helps to prevent anemia. If amenorrhea bothers her, she can choose another method, however. 3. Can young women, older women, and women without children useDMPA? Yes. DMPA is completely reversible. DMPA is safe for women who have not had children as well as for women who have children. Especially younger women and women without children should understand that it may take time for fertility to return, however-an average of 4 months longer than if she had been using combined oral contraceptives, an IUD, condoms, or a vaginal method. DMPA appears to be safe for women of any age. There is theoretical concern that DMPA might affect bone development in women under age 18. The World Health Organization, however, concludes that the advantages of the method generally outweigh this theoretical disadvantage; in general, young women can use DMPA. 7-20 Essentials of Contraceptive Technology 4. Is it dangerous if a pregnant woman uses DMPA? Usually no. It is best avoided, but the higher level of progestin in the body caused by DMPA is not harmful to the mother or the fetus. One study suggests the baby may be born at lower than normal weight, but this is not proven. 5. Does DMPA cause cancer? No. DMPA has not been shown to cause cancer in humans. Instead, it helps to prevent cancer of the endometrium (lining of the uterus) and perhaps cancer of the ovaries. The World Health Organization (WHO) has declared DMPA safe, but some questions remain about whether DMPA might speed up the development of preexisting breast cancer. Further studies are underway. 6. Has the US government approved DMPA? Yes. In 1992 the United States Food and Drug Administration (USFDA) approved DMPA for use as a contraceptive. The approval took many years because of concerns about animal studies. High doses of DMPA caused cancer in some laboratory animals. WHO studies of women using D MPA found no overall increase in cancer, however. Therefore the USFDA approved DMPA Altogether, more than 100 countries throughout Europe, Asia, Africa, the Near East, and Latin America and the Caribbean have approved DMPA 7. Does DMPA cause abortion? No. A woman who is already pregnant should not use any contraceptives except, if needed, condoms and/or spermicide to help prevent sexually transmitted disease. Nonetheless, there is no known harm to a fetus if DMPA is used during pregnancy. QUESOONS & ANSWERS About DMPA 7-21 Chapter 8 Norplant Implants < «.« <"cvetiiei£e,ii~J.jt<ilp~ ,;:~"c<:f;i<:~L < < «<. «.<'«« < < «< « ;.««~&'n~~<;«<c«««< . ····t$£~j~.'i~~~~,~,yi ;)i(i._1i~;i;I ·····))a~ . ~#~~~·~,··,·'···,· ;~(jil!jl:cl:i~;~ ;i~~.=&~f~i> 8-1 Chapter 8 Norplant Implants Contents = Introduction to Norplant Implants [] Deciding About Norplant Implants . How Do They Work? . . . . . How Effective? . . . . . . . . Advantages and Disadvantages Medical Eligibility Checklist. ~ Starting Norplant Implants . . . . When to Start. . . . . . . . Providing Norplant Implants Explaining How to Use . . . [j] Following Up . . . . . . . . . . . . . . Helping Clients at Any Return Visit . Managing Any Problems . . . . . . n Important Points for the User to Remember t:!1 Questions and Answers. . . . . . . . . . . 8-2 Essentials of Contraceptive Technology .8-3 · 8--4 · 8--4 · 8--4 · 8--4 .8-7 8-10 8-10 8-12 8-14 8-16 8-16 8-17 8-21 8-22 = Introduction to Norplant Implants • The Norplant* implant system is a set of 6 small, plastic capsules. Each capsule is about the size of a small matchstick. The capsules are placed under the skin of a woman's upper arm. • Norplant capsules contain a progestin, similar to a natural hormone that a woman's body makes. It is released very slowly from all 6 capsules. Thus the capsules supply a steady, very low dose. Norplant implants contain no estrogen. • A set of Norplant capsules can prevent pregnancy for at least 5 years. It may prove to be effective longer. Although other implants may be available, this chapter is limited to Norplant implants. " Norplant is the rt:gistered trademark of The Popul4tUm Council for Ievonorgestrel subdermal implants. INTRODUCTION to Norplant Implants 8-3 [] Deciding About Norplant Implants How Do They Work? • Thicken cervical mucus, making it difficult for sperm to pass through. • Stop ovulation (release of eggs from ovaries) in about half of menstrual cycles (after first year of use). They do NOT work by disrupting existing pregnancy. How EHective? Very effective----D.1 pregnancies per 100 women in first year of use (1 in every 1,000). Over 5 years, 1.6 pregnancies per 100 women (1 in every 62). Note: Pregnancy rates have been slightly higher among women weighing more than about 70 kilograms (about 150 Ibs). Over 5 years 2.4 pregnancies per 100 women (1 in every 42) in this heavier group (still a low pregnancy rate). Advantages and Disadvantages ADVANTAGES • Very effective, even in heavier women. • Long-term pregnancy protection but reversible. A single decision can lead to very effective contraception for up to 5 years. • No need to do anything at time of sexual intercourse. • Increased sexual enjoyment because no need to worry about pregnancy. • Nothing to remember. Requires no daily pill-taking or repeated injections. No repeated clinic visits required. • Effective within 24 hours after insertion. • Fertility returns almost immediately after capsules are removed. 