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 FEMALE STERlUZA110N (continued) ~ If she has any of the following, use CAUTION: • Past PID since last pregnancy, • Current breast cancer, • Uterine fibroids. ONo 0 Yes ~ If she has the following, DELAY female sterilization: • Acute heart disease due to blocked arteries, • Deep vein thrombosis or pulmonary embolism. '---.::I ~ If she has any of the following, REFER her to a center with experienced staff and equipment that can handle potential problems: • Moderate or severe high blood pressure (160/100 mm or higher), • Vascular disease, including diabetes-related, • Complicated valvular heart disease. ~ If she has any of the following, use CAUTION: • Mild high blood pressure (140/90 mm-159/99 mm), • History of high blood pressure where blood pressure can be evaluated, or adequately controlled high blood pressure where blood pressure cannot be evaluated, • Past stroke or heart disease due to blocked arteries, • Valvular heart disease without complications. 9-8 Essentials of Contraceptive Technology MEDICAL EUGIBIUTY CHECKUST FOR FEMALE STERIUZATION (continued) No D Yes ~ If she has any of the following, DELAY female sterilization: • Gallbladder disease with symptoms, • Active viral hepatitis, • Severe iron deficiency anemia (hemoglobin less than 7 gldl), • Acute lung disease (bronchitis or pneumonia), • Systemic infection or significant gastroenteritis, • Abdominal skin infection, • Abdominal surgery for emergency or infection at time sterilization is desired, or major surgery with prolonged immobilization, • Current AIDS-related acute illness. ~ If she has any of the following, REFER her to a center with experienced staff and equipment that can handle potential problems: • Severe cirrhosis of the liver, • Diabetes for more than 20 years, • Hyperthyroid, • Coagulation disorders (blood does not clot), • Chronic lung disease, • Pelvic tuberculosis, • Schistosomiasis with severe liver fibrosis. (Continued on next page) DECIDING About Female Sterilization 9-9 MEDICAL EUGIBIUTY CHECKUST FOR FEMALE STERIUZAOON (continued) . If she has any of the following, use CAUTION: • Epilepsy or taking medicine for seizures (phenytoin, carbamezapine, barbiturates, primidone), • Taking the antibiotics rifampin or griseofulvin, • Diabetes without vascular disease, • Hypothyroid, • Mild cirrhosis of the liver, liver tumors, or schistosomiasis with liver fibrosis (Are her eyes or skin unusually yellow?), • Moderate iron deficiency anemia (hemoglobin 7-10 gldl), • Sickle cell disease, • Inherited anemia, • Kidney disease, • Diaphragmatic hernia, • Severe lack of nutrition (Is she extremely thin?), • Obese (Is she extremely overweight?), • Elective abdominal surgery at time sterilization is desired, • Young age. 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. 9-10 Essentials of Contraceptive Technology Most Women Can Have Sterilization In general, most women who want sterilization CAN have safe and effective procedures in routine settings. * With proper counseling and informed consent, sterilization can be used in any circumstances by women who: • Have no children (with • Just gave birth (within proper counseling and 7 days), informed consent), • AIe breastfeeding. Also, women with these conditions CAN have sterilization in a routine setting in any circumstances: • Mild preedampsia, • HIV-positive or high • Past ectopic pregnancy, • Benign ovarian tumors, • Irregular or heavy vaginal bleeding patterns, painful menstruation, • Vaginitis without purulent cervicitis, • Varicose veins, risk of HIV or other STD infection, • Uncomplicated schistosomiasis, • Malaria, • Tuberculosis (nonpelvic), • Cesarean delivery (surgical delivery) at same time. *Characteristics and conditions listed in this box are in the WHO "Accept" category. See Appendix, page A-I. DECIDING About Female Sterilization 9-11 ~ Having a Female Sterilization I.IIi Procedure IMPORTANT: A woman who is considering female sterilization . needs good counseling. ~ A friendly provider who listens to a woman's concerns, answers her questions, and gives clear, practical information about the procedure, especially its permanence, will help the woman to make an informed choice and to be a successful and satisfied user. Careful counseling can help make sure that she will not be sorry later. (See page 9/10-2.) In counseling, the provider must cover all 6 points of informed consent (see page 9110-1). In some programs the client and the provider must sign a written consent form. The decision about female sterilization belongs to the woman hersel£ Generally, if a woman is married, it is best if she and her husband agree on sterilization. Her decision cannot be made for her, however, by her husband, a health care provider, a family member, or anyone else. Family planning providers have a duty to make sure that a woman's decision for or against female sterilization is not pressured or forced by anyone. Providers can and should help a woman think through her decision. If she decides against female sterilization, providers must accept and respect that decision. At the same time, they should not set up hard-and-fast rules that deny sterilization to some women who request it-for example, rules that they must be married or must have a certain number of children or must have reached a certain age. When Can a Woman Undergo Female Sterilization? A woman can have a female sterilization procedure almost any time that: • She decides that she will never want any more children or, if she has none, that she will never want any, and • It is reasonably certain that she is not pregnant. (See page 4-6.) 9-12 Essentials of Contraceptive Technology These times can include: • Immediately after childbirth or within 7 days (minilaparotomy procedure only), if she has made a voluntary, informed choice in advance; • 6 weeks or more after childbirth; or • Immediately after abortion (within 48 hours), if she has decided voluntarily in advance; and • Any other time, but NOT between 7 days and 6 weeks postpartum. Providing Female Sterilization Learning to perform female sterilization takes training and practice under direct supervision. Therefore this description is a summary and not detailed instructions. All family planning providers should understand these procedures and be able to discuss them with clients, both women and men. THE MINILAPAROTOMY PROCEDURE This is a description of the interval procedure, used more than 6 weeks after childbirth. The postpartum procedure, used less than 7 days after childbirth, is slightly different. 1. The provider uses proper infection-prevention procedures. 2. The provider asks questions about the woman's past and current health and performs a physical examination and a pelvic examination. This step is to make sure that the surgery is done safely. 3. The woman usually receives light sedation (through pills or intravenous tube) to relax her. Local anesthetic is injected in her abdomen just above the pubic hair line. She stays awake. A small incision (2 cm-5 cm) is made in the anesthetized area. This usually causes little pain. 4. The uterus is raised and turned with an instrument (uterine elevator) to bring each of the 2 fallopian tubes under the incision. This may cause discomfort. HAVING a Female Sterilization Procedure 9-13 5. Each tube is tied and cut, or else closed with a clip or ring. 6. The incision is closed with stitches and covered with adhesive bandages. 7. The woman receives instructions on what to do after she leaves the clinic or hospital (see page 9-16). She usually can leave in a few hours. THE LAPAROSCOPY PROCEDURE 1. The provider uses proper infection-prevention procedures. 2. The provider asks questions about the woman's past and current health and performs a physical examination and a pelvic examination. This step is to make sure that the surgery is done safely. 3. The woman usually receives light sedation (through pills or intravenous tube) to relax her. Local anesthetic is injected just under the woman's naveL She stays awake. The doctor places a special needle into the woman's abdomen and, through the needle, inflates the abdomen with gas or air. This raises the wall of the abdomen away from the organs inside. 4. The doctor makes a small incision (about 2 cm) just under the woman's navel and inserts a laparoscope. A laparoscope is a special long, thin tube containing lenses. Through the lenses the doctor can see inside the body and find the 2 fallopian tubes. 5. The doctor inserts an instrument through the laparoscope (or, less commonly, through a second incision) to close off the tubes. Each tube is closed with a clip, a ring, or by electrocoagulation (electric current that burns and blocks the tube). 6. After the tubes are closed, the instrument and laparoscope are removed. The gas or air is let out of the woman's abdomen. The incision is closed with stitches and covered with adhesive bandages. 7. The woman receives instructions on what to do after she leaves the clinic or hospital (see page 9-16). She usually can leave in a few hours. 9-14 Essentials of Contraceptive Technology Minilaparotomy for female sterilization involves a small incision just above the pubic hair. Laparoscopy for female sterilization usually involves 1 small incision just below the navel LOCAL ANESTHESIA Is BEST FOR FEMALE STERILIZATION Local anesthesia, used with or without mild sedation, is best. • Safer than general, spinal, or epidural anesthesia. • Lets the woman leave the clinic or hospital sooner. Health care providers am explain to a woman ahead of time that being awake during the procedure is safer for her. During the procedure providers talk with the woman and help to reassure her if needed. Many different anesthetics and sedatives are used. Dosage of anesthetic must be adjusted to body weight. General anesthesia may be needed in some cases. See "Medical Eligibility Checklist," pages 9-7 to 9-10, for medical conditions requiring referral to a center that can provide general anesthesia. HAVING a Female Sterilization Procedure 9-15 Explaining Self-Care for Minilaparotomy or Laparoscopy BEFORE THE PROCEDURE THE WOMAN SHOULD: • Not eat or drink anything for 8 hours before surgery; • Not take any medication for 24 hours before surgery (unless the doctor performing the procedure tells her to do so); • Bathe thoroughly the night before the procedure, especially her belly, genital area, and upper legs; • Wear clean, loose-fitting clothing to the health facility if possible; • Not wear nail polish or jewelry to the health facility; and • If possible, bring a friend or relative to help her go home afterwards. AFTER THE PROCEDURE THE WOMAN SHOULD: • Rest for 2 or 3 days and avoid heavy lifting for a week; • Keep the incision dean and dry for 2 or 3 days; • Be careful not to rub or irritate the incision for 1 week; • Take paracetamol (Tylenol, acetaminophen, Panadol) or another safe, locally available pain-relief medicine as needed. Stronger pain reliever is rarely needed. She should not take aspirin or ibuprofen, which slow blood dotting. • Not have sex for at least 1 week. If pain lasts more than 1 week, do not have sex until all pain is gone. EXPlAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR A woman should return to the clinic for any of these reasons: • For a follow-up visit, if possible, within 7 days or at least within 2 weeks and to have stitches removed, if necessary. Follow-up also can be done at home or at another health center. • She has questions or problems of any kind. 9-16 Essentials of Contraceptive Technology • Return at once if: - High fever (greater than 38°C) in the first 4 weeks and especially in the first week, or - Pus or bleeding from the wound, or - Pain, heat, swelling, or redness of the wound that becomes worse or does not stop (signs ofinfection), or - Abdominal pain, cramping, or tenderness that becomes worse or does not stop, or - Diarrhea, or - Fainting or extreme dizziness. If the clinic cannot be reached quickly, she should go to another doctor or nurse at once. • She thinks she might be pregnant. First symptoms of pregnancy are: - Missed period, - Nausea, and - Breast tenderness. She should come to the clinic at once if she also has signs of possible ectopic pregnancy: - Lower abdominal pain or tenderness on one side, - Abnormal or unusual vaginal bleeding, or - Faintness (indicating shock). Note on ectopic pregnancy: Pregnancies among users of voluntary sterilization are few. But when pregnancy occurs, it is more likely to be ectopic than the average pregnancy. Ectopic pregnancy is life-threatening. It requires immediate treatment. (See page 12-22.) HAVING a Female Sterilization Procedure 9-17 [jJ Following Up Helping Clients at Any Routine Return Visit IMPORTANT: Follow-up within 7 days or at least within 2 weeks is . strongly recommended. A health worker checks the site of the ~ incision, looks for any signs of complications, and removes any stitches. This can be done in the clinic, in the client's home (by a specially trained paramedical worker, for example), or at any other health center. No woman should be denied sterilization, however, because follow-up would not be possible. ASK QUESTIONS Ask if the client has any questions or anything to discuss and if she is satisfied. Give her any information or help that she needs and invite her to return any rime she has questions or problems. Managing Any Problems During recovery and healing, if a woman experiences strong pain, heat, swelling, or redness at or around the incision, she should come back to the clinic. If this happens, a health care provider should check for infection or abscess. For this problem: Infection (pus, heat, pain, or redness caused by bacteria or other genns) Abscess Ca pocket of pus under the skin caused by infection) Provide this treatment: 1. Clean site with soap and water or antiseptic. 2. Give oral antibiotics for 7 to 10 days. 1. Clean site with antiseptic. 2. Incise and drain the abscess. 3. Perform wound care. 4. If significant skin infection involved, give oral antibiotics for 7 to 10 days. 9-1 8 Essentials of Contraceptive Technology IMPORTANT POINTS About Female Sterilization 9-19 1. Will sterilization change a woman's monthly periods or make menstrual bleeding stop? No. Most studies find no major changes in bleeding patterns after female sterilization. A woman's menstrual bleeding pattern may change, however, if she was using a hormonal method or IUD before sterilization. Also, a woman's menstrual period usually becomes less regular as she gets older. 2. Will sterilization make a woman lose her sexual ability? Will it make her weak and fat? No. After sterilization a woman will look and feel the same as before. She can have sex the same as before. She may find that sex is better since she does not have to worry about getting pregnant. She will be as strong as before. 3. Will the female sterilization procedure hurt? Women receive local anesthetic to stop pain, and most women remain awake. There is often some minor pain. A woman can feel the health care provider moving her uterus and tubes. This can be uncomfortable. Laparoscopy may hurt less than mini- laparotomy. If a trained anesthetist or anesthesiologist and suitable equipment are available, general anesthesia may be chosen for women who are very frightened of pain. Postpartum minilaparotomy (just after delivery) requires less moving of the uterus. Therefore it may hurt less and is quicker than procedures at other times. A woman may feel sore and weak for several days or even a few weeks after surgery, but she will soon regain her strength. 9-20 Essentials of Contraceptive Technology 4. Isn't it easier for the woman and the health care provider to use general anesthesia? 'Why use local anesthesia? Local anesthesia is safer. General anesthesia is more dangerous than the sterilization procedure itself After general anesthesia, women usually feel nauseous. This does not happen after local anesthesia. Proper use of local anesthesia removes the single greatest source of risk in female sterilization procedures. When using local anesthesia, however, providers must take care not to overdose with the sedative. They also must handle the woman gently and talk with her throughout the procedure. This helps her to stay calm. Sedatives can be avoided in many clients, especially with good counseling and a skilled provider. 5. Will female sterilization stop working after a time? Does a woman who had a sterilization procedure ever have to worry about getting pregnant again? Generally, no. Female sterilization should be considered perma- nent. Failure rates are probably higher than previously thought, however. A major new US study found that the risk of preg- nancy within 10 years after sterilization is about 1.8 per 100 women-about 1 in every 55 women. The risk of sterilization failure is greater for younger women because they are more fertile than older women. Also, some methods of blocking the tubes work better than others. Methods that cut away part of each tube work better than spring clips or bipolar electrocoagu- lation (electric current). Effectiveness also depends on the skill of the provider. The same US study found that 1 of every 3 pregnancies after sterilization was ectopic. If a woman who has had sterilization ever thinks that she is pregnant or has an ectopic pregnancy, she should seek help right away. QUES'rIONS & ANSWERS About Female Sterilization 9-21 6. Pregnancy after female sterilization is rare, but why does it happen at all? The most common reason is that the woman was already pregnant at the time of sterilization. Pregnancy also can occur if the provider confused another structure in the body with the fullopian tubes and blocked or cut the wrong place. In other cases pregnancy results because clips on the tubes come open, because the ends of the tubes grow back together, or because abnormal openings develop in the tube, allowing sperm and egg to meet. 7. Can a woman have her sterilization reversed? Surgery to reverse sterilization is possible only for some women- those who have enough tube left. Even among these women, reversal surgery does not always lead to pregnancy. The procedure is difficult, expensive, and hard to find. When pregnancy occurs, the risk of ectopic pregnancy is increased. Sterilization should be considered permanent. People who may want more children should choose a different family planning method. 8. Is it better for the man to have a vasectomy or for the woman to have female sterilization? Each couple must decide for themselves which method is best for them. Both are very effective, safe, permanent methods for couples who know that they will not want more children. Vasectomy is simpler and safer to perform. It is less expensive and slightly more effective (after the first 20 ejaculations or first 3 months). Ideally, a couple should consider both methods. Ifboth are acceptable to the couple, vasectomy would be preferred for medical reasons. 9. Should sterilization be offered only to women who have had a certain number of children or who have reached a certain age? No. Health care providers must not limit access to female sterili- zation because of rigid rules about a woman's age, the number of children she has, or the age of her last child. Each woman must be allowed to decide for herself whether she will want no more children and whether or not to have sterilization. 9-22 Essentials of Contraceptive Technology An important counseling task is to help a woman think through her decision clearly and fully. For example, family planning providers can help her think about possible life changes (such as a change of partner or loss of existing children) and how these changes would affect her decision. (See page 9/10-2.) 10. How can health care providers help a woman decide about female sterilization? • Provide clear, balanced information about female sterilization and other family planning methods. • Discuss thoroughly her feelings about having children and ending her fertility. • If possible, arrange for her to talk with women who have already had female ster~tion. • Review the 6 key points of informed consent to be sure the woman understands the sterilization procedure. (See page 9110-1.) 11. How can health care providers who do not perform sterilization procedures help women get them? • Learn where female sterilizations are performed in the area and set up a referral system. • Find training to perform female sterilization. For more information about training, contact: - In-country training institutions. - EngenderHea1th (AVSC International), 440 Ninth Avenue, New York, New York 10001, USA - The Johns Hopkins Program for International Education in Reproductive Health OHPIEGO), Browns Wharf, 1615 Thames Street, Suite 200, Baltimore, Maryland 21231, USA - Pathfinder International, 9 Galen Street, Suite 217, Watertown, Massachusetts 02172, USA. QUE5nONS & ANSWERS About Female Sterilization 9-23 The 6 Points of Informed Consent To make an informed choice about sterilization, the client must understand the following points: 1. Temporary contraceptives also are available to the client and her or his partner. 