8-4 Essentials of Contraceptive Technology • Quantity and quality of breast milk do not seem harmed. Can be used by nursing mothers starting 6 weeks after childbirth. • No estrogen side effects. • Help prevent iron deficiency anemia. • Help prevent ectopic pregnancies. • May help prevent endometrial cancer. • May make sickle cell crises less frequent and less painful. • Insertion involves only minor pain of anesthesia needle. Not painful if anesthetic is given properly. DISADVANTAGES • Common side effects (not signs of sickness): Changes in menstrual bleeding are normal, including: - Light spotting or bleeding between monthly periods (common), - Prolonged bleeding (uncommon, and often decreases after first few months), or - Amenorrhea. (Some women see amenorrhea as an advantage.) Some women have: - Headaches, - Enlargement of ovaries or enlargement of ovarian cysts, - Dizziness, - Breast tenderness andlor discharge, - Nervousness, - Nausea, - Acne or skin rash, - Change in appetite, - Weight gain (a few women lose weight), - Hair loss or more hair growth on the face. Most women do not have any of these side effects, and most side effects go away without treatment within the first year. • Client cannot start or stop use on her own. Capsules must be inserted and removed by a specially trained health care provider. DECIDING About Norplant Implants 8-5 • Minor surgical procedures required to insert and remove capsules. Some women may not want anything inserted in their arms or may be bothered that implants may be seen or felt under the skin. • Discomfort for several hours to 1 day after insertion for some women, perhaps for several days for a few. Removal is sometimes painful and often more difficult than insertion. • In the very rare instances when pregnancy occurs, as many as 1 in every 6 pregnancies is ectopic. • Do not protect against sexually transmitted diseases including HN/AIDS. IMPORTANT: Ask the client if she thinks she might have or ~ get a sexually transmitted disease (STD). (Has more than one . sex panner? Partner has more than one partner? Could this happen in future?) If she has or might get an STD, urge her to use condoms regularly. Give her condoms. She can still use Norplant implants. Using the Medical Eligibility Checklist The list on the next page checks whether the client has any known medical conditions that prevent use of Norplant implants. It is not meant to replace counseling. The questions in the checklist refer to known conditions. Generally, you can learn of these conditions by asking the client. You do not usually have to peiform laboratory tests or physical examinations. IMPORTANT: Norplant implants contain no estrogen. Many of ~ the criteria that restrict use of combined oral contraceptives, . which contain estrogen, do not apply to Norplant implants. 8-6 Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FOR Norplant Implants Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use Norplant implants if she wants. If she answers YES to a question below, follow the instructions. In some cases she can still use Norplant implants. o No 0 yes . She can start using Norplant implants beginning 6 weeks after childbirth. If she is fully or almost fully breastfeeding, however, she is protected from pregnancy for 6 months after childbirth or until her menstrual period returns--whichever comes first. Then she must begin contraception at once to avoid pregnancy. Encourage her to continue breastfeeding. yes . Perform physical exam or refer. If she has serious active liver disease (jaundice, painfol or enlarged liver, viral hepatitis, liver tumor), do not provide Norplant implants. Refer for care. Help her choose a method without hormones. o No 0 yes . Do not provide Norplant implants. Help her choose a method without hormones. (Continued on next page) DECIDING About Norplant Implants 8-7 MEDICAL ELIGIBILITY CHECKLIST FOR NORPLANT (continued) o No 0 yes . If she has unexplained vaginal bleeding that suggests pregnancy or an underlying medical condition, do not provide Norplant implants. Assess and treat any underlying condition, as appropriate, or refer. Help her choose a method without hormones to use until the problem is assessed. Then she can start using Norplant implants. ONo 0 yes . If she is taking phenytoin, carbamezapine, barbiturates, or primidone for seizures or rifompin or griseofolvin, provide condoms or spermicide to use along with Norplant implants. If she prefers, or if she is on long- term treatment, help her choose another effective method. o No Dyes . Assess whether pregnant (see page 4-6). If she might be pregnant, give her condoms or spermicide to use until reasonably sure that she is not pregnant. Then she can start Norplant implants. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable when relevant to the client. 8-8 Essentials of Contraceptive Technology Most Women Can Use Norplant Implants In general, most women CAN use Norplant implants safely and effectively. * Norplant implants can be used in any circumstances by women who: • Are breastfeeding (starting as • Are any age, including soon as 6 weeks after adolescents and over 40, childbirth) , • Smoke cigarettes, • Have no children, • Are fat** or thin, • Have just had abortion or mlscarnage. Also, women with these conditions CAN use Norplant implants in any circumstances: • Benign breast disease, • Headaches, • High blood pressure, • Iron deficiency anemia, • Varicose veins, • Valvular heart disease, • Diabetes, • Malaria, • Sickle cell disease, • Schistosomiasis, • Thyroid disease, • Irregular or painful menstrual periods, • Pelvic inflammatory disease, • Benign ovarian tumors or uterine fibroids, • Endometriosis, • Sexually transmitted diseases, • Epilepsy, • Tuberculosis (unless taking rifampin; see checklist question 6 on page 8-8). *Characteristics and conditions listed in this box are in WHO Eligibility Criteria category 1. Women with characteristics and conditions in WHO category 2 also can use this method. See Appendix, page A-I. **Very fat is WHO category 2. DECIDING About Norplant Implants 8-9 ~ Starting Norplant Implants When to Start Woman's situation When to start Having • Any time it is reasonably certain that she is not menstrual pregnant. (See page 4-6.) cycles (including IMPORTANT: If she is not at risk of pregnancy . switching (for example, has not had sex since last menstrual . from a period), she may start using Norplant at any time nonhormonal she wants. method or • If starting during the first 7 days after menstrual progestin-only bleeding starts. no back-up method is needed for pills) , extra protection. • If she is statting on or after day 8 of her menstrual period, she should use condoms or spermicide or avoid sex for the next 7 days after insertion. If possible, give her condoms or spermicide. When • Immediately. switching fromcom- bined pills or injectables Breastfeeding • As early as 6 weeks after childbirth. • Fully or nearly folly breastfeeding effectively prevents pregnancy for at least 6 months or until she has a menstrual period, whichever comes first (see Chapter 15). Norplant implants can give her extra protection if she wants it. • If only partially breastfeeding and child receives much other food or drink, 6 weeks after childbirth is the best time to start Norplant implants. If she waits longer, fertility may return. 8-10 Essentials of Contraceptive Technology Woman's situation Breastfeeding (continued) After childbirth if not breastfeeding After miscarriage or abortion When to start • If menstrual periods have returned, she can start Norplant implants any time it is reasonably certain that she is not pregnant. (See page 4-6.) See "Having menstrual cycles," page 8-10. • Immediately or at any time in the first 6 weeks after childbirth. No need to wait for her menstrual period to return. • After 6 weeks, any time it is reasonably certain that she is not pregnant. (See page 4-6.) If not reasonably certain, she should avoid sex or use condoms or spermicide until her first period begins and then start Norplant implants. • Immediately or in the first 7 days after either first- or second-trimester miscarriage or abortion. • Later, any time it is reasonably certain that she is not pregnant . • The template (above left) can help providers position Norplant capsules correctly. The provider places the template against a woman's arm and marks the ends of the 6 slots on her skin with a ballpoint pen or similar marker (see photo). When inserting the capsules, the provider lines up each capsule with one of the marks. STARnNG Norplant Implants Providing Norplant Implants IMPORTANT: A woman who chooses Norplant implants benefits . from good counseling. ~ A friendly provider who listens to a woman's concerns, answers her questions, and gives dear, practical information about side effects, especially probable bleeding changes, will help the woman use Norplant implants with success and satisfaction. IMPORTANT: All women who choose Norplant implants must have . convenient access to removal whenever they want it. All family planning ~ programs that o£Ier Norplant implants must have qualified staff to remove them, or they must set up referral arrangements for removals. All staff must understand and agree that any woman can have her implants removed whenever she wants. Women must not be forced or pressured to continue using Norplant implants. INSERTING NOR PLANT CAPSULES Learning Norplant implant insertion requires training and practice under direct supervision. Therefore the following description is a summary and not detailed instructions. All family planning providers should be able to tell their clients about insertion of Norplant implants. 