2. Voluntary sterilization is a surgical procedure. 3. There are certain risks in the procedure as well as benefits. (Both risks and benefits must be explained in a way that the client can understand.) 4. If successful, the operation will prevent the client from having any more children. 5. The procedure is considered permanent and probably cannot be reversed. 6. The client can decide against the procedure at any time before it takes place (without losing rights to other medical, health, or other services or benefits). 9/10-1 Essentials of Contraceptive Technology Because Sterilization Is Permanent A woman or man considering sterilization should think carefully: "Could I want more children in the future?" Health care providers can help the client think about this question and make an informed choice. If the answer is "Yes, I could want more children," another family planning method would be better. ~ Questions can help. The provider might ask: • "Do you want to have any more children in the future?" • "If not, do you think you could change your mind later? What might change your mind? Suppose one of your children died? Suppose you lost your spouse, and you married again?" • "Have you discussed sterilization with your spouse?" • "Does your spouse want more children in the futurd" • "Do you think your spouse might change his or her mind later?" Clients who cannot answer these questions may need encourage- ment to think further about their decisions on sterilization. ~ Take special care: In general, people most likely to regret sterilization have these characteristics: • Young, • Few or no children, • Have not talked with spouse about sterilization, • Spouse opposes sterilization, • Not married, • Having marriage problems. Also, for a woman, just after delivery or abortion is a convenient and safe time for voluntary sterilization, but women sterilized at this time are more likely to regret it later. Thorough counseling during pregnancy and the woman's decision btfore labor and delivery help avoid regrets. ~ The choice belongs to the client. None of these characteristics rules out sterilization. Sterilization should not be denied to people with these characteristics. Rather, health care providers should make especially sure that people with these characteristics make informed, careful choices. IMPORTANT INFORMADON About Sterilization 9/10-2 Chapter 10 Vasectomy 10-1 Chapter 10 Vasectomy Contents = Introduction to Vasectomy . r-1 Deciding About Vasectomy . How Does It Work? . . How Effective? . . . . Advantages and Disadvantages Medical Eligibility Checklist. . ~ Having a Vasectomy . . . . . . . . . . . . When Can a Man Have a Vasectomy? . Providing Vasectomy Explaining Self-Care [i) Following Up . . Helping Clients at Any Routine Return Visit Managing Any Problems . . . . . . . H Important Points for the User to Remember t:!l Questions and Answers. . . . . . . . . . . 10-2 Essentials of Contraceptive Technology 10-3 10-4 10-4 10-4 10-4 10-8 10-10 10-11 10-11 10-12 10-14 10-14 10-14 10-16 10-17 = Introduction to Vasectomy • Vasectomy provides permanent contraception for men who decide they will not want more children. • It is a safe, simple, and quick surgical procedure. It can be done in a clinic or office with proper infection-prevention procedures (see page 4-10). • It is not castration, it does not affect the testes, and it does not affect sexual ability. • Also called male sterilization and male surgical contraception. See Chapter 9 for information about female sterilIzation, the permanent method of family planning for women. Bladder -I~'" Penis INTRODucnON to Vasectomy 10-3 [] Deciding About Vasectomy How Does It Work? The health care provider makes a small opening in the man's scrotum (the sac of skin that holds his testicles) and closes off both tubes that carry sperm from his testicles. (See drawing, page 10-3.) This keeps sperm out of his semen. The man still can have erections and ejaculate semen. His semen no longer makes a woman pregnant, however, because it has no sperm in it. How EHective? ~ry effective and permanent as commonly used-O.15 pregnancies per 100 men in the first year after the procedure (about 1 in every 700). Even a bit more effective when used correctly. Correct use means using condoms or another effective family planning method consistently for at least the first 20 ejaculations or for 3 months after the procedure-whichever comes first. Ifhe wants, a man can have his semen checked to be sure that the vasectomy is effective. He can do this at any time after 3 months following the procedure or after 20 ejaculations. If no sperm are found in his semen, he can be sure his vasectomy is working. A semen examination is not necessary, however. Advantages and Disadvantages ADVANTAGES • Very effective. • Permanent. A single, quick procedure leads to lifelong, safe, and very effective family planning. 10-4 Essentials of Contraceptive Technology • Nothing to remember except to use condoms or another effective method for at least the first 20 ejaculations or the first 3 months, whichever comes first. • No interference with sex. Does not affect a man's ability to have sex. • Increased sexual enjoyment because no need to worry about pregnancy. • No supplies to get, and no repeated clinic visits required. • No apparent long-term health risks. • Compared with voluntary female sterilization, vasectomy is: - Probably slightly more effective, - Slightly safer, - Easier to perform, - If there is a charge, often less expensive, - Able to be tested for effectiveness at any time, - If pregnancy occurs in the man's partner, less likely to be ectopic than a pregnancy in a woman who has been sterilized. DISADVANTAGES • Common minor short-term complications of surgery: - Usually uncomfortable for 2 or 3 days, - Pain in the scrotum, swelling and bruising, - Brief feeling of faintness after the procedure. • Uncommon complications of surgery: - Bleeding or infection at the incision site or inside the incision, - Blood clots in the scrotum. • Requires minor surgery by a specially trained provider. • Not immediately effective. At least the first 20 ejaculations after vasectomy may contain sperm. The couple must use another contraceptive method for at least the first 20 ejaculations or the first 3 months-whichever comes first. DECIDING About Vasectomy 10-5 • Reversal surgery is difficult, expensive, and not available in most areas of the world. Success cannot be guaranteed. Men who may want to have more children in the future should choose a different method. • No protection against sexually transmitted diseases (STDs) including HIV/AIDS. IMPORTANT: Ask the client if he might have or get a sexually . transmitted disease (STD). (Has more than one sex partner? ~ Partner has more than one partner? Could this happen in future?) Ifhe has or might get an STD, urge him to use condoms regularly. Give him condoms. He can still use vasectomy. In a vasectomy procedure the provider makes either 1 or 2 smaU incisions in the scrotum. After the sperm-carrying tubes, or vasa, are cut and tied, the incisions are closed with a few stitches, as shown here, or just with a bandage. The new no-scalpel technique involves a tiny puncture instead of any incisions. (See pages 10-10 and 10-11.) 1 0-6 Essentials of Contraceptive Technology Using the Medical Eligibility Checklist The list on pages 10-8 and 10-9 checks whether the client has any known medical conditions that limit when, where, or how vasectomy should be performed. The checklist should be used after your client has decided that he will not want more children, and he has chosen vasectomy. 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. J0u do not usuaUy have to perform special laboratory tests to rule out these conditions. ~ No medical condition prevents a man from using vaSectomy. Some conditions and circumstances call for delay; referral, or caution, however. The conditions are noted in the checklist. DELAY means delay vasectomy. These conditions must be treated and resolved before vasectomy can be performed. 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, vasectomy can be performed in these routine settings: Almost any health facility, including health care centers, family planning clinics, and the treatment rooms of private doctors. Where other vasectomy services are not available, mobile teams can perform vasectomies and any follow-up examinations in nonmedical facilities or in specially equipped vehicles where basic medications, supplies, instrument:s, and equipment are readily available. DECIDING About Vasectomy 10-7 MEDICAL ELIGIBILITY CHECKLIST FOR Vasectomy Ask the client the questions below. If he answers NO to All of the questions, then the vasectomy procedure can be performed in a routine setting without delay. If he answers YES to a question below, follow the instructions. D No DYes" If he has any of the following, DELAY vasectomy and refer for treatment: • Active sexually transmitted disease (STD), • Inflamed (swollen, tender) tip of the penis, sperm ducts, or testicles, • Scrotal skin infection or a mass in the scrotum . . If he has any of the following, REFER him to a center with experienced staff and equipment that can handle potential problems: • Hernia in the groin. (The provider, if able, can perform vasectomy at the same time as repairing the hernia. If this is not possible, the hernia should be repaired first.) • Undescended testicles-both sides . . If he has any of the following, use CAUTION: • Previous scrotal surgery or injury, • Large varicocele or hydrocele (swollen veins or membranes in the spermatic cord or testes, causing swollen scrotum), • Undescended tesricle-one side only. (Vasectomy is performed only on the normal side. Then if any semen is present in a semen sample after 3 months, the other side must be done, too.) 10-8 Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FCIR VASECTOMY (continued) No 0 Yes'" Ifhe has any of the following, DELAY vasectomy and refer for treatment: • Acute systemic infection or significant gastroenteritis, • Filariasis or elephantiasis . . If he has any of the following, REFER him to a center with experienced staff and equipment that can handle potential problems: • Current AIDS-related illness, • Coagulation disorders (blood fails to clot) . . If he has the following, use CAUTION: • Diabetes. 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. Most Men Can Have Vasectomy Most men who want vasectomy CAN have safe and effective procedures in routine settings. This includes men of any age; who have no children; who have sickle cell disease or hereditary anemia; or who are HN-positive or at high risk ofHN or other STD infection. (Vasectomy does not prevent a man from passing HN and other STDs, however.) DECIDING About Vasectomy 10-9 ~ Having a Vasectomy IMPORTANT: A man considering vasectomy needs good counseling. A friendly provider who listens to a man's concerns, answers his questions, and gives dear, practical information about the procedure, especially its permanence, will help the man make an informed choice and be a successful and satisfied user. Careful counseling can help make sure that he will not be sorry later. (See page 9/10-2.) In counseling, the provider must cover all 6 points of informed consent (see page 9110-1). In some programs the dient and the provider must sign a written informed consent form. Any man should be able to choose vasectomy regardless of his age, whether or not he has children, how many children he has, or whether or not he is married. Generally, if a man is married, it is best if he and his wife agree on sterilization. A man's request for vasectomy should not be rejected, however, just because his wife is against it or because he does not have a partner. New-No-Scalpel Vasectomy The no-scalpel vasectomy is a newer procedure now used in many programs. Differences from conventional procedure: • Uses a small puncture instead of 1 or 2 incisions in the scrotum. • Special anesthesia technique needs only 1 needle puncture instead of 2 or more. Advantages: • Less pain and bruising and shorter recovery time. • May reduce operating time. Both no-scalpel and conventional procedures are quick, safe, and effective. 10-10 Essentials of Contraceptive Technology When Can a Man Have a Vasectomy? Any time he decides that he will never want any more children. Providing Vasectomy Learning to perform vasectomy takes training and practice under direct supervision. Therefore this description is a summary and not detailed instructions. All family planning providers should understand this procedure and be able to discuss it with clients, both men and women. THE VASECTOMY PROCEDURE 1. The provider uses proper infection-prevention procedures at all times (see page 4-10). 2. The man receives injection of local anesthetic in his scrotum to prevent pain. He stays awake throughout the procedure. 3. The health care provider feels the skin of the scrotum to find each tube (vas deferens) inside. The provider makes a tiny incision in the skin with a scalpel or else uses a special sharp surgical instrument to make a puncture (the "no-scalpel" vasectomy technique). 4. The provider lifts each tube out of the incision. Most providers cut each tube and then tie one or both cut ends dosed with thread. Some dose off the tubes with heat or clips. The incision may be sewn shut or just covered with an adhesive bandage. The procedure is over. 5. The man may feel faint briefly after the procedure. If possible, he should rest for 15 to 30 minutes. 6. The man receives instructions on how to care for the wound (see page 10-12). Ifhis wife is not using an effective contraceptive, he receives at least 20 condoms to use until sperm are cleared from his system. He leaves the clinic within a few hours, often in less than 1 hour. HAVING a Vasectomy 10-11 Explaining Self·Care BEFORE THE PROCEDURE THE MAN SHOULD: • Bathe thoroughly, especially the genital area and upper inner thighs, • Wear clean, loose-fitting clothing to the health facility, • Not take any medication for 24 hours before the procedure (unless the health care provider performing the vasectomy tells him to do so). AFTER THE PROCEDURE THE MAN SHOULD: • If possible, put cold compresses on the scrotum for 4 hours to lessen swelling. He will have some discomfort, swelling, and bruising. These should stop in 2 to 3 days. • Rest for 2 days. He should not do any heavy work or vigorous exercise for a few days. • Keep the incision clean and dry for 2 to 3 days. He can use a towel to wipe his body clean but should not soak in water. • Wear snug underwear or pants for 2 to 3 days to help support the scrotum. This will lessen swelling, bleeding, and pain. • Take paracetamol (1Jlenol, acetaminophen, Panadol) or another safe, locally available pain-relief medication as needed. He should not take aspirin or ibuprofen, which slow blood clotting. • Use condoms or another effective family planning method for at least his next 20 ejaculations or 3 months after the procedure--whichever comes first. He can have sex within 2 or 3 days after the procedure if it is not uncomfortable. He can expect his sexual performance to be unchanged. Vasectomy does not affect a man's ability to have sex. (See page 10-17, question 1.) 10-12 Essentials of Contraceptive Technology EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR A man should return to the clinic for any of these reasons: • For a follow-up, if possible, within 7 days or at least within 2 weeks and to have stitches removed, if necessary. Follow-up also can be done at home or at another health center. • His wife misses her menstrual period or thinks that she is pregnant. • He has questions or problems of any kind. • Return at once if he has: - High fever (greater than 38°C) in the first 4 weeks and especially in the first week, or - Bleeding or pus rrom the wound, or - Pain, heat, swelling, or redness at an incision that becomes worse or does not stop (signs of infection). . If the clinic cannot be reached quickly, he should go to another doctor or nurse at once. HAVING a Vasectomy 10-13 [jJ Following Up Helping Clients at Any Routine Return Visit IMPORTANT: Follow-up within 7 days or at least within 2 weeks is .1IIIIIIII strongly recommended. A health worker checks the site of the ~ incision, looks for any signs of complications, and removes any stitches. This can be done in the clinic, in the client's home (by a specially trained paramedical worker, for example), or at any other health center. No man should be denied vasectomy, however, because follow-up would not be possible. A man may want to come back to have his semen examined, if feasible, at least 3 months after the vasectomy. This microscopic examination can make sure his semen contains no sperm, and his vasectomy is working. ASK QUESTIONS At any return visit: 1. Ask if the client has any questions or anything to discuss. 2. Ask the client about his experience with vasectomy, whether he is satisfied, and whether he has any problems. Give him any information or help that he needs, and invite him to return any time he has questions or problems. Managing Any Problems During recovery and healing, if a man experiences strong pain, heat, swelling or redness at or around the incision, he should come back to the clinic. If this happens, a health care provider should check for clots, pus, infection, or abscess. 10-14 Essentials of Contraceptive Technology For this problem: Provide this treatment: Pain Check for blood clots in the scrotum: Infection (pus, heat, pain or redness caused by bacteria or other germs) Abscess (a pocket of pus under the skin caused by infection) Fear of impotence • Small, uninfected blood clots require rest and pain-relief medication such as paracetamol. • Large blood clots may need to be surgically drained. • Infected blood clots require antibiotics and hospitalization. 1. Clean site with soap and water or antiseptic. 2. Give 7- to 10-day course of oral antibiotics. 1. Clean site with antiseptic. 2. Incise and drain the abscess. 3. Perform wound care. 4. If significant skin infection involved, give 7- to 10-day course of oral antibiotics. In counseling before the procedure, the health care provider should assure the client that vasectomy does not physically change sexual desire, functioning, or pleasure. This information can be repeated at any follow-up visit. FOLLOWING UP on Vasectomy 1 0-15 1 0-16 Essentials of Contraceptive Technology 1. Will vasectomy make a man lose his sexual ability? Will it make him weak or fat? No. After vasectomy, a man will look and feel the same as before. He can have sex the same as before. He may find that sex is better since he is free from worry about making his partner pregnant. He can work as hard as before. His erections and ejaculations of semen will be the same. His beard will still grow. His voice will not change. Vasectomy is not castration. Vasectomy does not harm the testicles, which are the organs that produce male hormones. 2. Will the vasectomy stop working after a time? Generally, no. Vasectomy is permanent. In rare cases the tubes grow back together, but this is very unlikely. 3. Can a man have his vasectomy reversed ifhe decides that he wants another child? Surgery to reverse vasectomy is possible. It does not always lead to pregnancy, however. The procedure is difficult, expensive, and hard to find. Vasectomy should be considered permanent. People who may want more children should choose another method. 4. Is it better for the man to have a vasectomy or for the woman to have female sterilization? Each couple must decide for themselves which method is best for them. Both are very effective, safe, permanent methods for couples who know they will not want more children. Vasectomy is simpler and safer to perform. It is less expensive and slightly more effective (after at least the first 20 ejaculations or the first 3 months). Ideally, a couple should conSIder both methods. If both are acceptable to the couple, vasectomy would be preferred for medical reasons. QUEsnONS & ANSWERS About Vasectomy 10-17 5. Does vasectomy increase a mans risk of prostate cancer or heart disease later in life? No. The best evidence is that vasectomy does not increase risks of prostate cancer or heart disease. 6. Should vasectomy be offered only to men who have reached a certain age or have a certain number of children? No. Health care providers must not limit access to vasectomy because of rigid rules about a man's age, the number of children he has, or the age of his last child. Each man must be allowed to decide for himself whether he will want no more children and whether or not to have a vasectomy. An important counseling task is to help a man think through his decision dearly and fully. For example, family planning providers can help him think about possible life changes (such as a change of partner or loss of existing children) and how these changes would affect his decision. (See page 9/10-2.) 