1. The provider uses proper infection-prevention procedures. 2. The woman receives an injection of local anesmecic under the skin to prevent pain in her arm. She stays fully awake throughout the procedure. 3. The health care provider makes a small incision in the skin on the inside of the upper arm. The provider inserts the capsules just under the skin. This makes the capsules easier to remove later. 4. After all 6 capsules are inserted, the health care provider closes the incision with an adhesive bandage. Stitches are not needed. The incision is covered with a dry clom and wrapped with gauze. Insertion takes about 10 minutes. Bruising or slight bleeding at the insertion site is normal and common during the first few days after insertion. 8-12 Essentials of Contraceptive Technology Explaining How to Use GIVE SPECIFIC INSTRUCTIONS A woman who has Norplant capsules inserted should: 1. Keep the insertion area dry for 4 days. She can take off the gauze after 2 days and the adhesive bandage after 5 days. 2. Remember that, after the anesthetic wears off, her arm may be sore for a few days. She also may have swelling and bruising at the insertion site. This is not cause for alarm. 3. Return to the clinic or see a nurse or doctor if the capsules come out or if soreness in her arm lasts more than a few days. FOllOW THIS PROCEDURE If possible, give each woman a durable card. The card should state: • Where to go if she has questions or problems. • Date of Norplant implant insertion. • Date when 5 years of Norplant implant use would end. After 5 years she should have the capsules removed. Whether or not you can give her a card, discuss this information with her. Discuss how to remember the date to return, perhaps tying it to the growth of a child or a child's year in schooL GIVE ADVICE ON COMMON PROBLEMS 1. Mention the most common side effects. In particular, she can expect changes in menstrual bleeding, including spotting, bleeding between periods, or amenorrhea. She also may have other side effects. (See page 8-5 for list.) 2. Explain about these side effects: • Some of these changes are common. None of them are harmful. Bleeding changes are normal. They do not mean that she is pregnant or sick or that bad blood is building up inside her. Little or no bleeding can make some women healthier. It helps prevent anemia. 8-14 Essentials of Contraceptive Technology IMPORTANT: Thorough counseling about bleeding changes and other side effects must come before inserting Norplant implants. Often, counseling beforehand and repeated reassurance afterward help women deal with bleeding changes. She should be urged to come back if bleeding changes are bothersome. Bleeding problems can be relieved with medication, or the capsules can be removed if she wishes. (See page 8-17.) EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR Describe the symptoms of serious problems that require medical attention. Serious complications of Norplant implants are rare. Still, a woman should see a doctor or nurse or return to the clinic if she has questions or problems or any of the following possible symptoms of more serious problems. Norplant implants mayor may not cause these problems. • Might be pregnant (for example, missed period after several regular cycles), especially if she also has signs of ectopic pregnancy-abdominal pain or tenderness, or faintness. A woman who develops these signs must seek care at once. (See "Note on ectopic pregnancy," below.) • Severe pain in the lower abdomen, • Infection at the insertion site (pain, heat and redness), pus or abscess, • Very heavy menstrual bleeding (twice as much or twice as long as usual for her), • Very bad headaches that start or become worse after she begins using Norplant implants, • Skin or eyes become unusually yellow. Other specific reasons to return to the clinic or see a health care provider: • Any time that she wants the capsules removed for any reason. • 5 years have passed-time to have the capsules removed. She can get a new set of capsules if she wants. Note on ectopic pregnancy: Pregnancies among users of Norplant implants are very few. Norplant implants offer much protection against pregnancy outside the uterus (ectopic pregnancy), but they still sometimes occur. When pregnancy occurs, 1 pregnancy in every 6 is ectopic. Ectopic pregnancy is life-threatening and requires treatment right away. (See page 12-22.) STARnNG Norplant Implants 8-15 [j] Following Up IMPORTANT: No routine return visit is required until it is time . for the implants to be removed. The dient should be dearly invited ~ to return, however, any time she wants help, advice, information, or to have the implants removed for any reason, whether or not she wants another method. Helping Clients at Any Return Visit ASK QUESTIONS At any return visit: 1. Ask if the client has any questions or anything to discuss. 2. Ask the client about her experience with the method, whether she is satisfied, and whether she has any problems. If she has problems that cannot be resolved, remove the capsules or refer for removal, and help her choose another method. Give her any information or help that she needs and invite her to return any time she has questions or concerns. Remind her how long her implants will keep working. 3. Ask about her bleeding patterns. 4. Ask if she has had any health problems since her last visit. • If the client has developed active liver disease or breast cancer or she is taking medicine for seizures, rifompin, or griseofolvin, see pages 8-7 and 8-8 for instructions. If appropriate, remove the capsules or refer for removal, and help her choose another method. • If the client has developed any of the following conditions, see "Managing Any Problems" (pages 8-17 to 8-20): - Unexplained abnormal vaginal bleeding that suggests pregnancy or an underlying medical condition. - Heart disease due to blocked arteries, stroke, or blood clots (except superficial clots). - Very bad heatUzches. 8-16 Essentials of Contraceptive Technology Managing Any Problems If the client reports any of the common side effects of Norplant implants: 1. Do not dismiss the woman's concerns or take them lightly. 2. If the woman is worried, reassure her that such side effects are not usually dangerous or signs of danger. 3. If the woman is not satisfied after treatment and counseling, ask her if she wants the Norplant capsules removed. If so, remove the capsules or refer for removal even if her problems with the Norplant implants would not harm her health. If she wants a new method, help her choose one. For this problem: Amenorrhea (no monthly bleeding period) Spotting or bleeding between monthly periods over several months that bothers the client Try this suggestion: • Reassure her that amenorrhea is normal among Norplant implant users and not harmful. She is not sterile. She is almost certainly not pregnant. Menstrual blood is not building up inside her. Instead, her body is not producing menstrual blood. This could help prevent anemia. • If the client still finds amenorrhea unacceptable, remove the implants or refer for removal. Help her choose another method. • Reassure her that spotting and bleeding between periods are normal and very common, especially in the first 3 to 6 months. They are not harmful. • If the client finds the bleeding unacceptable offer: - Ibuprofen or other nonsteroidal anti-inflammatory drugs, but NOT aspirin. OR - 1 cycle of low-dose combined oral contraceptives if no condition rules out estrogen. A pill containing an estrogen and the progestin levonorgestrel (the same progestin as in Norplant implants) is best for controlling bleeding. FOLLOWING UP on Norplant Implants 8-17 For this problem: Spotting or bleeding (continued) Very heavy or prolonged bleeding Unexplained abnormal vaginal bleeding that suggests pregnancy or underlying medical condition Try this suggestion: • If spotting or bleeding persists or follows a period of amenorrhea, rule out gynecologic problems when clinically warranted. Be alert for possible ectopic pregnancy. If a gynecologic problem is found, treat or refer. - If pregnant, remove implants or refer for removal. Advise her not to take aspirin. - If pelvic inflammatory disease or sexually transmitted diseases, implants can remain in place. • Rare, but requires attention. • Ifbleeding persists or follows a period of amenorrhea, rule out gynecologic problems when clinically warranted. If a gynecologic problem is found. treat or refer. • If no gynecologic problem explains the bleeding, offer nonsteroidal anti-inflammatory drugs or combined oral contraceptives-same as for treatment of spotting (see above). Pills with 50 micrograms of estrogen may be needed. • Check for anemia. If found, treat or rekr fur care. • Name foods containing iron and suggest that she eat more of them if possible. Note: Uterine evacuation is not necessary unless a medical condition requiring it is suspected. • She can continue using Norplant implants while her condition is being evaluated. • Explain that Norplant implants usually change vaginal bleeding patterns. This is not harmful. • Evaluate and treat any underlying medical problem. or refer for care. 8-18 Essentials of Contraceptive Technology For this problem: Severe pain in lower