7. How can providers help a man decide about vasectomy? • Provide dear, complete information about vasectomy and other family planning methods. • Discuss thoroughly his feelings about having children and ending his fertility. • If possible, arrange for him to talk with men who have already had vasectomies. • Review the 6 key points of informed consent to be sure the man understands what it means to have a vasectomy. (See page 9/10-1.) 8. Is it possible to check to see if a vasectomy is working? Yes. A provider looks in a microscope for sperm in a semen specimen collected either through masturbation or in a condom. If the provider sees no sperm, the vasectomy is working. 1 0-1 8 Essentials of Contraceptive Technology 9. How can health care providers who do not perform vasectomies help men get vasectomies? • Learn where vasectomies are performed in the area and set up a referral system. • Find training to perform vasectomies. For more information about training, contact: - In-country training institutions. - EngenderHealth (AVSC International), 440 Ninth Avenue, New York, New York 10001, USA. - The Johns Hopkins Program for International Education in Reproductive Health OHPIEGO), Browns Wharf, 1615 Thames Street, Suite 200, Baltimore, Maryland 21231, USA. QUES1'IONS & ANSWERS About Vasectomy 10-19 Chapter 11 Condoms ',. • •• :~~~;f~~I'~; •.• ~~~::t.,j'!!i~·;~{' '&:5~~.:ij =e;~~'~2 ····.5~!~~~~~~/t, 11-1 Chapter 11 Condoms Contents = Introduction to Condoms [] Deciding About Condoms . . How Do They Work? . How Effective? . . . . Advantages and Disadvantages Medical Eligibility Checklist . Female Condoms . C Starting Condoms . . . . . Providing Condoms. . Explaining How to Use [iJ Following Up . . . . . . . . . . . . . . . . . Helping Clients at Any Routine Return Visit Managing Any Problems . . . . . . . n Important Points for the User to Remember t:iJ Questions and Answers. . . . . . . . . . . 11-2 Essentials of Contraceptive Technology 11-3 11-4 11-4 11-4 11-5 11-6 11-7 11-8 11-8 11-9 11-12 11-12 11-13 11-15 11-16 ~ Introduction to Condoms • A condom is a sheath, or covering, made to fit over a man's erect penis. • Also called rubbers, sheaths, skins, and prophylactics, and known by many different brand names. Most condoms are made of thin latex rubber. Some condoms are coated with a dry lubricant or with spermicide. Different sizes, shapes, oolors, and textures may be available. • "Female condoms" that are inserted into a woman's vagina are available in some places. (See page 11-7.) INTRODUCTION to Condoms 11-3 ~ Deciding About Condoms How Do They Work? Condoms help prevent both pregnancy and sexually transmitted diseases (STDs). Used correctly, they keep sperm and any disease organisms in semen out of the vagina. Condoms also stop any disease organisms in the vagina from entering the penis. How EHective? IMPORTANT: Must be used correctly every time to be highly ~ effective. Many men do not use condoms correctly or do not use . them every time they have sex. Thus they may risk causing pregnancy, getting STOs, or giving STOs to their partners. Somewhat effective for preventing pregnancy as commonly used- 14 pregnancies per 100 women in the first year of use (1 in every 8). Effective for preventing pregnancy when used correctly every tim~ 3 pregnancies per 100 women in first year of use (1 in every 33). Help prevent sexually transmitted diseases. During sex, condoms are the best protection against catching STDs or giving STDs to a partner. Condoms can stop sexual transmission of many diseases including HNIAIDS, gonorrhea, syphilis, chlamydia, and trichomoniasis. Condoms probably protect somewhat, but not as well, against herpes, genital wart virus (HPV), and other diseases that can cause sores on skin not covered by condoms. In general, studies show that condom users have about two-thirds as much risk of getting gonorrhea, trichomoniasis, or chlamydial infection as people who never use condoms. Condom users have less than half the risk ofHN infection, which leads to AIDS. These studies included some people who used condoms incorrectly or inconsistently, however. People who use condoms correctly every time face even less risk of disease. They can reduce their risk of STDs to a very low level. 11-4 Essentials of Contraceptive Technology Advantages and Disadvantages ADVANTAGES • Prevent STDs, including HNIAIDS, as well as pregnancy, when used correctly with every act of sexual intercourse. • Help protect against conditions caused by STDs-pelvic inflammatory disease, chronic pain, and possibly cervical cancer in women, infertility in both men and women. • Can be used to prevent STD infection during pregnancy. • Can be used soon after childbirth. • Safe. No hormonal side effects. • Help prevent ectopic pregnancies. • Can be stopped at any time. • Offer occasional contraception with no daily upkeep. • Easy to keep on hand in case sex occurs unexpectedly. • Can be used by men of any age. • Can be used without s(~eing a health care provider first. • Usually easy to obtain and sold in many places. • Enable a man to take responsibility for preventing pregnancy and disease. • Increased sexual enjoyment because no need to worry about pregnancy or STDs. • Often help prevent premature ejaculation (help the man last longer during sex). DECIDING About Condoms 11-5 DISADVANTAGES • Latex condoms may cause itching for a few people who are allergic to latex. Also, some people may be allergic to the lubricant on some brands of condoms. • May decrease sensation, making sex less enjoyable for either partner. • Couple must take the time to put the condom on the erect penis before sex. • Supply must be ready even if the woman or man is not expecting to have sex. • Small possibility that condom will slip off or break during sex. • Condoms can weaken if stored too long or in too much heat, sunlight, or humidity, or if used with oil-based lubricants-and then may break during use. • A man's cooperation is needed for a woman to protect herself from pregnancy and disease. • Poor reputation. Many people connect condoms with immoral sex, sex outside marriage, or sex with prostitutes. • May embarrass some people to buy, ask partner to use, put on, take off, or throwaway condoms. MEDICAL ELIGIBILITY CHECKLIST FOR Condoms Only one medical condition prevents use of condoms- severe allergy to latex rubber (severe redness, itching, swelling after condom use). You can learn of this condition by asking the client. You do not have to perform tests or examinations. If the client is at risk of STDs, including HIVI AIDS, he or she may want to keep using condoms despite the allergy. (See page 11-13.) In general, anyone CAN use condoms safely and effectively if not allergic to latex. 11-6 Essentials of Contraceptive Technology Female Condom-New Method for Women • A woman-controlled method to protect against STDs including HN / AIDS and against pregnancy. • A sheath made of thin, transparent, soft plastic. Before sex a woman places the sheath in her vagina. During sex the man's penis goes inside the female condom. Effectiveness similar to male condoms and to other vaginal methods. Pregnancies per 100 women in first year of use: As commonly used-21. Used correctly and consistently-5. Some advantages: Some disadvantages: • Controlled by the woman. • Expensive at this time. • Designed to prevent both STDs and pregnancy. • Only somewhat effective as commonly used. • No medical conditions appear to limit use. • Usually needs partner's okay. • Supply must be on hand. • No apparent side effects; no • Woman must touch her allergic reactions. genitals. How used: Some time before sex, the woman places the closed end of the sheath high in her vagina. The closed end contains a flexible, removable ring to help with insertion. A larger flexible ring around the open end of the sheath stays outside the vagina. • Meant for one-time use. • Can be used with other family planning methods to add STD protection. Where available: As of 1997, public and private sources provide female condoms in the US and many European countries. Research is going on in many places, and the method is being introduced in a number of developing countries. DECIDING About Condoms 11-7 ~ Starting Condoms Providing Condoms IMPORTANT: A person who chooses condoms benefits from good counseling. At the same time, condoms should be made widely available, even where counseling is not possible. A provider who listens to a client's concerns, answers questions, and gives clear, practical information, including how to discuss condom use with one's sex partner, will help the client use condoms with success and satisfaction. FOLLOW THIS PROCEDURE 1. Give each client a 3-month supply of condoms if possible--or more. How often people have sex varies, but 40 condoms probably will last most clients for at least 3 months. Ask clients how many they will need. 2. Give clients spermicides, too, if they want extra protection and spermicides are available. Counsel about spermicide use. (See page 13-10.) EXPLAIN WHY USING A CONDOM EVERY TIME IS IMPORTANT 1. Just one unprotected act of sexual intercourse can lead to pregnancy or sexually transmitted disease (STD). 2. Looking at a person cannot tell you ifhe or she has an STD. A person with an STD, including HNIAIDS, can look perfectly healthy. 3. A person cannot always tell if he or she has an STD, including HN infection. 11-8 Essentials of Contraceptive Technology Explaining How to Use IMPORTANT: Whenever possible, show clients how to put on and take off a condom. Use a modd, a stick, a banana, or 2 fingers to demonstrate putting on the condom. Suggest to a new user that he practice putring on a condom by himself before he next has sex. GIVE SPECIFIC INSTRUCTIONS 1. Put the condom on the erect penis before the penis touches the vagina. • Hold the pack at its edge and open by tearing from a ribbed edge. • Hold the condom so that the rolled rim is facing up, away from the penis. • Pull the foreskin back if the penis is uncircumcised. • Place the condom on the tip of the penis. • Unroll the condom all the way to the base of the penis. The condom should unroll easily. If it does not, it is probably backwards. If more mndoms are available, throw this one away and use a new condom. If this is the only condom available, turn it over and try again. Puffing On a Condom o Hold the condom with the rim away from the body and unroll all the way to base of penis. STARTING Condoms 11-9 2. Any lubricant used should be water-based. Good lubricants include spermicides, glycerine, and specially made products. Water can be used, also. They help keep condoms from tearing during sex. Natural vaginal secretions also act as a lubricant. Do not use lubricants made with oil. Most of them damage condoms. Do NOT use cooking oil, baby oil, coconut oil, mineral oil, petroleum jelly (such as Vaseline®), skin lotions, suntan lotions, cold creams, butter, cocoa butter, or margarine. 3. After ejaculation hold the rim of the condom to the base of the penis so it will not slip off. The man should pull his penis out of the vagina before completely losing his erection. 4. Take off the condom without spilling semen on the vaginal openmg. 5. Throw the condom away in a pit latrine (toilet), burn it, or bury it. Do not leave it where children will find it and play with it. Do not use a condom more than once. Taking OH a Condom Disposing of a Used Condom ., Slip off the condom without spilling semen. Burn the used condom, throw it in the latrine, or bury it. 1 1-10 Essentials of Contraceptive Technology If a condom breaks: • Immediately insert a spermicide into the vagina, if spermicide is available. Also, washing both penis and vagina with soap and water should reduce the risk of STDs and pregnancy. • Some clients may want to use emergency oral contraception to prevent pregnancy. (See pages 5-20 through 5-25.) GIVE TIPS ON CARING FOR CONDOMS 1. Store condoms in a cool, dark place, if possible. Heat, light, and humidity damage condoms. 2. If possible, use lubricated condoms that c;ome in square wrappers and are packaged so that light does not reach them. Lubrication may help prevent tears. 3. Handle condoms carefully. Fingernails and rings can tear them. 4. Do not unroll condoms before use. This may weaken them. Also, an unrolled condom is difficult to put on. 5. Always use a differem condom if the one you have: • Has torn or damaged packaging, • Has a manufacturing date on the package that is more than 5 years past, • Is uneven or changed in color, • Feels brittle, dried out, or very sticky. EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR Urge clients to return or see a doctor or nurse if they or their sex partners: • Have symptoms of STDs such as sores on the genitals, pain when urinating, or a discharge (drip). (See Chapter 16.) • Have an allergic reaction to condoms (itching, rash, irritation). (See page 11-13.) Other specific reasons to return: need more condoms, dissatisfied with condoms for any reason, have any questions or problems. STARTING Condoms 11-11 [iJ Following Up Helping Clients at Any Routine Return Visit ASK QUESTIONS At any return visit: 1. Ask if the c~ient has any questions or anything to discuss. 2. Ask the client about his or her experience with condoms, whether the client is satisfied, and whether the client has any problems. Is the client able to use a condom correctly every time? Also, you can check if the client knows how to use a condom; ask the client to put a condom on a model or a stick. Give any information and advice that the client needs. If the client has problems that cannot be resolved, help the client choose another method. IMPORTANT: Urge clients at risk for STDs including HNIAIDS . to keep using condoms despite any dissatisfaction. Explain that ~ only condoms protect against STDs during sex. 3. If clients are satisfied: - Give them plenty of condoms. - Remind them to return if they or their sex partners have symptoms of STDs, such as sores on the genitals, pain when urinating, or a discharge (drip), or are dissatisfied with condoms. - Give clients spermicide if they want extra protection. Counsel about spermicide use. (See page 13-10.) - Invite them to return again at any time that they have questions or concerns. 1 1-12 Essentials of Contraceptive Technology Managing Any Problems If the client reports any problems with condoms: 1. Do not dismiss the client's concerns or take them lightly. 2. If the client is not satisfied after counseling, help the client think about STD risk (see page 16-5). If the client has or might get an STD, encourage continued condom use. If not, help the client choose another method if he or she wishes. For this problem: Condom or lubricant causes itching or rash on genitals Try this suggestion: 1. Suggest using water as a lubricant (if additional lubricant is desired), 2. If itching continues, clients (and possibly their partm:rs) should be assessed for infection. 3. If there is no infection and allergy to latex seems likely, help the client choose another method unless the client is at risk for STDs. If the clic::nt is using lubricated condoms or condoms with spermicide: 1. Recommend a dry condom or one without spermicide. (Can use water to lubricate.) 2. If the problem continues, help the client choose another method unless the client is at risk for STDs. FOLLOWING UP on Condoms 11-13 For this problem: Condom or lubricant causes itching or rash on genitals (continued) Man cannot maintain an erection while putting on orusmga condom Try this suggestion: IMPORTANT: For clients at risk of STDs including HNIAIDS: Urge continued use of condoms despite discomfort. Explain that the only ways to be reasonably sure of not getting STDsare: • Using condoms every time you have sex, or • Having sex with only one partner who does not have an STD and does not have any other partners, or • Not having sex (abstinence). Note: Plastic condoms and condoms made of purified rubber are becoming available in some places. They may be a good choice for people allergic to latex. • Often due to embarrassment. Discuss how to make condom use more enjoyable and less embarrassing. If the woman puts the condom on for the man, this may make use more enjoyable. Explain that, with experience, most couples are less embarrassed. • Suggest a small amount of water or water-based lubricant on the penis and extra lubricant on the outside. This may increase sensation and help . . mamtam an erectIon. 11-14 Essentials of Contraceptive Technology IMPORTANT INFORMATION About Condoms 11-15 1. Is the condom an effective family planning method? Yes, but only if condoms are used correctly every time the user has sex. As they are commonly used, condoms are only somewhat effective. This is because many users do not use them every time. 2. How effective are condoms at preventing sexually transmitted diseases (STDs)? Condoms can provide excellent protection against STDs, including HIV/AIDS, when used correctly every time a person has sexual intercourse of any kind (vaginal, anal, or oral). Unfortunately, many people use condoms incorrectly or do not use them every time with all partners. The best protections against STDs are either abstinence or else sex only with a faithful and uninfected partner. 3. Can the AIDS virus (HIV) get through a condom? No. Condoms can prevent AIDS and other sexually transmitted diseases. HN is very small, but it cannot pass through an unbroken latex condom. Condoms made from animal intestines may not be as safe, however. Some disease-causing organisms probably can pass through them. 4. Will condoms make a man weak and impotent (unable to have an erection)? Not for most men. Impotence has many causes. Some causes are physical, and some are emotional. A few men may have trouble keeping an erection when using condoms. They may be embarrassed about using condoms. Condoms themselves do not cause impotence, however. In fact, some men find that condoms help them keep an erection longer. 11-16 Essentials of Contraceptive Technology 5. Do condoms make sex less enjoyable? Some people find that they enjoy sex less when using condoms, but many enjoy sex as much or even more because they are free from worry about pregnancy or STDs. Also, sexual intercourse and the intense pleasure before ejaculation may last longer. 6. How can a woman get her sex partner to use condoms? Men have different reasons for. not using condoms. Often their reasons are based on rumors or misunderstanding. A woman can talk to her sex partner. She might tell him: • Condoms prevent pregnancy and serious illness and even can save a person's life. • Using condoms correctly is easy with a little practice, and sex can be just as enjoyable. • Many couples use condoms. They are not just for prostitutes. • She knows he would not intentionally infect her with a disease, but many people have STDs, including HIV/AIDS, without knowing it. • Some men last longer during sex when they use condoms, and this makes sex more enjoyable for both the man and the woman. It is not easy to get some men to use condoms, and no one way always works. Still, every approach must be tried. The risks are too high not to try. 7. Aren't condoms used mostly by prostitutes? No. Married couples all over the world use condoms. In Japan more married couples use condoms than any other family planning method. Because of the high risk of STDs, however, it is especially important to use a condom whenever having sex with a prostitute. QUESnONS & ANSWERS About Condoms 11-17 8. Do condoms often break during sex? A small percentage of condoms break. When used properly, they seldom break. Condoms are more likely to break if a woman's vagina is dry. More love play before sex often makes a woman's vagina wetter. Water-based lubricant on the outside of the condom helps, too. IMPORTANT: Never use any oil or lubricants made with oil, such as petroleum jelly or skin cream. They weaken latex rubber very quickly and make condoms more likely to break. 9. Does a person need to use condoms to protect against STOs when having oral or anal sex? Yes. STDs can be passed from one person to another during any sex act that involves penetration (inserting the penis into any part of another person's body). All clients should be urged to use a condom when having oral, genital, or especially anal sex with someone who may have an STD-or if the client has an STD. 11-18 Essentials of Contraceptive Technology Chapter 12 Intrauterine Devices (IUDs) 12-1 Chapter 12 Intrauterine Devices (IUDs) Contents = Introduction to IUDs 12-3 [] Deciding About the IUD 12-4 How Does It Work? . l2-4 How Effective? . . . 