abdomen Pain after insertion of the capsules Infection at the insertion site (pain, heat and redness) or abscess (pus present) Try this suggestion: • Check for ovarian cysts, twisted ovarian follicles, ovarian tumor, pelvic inflammatory disease, appen- dicitis, ectopic pregnancy, or ruptured liver tumor. • If pain is due to ectopic pregnancy, treat or refer for care. Remove the implants or refer for removal. Help her choose another method. • If pain is due to ovarian cysts, implants can remain in place. Reassure the client that these cysts usually disappear on their own without surgery. To be sure the problem is resolving, see the client again in about 3 weeks if possible. • If pain is due to other problems: Implants can remain in place. Treat or refer for care. • Advise her to: - Make sure the bandage on her arm is not too tight. - Put a new bandage on the arm. - Avoid pressing on the implants for a few days and never press on the implants if tender. • Give aspirin or another nonsteroidal anti- inflammatory drug. Infection but no abscess? • Do not remove the implants. • Clean the infected area with soap and water or antiseptic. • Give an oral antibiotic for 7 days and ask the client to return in one week. Then, if no better, remove the implants or refer for removal. FOLLOWING UP on Norplant Implants 8-19 For this problem: Infection at the insertion site (continued) Heart disease due to blocked arteries (ischemic heart disease), stroke, or blood clots (except superficial clots) Very bad headaches (migraines) with blurred VISIon Try this suggestion: Abscess? • Prepare the infected area with antiseptic, make an incision, and drain the pus. • Remove the implants or refer for removal. • Treat the wound. • If significant skin infection is involved, give oral antibiotic for 7 days. • A woman who has this condition can safely start using Norplant implants. If, however, the condition develops after she starts Norplant implants, the capsules should be removed. Help her choose a method without hormones. • Refer for care as appropriate. • A woman who gets migraine headaches can safely start using Norplant implants. She should switch to a method without hormones, however, if these headaches start or become worse after she begins using Norplant implants and these headaches involve blurred vision, temporary loss of vision, seeing flashing lights or zigzag lines, or trouble speaking or moving. • Refer for care as appropriate. IMPORTANT: When a woman seeks help, make sure you understand ~ what she wants. After counseling and discussion, ask her directly ~ whether she wants to continue Norplant or to have the capsules removed. Help her make her own decision without pressure. If you do not find out and heed her true wishes, people may say that you forced her to continue using implants or that you refused to remove the capsules. To avoid such rumors, find out what your client wants, and do it. 8-20 Essentials of Contraceptive Technology IMPORTANT POINTS About Norplant Implants 8-21 1. Can young women, women without children, and older women use Norplant implants? Yes. Women of any age, with or without children, can use Norplant implants. 2. Is it dangerous to have Norplant implants for more than 5 years? Norplant implants themselves are not dangerous if left in for more than 5 years. Leaving them in is not recommended, however, unless the woman wants to avoid removal and has either no need for contraception or chooses sterilization. Norplant implants become less effective after 5 years, and the risk of pregnancy, including ectopic pregnancy, may rise unless a woman uses another effective method. 3. If a woman becomes pregnant with Norplant implants in place, should she have them removed? This is recommended if she continues the pregnancy, although there are no known risks for the fetus. 4. Do Norplant implants cause cancer? No. The implants do not cause cancer. Instead, they may help to prevent endometrial cancer (cancer of the lining of the uterus). 5. Can a woman using Norplant implants have ovarian cysts? Yes. The great majority of cysts disappear on their own without surgery. If a health care provider finds an ovarian cyst, he or she should reexamine the woman again in about 3 weeks to make sure it is shrinking. 6. Must a woman have a pelvic examination before she can use Norplant implants? No. If a woman has symptoms of reproductive tract conditions, a pelvic exam may help diagnose them. The exam does not help decide about Norplant use, however. 8-22 Essentials of Contraceptive Technology 7. Must women using Norplant implants return often for follow-up? No. Periodic visits are not necessary. Annual visits may be helpful for other preventive care, but they are not required for a woman to use Norplant implants. Of course, a woman is welcome to return whenever she wants to ask questions or has problems. 