12-4 Advantages and Disadvantages 12-5 Medical Eligibility Checklist. 12-7 C Starting the IUD . . . . . . 12-10 When to Start. . . . . 12-10 Providing the IUD . . 12-11 Explaining How to Use l2-14 [iJ Following Up . . . . . . . . . . . . . . . . . 12-17 Helping Clients at the Routine Return Visit . 12-17 Managing Any Problems . . . . . . . 12-18 H Important Points for the User to Remember 12-24 tI1 Questions and Answers . . . . . . . . . . . 12-25 12-2 Essentials of Contraceptive Technology = Introduction to IUDs • An intrauterine device (IUD) usually is a small, flexible plastic frame. It often has copper wire or copper sleeves on it. It is inserted into a woman's uterus through her vagina. • Almost all brands of IUDs have one or two strings, or threads, tied to them. The strings hang through the opening of the cervix into the vagina. The user can check that the IUD is still in place by touching the strings. A provider can remove the IUD by pulling gently on the strings with forceps. • IUDs are also called IUCDs (intrauterine contraceptive devices). Specific IUDs are called "the loop," Lippes Loop (no longer available in most countries), copper T, TCu-380A, MLCu-375 (Multiload), Nova T, Progestasert, and LNG-20. The type now most widely used is: • Copper-bearing IUDs (made of plastic with copper sleeves andl or copper wire on the plastic). TCu-380A and MLCu-375 are this type. This chapter focuses on copper-bearing IUDs. Less widely available are: • Hormone-releasing IUDs (made of plastic; steadily release small amounts of the hormone progesterone or another progestin such as levonorgestrel). LNG-20 and Progestasert are this type. • Inert, or unmedicated IUDs (made of plastic or stainless steel only). Lippes Loop was this type-all plastic. INTRODUCTION to IUDs 12-3 [] Deciding About the IUD How Does It Work? IUDs work chiefly by preventing sperm and egg from meeting. Perhaps the IUD makes it hard for sperm to move through the woman's reproductive tract, and it reduces the ability of sperm to fertilize an egg. Possibly could prevent egg from implanting in wall of uterus. How EHective? TCu-380A IUD (widely available and lasts at least 10 years): Very effective-O.6 to 0.8 pregnancies per 100 women in first year of use (1 in every 125 to 170). Rates for the MLCu-375 (which lasts 5 years) are nearly as low. Various other copper-bearing and inert IUDs: Effective as commonly used-3 pregnancies per 100 women in first year of use (about 1 in every 30). 12-4 Essentials of Contraceptive Technology Advantages and Disadvantages ADVANTAGES • A single decision leads to effective long-term prevention of pregnancy. • Long-lasting. The most widely used IUD (outside China), the TCu-380A, lasts at least 10 years. Inert IUDs never need replacement. • Very effective. Little to remember. • No interference with sex. • Increased sexual enjoyment because no need to worry about pregnancy. • No hormonal side effects with copper-bearing or inert IUDs. • Immediately reversible. When women have their IUDs removed, they can become pregnant as quickly as women who have not used IUDs. • Copper-bearing and inert IUDs have no effect on amount or quality of breast milk. • Can be inserted imme~diately after childbirth (except hormone- releasing IUDs) or after induced abortion (if no evidence of infection). • Can be used through menopause (one year or so after last menstrual period). • No interactions with any medicines. • Helps prevent ectopic pregnancies. (Less risk of ectopic pregnancy than in women not using any family planning method.) DECIDING About IUDs 12-5 DISADVANTAGES • Common side effects (not signs of sickness): - Menstrual changes (common in the first 3 months but likely to lessen after 3 months): • Longer and heavier menstrual periods, • Bleeding or spotting between periods, • More cramps or pain during periods. • Other, uncommon side effects and complications: - Severe cramps and pain beyond the first 3 to 5 days after insertion. - Heavy menstrual bleeding or bleeding between periods, possibly contributing to anemia. More likely with inert IUDs than with copper or hormone-releasing IUDs. - Perforation (piercing) of the wall of the uterus (very rare iflUD properly inserted). • Does not protect against sexually transmitted diseases (STDs) including HIV/AIDS, Not a good method for women with recent STDs or with multiple sex partners (or partners with multiple sex partners). • Pelvic inflammatory disease (PID) is more likely to follow STD infection if a woman uses an IUD. PID can lead to infertility. • Medical procedure, including pelvic exam, needed to insert IUD, Occasionally, a woman faints during the insertion procedure. • Some pain and bleeding or spotting may occur immediately after IUD insertion. Usually goes away in a day or two. • Client cannot stop IUD use on her own. A trained health care provider must remove the IUD for her. • May come out of the uterus, possibly without the woman's knowing (more common when IUD is inserted soon after childbirth), • Does not protect against ectopic pregnancy as well as it does against normal pregnancy. • The woman should check the position of the IUD strings from time to time. To do this, she must put her fingers into her vagina. Some women may not want to do this. 12-6 Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FOR Copper-Bearing IUDs Ask the client the questions below. If she answers NO to All of the questions, then she CAN use an IUD if she wants. If she answers YES to a question below, follow the instructions: o No 0 Yes. If she has unexplained vaginal bleeding that suggests an underlying medical condition, do not insert IUD until the problem is diagnosed. Evaluate by history and during pelvic exam. Diagnose and treat as appropriate, or refer. Yes. If she has puerperal sepsis (genital tract infection during the first 42 days after childbirth), do not insert lUDo Refer for care. Help her choose another effective method. (Continued on next page) Using the Medical Eligibility Checklist The list on this page and the next checks whether the client has any known medical conditions that prevent use of an IUD. 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 perform laboratory tests. DECIDING About ILlDs 12-7 MEDICAL EUGIBIUTY CHECKUST FOR COPPER-BEARING IUDs (continued) Note: Assure confidentiality before asking remaining questions. o No Dyes . If she has AIDS, is infected with HIY, or is being treated with any medicines that make her body less able to fIght infections, careful clinical judgement should be made. In general, do not insert IUD unless other methods are not available or acceptable. Whatever method she chooses, urge her to use condoms. Give her condoms. o No Dyes . Known cervical endometrial or ovarian cancer; benign or malignant trophoblast disease,' pelvic tuberculosis: Do not insert IUD. Treat or refer for care as appropriate. Help her choose another effective method. Be sure to explain the health benefIts and risks and the side effects of the method that the dient will use. Also, point out any conditions that would make the method inadvisable when relevant to the client. 12-8 Essentials of Contraceptive Technology Many Women Can Use Copper-Bearing IUDs In general, women CAN use IUDs safely and effectively. * IUDs can be used in any circumstances by women who: • Smoke cigarettes, • Have just had an abortion or miscarriage (if no evidence of infection or risk of infection), • Take antibiotics or anticonvulsants, • Are fat or thin, • Are breastfeeding. Also, women with these conditions CAN use IUDs in any circumstances: • Benign breast disease, • Breast cancer, • Headaches, • High blood pressure, • Irregular vaginal bleeding (after evaluation), • Blood dotting problems, • Varicose veins, • Heart disease (disease involving heart valves may require treatment with antibiotics before IUD insertion), • History of stroke, • Diabetes, • Liver or gallbladder disease, • Malaria, • Schistosomiasis (without anemia), • Thyroid disease, • Epilepsy, • Nonpelvic tuberculosis, • Past ectopic pregnancy, • Past pelvic surgery. *Characteristics and conditions listed in this box are in WHO Eligibility Criteria categoty 1. Women with characteristics and conditions in WHO categoty 2 also can use this method. With proper counseIing, women of any age or number of children can use IUDs. (Age less than 20 and having no children are characteristics in WHO Eligibility Criteria category 2.) See Appendix, page A-I. DECIDING About IUDs 12-9 t:::::J Starting the IUD When to Start Woman's situation Having menstrual cycles After childbirth After miscarriage or abortion When to start • Any time within the first 12 days after the start of menstrual bleeding, at the woman's convenience. • Any other time during the menstrual cycle (not just during menstruation) if it is reasonably sure that the woman is not pregnant (see page 4-6) and has a healthy uterus. If a woman has been using a reliable contraceptive or has not been having sex, the best time to insen her IUD is when she asks for it. • During hospital stay after childbirth, if she has decided voluntarily in advance. The IUD is best inserted within 10 minutes after delivery of the placenta. Can be inserted any time within 48 hours after childbirth. (Special training required.) • If not immediately after childbirth, as early as 4 weeks after childbirth for copper T IUD such as TCu-380A. At least 6 weeks after childbirth for other IUDs. • Immediately if no infection present. • If infection present, treat and help the client choose another effective method. After 3 months, if no infection remains, reinfection is not likely, and she is not pregnant, the IUD can be inserted. 12-10 Essentials of Contraceptive Technology Woman's situation When stopping another method • Immediately. Providing the IUD When to start IMPORTANT: A woman who chooses the IUD benefits from good counseling. A provider who listens to a woman's concerns, answers her questions, and gives dear, practical information about side effects, especially probable bleeding changes and possible pain after insertion, will help the woman use the IUD with success and satisfaction. IMPORTANT: All women who choose IUDs must have access to ~ IUD removal. All family planning programs that offer IUDs must . have qualified staff to remove them, or they must set up convenient referral arrangements for removals. STARTING the IUD 12-11 Inserting the IUD Learning IUD insertion takes training and practice under direct supervision. The following description of procedures is a summary and not detailed instructions. All family p"mning providers should know about IUD insertion so that they can tell their clients about it. 1. The provider follows proper infection-prevention procedures. Generally, the health care provider will insert a new, presterilized. IVD that was individually packaged. 2. "No-touch" insertion technique is preferred. "No-touch" technique includes: (1) Loading the IVD in the inserter while both parts are still in the sterile package; (2) Cleaning the cervix with antiseptic before IVD insertion; (3) Being careful not to touch the vaginal wall or speculum blades with the uterine sound or loaded IUD inserter; (4) Passing both the uterine sound and the loaded IUD inserter only once through the cervical canal. 3. The woman is asked to tell the provider if she feels discomfort or pain at any time during the procedure. Ibuprofen may be given 30 minutes before insertion to reduce cramping and pain. 4. The health care provider conducts a careful pelvic examination (speculum and bimanual) and checks the position of the uterus to make sure that the woman can use an IUD safely and effectively. 5. The provider carefully cleans the cervix and vagina several times with an antiseptic solution such as iodine. 6. Working slowly and gently, the provider inserts the IVD, following the manufacturers instructions. 7. After the insertion, the provider asks the client how she feels and, if she feels dizzy when sitting, suggests that she lie quietly for 5 or 10 minutes. Any cramping probably will not last long. IMPORTANT: Postpartum insertion: Only providers who have . special training should insert IVOs after childbirth. Proper insertion . technique is important to reduce the risk of expulsion. An IVO can be inserted just after delivery of the placenta or up to 48 hours after childbirth. An IVO can be inserted after vaginal delivery or after cesarean (surgical) delivery. 12-12 Essentials of Contraceptive Technology Removing the IUD Possible reasons for removal: • The client requests removal. IMPORTANT: Providers must not refuse or delay when the client . asks to have her IUD removed, whatever her reason, whether ~ it is personal or medical. • Any side effects that make the client want her IUD removed, including pain. • A medical reason for removal: - Pregnancy, - Acute pelvic inflammatory disease (endometritis or salpingitis), - Perforation of the uterus, - IUD has come out of place (partial expulsion), - Abnormal, very heavy bleeding that puts the woman's health at risk. • When the effective lifespan of a copper-bearing or hormone- releasing IUD has passed. • When the woman reaches menopause (at least one year after her last period). To remove the IUD: • Removing an IUD is usually simple. It can be done any time throughout the menstrual cycle. Removal may be somewhat easier during menstruation, when the cervix is dilated. • Proper infection-prevention procedures are followed. • The health care provider pulls the IUD strings slowly and gently with forceps. • If removal is not easy, the provider may dilate the cervix using a uterine sound or alligator forceps or refer the client to a specially trained provider. STARTING the IUD 12-13 Explaining How to Use FOLLOW THIS PROCEDURE 1. Plan with the woman for a return visit after her next menstrual period or in 3 to 6 weeks for checkup and pelvic examination. This checkup and exam make sure that her IUD is still in place and no infection has developed. The visit can be at any time convenient for her when she is not menstruating. After this one return visit, no further routine visits are required. 2. Make sure she knows: • Exactly what kind of IUD she has and what it looks like. • When to have her IUD removed or replaced. (For the TCu-380A IUD, 10 years after insertion.) Discuss how to remember the year to return. If she wants a new IUD, it can be inserted as soon as her old IUD is removed. • When she visits health care providers, she should tell them that she has an IUD. IMPORTANT: Provide the client with a written record of month ~ and year of IUD insertion and month and year when it should ~ be removed. GIVE SPECIFIC INSTRUCTIONS A woman who chooses an IUD should know what will happen during the insertion procedure (see page 12-12). She also should understand the following: 1. She can expect: • Some cramping pain for the fIrst day or two after insertion. She can take aspirin, paracetamol, or ibuprofen. • Some vaginal discharge for a few weeks after insertion. This is normal. • Heavier menstrual periods. Possible bleeding between menstrual periods, especially during the fIrst few months after IUD insertion. 12-14 Essentials of Contraceptive Technology 2. Checking the IUD. Sometimes IUDs come out. This can happen especially in the first month or so after insertion or during a menstrual period. An IUD can come out without the woman feeling it. A woman should check that her IUD is in place: • Once a week during the first month after insertion. • After noticing any possible symptoms of serious problems. (See page 12-16.) • After a menstrual period, from time to time. IUDs are more likely to come out along with menstrual blood. To check her IUD, a woman should: 1. Wash her hands. 2. Sit in a squatting position. 3. Insert 1 or 2 fingers into her vagina as far as she can until she feels the strings. She should return to the health care provider if she thinks the IUD might be out of place. IMPORTANT: She should not pull on the strings. She might ~ pull the IUD out of place. ~ 4. Wash her hands again. Note: After postpartum insertion, strings do not always come down through the cervix. STARTING the IUD 12-15 EXPLAIN SPECIFIC REASONS TO SEE A NURSE OR DOCTOR Describe the possible symptoms of serious problems that require medical attention. Serious complications ofIUD use are rare. Scill, a woman should see a doctor or nurse if she has any of these symptoms of more serious problems. The IUD mayor may not cause these problems. • Missed menstrual period, or thinks she might be pregnant, especially if she also has symptoms of ectopic pregnancy: abnormal vaginal bleeding, abdominal pain or abdominal tenderness, fainting. A woman who develops these symptoms must seek care at once. (See "Note on ectopic pregnancy," page 12-22.) • Thinks she may have been exposed to a sexually transmitted disease, or she has HIV/AIDS. • When checking her IUD strings, she thinks the IUD might be out of place. For example, she finds: - Strings missing or strings seem shorter or longer. - Something hard in her vagina or at the cervix. It may be part of the lUDo • Especially in the first month after IUD insertion, increasing or severe pain in the lower abdomen, especially if also fever and/or bleeding between menstrual periods (signs and symptoms of pelvic inflammatory disease). OTHER SPECIFIC REASONS TO RETURN TO THE CLINIC • Her sex partner feels the IUD strings during sex and this bothers him. At the clinic she can have the strings cut shorter. • Heavy or prolonged bleeding that bothers the client. • She or her partner is not pleased with the IUD. • Copper-bearing or hormonal IUD has reached the end of its effectiveness: She needs it removed or replaced. • She wants the IUD removed for any reason at any time. • She has questions. • She wants another family planning method. 12-16 Essentials of Contraceptive Technology [jJ Following Up Helping Clients at the Routine Return Visit (3 to 6 Weeks after IUD Insertion) FOLLOW THIS PROCEDURE Conduct a pelvic exam as appropriate. Definitely conduct a pelvic exam if you suspect: - Sexually transmitted disease or pelvic inflammatory disease. - The IUD is out of place. ASK QUESTIONS 1. Ask if the client has any questions or anything to discuss. 2. Ask the client about her experience with the IUD, 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. Remind her of the reasons for returning. (See page 12-16.) 4. Remind her how long her IUD will keep working and when it should be removed. 5. Ask if she has had any health problems since her last visit. • If she has developed any condition that means she should not use an IUD (see pages 12-7 and 12-8), take out the IUD. Help her choose another method. • She may be able to keep using the IUD, however, even if she has developed (1) unexplained abnormal vaginal bleeding that may suggest pregnancy or an underlying medical condition (see "Managing Any Problems," page 12-19) or (2) cervical endometrial or ovarian cancer. FOLLOWING UP on ILlDs 12-17 Managing Any Problems If the client reports any of the common side effects of IUDs, such as menstrual changes: 1. Do not dismiss the woman's concerns or take them lightly. 2. If the woman is worried but wants to continue the method, 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 IUD removed. If so, remove the IUD or refer for removal even if her problems with the IUD would not harm her health. If she wants a new method, help her choose one. For this problem: Prolonged or heavy bleeding (Prolonged bleeding more than 8 days. Heavy bleeding = twice as long or twice as much as usual for her.) Try this suggestion: • Reassure her that heavier and longer bleeding are common in the first 3 to 6 months of use and will probably lessen over time. • If she wants treatment, you can offer: - Nonsteroidal anti-inflammatory drugs (not aspirin) OR - T ranexamic acid. • Rule out gynecological problems if clinically warranted. If a gynecologic problem is found, treat or refer. She can continue using her IUD while her condition is being evaluated. (For more about PID, see page 12-19. For more about ectopic pregnancy, see page 12-22.) • To avoid anemia, give her iron supplements and/or name foods containing iron and advise the woman to eat more of them if possible. • If the dient wishes or if bleeding continues to be heavy or prolonged-and especially if she shows signs of anemia-remove the IUD and help her choose another method. 