8. "What if a woman decides she wants to have her capsules removed before 5 years? This is what a woman can expect if she asks to have her capsules removed before 5 years: • To be asked courteously why she wants the capsules removed. • To have her questions and concerns answered clearly and accurately. • To be reassured if her problems are not serious. • Never to feel pressured, threatened, or shamed for wanting to stop using Norplant implants. • After counseling, to be asked clearly, "Do you want to keep the capsules or to have them removed?" • If she wants them removed-no matter what her reason-for the health care provider to remove the capsules immediately or to arrange for their prompt removal. 9. Should heavy women avoid Norplant implants? No. Studies found that women weighing more than 70 kilograms were somewhat more likely to get pregnant than women weighing less, but Norplant implants were still very effective for these women. 10. Can implants break or move around within a woman's body? No. The capsules are flexible and cannot break under the woman's skin. They remain where they are inserted until they are removed. QUESTIONS & ANSWERS About Norplant Implants 8-23 11. Can a woman work immediately after insertion? Yes. She can do her usual work immediately after leaving the clinic as long as she does not bump the insenion site or get it wet. She should keep the insertion site dry and clean for at least 48 hours. After healing (usually 3 to 5 days), the area can be touched and washed with normal pressure. 12. Isn't there a version of Norplant implants with just 2 rods instead of 6 capsules? This version, sometimes called Norplant If, is being studied in clinical trials. It is not yet available for general use. A I-capsule implant system also is being studied. It uses the progestin desogestrel. One- or 2-capsule implants would greatly simplify insenion and removal. 8-24 Essentials of Contraceptive Technology Chapter 9 Female Sterilization 9-1 Chapter 9 Female Sterilization Contents = Introduction to Female Sterilization . 9-3 [] Deciding About Female Sterilization . 9-4 How Does It Work? . . . . . . . 9-4 How Effective? . . . . . . . . . 9-4 Advantages and Disadvantages . 9-4 Medical Eligibility Checklist. . . 9-7 ~ Having a Female Sterilization Procedure . . . . . . 9-12 When Can a Woman Undergo Female Sterilization? 9-12 Providing Female Sterilization. 9-13 Explaining Self-Care . 9-16 [j) Following Up . . . . 9-18 Helping Clients at Any Routine Return Visit 9-18 Managing Any Problems . . . . . . . 9-18 H Important Points for the User to Remember 9-19 t:l1 Questions and Answers. . . . . . . . . . . 9-20 9-2 Essentials of Contraceptive Technology = Introduction to Female Sterilization • Female sterilization provides permanent contraception for women who will not want more children. • It is a safe and simple surgical procedure. It can usually be done with just local anesthesia and light sedation. Proper infection-prevention procedures are required (see page 4-10). • The 2 most common approaches are minilaparotomy and laparoscopy. Both are described in this chapter. • Female sterilization also is known as voluntary surgical contraception (VSC), tuballigation (TL), tying the tubes, minilap, and "the operation." See Chapter 1 0 for information about vasectomy, the permanent method of family planning for men. INTRODUCTION to Female Sterilization 9-3 [] Deciding About Female Sterilization How Does It Work? The health care provider makes a small incision in the woman's abdomen and blocks off or cuts the 2 fallopian tubes. These tubes would carry eggs from the ovaries to the uterus. With the tubes blocked, the woman's egg cannot meet the malls sperm. (See drawing, page 9-3.) The woman continues to have menstrual periods. How EHective? Very effective and permanent- In the first year after the procedure: 0.5 pregnancies per 100 women (1 in every 200 women). Within 10 years after the procedure: 1.8 pregnancies per 100 women (1 in every 55 women). Effectiveness depends partly on how the tubes are blocked, but all pregnancy rates are low. Postpartum tuballigation is one of the most effective female sterilization techniques. In the first year after the procedure-O.05 pregnancies per 100 women (1 in every 2,000 women). Within 10 years after the procedure- 0.75 pregnancies per 100 women (1 in every 133). Advantages and Disadvantages ADVANTAGES • Very effective. • Permanent. A single procedure leads to lifelong, safe, and very effective family planning. • Nothing to remember, no supplies needed, and no repeated clinic visits required. • No interference with sex. Does not affect a woman's ability to have sex. • Increased sexual enjoyment because no need to worry about pregnancy. • No effect on breast milk. • No known long-term side effects or health risks. 