12-18 Essentials of Contraceptive Technology For this problem: Unexplained abnonnal vaginal bleeding that suggests pregnancy or an underlying medical condition Lower abdominal pain that suggests pelvic inflammatory disease (PID) Try this suggestion: • She can continue using her IUD while her amdition is being evaluated. • Evaluate and treat any underlying medical problem, or refer for care. 1. Diagnose. Take history and do abdominal and pelvic exams. If pelvic exam is not possible, do an external genital exam. If one or more of the following is fOund, refer to a capable provider at once: • Missed a menstrual period, her period is late, or she is pregnant, • Recently given birth or had an abortion, • Pain or tenderness when pressure is put on the abdomen during exam, • Vaginal bleeding, • A pelvic mass. If she has none of the above conditions, diagnose as PID if she has one or more of the following (the more conditions she has, the stronger the diagnosis): • Oral temperature of38.3°C (101°F) or higher, • Abnormal cervical or vaginal discharge, • Pain when moving the cervix during pelvic exam, • Tenderness in the area of fallopian tube or ovary, • Recent sex partner with urethral discharge or treated for gonorrhea. FOLLOWING UP on IUDs 12-19 For this problem: Lower abdominal pain that suggests pelvic inflammatory disease (PID) (continued) Try this suggestion: Note: Diagnosis can be difficult. PID signs and symptoms may be mild or absent. Also, the common signs and symptoms of PID often also occur with other abdominal conditions, such as ectopic pregnancy or appendicitis. 2. Treat or immediately refer for treatment. Treat for a range of pathogens (see page 16-18). 3. The IUD can stay in place if the woman wants to keep it. If she wants it removed, take it out. Start antibiotic treatment before taking out the IUD. 4. Follow up. If the woman does not improve in 2 or 3 days after starting treatment, or if she develops a tubal abscess, she should be sent to hospital. The IUD may be removed. If she improves, schedule another follow-up for just after she has finished taking all of her medicine. 5. Treat sex partner(s). Urge the client to have her sex partner or partners come for STD treatment. 12-20 Essentials of Contraceptive Technology For this problem: Active sexually transmitted disease (STD) now or in the last 3 months, or acute purulent cervicitis (a pus-like discharge from the opening of the cervix). Pregnancy Try this suggestion: • Remove the IUD. • Diagnose and treat the STDs, or refer. (See Chapter 16.) • If the IUD strings are visible and pregnancy is in the first trimester (less than 13 weeks): Explain that it is best to remove the IUD to avoid risk of severe infection, miscarriage, and premature birth. Explain that the IUD removal itself will have a slightly increased risk of miscarriage. - If she consents, remove the IUD or refer for removal. Explain that she should see a nurse or doctor if she has excessive bleeding, cramping, pain, abnormal vaginal discharge, or fever. • If the strings cannot be found and/or the pregnancy is beyond the first trimester: - Explain that she is at risk of serious infection, which could threaten her life. Given this risk, if she does not want to continue the pregnancy, and if therapeutic termination of pregnancy is legally available, refer according to clinic guidelines. FOLLOWING UP on IUDs 12-21 For this problem: Pregnancy (continued) Try this suggestion: - If client wants to or must continue her pregnancy, make clear that she faces increased risk of spontaneous abortion and infection. Her pregnancy should be followed closely by a nurse or doctor. She should see a nurse or doctor if she has excessive bleeding, cramping, pain, abnormal vaginal discharge, or fever. IMPORTANT: Note on ectopic pregnancy: Pregnancies among users ~ of IUDs are few. When pregnancy occurs, however, 1 in every 30 is . ectopic. IUDs, especially the TCu-380A, offer significant protection against ectopic pregnancy, but they still sometimes occur. Ectopic pregnancy is life-threatening and requires immediate treatment. Signs of ectopic pregnancy: amenorrhea, nausea, breast tenderness (first symptoms of pregnancy); abnormal vaginal bleeding, abdominal pain or tenderness, anemia, fainting (suggesting shock). Symptoms may be absent or slight. Care: Anemia and/or fainting indicate a possible ruptured ectopic pregnancy, an emergency condition requiring immediate surgery. If nonruptured ectopic pregnancy is suspected, perform a pelvic exam only if facilities for immediate surgery are available. If they are not available, refer at once for definitive diagnosis and care. 12-22 Essentials of Contraceptive Technology For this problem: Partner complains aboutIUD strings Try this suggestion: • Explain to woman (and partner, if possible) that what her partner feels is normal. Recommend that they try again. • Describe other options to the client: - Strings can be cut shorter. - The IUD can be removed. 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 using her IUD or to have it 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 the IUD or that you refused to remove it. To avoid such rumors, find out what your client wants, and do it. FOLLOWING UP on IUDs 12-23 12-24 Essentials of Contraceptive Technology 1. Can the IUD travel from the woman's uterus to other parts of her body, such as her heart or her brain? The IUD normally stays within the uterus like a seed within a shell. Very rarely, the IUD may come through the wall of the uterus and rest in the abdomen. This is probably due to a mistake during insertion and not to slow movement through the wall of the uterus. The IUD never travels to any other part of the body. 2. Will the IUD prevent a woman from having babies after it is removed? In general, no. A woman can become pregnant after her IUD is removed. But the IUD does not protect her from sexually transmitted diseases (STDs). A woman should understand that the IUD may somewhat increase her chances of getting pelvic inflammatory disease if she gets STDs. These infections could make her infenile. Therefore, it is important for a woman who uses an IUD to have sex with only one, uninfected man and for him to have sex only with her. 3. Can a woman who has never had a baby use an IUD? Yes, as long as she does not have sexually transmitted diseases and there is little chance that she will get any. The IUD is not the best method for a woman who has not had a baby and wants a baby in the future. Also, a woman who has not had children is more likely to expel the IUD because her uterus is small. When properly counseled, however, these women may choose IUDs. 4. Can a woman get an IUD just after she has a baby? Yes, if the person who inserts her IUD has been properly trained. The IUD can be insened after a vaginal delivery or through the abdominal incision after a cesarean section (surgical delivery). QUESTIONS & ANSWERS About IUDs 12-25 5. Can a woman get an IUD just after abortion or miscarriage? Yes. An IUD can be inserted after an abortion or miscarriage unless she has a pelvic infection. Insertion following miscarriage after 16 weeks gestation requires special training. 6. Must an IUD be inserted only during a womatis menstrual period? No. An IUD can be inserted at any time during her menstrual cycle if it is reasonably sure that the woman is not pregnant. During her period may be a good time because she is not likely to be pregnant, and insertion may be easier for some women. It is not as easy to see signs of infection during menstruation, however. Some providers like to insert the IUD midway through the menstrual cycle because the mouth of the cervix is a little wider then. 7. Should antibiotics be given before IUD insertion to prevent infection? Not necessarily. When IUD insertion is done correctly with well-screened clients, there is little risk of infection for healthy women, and antibiotics are not necessary for IUD insertion. In any case, most recent research suggests that antibiotics do not significantly reduce the risk of pelvic inflammatory disease (PID). 8. Can a woman be too young or too old to use an IUD? No. There is no minimum or maximum age, so long as the woman is not at risk for a sexually transmitted disease and is properly counseled about the advantages and disadvantages of the IUD. An IUD should be removed from the woman after menopause-at least one year after her last menstrual period. 9. Can a woman get her IUD on the same day that she has her initial counseling? Yes. If it is reasonably certain that she is not pregnant and has no infections, there is no medical reason for a separate visit. It may be inconvenient for a woman to come back again. Also, she may become pregnant before she returns to have her IUD inserted. 12-26 Essentials of Contraceptive Technology 10. Can a woman with diabetes use an IUD? Yes. IUOs are safe for women with diabetes. Women with diabetes are at greater risk of many infections, however. They should see a nurse or doctor if they notice possible signs of sexually transmitted disease or other infection, particularly just after IUO insertion. 11. Should a woman have a "rest period" after using her IUD for several years or after the IUD reaches its recommended time for removal? No. This is not necessary, and it may be harmful. There is less risk of pelvic infection in replacing an IUO at one time than in 2 separate procedures. Also, a woman could become pregnant before her new IUO is inserted. 12. When does a copper IUD need to be replaced? The latest models of copper-bearing IUOs are effective for many years. The TCu-380A has been approved by the US Food and Drug Administration for 10 years of use. (It probably can prevent pregnancy even longer.) 13. Will the IUD cause discomfort to a woman's partner during sex? Generally, no. Sometimes a man can feel the strings. If this bothers him, cutting the strings shorter should solve the problem. The woman should be told beforehand, however, that this will mean she will not be able to feel the strings to check her IUO, and removing her IUO may be more difficult. A man may feel discomfort during sex if the IVO has started to come out through the cervix. If a women suspects this, she should see a doctor or nurse immediately. QUESTIONS & ANSWERS About IUDs 12-27 Chapter 13 Vaginal Methods 13-1 Chapter 13 Vaginal Methods Contents = Introduction to Vaginal Methods . 13-3 [] Deciding About Vaginal Methods 13-4 How Do They Work? . . . 13-4 How Effective? . . . . . . . 13-4 Advantages and Disadvantages 13-5 Medical Eligibility Checklist . 13-8 ~ Starting Vaginal Methods . 13-9 When to Start. . . 13-9 Providing Vaginal Methods 13-9 Explaining How to Use . . 13-10 [iJ Following Up . 13-14 Helping Clients at Any Routine Return Visit. 13-14 Managing Any Problems . 13-15 H Important Points for the User to Remember 13-17 t!1 Questions and Answers. . . . . . . . . . . 13-18 13-2 Essentials of Contraceptive Technology = Introduction to Vaginal Methods Vaginal methods are contraceptives that a woman places in her vagina shortly before sex. There are several vaginal methods: • Spermicides, including foaming tablets or suppositories, melting suppositories, foam, melting film, jelly, and cream. • Diaphragm, a soft rubber cup that covers the cervix. Should be used with spermicidal jelly or cream. • Cervical cap-like the diaphragm but smaller. Not widely available outside North America, Europe, Australia, and New Zealand. Diaphragm Cervical Caps Spermicides INTRODUCTION to Vaginal Methods 13-3 [] Deciding About Vaginal Methods How Do They Work? • Spermicides kill sperm or make sperm unable to move toward the egg. • Diaphragms and cervical caps block sperm from entering the uterus and tubes, where sperm could meet an egg. How EHective? IMPORTANT: Effectiveness depends on whether a woman uses a vaginal method correctly every time she has sex and on which vaginal method she uses. Pregnancies per 100 Women in First Year of Use Cervical cap for women Cervical cap who have for women not had who have Spermicides Diaphragm children had children As 26 20 20 40 commonly somewhat somewhat somewhat poorly effective used effective effective effective (1 in every (1 in every 4) (1 in every 5) (1 in every 5) 2 or 3) Used 6 6 9 26 consistendy effective effective effective somewhat and correcdy (1 in every 17) (1 in every 17) (1 in every 11) effective (1 in every 4) Vaginal methods may help to prevent some sexually transmitted diseases (STDs) (and possibly HNIAIDS, although studies have not shown this so far). It is not clear whether vaginal methods prevent STDs as well as condoms do. Still, using vaginal methods alone is better than not using either a vaginal method or a condom. Also, a woman- controlled method may be used more consistently than a condom. 13-4 Essentials of Contraceptive Technology Advantages and Disadvantages ADVANTAGES OF ALL VAGINAL METHODS • Safe, woman-controlled methods that almost every woman can use. • Help prevent some STDs and conditions caused by STDs-pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and possibly cervical cancer. May offer some protection against HNIAIDS, but not demonstrated yet. • Offer contraception just when needed. • Prevent pregnancy effectively if used correctly with every act of sexual intercourse (except cervical cap for women who have had children). • No side effects from hormones. • No effect on breast milk. • Can be stopped at any time. • Easy to use with a little practice. Additional Advantages of Spermicide • Can be inserted as much as one hour before sex to avoid interrupting sex. • May increase vaginal lubrication. • Can be used immediately after childbirth. • No need to see a health care provider before using. Additional Advantages of Diaphragm or Cervical Cap Used with Spermicide • Diaphragm can be inserted up to 6 hours before sex to avoid interrupting sex. Cap may be inserted even earlier since it protects for up to 48 hours after insertion. DECIDING About Vaginal Methods 13-5 DISADVANTAGES OF All VAGINAL METHODS • Side effects: - Spermicide may cause irritation to woman or her partner, especially if used several times a day. - Spermicide may cause local allergic reaction (rarely) in the woman or her partner. - Can make urinary tract infections more common. (A woman can avoid this by always urinating after sex.) • Effectiveness requires having method at hand and taking correct action before each act of sexual intercourse. • Require woman or her partner to put fingers or inserter into her vagina. (Should wash hands first.) • Interrupt sex if not inserted beforehand. • Spermicide may be messy. • May be hard to conceal from partner. Additional Disadvantages of Spermicide • Melting types must be placed in vagina at least 10 minutes before the man ejaculates but not more than 1 hour before. • Some types may melt in hot weather. • Foaming tablets may cause warm sensation. • In theory, irritation caused by use several times a day may increase STD/HN risk. Additional Disadvantages of Diaphragm and Cervical Cap Used With Spermicide • Requires fitting by a family planning provider, involving pelvic examination. • May be difficult to remove. Diaphragm can tear as the woman removes it (rare), 13-6 Essentials of Contraceptive Technology • Woman may need a different size diaphragm after childbirth. • Cervical cap appears to be less effective for women who have given birth. • Diaphragm or cap should be washed with mild soap and clean water after each use. • Diaphragm needs careful storage to avoid developing holes. Using the Medical Eligibility Checklist The list on the next page checks whether the client has any known medical conditions that prevent use of vaginal methods. 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 perform laboratory tests or physical examinations. lA pelvic examination is needed for a diaphragm or cap.) IMPORTANT: Nonmedical providers can safely offer . spermicides to all women. Nonmedical providers include . retailers and community-based distributors. DECIDING About Vaginal Methods 13-7 MEDICAL ELIGIBILITY CHECKLIST FOR Vaginal Methods Ask the client the questions below. If she answers NO to All of the questions, then she CAN use vaginal methods if she wants. If she answers YES to a question below, follow the instructions. o No 0 Yes" Diaphragm and cervical cap generally should not be fitted until 6 to 12 weeks after childbirth or second- trimester abortion, depending on when the uterus and cervix return to normal. Can use spermicide alone. o No 0 Yes . May be impossible or ineffective for her to use a diaphragm or cap. A pelvic exam may be necessary to determine whether diaphragm or cap can be correctly placed and will stay in place. o No 0 Yes . She may want a more effective method. She may use vaginal methods, however, if she makes an informed choice and receives proper instruction on effective use. o No 0 Yes . Generally should not use diaphragm or cervical cap. Can use spermicides alone or another method. 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. 13-8 Essentials of Contraceptive Technology I:::] Starting Vaginal Methods When to Start A woman can begin using a vaginal method any time during her monthly cycle and soon after childbirth, abonion, or miscarriage. The diaphragm and cervical cap generally should not be fitted, however, in the first 6 to 12 weeks after full-term delivery or second-trimester spontaneous or induced abortion, depending on when the uterus and cervix return to their normal sizes. If needed, a woman can use spermicide alone or with condoms until then. Providing Vaginal Methods IMPORTANT: A woman who chooses a vaginal method benefits from good counseling. A friendly provider who listens to a woman's concerns, answers her questions, and gives dear, practical information, especially about the importance of consistent use, will help clients use vaginal methods with success and satisfaction. You can follow these steps to provide vaginal methods: 1. Give her plenty of spermicide--up to a year's supply; if possible. 2. Explain how to use vaginal methods, including insertion and, for diaphragm and cervical cap, removal (see pages 13-10 to 13-13). 3. If she chooses a diaphragm or cap, arrange for proper fitting and placement with a specifically trained provider. Refer if necessary. 4. Plan a return visit when she will need to get more spermicide if she does not prefer to get it elsewhere. 5. Invite the client to come back any time she has questions, problems, or wants another method. STARTING Vaginal Methods 13-9 Explaining How to Use IMPORTANT: For all vaginal methods, the woman must use the method. each time she has sexual intercourse. SPERMICIDE Inserting spermicide 1. The woman inserts the spermicide in her vagina before each time she has sexual intercourse. 2. She inserts more spermicide before each act of sexual intercourse and ejaculation of semen into her vagina. 3. She does not douche for at least 6 hours after sex. Type of spermicide Foam or cream Tablets, suppositories, film Storing spermicide How to insert Any time less than 1 hour before sex, the woman squeezes foam or cream from the can or tube into a plastic applicator. She inserts the applicator deep into her vagina and pushes its plunger. With foam, she must shake the can strongly just before filling the applicator. Less than 1 hour but more than 10 minutes before sex, the woman inserts a tablet, suppository, or film deep into her vagina with an applicator or with her fingers. Film must be folded in half and insened with dry fingers near the cervix, or else the film will stick to the fingers and not the cervix. Most spermicides--especially some suppositories-should be stored in a cool, dry place, if possible, or they may melt. If kept dry, foaming tablets are not so likely to melt in hot weather. 13-10 Essentials of Contraceptive Technology DIAPHRAGM Inserting the diaphragm The woman inserts the diaphragm with spermicide in the proper position in the vagina before having sexual intercourse. 1. The woman holds the diaphragm with the dome down (like a cup). 2. She squeezes about a tablespoon of spermicidal cream or jelly into the cup of the diaphragm and around the rim. 3. She presses opposite sides of the rim together and, with dome side toward palm of hand, pushes the diaphragm into the vagina as far as it goes. (See drawing, page 13-12.) 4. With a finger, she touches the diaphragm to make sure that it covers the cervix. Through the dome of the diaphragm, the cervix feels like the tip of the nose. 5. For each additional act of intercourse, she uses an applicator to insert additional spermicide. She does NOT remove the diaphragm. Removing the diaphragm 1. The woman leaves the diaphragm in place for at least 6 hours after the man's last ejaculation. She does NOT leave the diaphragm in for more than 24 hours. Doing so might increase the risk of toxic shock syndrome. * 2. She inserts a finger into the vagina until she feels the rim of the diaphragm. 3. She gently slides a finger under the rim and pulls the diaphragm down and out. She is careful not to tear the diaphragm with a fingernail. 4. She washes the diaphragm with mild soap and dean water after each use. She checks for holes by filling it with water or by holding it up to the light. 