9-4 Essentials of Contraceptive Technology • Minilaparotomy can be perfOrmed just after a woman gives birth. (Best if the woman has decided before she goes into labor.) • Helps protect against ovarian cancer. DISADVANTAGES • Usually painful at first, but pain starts to go away after a day or two. • Uncommon complications of surgery: - Infection or bleeding at the incision, - Internal infection or bleeding, - Injury to internal organs. - Anesthesia risk: • With local anesthesia alone or with sedation, rare risks of allergic reaction or overdose. • With general anesthesia, occasional delayed recovery and side effects. Complications are more severe than with local anesthesia. Risk of overdose. • Very rarely, death due to anesthesia overdose or other complication. • In rare cases when pregnancy occurs, it is more likely to be ectopic than in a woman who used no contraception. • Requires physical examination and minor surgery by a specially trained provider. • Compared with vasectomy, female sterilization is: - Slightly more risky. - Often more expensive, if there is a fee. • Reversal surgery is difficult, expensive, and not available in most areas. Successful reversal is not: guaranteed Women who may want to become pregnant in the future should choose a different method. • No protection against sexually transmitted diseases (STDs) including HNIAIDS. IMPORTANT: Ask the client if she might have or get a sexually .1IIIIIIII transmitted disease (STD). (Has more than one sex panner? """1IIIIIIII Panner has more than one panner? Could this happen in future?) If she has or might get an STD, urge her to use condoms regularly. Give her condoms. She can still use female sterilization. DECIDING About Female Sterilization 9-5 Using the Medical Eligibility Checklist The list on pages 9-7 to 9-10 checks whether the client has any known medical conditions that limit when, where, or how female sterilization should be performed. The checklist should be used after your client has decided that she will not want any more children, and she has chosen female sterilization. It is not meant to replace counseling. The questions in the checklist refer to known conditions. Generally, you can learn of these conditions by asking the client. .Vim do not usually have to perform special laboratory tests to rule out these conditions . . No medical condition prevents a woman from using sterilization. Some conditions and circumstances call for delay, referral, or caution, however. These conditions are noted in the checklist. DELAY means delay female sterilization. These conditions must be treated and resolved before female sterilization can be done. Temporary methods should be provided. REFER means refer client to a center where an experienced surgeon and staff can perform the procedure in a setting equipped for general anesthesia and other medical support. Temporary methods should be provided. (Called "special" conditions by WHO.) CAUTION means the procedure can be performed in a routine setting but with extra preparation and precautions, depending on the condition. . If no conditions require delay or referral, female sterilization can be performed in these routine settings: Minilaparotomy: In maternity centers and basic health facilities where surgery can be done. These include both permanent and temporary facilities that can refer clients for special care if needed. Laparoscopy requires a better equipped center, where laparoscopy is performed regularly and an anesthetist can be available. 9~ Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FOR Female Sterilization Ask the client the questions below. If she answers NO to All of the questions, then the female sterilization procedure can be performed in a routine setting without delay. If she answers YES to a question below, follow the instructions. o No 0 Yes'" If she has any of the following, DElAY female sterilization and treat if appropriate or refer: • Pregnancy, • Postpartum or after second-trimester abortion (7-42 days), • Serious postpartum or postabonion complications (such as infection or hemorrhage) except uterine rupture or perforation (see below), • Unexplained vaginal bleeding that suggests a serious condition, • Severe preeclampsialeclampsia, • Pelvic inflammatory disease (PID) within past 3 months, • Current sexually transmitted disease (STD), • Pelvic cancers (treatment may make her sterile in any case), • Malignant trophoblast disease . . If she has any of the following, REFER her to a center with experienced staff and equipment that can handle potential problems: • Fixed uterus due to previous surgery or infection, • Endometriosis, • Hernia (umbilical or abdominal wall), • Postpartum uterine rupture or perforation or postabortion uterine perforation. (Continued on next page) DECIDING About female Sterilization 9-7 MEDICAL EUGlBIUTY CHECKUST FOR

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