5. She dries the diaphragm and stores it in a dean, dark, cool place, if possible. * Toxic shock syndrome is a rare but serious illness caused by bacreria. A few cases have been reporred in diaphragm users. The longer a diaphragm or cap is left in place, rhe more rhe bacteria can grow. Symptoms are sudden high fever, body rash like sunburn, vomiting, diarrhea, dizziness, sore rhroat, and muscle aches. A woman who develops rhese symptoms should go at once to the nearest healrh center. Treatment wirh antibiotics and intravenous fluids is very effective. STARTING Vaginal Methods 13-11 Checking Proper Placement of a New Diaphragm or Cervical Cap An experienced user of diaphragm or cap or else a specifically trained provider must show a new user how to place the device within the vagina. She should allow the woman to practice privately, and then she should check placement. B To insert a diaphragm, a woman squeezes its sides together and pushes it into her vagina as for as it will go ~). Then with her finger she checks that the diaphragm fits snugly behind the pubic bone and covers the cervix (B). CERVICAL CAP Inserting the cervical cap The woman inserts the cervical cap with spermicide in the proper position in the vagina before having sexual intercourse. 1. She fills the dome of the cap 1/3 full with spermicidal cream or jelly. 2. She squeezes the rim of the cap between thumb and index finger, and, with the dome side toward the palm of the hand, slides the cap into the vagina as far as it goes. 3. She uses a finger to locate the cervix, which feels like the tip of the nose. She presses the rim of the cap around the cervix until it is completely covered. She sweeps a finger around the cap rim to be sure the cervix is covered. 4. She does not need additional spermicide for additional acts of intercourse that occur within 48 hours after insertion, as long as she keeps the cap in place. 13-12 Essentials of Contraceptive Technology Removing the cervical cap 1. The woman leaves the cap in for at least 6 hours after the man's last ejaculation. She does NOT leave the cap in for more than 48 hours. Doing so could cause a bad odor and may increase the risk of toxic shock syndrome. * 2. She inserts a finger into the vagina until she feels the rim of the cap. 3. She presses on the cap rim until the seal against the cervix is broken; then she tilts the cap off the cervix. 4. She hooks a finger around the rim and pulls it sideways out of the vagina. 5. She washes the cap with mild soap and clean water after each use. She checks for holes by filling it with water or by holding it up to the light. 6. She dries the cap and stores it in a clean, dark, cool place, if possible. EXPLAIN SPECIFIC REASONS TO RETURN TO THE PROVIDER Urge the client to return for any of these reasons: • For more spermicide. • When a diaphragm or cap wears out, gets thin, develops holes, or becomes stiff. It needs to be replaced. • After delivery or abortion to check the fit of her diaphragm or cervical cap. • She or her partner has an allergic reaction (itching, rash, irritation). (See page 13-15.) • She stops using the method. • She has any questions or problems or wants another method. • See fOotnote on page 13-11. STARnNG Vaginal Methods 13-13 [j] Following Up Helping Clients at Any Routine Return Visit IMPORTANT: A scheduled return visit is not necessary. At any time convenient for the dient, she can return for more spermicide or for advice on diaphragm or cap use and fit. 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. • If she has developed allergy to latex, a medical condition that makes pregnancy dangerous, or toxic shock syndrome or recently had a foil-term delivery or second-trimester spontaneous or induced abortion, see page 13-8 for instructions. If appropriate, help her choose another method. • If she has developed urinary tract injection, see "Managing Any Problems," page 13-15. 13-14 Essentials of Contraceptive Technology Managing Any Problems If the client reports any problems with vaginal methods: 1. Do not dismiss the woman's concerns or take them lightly. 2. Help her with any problems. If she wants to keep using the method, encourage her to keep using it with every act of intercourse. 3. If she is not satisfied after counseling and advice, help her choose another method if she wishes. For this problem: Allergic reaction or sensitivity to spennicide, such as burning or itching Urinary tract infection Try this suggestion: • Check for infection (signs: abnormal vaginal discharge, redness and! or swelling of the vagina, and itching of the vulva), and treat or refer as appropriate. • If no infection, suggest a different type or brand of spermicide. • Treat with antibiotics such as. ampicillin or trimethoprim plus sulfamethoxazole for 10 to 14 days. • Suggest that the woman urinate soon after sex to help prevent future infections. Also suggest that she drink plenty of fluids, urinate often, and eat food containing vitamin C, such as oranges, grapefruit, and limes, if possible. • If infection is frequent or recurrent, check that the diaphragm is not too tight. (You should be able to fit a gloved finger in front of the rim.) Also consider possibility of STD. • Continued use of the diaphragm is usually not recommended for a woman who has chronic or recurrent urinary tract infection that does not respond to treatment. FOLLOWING UP on Vaginal Methods For this problem: Pain from pressure on bladder or rectum with diaphragm use Difficulty inserting diaphragm or cap Sudden high fever, body rash, vomiting, diarrhea, dizziness, and muscle aches (very rare) Vaginitis with diaphragm use Unusual vaginal discharge with diaphragm use Vaginal lesion with diaphragm use Try this suggestion: • Check diaphragm fit and look for vaginal lacerations. If diaphragm is too large, fit with smaller model. • Give additional advice on insertion. Have her try insertion in the clinic and then check placement. • Her sex partner sometimes can help with insertion. • The woman should be taken immediately to the nearest health center. She may have toxic shock syndrome. • If she has toxic shock syndrome, treatment with antibiotics and intravenous fluids is very effective and should be given right away. • Suggest that she dean her diaphragm thoroughly after each use and make sure it is dry before using it again. • Suggest that she remove the diaphragm promptly (but no sooner than 6 hours after having sex) and dean it after each use. • Suggest that she use another method temporarily and give her supplies. • Check diaphragm fit and how the dient removes her diaphragm. 13-16 Essentials of Contraceptive Technology IMPORTANT POINTS About Vaginal Methods 1 3-17 1. Do spermicides cause birth defects? No. The best evidence is that spermicides do not cause birth defects. Spermicides do not harm the baby even if a woman uses them while pregnant. 2. Do spermicides cause cancer? No. In fact, spermicides, diaphragms, and cervical caps may help prevent cancer of the cervix. 3. Is the diaphragm uncomfortable for the woman? No, not if it is fitted and inserted correctly. The woman and her partner generally cannot feel the diaphragm during sex:. The provider selects the right size diaphragm for each woman so that it fits and does not hurt. 4. If a woman uses the diaphragm without spermicide, will it work at all? Yes, but without the spermicide, the diaphragm will be less effective. Therefore using a diaphragm without spermicide is not recommended. 5. Could a woman leave a diaphragm in all day? Although not usually recommended, a woman who wants to use the diaphragm but may not always be able to put it in before sex could leave it in all day. She should remove it and wash it every day to avoid urinary tract infections and toxic shock syndrome. 13-18 Essentials of Contraceptive Technology 6. Can a woman use lubricants with a diaphragm or cap? Oil-based lubricants can damage the latex rubber in a diaphragm or cap. Therefore a woman should not use oil-based vaginal lubricants or medications along with diaphragm or cap. These include petroleum jelly (Vaseline®), mineral oil, hand lotion, vegetable oil, butter, margarine, and cocoa butter as well as common vaginal yeast creams. She can use contraceptive jelly or a water-soluble lubricant specifically made for use with latex condoms. 7. Do vaginal methods protect against sexually transmitted diseases (STDs) including HIV/AIDS? Spermicides can kill organisms that cause some STDs. The diaphragm and cervical cap can help block these organisms. They may also offer some protection against HI¥, which causes AIDS, but this has not been shown. The best protection during sex may be using both a condom and spermicide together, every time. If only one method is used, the condom is best. But a woman- controlled vaginal method might be used more regularly than condoms when a woman cannot convince her partner to use condoms. QUESTIONS & ANSWERS About Vaginal Methods 13-19 Chapter 14 Fertility Awareness-Based Methods Including Periodic Abstinence 14-1 Chapter 14 Fertility Awareness-Based Methods Including Periodic Abstinence Contents = Introduction to Fertility Awareness-Based Methods. 14--3 [] Deciding About Fertility Awareness-Based Methods 14-4 How Do They Work? . . . . . . . . . . . . 14-4 How Effective? . . . . . . . . 14-4 Advantages and Disadvantages 14--6 Medical Eligibility Checklist. . 14--8 ~ Using Fertility Awareness-Based Methods. 14--10 When to Start. . . . . . . . . . . . 14--10 Teaching Fertility Awareness-Based Methods 14--10 Explaining How to Use . . . . . . . . . . . 14--11 [j] Following Up . . . . . . . . . . . . . . . . 14--15 Helping Clients at Any Routine Return Visit 14--15 Managing Any Problems . . . . . 14--16 H Important Points for the User to Remember 14--17 t:!1 Questions and Answers. . . . . . . . . . . 14--18 14-2 Essentials of Contraceptive Technology ~ Introduction to Fertility IIIIliiIIII Awareness-Based Methods "Fertility awareness" means that a woman learns how to tell when the fertile time of her menstrual cycle starts and ends. (The fertile time is the time when she can become pregnant.) A woman can use several ways to tell when her fertile time begins and ends: • Calendar calculation: A woman can count calendar days to identify the start and end of the fertile time. The nwnber of days depends on the length of previous menstrual cycles. • Cervical secretions: When a woman sees or feels cervical secretions, she may be fertile. Can be just a sense of vaginal wetness. • Basal body temperature (BBT): A woman's resting body temperature goes up slightly around the time of ovulation (release of an egg), when she could become pregnant. • Feel of the cervix: As the fertile time begins, the opening of the cervix feels softer, opens slightly, and is moist. When she is not fertile, the opening is firmer and closed. (Seldom used as the only sign.) A woman may use one of these or a combination. To tell when the fertile time starts, she can use calendar calculations and cervical secretions. To tell when the fertile time ends, she can use BBT, cervical secretions, and calendar calculation. (For details, see pages 14-10 through 14-14.) INTRODUCTION to Fertility Awareness 14-3 [] Deciding About Fertility Awareness-Based Methods How Do They Work? Fertility awareness helps a woman know when she could become pregnant. The couple avoids pregnancy by changing their sexual behavior during fertile days. They can: • Abstain from vaginal intercourse-avoiding vaginal sex completely during the fertile time. Also called periodic abstinence and Natural Family Planning (NFP). • Use barrier methods------condoms, diaphragm and spermicide, or spermicide alone. • Use withdrawal-taking the penis out of the vagina before ejaculation. Also called coitus interruptus and "pulling out." Or they can have other sexual contact without vaginal intercourse. How EHective? Note: The pregnancy rates in this section are for periodic abstinence only. IMPORTANT: Effectiveness of periodic abstinence varies more than ~ for any other family planning method. For highest effectiveness, . couples should never guess about the fertile time. They should abstain completely from sexual intercourse during fertile times. Only somewhat effective as commonly used-20 pregnancies per 100 women in the first year of use (1 in every 5). (This rate comes from survey findings. It is not known how these women identified their fertile time.) 14-4 Essentials of Contraceptive Technology Effective or very 4fective when used consistently and correctly- Consistent Use of Single-Indicator Methods Cervical secretions: 3 pregnancies per 100 women in first year of use (1 in every 33). Basal body temperature: 1 pregnancy per 100 women in first year of use (when intercourse takes place only after ovulation and before next menstrual period; see page 14-11). Calendar: 9 pregnancies per 100 women in first year of use (1 in every 11). Consistent Use of Multiple-Indicator Method Sympto-thermal or multi-index (usually cervical secretions + BBT, and perhaps also calendar calculations and feeling the cervix): 2 pregnancies per 100 women in the first year of use (1 in every 50). Note: There is little information on effectiveness of fertility awareness used with barrier methods or withdrawal. Some couples find using barrier methods during the fertile time easier-and thus possibly more effective-than avoiding sex. Couples who regularly use barrier methods also can use fertility awareness and avoid sex while the woman is fertile. This may be more effective than using barrier methods alone. DECIDING About Fertility Awareness 14-5 Advantages and Disadvantages ADVANTAGES • Once learned, can be used to avoid pregnancy or to become pregnant, according to the couple's wishes. • No physical side effects. • Very little or no cost. • Can be used by most couples if they are committed to it. • Effective if used correctly and consistently. • Once learned, may require no further help from health care providers. • Can be learned from trained volunteers. Contact with medical personnel is not necessary. • Immediately reversible. • Periodic abstinence is acceptable to some religious groups that reject or discourage use of other methods. • No effect on breastfeeding or breast milk. No hormonal side effects. • Involves men in family planning. • Educates people about women's fertility cycles. DISADVANTAGES • Usually only somewhat effective. • Takes up to 2 or 3 cycles to learn how to identifY fertile time accurately using cervical secretions and BBT. Less time to learn the calendar method, although it is best if a woman has records of the last 6 to 12 cycles to identifY the fertile time. • If using periodic abstinence, requires long periods without vaginal intercourse-8 to 16 days each menstrual cycle. Abstinence may be difficult for some couples. • Will not work without continuing cooperation and commitment of both the woman and the man. 14-6 Essentials of Contraceptive Technology • Can become unreliable or hard to use if the woman has a fever, has a vaginal infection, is breastfeeding, or has any other condition that changes body temperature, cervical mucus, or menstrual cycle length. • After childbirth, may be hard to identify the fenile time until menstrual cycle becomes regular again. • Calendar method may not be effective for women with irregular menstrual cycles. • May be very difficult to practice if a woman has more than one sex partner. • Most methods require women or couples to keep careful daily records and pay close attention to body changes. • Does not protect against sexually transmitted diseases (STDs) including HNIAIDS. IMPORTANT: Ask the dient if she might have or get a sexually ~ transmitted disease (STD). (Has more than one sex partner? . 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. Using the Medical Eligibility Checklist The list on the next page checks whether the client has any known medical conditions that might interfere with use of fertility awareness-based methods. 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 perform laboratory tests or physical examinations. DECIDING About Fertility Awareness 14-7 MEDICAL ELIGIBILITY CHECKLIST FOR Fertility Awareness-Based Methods Ask the client the questions below. If she answers NO to ALL questions, she CAN use any fertility awareness-bosed method jf she wonts. If she answers YES to any question, follow the instructions. No conditions restrict use of these methods, but some conditions can make them harder to use effectively. o No 0 Yes . These conditions do not restrict use of fertility awareness- based methods. But these conditions may affect fertility signs, making fertility awareness-based methods hard to use. For this reason, a woman or couple may prefer a different method. If not, they may need more counseling and follow-up to use the method effectively. ONo 0 Yes . These conditions may affect fertility signs, making fertility awareness-based methods hard to use. Once an infection is treated and reinfection is avoided, however, a woman can use fertility awareness-based methods more easily. 14-8 Essentials of Contraceptive Technology MEDICAL ELIGIBILITY CHECKLIST FOR FERTILITY AWARENESS (continued) o No 0 Yes . Predicting her fertile time correctly may be difficult or impossible if she uses only the cervical mucus method. She can use BBT and/or the calendar method, or she may prefer another method. 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. Most Women Can Use Fertility Awareness-Based Methods In general, most women CAN use fertility awareness-based methods safely and effectively. Fertility awareness-based methods can be used in any circumstances by women who: • Are fat or thin, • Have children, • Have no children, • Smoke cigarettes. Also, women with these conditions CAN use fertility awareness-based methods in any circumstances: • Mild high blood pressure, • Uterine fibroids, • Deep vein thrombosis or • Endometriosis, pulmonary embolism, • Ovarian cysts, • Varicose veins, • Iron deficiency anemia, • Mild or severe headaches, • Viral hepatitis, • Painful menstruation, • Malaria. DECIDING About Fertility Awareness 14-9 ~ Using Fertility Awareness-Based ~ Metl10ds When to Start Once trained, a woman or couple can begin using fertility awareness- based techniques at any time. Before starting to use the calendar method, a woman must record the length of her menstrual cycles for at least 6 months. Immediately after chlldbirth or abortion: Once bleeding stops after delivery, cervical secretions can be used, but with difficulty. The calendar method and BBT are unreliable. Some providers encourage women to begin monitoring their fertility before marriage or before they become sexually active. In this way women can learn to detect their fertile times before they face any risk of pregnancy. For couples already sexually active, a trainer may recommend a cycle of abstinence so that a woman can learn to observe her fertility signs. Teaching Fertility Awareness-Based Methods IMPORTANT: A woman or couple who chooses to use fertility . awareness-based methods needs good counseling to use these ~ methods most effectively and confidently. A friendly provider who listens to a woman or couple's concerns, answers their questions, and gives clear, practical information and advice will help clients use fertility awareness-based methods with success and satisfaction. Health care providers, volunteers, counselors, and couples experienced with fertility awareness methods can counsel and train others. Trainers should be able to: • Help a woman and her partner learn to recognize fertility signs. • Encourage couples repeatedly to avoid sex or to use withdrawal or barrier methods during the fertile time. Also, be able to counsel couples about any problems with abstinence. • Provide materials to chart body changes, such as special, expanded- scale BBT thermometers, calendars, and paper or notebooks, if possible. • Tell couples about other methods or refer them to a source ofinfOrrnarion, supplies, and services for other methods if the couple asks. 14-10 Essentials of Contraceptive Technology Explaining How to Use IMPORTANT: Couples who choose to use fertility awareness- . based methods usually need personal guidance from a trained "'IIIIIIIIIIII counselor, usually over several months. During this time the couple must use another method or avoid intercourse. Some trainers emphasize specific sets of rules, called by such names as the cervical mucus, Billing;, or ovulation method, the basal body temperature (BBT) method., and the sympto-thermal method. Here, specific rules of behavior are highlighted in dark type. For all fertility awareness-based methods: The couple avoids unprotected vaginal intercourse during the fertile time. Cervical Secretions To Identify Start and End of the Fertile Tune: 1. A woman checks every day for any cervical secretions. She may feel wetness at the opening of her vagina or see secretions on her finger, underpants, or tissue paper. As soon as she notices any secretions, the couple avoids sex, uses a barrier method, or uses withdrawal. 2. The secretions have a peak day, when they are most slippery, stretchy, and wet. The couple continues to avoid sex, use withdrawal, or use a barrier method until 4 days after the peak day. Avoid Sex Secretions-especially when slippery, wet, and can be stretched-mean the couple should avoid sex or use withdrawal or a barrier method until the 4th day after the peak day. Can Have Sex No secretions mean the woman probably cannot become pregnant. She can have unprotected vaginal sex. USING Fertility Awareness 14-11 3. In a few days the secretions become sticky, pasty, or crumbly, or the woman has no secretions at all. The couple can have unprotected sex until menstrual bleeding begins again. 4. Some trainers recommend that couples avoid unprotected sex during menstrual bleeding because cervical secretions could be hard to notice. The chances of pregnancy in the first 5 or 6 days of the cycle are slight, however. 5. After menstrual bleeding stops, the woman may have several days with no secretions. Sex is usually considered safe during this time. It should be limited to every second day, however, because vaginal fluids and semen could be confused with secretions. Spermicides, vaginal infections, and some drugs also affect the normal pattern of a woman's secretions. The couple does not have unprotected vaginal sex if they are unsure whether there are secretions. Basal Body Temperature (BBT) To Identify End of the Fertile Time: 1. The woman must take her body temperature in the same way, either orally, rectally, or vaginally, at the same time each morning before she gets out of bed. She must know how to read a thermometer and must record her temperature on a special graph. 2. The woman's temperature rises 0.2° to 0.5°C (0.4° to 1.0°F) around the time of ovulation (about midway through the menstrual cycle for many women). 3. The couple avoids sex, uses a barrier method, or uses withdrawal from the first day of menstrual bleeding until the woman's temperature has risen above her regular temperature and stayed up for 3 full days. This means that ovulation has occurred and passed. 4. After this, the couple can have unprotected sex (over the next 10 to 12 days) until her next menstrual bleeding period begins. 14-1 2 Essentials of Contraceptive Technology Cervical Secretions + Basal Body Temperature To Identify the Start and End of the Fertile Time: Users identify fertile and infertile days by combining BBT and cervical secretion observations and instructions and, often, other signs and symptoms of ovulation. 1. The couple starts avoiding unprotected sex when the woman senses cervical secretions. For more protection the couple can start avoiding sex with the first day of menstrual bleeding. 2. The couple keeps avoiding unprotected intercourse until both the fourth day after peak cervical secretions and the third full day after the rise in temperature (BBT). If one of these events happens without the other, the couple waits for the other event before having unprotected sex. 3. Other signs and symptoms of ovulation include: abdominal pain, cervical changes, and breast tenderness. Also, the calendar method may help identify the start of the fertile time. Calendar (Rhythm) Method To Identify Start and End of the Fertile Time: 1. Before relying on this method, the woman records the number of days in each menstrual cycle for at least 6 months. The first day of menstrual bleeding is always counted as day 1. 2. The woman subtracts 18 from the length of her shortest recorded cycle. This tells her the estimated first day of her fertile time. Then she subtracts 11 days from the length of her longest recorded cycle. This tells her the last day of her fertile time. The couple avoids sex, uses a barrier method, or uses withdrawal during the fertile time. Example: • If her recorded cycles vary from 26 to 32 days, 26 - 18 = 8. Start avoiding unprotected sex on day 8. 32 - 11 = 21. Okay to have unprotected sex again after day 21. USING Fertility Awareness 14-1 3 • She must avoid unprotected sex from day 8 through day 21 of her cycle (14 days of avoiding unprotected sex). The calendar method may require 16 days or more in a row of avoiding sex or using withdrawal or a barrier method in each cycle, especially for women with irregular menstrual cycles. This much abstinence may be too restrictive for some couples. For this reason the BBT method or barrier methods during fertile days are often recommended along with the calendar method. EXPLAIN REASONS TO RETURN Trainers should encourage the woman or couple to meet with them several times during the first few cycles to discuss their experience with the method and to receive encouragement or guidance. Also: • When they have any questions or problems with the method, • If the woman's situation changes in ways that can affect fertility signs-for example, when the woman has just had a baby, is breastfeeding, or is close to menopause, • If they stop using the method, • If they want another method. 14-14 Essentials of Contraceptive Technology [j] Following Up Helping Clients at Any Routine Return Visit ASK QUESTIONS At any return visit: 1. Ask if the client or couple has any questions or anything to discuss. 2. Ask the client or couple about their experience with the method, whether they are satisfied, and whether they have any problems. Review the couple's observations and any records of fertility signs that they have kept. Check whether they are using the method correctly. Give them any information or help they need. If they have any problems that cannot be resolved, help them choose another method. 3. Ask if the woman has had any health problems since her last visit. If she has developed any conditions that will make fertility awareness-based methods difficult to use or too unreliable (see checklist on pages 14-8 and 14-9), help the woman or couple to decide if they should choose another method. If she has developed any conditions that would make pregnancy especially dangerous (see page 4-13), help her choose a more effective method if she is willing. PLAN FOR THE NEXT VISIT If the woman or couple are satisfied with the method, encourage them to continue using fertility awareness-based methods and to continue abstaining from sex or using barrier methods during the fertile time. If they need more training, counsel them now and plan as needed for their next visit to check that they are satisfied with the method and using it correctly. FOLLOWING UP on Fertilily Awareness 14-15 Managing Any Problems For inability to abstain from sex during the fertile time: Difficulty with abstinence is the most common problem with fertility awareness-based methods. Discuss the problem openly with the couple and help them feel at ease, not embarrassed. • Discuss possible use of condoms or vaginal methods or sexual contact without vaginal intercourse that the couple can enjoy during the fertile time. • If the problem cannot be resolved and leads to marital disputes or may lead to unintended pregnancy, suggest that the couple also use condoms or spermicide or else choose another method. 14-16 Essentials of Contraceptive Technology IMPORTANT POINTS About Fertility Awareness 14-17 1. Can only highly educated couples use fertility awareness-based methods for family planning? No. Couples with little or no formal schooling can use fertility awareness-based methods effectively. All couples must be highly motivated, well-trained, and committed to avoiding sex or using withdrawal or barrier methods during the fertile time. 2. Are fertility awareness-based methods unreliable for contraception? For many women, these methods can provide reliable information about the fertile days. If the couple consistently uses periodic abstinence, withdrawal, or a barrier method during the woman's fertile time, fertility awareness-based methods can be effective. In general, however, pregnancy rates are higher among users of these methods than among women using most other methods (see page 4-20). 14-18 Essentials of Contraceptive Technology Chapter 15 Lactational Amenorrhea Method (LAM) 15-1 Chapter 15 Lactational Amenorrhea Method (lAM) Contents = Introduction to LAM [] Deciding About LAM . . . . . How Does It Work? . . . . How Effective? . . . . . . Advantages and Disadvantages Medical Eligibility Checldist . . . t:] Starting LAM . . . . . . . . . . . When to Start. . . . . . . . . . . . . Providing LAM . . . . . . . . Explaining How to Use . . [iJ Following Up . . . . . . . . . . . . Helping Clients at Any Routine Return Visit . Managing Any Problems . . . . . . . . H Important Points for the User to Remember . . t:ZJ Questions and Answers. . . . . . . . . . . . . 15-2 Essentials of Contraceptive Technology 15-3 15-4 15-4 15-4 15-4 15-6 15-7 15-7 15-8 15-9 15-11 15-11 15-12 15-14 15-15 = Introdudion to LAM • The Lactational Amenorrhea Method (LAM) is the use of breastfeeding as a temporary family planning method. ("Lactational" means related to breastfeeding. "Amenorrhea" means not having menstrual bleeding.) • LAM provides natural protection against pregnancy and encourages starting another method at the proper time. A woman is naturally protected against pregnancy when: - Her baby gets at least 85% ofms or her feedings as breast milk, and she breastfeeds her baby often, both day and night, AND - Her menstrual periods have not returned, AND - Her baby is less than 6 months old. • If she keeps breastfeeding very often, her protection from pregnancy may last longer than 6 months and perhaps as long as 9 or 12 months. • LAM makes sure that the baby gets needed nutrients and protection from disease provided by breast milk. Breastfeeding is the healthiest way to feed most babies during the first 6 months of life. Along with other foods, breast milk can be a major part of the child's diet for 2 years or more. INTRODUCTION to lactational Amenorrhea Method (lAM) 15-3 [] Deciding About lAM How Does It Work? Stops ovulation (release of eggs from ovaries) because breastfeeding changes the rate of release of natural hormones. How EHective? Effective as commonly used-2 pregnancies per 100 women in the first 6 months after childbinh (I in every 50). Very effective when used correctly and consistent!y-O.5 pregnancies per 100 women in the first 6 months after childbinh (I in every 200). IMPORTANT: Correct and consistent use means: (1) The baby gets at least 85% of his or her feedings as breast milk, and the mother breastfeeds often, both day and night, AND (2) The mother's menstrual periods have not returned, AND (3) The baby is less than 6 months old. If any of these is not true, the woman should: • Use another method for effective family planning-one that does not interfere with breastfeeding. (See page 4-8.) • Keep breastfeeding her baby if possible, even while starting to give the baby other food. Advantages and Disadvantages ADVANTAGES • Effectively prevents pregnancy for at least 6 months and maybe longer if a woman keeps breastfeeding often, day and night. • Encourages the best breastfeeding patterns. • Can be used immediately after childbirth. • No need to do anything at time of sexual intercourse. • No direct cost for family planning or for feeding the baby. • No supplies or procedures needed to prevent pregnancy. 15-4 Essentials of Contraceptive Technology • No hormonal side effects. • Counseling for LAM encourages starting a follow-on method at the proper time. • Breastfeeding practices required by LAM have other health benefits for baby and mother including: - Provides the healthiest food for the baby. - Protects the baby from life-threatening diarrhea. - Helps protect the baby from life-threatening diseases such as measles and pneumonia by passing the mother's immunities to the baby. - Helps develop close relationship between mother and baby. DISADVANTAGES • Effectiveness after 6 months is not certain. • Frequent breastfeeding may be inconvenient or difficult for some women, especially working mothers. • No protection against sexually transmitted diseases (STDs) including HWI AIDS. • If the mother has HIV (the virus that causes AIDS), there is a small chance that breast milk will pass HIV to the baby. IMPORTANT: Ask her if she might have or get a sexually transmitted . disease (STD). (Has more than one sex partner? 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 LAM, except possibly with HIV/AIDS (see checklist question 5, page 15-6). Using the Medical Eligibility Checklist The list on the next page checks whether the client can use LAM. It is not meant to replace counseling. The questions in the checklist refer to known conditions. No medical conditions rule out LAM, and LAM has no known ill effects on a woman's health. Medical conditions that prevent or limit breastJeeding, however, can limit use of LAM. Generally, you can learn of these conditions by asking the client. J0u do not usually have to perform laboratory tests or physical examinations. DECIDING About Lactational Amenorrhea Method (LAM) MEDICAL ELIGIBILITY CHECKLIST FOR Lactational Amenorrhea Method (LAM) Ask the client the questions below. If she answers NO to ALL of the questions, then she CAN use LAM. If she answers YES to a question below, follow the instructions. ONo 0 Yes" If the baby's feeding pattern has just changed, explain that she must fully or nearly fully breastfeed - day and night - to protect against pregnancy. At least 85% of her baby's feedings should be breastfeeds. If she is not fully or nearly fully breastfeeding, she cannot use LAM as effectively. Help her choose another nonhormonal method. ONo 0 Yes" If she is not breastfeeding, she cannot use LAM. Help her choose another method. A woman should not breastfeed if she is taking mood- altering drugs, reserpine, ergotamine, antimetabolites, cyclosporine, cortisone, bromocriptine, radioactive drugs, lithium, or certain anticoagulants, if her baby has a specific infant metabolic disorder, or possibly if she has active viral hepatitis. All others can and should breastfeed for the health benefits. ONo 0 Yes" Where infectious diseases kill many babies, she should be encouraged to breastfeed. HIV may be passed to the baby in breast milk, however. When infectious diseases are a low risk and safe, affordable other food for the baby is available, advise her to feed her baby that other food. Help her choose a family planning method other than LAM. (Some other infectious conditions, such as active viral hepatitis, also can be transmitted during breastfeeding.) 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. 15-6 Essentials of Contraceptive Technology Most Women Can Use LAM After Childbirth In general, most women CAN use LAM safely and effectively. * LAM can be used in any circumstances by women who: • Smoke cigarettes, • Are fat or thin. • Are young or old, Also, women with these conditions CAN use LAM in any circumstances: • Benign breast disease, • Iron deficiency anemia, • Breast cancer, • Malaria, • Headaches, • Sickle cell disease, • High blood pressure, • Gallbladder disease, • Varicose veins, • Thyroid disease, or • Valvular hean disease, • Uterine fibroids. • Diabetes, The only conditions that limit use of LAM are conditions that make breastfeeding difficult or that rule out breastfeeding (see checklist questions 4 and 5, page 15-6). *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. ~ Starting lAM When to Start Start breastfeeding as soon as possible after the baby is born. • In the first few days after childbirth, breast milk contains substances very important to the baby's health. • Early and frequent breastfeeding helps the mother produce enough milk to keep her baby well-fed and healthy. It also ensures effective protection from pregnancy. STARTING lactational Amenorrhea Method IlAM) IMPORTANT: A woman can start LAM at any time if she meets the ~ conditions required for using the method. See chart below. ~ Can a Woman Use LAM? Ask the mother, or advise her to ask herself, these 3 questions: . 1. Have your If YES The mother's chance menstrual periods ~ of pregnancy is returned? increased. For continued 2. Are you regularly protection, advise giving the baby her to begin using much other food a complementary besides breast milk If YES ~ family planning or allowing long method and periods without to continue breastfeeding, breastfeeding for either day or night? the child's health. If YES ~ ~ 3. Is your baby more ~I than 6 months old? I . But, when the If the answer to ALL answer to any ONE of these questions is NO of these questions becomes YES- . ~ She can use LAM. There is only a 1 % to 2% chance of pregnancy at this time. * *'The mother may choose to use a complementary fiunily planning method at any time, however. Providing LAM IMPORTANT: A woman who chooses LAM benefits from good ~ counseling. ~ A provider who listens to a woman's concerns, answers her questions, and gives clear, practical information about LAM, especially how to breastfeed properly and when to start a follow-on contraceptive method, will help the woman use LAM with success and satisfaction. 15-8 Essentials of Contraceptive Technology Explaining How to Use GIVE SPECIFIC INSTRUCTIONS A woman who uses LAM should be encouraged to: 1. Breastfeed often. An ideal pattern is at least 8 to 10 times a day including at least once at night. No daytime feedings regularly more than 4 hours apart, and no night feedings regularly more than 6 hours apart. IMPORTANT: Some babies may not want to breastfeed 8 to 10 . times a day and may want to sleep through the night. These ~ babies may need more encouragement to breastfeed enough. 2. Breastfeed properly. Counsel her on breastfeeding technique and diet. 3. Start other foods when the baby is 6 months old. 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 breast milk production. IMPORTANT: The baby may breastfeed less after starting to eat other foods. Therefore LAM may no longer be as effective. An additional family planning method is recommended. 4. Start another family planning method when: • Her menstrual periods return (bleeding in the first 56 days, or 8 weeks, after childbirth is not considered menstrual bleeding), OR • She stops fully or nearly fully breastfeeding, OR • Her baby is 6 months old (about the time the baby starts sitting up), OR • She no longer wants to rely on LAM for family planning. STARTING lactotional Amenorrhea Method (lAM) 15-9 If possible, give her another method now that she can start later, when needed. For example, if she has no condition that would prevent using progestin-only oral contraceptives, she can be given these pills along with instructions for taking them (see pages 6-9 and 6-10). Encourage her to return when she needs more supplies or she needs or wants another method. For more about other methods during breastfeeding, see pages 4-8 and 4-9. 15-10 Essentials of Contraceptive Technology [j] Following Up 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 breastfeeding, 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 family planning method but encourage her to continue breastfeeding as much as possible. 3. Ask if: • Her menstrual period has returned, OR • Her baby is no longer breastfeeding fully or nearly fully, OR • Her baby is 6 months old or older. If ANY of these changes has occurred, LAM no longer applies. Help her choose another method. If the new method cannot be started that day, provide enough condoms or spermicide to last until she can start her new method. 4. Ask if she has had any health problems since her last visit. • If she has started any medicines listed in question 4 on page 15-6, has active viral hepatitis, or has been infected with HIV, see answers to questions 4 and 5, page 15-6. FOLLOWING UP on Lactational Amenorrhea Method (LAM) 15-11 PLAN FOR HER NEXT VISIT If she has not developed any conditions that mean she should not use LAM: • Plan for her next visit when she will need to choose another method. If possible, give condoms and spermicide or progestin-only oral contraceptives now in case she needs them. Managing Any Problems If the client reports any problems with using lAM: 1. Do not dismiss the woman's concerns or take them lightly. 2. Give help and advice about breastfeeding technique, as appropriate, and encourage her to continue breastfeeding for the health of the baby as well as for protection against pregnancy. 3. If the woman is not satisfied with LAM after counseling and discussion, help her choose another method if she wishes. Encourage her to continue breastfeeding, even if she chooses another family planning method. Encourage her to choose a barrier method, an IUD, or a progestin-only method such as progestin-only oral contraceptives, Norplant implants, or DMPA injectable contraceptive. These methods do not appear to interfere with breastfeeding. For this problem: Not enough milk. supply Try this suggestion: Is she breastfoeding often enough? Feeding the baby more often increases milk supply. Just after childbirth she should breastfed her baby at least every 1 to 3 hours. Is she getting little sleep and rest? Is she under great stress? If so, her milk supply may decrease. Suggest that she ask relatives or friends to help with her work at home. 15-12 Essentials of Contraceptive Technology For this problem: Not enough milk supply {continued} Sore nipples Sore breasts Try this suggestion: Has she been eating and drinking enough? She should drink plenty of fluid every day and eat plenty of healthy food. Are her nipples cracked? If so, assure her that they will heal. She can continue breastfeeding. To aid in healing, she should: • Feed more often, starting on the less sore nipple. • Let her nipples dry in the air after breastfeeding. She may not be holding the baby in the right position. Advise her on proper breastfeeding techniques. Examine for signs of thrush (fungus infection). Does she have a fever and foel tired? Are her breasts red and tender? Her breasts may be infected. Treat with antibiotics according to clinic guidelines. Advise her to: • Continue breastfeeding often. • Get more rest. If no signs of infection, are her breasts tender only in certain places? Do they have lumps? Are they foIl hard, and tender? These signs may point to plugged milk ducts or engorgement (congestion). Advise her to: • Vary her position when breastfeeding. • Get more rest. She may not be holding the baby in the right posi- tion. Advise her on proper breastfeeding techniques. Explain signs of infection and tell her to return right away if she sees those signs-fever, fatigue, red and tender breasts. FOLLOWING UP on Lactational Amenorrhea Method (lAM) 15-13 15-14 Essentials of Contraceptive Technology 1. Is LAM an effective method of family planning? Yes. Breastfeeding is effective if the woman's monthly menstrual period has not returned, she is fully or nearly fully breastfeeding, and her baby is less than 6 months old. 2. When should a mother start giving her baby other foods besides breast milk? Usually when the baby is 6 months old. When women start giving other foods, they should always breastfeed before offering the other foods. Then the baby's hunger is first satisfied by breast milk. Also, frequent breastfeeding encourages milk production. Along with other foods, breast milk can be a major part of the child's diet for 2 years or more. 3. If the mother has AIDS or is infected with HI¥, the AIDS virus, can the baby get it from the mother's milk? Yes. There is a small chance that a mother can pass the virus to her baby through her breast milk. Still, in most of the world babies are more likely to die because of infectious diseases than from HIV in breast milk. Unless she can always get suitable food for her baby, a woman with HIV should fully breastfeed her baby if she can. The World Health Organization (WHO) advises that, where infectious diseases kill many infants, women infected with HIV should breastfeed to pass immunities to their babies. Where risk of infectious disease is slight and other safe, affordable food is available, WHO advises infected women to use the safe alternative. QUESTIONS & ANSWERS About loctotionol Amenorrheo Method (lAM) 15-15 Chapter 16 Sexually Transmitted Diseases Including HN/AIDS 16-1 Chapter 16 Sexually Transmitted Diseases Including HNIAIDS Contents Introduction to Sexually Transmitted Diseases 16-3 Family Planning Providers and STDs . 16--4 Why Should Family Planning Providers Know About STDs? . . . . . . . . . . . . . . . . 16--4 How Can Health Care Providers Help Fight STDs? . 16--4 Dealing with STDs . 16-6 Checklist for Recognizing STD Risk 16-6 Preventing STDs . 16-8 Recognizing STDs . 16-8 Getting Treated . . . . . 16-9 Dealing with HN and AIDS . 16-10 What Are HN and AIDS? 16-10 How Is HN Carried and Spread? 16-10 How Can HIV/AIDS Be Prevented? 16-11 Symptoms and Likely Diagnosis of Common STDs and Other Genital Infections. . . . . . . . . . . . . . . 16-12 Treatments for Common STDs and Other Genital Infections. . . . . 16-17 Important Points for the Client to Remember 16-22 16-2 Essentials of Contraceptive Technology Introduction to Sexually Transmitted Diseases Sexually transmitted diseases (STDs) are diseases that can spread from one person to another by sexual contact. STDs can cause pain, and some can cause infertility and death if not treated. Some common curable STDs are gonorrhea, trichomoniasis, chlamydial infection, and syphilis. AIDS refers to Acquired Immune Deficiency Syndrome. AIDS is caused by the human immunodeficiency virus (HIV). HN can be transmitted by sexual contact, by blood, and from a pregnant woman to her child during pregnancy, childbirth, or, occasionally, by breastfeeding. As of 200 1 AIDS has no definite cure. Treatments have improved the quality and length oflife for people with HNI AIDS, however. Each year there are more than 333 million new cases of curable STDs, 1 million new cases of HN infection, and millions of other viral STDs such as herpes and hepatitis B. STDs are more common than malaria. INTRODUCTION to Sexually Transmitted Diseases ISTDs) 16-3 Family Planning Providers and STDs Why Should Family Planning Providers Know About STDs? • STDs are common. They cause much suffering and disability. All health care providers have a responsibility to do what they can about STDs. • Family planning clients may ask about changes or conditions of their sex organs. These could be signs of STDs or other reproductive tract infections. To help clients, providers should recognize signs of STDs and either promptly treat or refer for treatment. • Providers can recognize STD risk (see pages 16-6 and 16-7), and they can recommend and teach STD prevention. • Women who currently have an STD or are likely to get an STD should not use IUDs. Providers should diagnose and treat known STDs before inserting an IUD. (See Chapter 12.) • Men and women who have several sex partners have more chances of getting STDs. Sex workers and the clients of sex workers are most likely to get STDs. Female sex workers also usually want to avoid pregnancy, and so they may come to family planning providers. Reaching the people at greatest STD risk is an important way to limit the spread of these diseases. How Can Health Care Providers Help Fight STDs? All health care providers, including family planning providers, can do something to fight STDs. Some ways to fight STDs are listed here. Programs and providers can choose ways that fit their resources, their clients' needs, and available services for referral. • Routinely tell clients how to prevent STDs and how to know if they have an STD (see pages 16-6 and 16-7). Find or make posters or signs, too. 16-4 Essentials of Contraceptive Technology • Encourage people to seek care if they suspect infection or if they develop symptoms, and tell them where to find care. • Ask standard questions to find out if clients are likely to get an STD. See checklist, page 16-6. • Encourage people who might get STDs to use condoms or, if condoms are not possible, sperinicide--even if they also use another family planning method. • Make condoms available--free, if necessary. In some countries, social marketing programs may be able to provide condoms for sale at low prices. • If you cannot provide them, find out where condoms are available in the community, and tell clients. If condoms are not available, try to talk with shop owners about selling them, or find another supplier. • Learn which STDs are common in your area, know their symptoms, and recognize them among your clients. • Offer diagnosis and treatment, if possible. If not, arrange for referral. • Know and use good infection-prevention techniques in the clinic because many STDs can be spread in body fluids, especially blood. (See page 4-10.) • Help educate the community. Mass-media and person-to-person programs help clients recognize their risk and change their sexual behavior. They also can encourage people to seek treatment. FAMILY PLANNING PROVIDERS and STDs 16-5 Dealing with STDs Because family planning clients usually are sexually active people, they need to know about STDs. They need to know: • If they risk getting STDs, • How to prevent STDs. And, if they risk getting STDs, they also need to know: • How to recognize STD symptoms, and • How to get treated for STDs. Checklist for Recognizing STD Risk Answering these questions can help a person recognize if he or she is likely to get STDs. The answers also can guide the family planning provider: If the client is likely to get STDs, the client needs a supply of condoms and possibly spermicide and also counseling about avoiding STDs, recognizing possible symptoms, and getting treatment if symptoms appear. If the client has any symptoms, the client also needs diagnosis and treatment, or referral. Sex workers and their clients face the highest risk of getting STDs. Among people with lower risk, in many countries STD rates are highest among people under age 20. ~ Ask the client the questions below. * 1. Do you have more than one sex partner? Does your partner? Have you or your partner had any other sex partners in the last several months? If so, do you sometimes have sex without a condom? Could this happen in the future? o No 0 Yes *NOTE: Question 1 alone does not panicularly help to tell if a person without symptoms already HAS an STD. In women, many STDs do not always cause obvious symptoms. Also, conditions in women that are not STDs may have the same symptoms as STDs. By comparison, in men STDs are usually easier to detect. Men are more likely to have symptoms, and there are fiewer other possible causes. 16-6 Essentials of Contraceptive Technology ., If YES to question 1, the client may be likely to get an STD. Urge the client to use condoms, try to have a mutually faithful relationship, or abstain (see "Preventing STDs," next page). If YES to question 1, go on to ask questions 2 and 3. FORAWOMAN 2. Do you have any of the following? • Unusual discharge from your vagina? o No 0 Yes • Itching or sores in or around your vagina? o No 0 Yes • Pain or burning when you urinate? o No 0 Yes FORA MAN 2. Do you have any of the following? • Pain or burning when you urinate? o No 0 Yes • Open sores anywhere in your genital area? o No 0 Yes • Pus coming from your penis? o No 0 Yes • Swollen testicles or penis? o No 0 Yes 3. Do you think your sex partner might have an STD? Does he/she have open sores anywhere in the genital area? Does he have pus coming from his penis? OR Does she have an unusual discharge from her vagina? ., If YES to any parts of question 1 and either 2 or 3, these symptoms may be caused by an STD. Diagnose and treat, or refer. Urge that the client avoid sex until 3 days after treatment is done and symptoms are gone. Urge these clients to bring or send their sex partners for care. DEAUNG WITH SIDs 16-7 Preventing STDs People can avoid STDs by changing their sexual behavior. They can follow any of the ABCs-Abstain, Be mutually faithful, and Consistently Use Condoms: El Abstain from sex. This is the only guaranteed protection. or 11 Be mutually faithful. Always have sex with the same person. or This person also must not have sex with anyone else and must not have an STD. IMPORTANT: You usually cannot tell if a person has an STD just by looking at him or her. People with STDs, including ~ HIV, usually do not look sick. B Consistendy Use Condoms. Use them every time and use them correctly. To prevent STDs, people at risk should use condoms even when they use another family planning method. If a woman's sex partner will not use condoms, she should try to use spermicide. Spermicides may not stop HNI AIDS, however. The diaphragm and cervical alp also may help prevent some STDs somewhat. (See Chapter 11- Condoms, and Chapter 13-Vaginal Methods.) Recognizing STDs People who might get an STD need to know: • The common signs and symptoms of STDs, • Where to seek care if symptoms appear, • To protect their sex partners by avoiding sex if symptoms appear. Common symptoms of STDs are listed in question 2 of the checklist on page 16-7. For more information about symptoms, see pages 16-12 through 16-16. Any of these symptoms could mean STD infection. These symptoms might have other causes, however, especially in women. Some people, especially women, may have no symptoms at all, especially early in the infection. They can still give the infection to their sex parmers, however. 16-8 Essentials of Contraceptive Technology Geffing Treated Many STDs can be treated and cured, especially in their early stages. Some, such as HN and herpes, cannot be cured, but sometimes their effects can be stopped for a time. Prevention is better than treatment, however. Even when the STD itself is cured, sometimes scarring or infertility can follow. A person who thinks that she or he may have an STD should: 1. Get diagnosed and treated immediately. 2. Take all of the medicine according to instructions, even if symptoms go away. The medicine can cause some side effects such as vomiting, diarrhea, or a rash. If any of these side effects occurs and is severe, the person must return to the clinic that provided the medicine. All of the medicine must be taken for a lasting cure. 3. Avoid sex with anyone until 3 days after treatment is finished and all symptoms are gone. 4. Tell his or her sex partner or partners so that they can get treated, too. Unless all sex partners are treated at the same time, they will infect each other again and again. It is especially important that a man tell a woman. This is because many women do not have symptoms until the STD has reached a more serious stage. 5. If friends have symptoms, urge them to seek care. Urge them not to have sex until they are treated. If friends have multiple sex partners, urge them to use condoms and/or spermicide and to see a health care provider for a check-up. For more information about treatment, see pages 16-17 to 16-21. DEAUNG WITH STDs 16-9 Dealing with HIV and AIDS What Are HIV and AIDS? HIV is the virus that causes AIDS. AIDS reduces the body's ability to fight other diseases. People with HIV/AIDS get sick very easily with certain diseases, such as pneumonia, tuberculosis, and diarrhea. Most people with AIDS die from diseases that their bodies no longer can fight. A person who does not look sick can still pass HIV to others. A person may have HIV for years before any symptoms appear. Other STDs increase a person's chances of getting HIV or spreading it to others. Clients with STDs need to seek treatment and, if possible, to be tested for HIV and counseled. How Is HIV Carried and Spread? HIV is carried in body fluids. The most important are: • Semen, • Blood, • Vaginal fluid. HIV can be spread through: • Vaginal sexual intercourse, • Anal intercourse, • Sharing intravenous needles with an infected person, • Transfusions of infected blood, • Other activities that allow semen, blood, or vaginal fluid to enter the mouth, anus, or vagina or to touch an open cut or sore. • A pregnant woman with HIV is able to pass HIV to her fetus during pregnancy or childbirth. Sometimes, a woman passes HIV to her baby through her breast milk. Still, where many babies die from infectious diseases, women with HIV should breastfeed their babies. HIV is not spread by kissing, shaking hands, or sharing food, dothing, or toilets. 16-1 0 Essentials of Contraceptive Technology How Can HIV I AIDS Be Prevented? HIV/AIDS can be prevented in the same way that other STDs are prevented. Follow the ABCDs: El Abstain from sex. or I] Be mutually faithful. Have sex with only one partner, who also is not infected. This person also must not have sex with anyone else and must not share hypodermic needles with others. or B Consistently use Condoms. ALSO m Do not use a hypodermic needle that has not been sterilized or soaked in bleach. Symptoms and Likely Diagnosis of Common STDs and Other Genital Infections Infections That Cause Painful Urination or Unusual Genital Discharge Ukely Diagnosis Gonorrhea and/or chlamydia Difficult to diagnose. For treatments, see pages 16-17 and 16-18. Typical Symptoms Fora woman: • Unusual vaginal discharge. • Unusual vaginal bleeding. • Lower abdominal pain. A woman can have gonorrhea or chlamydial infection for several months without symptoms. For a man: • Painful urination. • Drops of pus from his penis. In men symptoms usually appear soon afrer infection. Without treatment, gonorrhea and chlamydial infection can cause sterility. If an infected woman gives binh, her baby could get infected and go blind unless treated. 16-12 Essentials of Contraceptive Technology Likely Diagnosis Trichomoniasis For treatments, see page 16-18. Bacterial vaginosis A common infection, not sexually transmitted. Can come from douching, pregnancy, or antibiotics. Treatments same as for trichomoniasis. See page 16-18. Candidiasis Rarely sexually transmitted. A very common genital infection. For treatments, see page 16-18. Typical Symptoms Fora woman: • Vaginal burning and itching. • Foamy, green-yellow fluid with a bad smell from the vagina. • Pain or burning when urinating. Fora man: • Watery, white fluid from the penis. • Pain or burning when urinating. For a woman: • Gray, sticky fluid from the vagina (with a fishy smell especially after sex). For a woman: • Intense vaginal burning and itching. • Clumpy white fluid in and around the vagina. For a man: • Itchiness of the genitals. • White fluid under the foreskin (if uncircumcised). SYMPI'OMS and LIKELY DIAGNOSIS cl Common SIDs and Other Genoollnfections 16-13 STDs That Cause Sores on the Genitals Ukely Diagnosis Syphilis An inexpensive screening test for syphilis is widely available. For treatments, see page 1~19. Chancroid For treatments, see page 1~20. Typical Symptoms • Painless sore on the penis, vagina, or anus. Sore may last only a few days, usually goes away without treatment, and women may not notice it. But the disease keeps spreading throughout the body. • Weeks or months later, the person may have: - Sore throat, - Skin rashes, and/or - Mild fever. All these symptoms may disappear. Without treatment, however, syphilis causes heart disease, paralysis, insanity, and even death. A pregnant woman can pass syphilis to her fetus before birth. • Soft, painful sore on penis, vagina, or anus. • Swollen lymph nodes in the groin that contain pus, may open and drain pus, and scar up. In women, symptoms may not appear or may be difficult to notice. 16-14 Essentials of Contraceptive Technology Likely Diagnosis Lymphogranuloma venerewn For treatments, see page 16-20. Genital herpes For treatments, see pages 16-20 and 16-21. Granuloma inguinale (donovanosis) For treatments, see page 16-21. Typical Symptoms Early: • Swollen lymph nodes in the groin that may open and drain pus. Very common in men. Less common in women. • Painful, oozing sores around the anus. More common in women than in men. Late: • Enlarged genitals, abscesses around the anus, narrowed rectum, anal fistula. • One or more very painful small blisters around the vagina, on the penis, or around the anus. • Blisters burst open and dry up to become scabs. Sores can last for 3 weeks or more with first infection and then disappear. • New blisters usually appear from time to time because the virus stays in the body. Blisters last a shorter time than on first infection. • Lumps under the skin in the genital area, most often between the scrorum and thighs on men or between the labia and vagina on women. • Lumps grow, then break down into beefy, red ulcers. • Ulcers are painless but bleed when touched. If not treated, can lead to destruction of the genital organs. SYMPTOMS and UKELY DIAGNOSIS of Common SIDs and Other GenHallnfeclions 16-15 STD That Causes Warts Likely Diagnosis Genital human papillomavirus (HPV) An STD caused by a virus. Certain subtypes are responsible for most cases of cervical cancer. For treatment, see page 16-21. Typical Symptoms • Warts on or near penis, vagina, or anus. Warts may not appear or may be difficult to notice. 16-16 Essentials of Contraceptive Technology Treatments for Common STDs and Other Genital Infections These treatments are based largely on the 2001 recommendations of the World Health Organization. IMPORTANT: Various treatments are listed below. For the appropriate likely . diagnosis, choose ONE treatment from the list. Choose a treatment known to be . effective in your area. Consult supervisors if you are not sure. You can place an X or V' in a box (D) to mark the appropriate treatment for your area. Gonorrhea and/or chlamydial infection If possible, test, or refer patient to a convenient place for test and treatment. (Gonorrhea test alone is useful because it may rule out that disease.) If not possible to test, both gonorrheaand chlamydial infection can be treated at the same time. Gonorrhea treatments (choose ONE) D Ciprofloxacin, 500 mg tablet by mouth as a single dose. (Do NOT give to pregnant or breastfeeding women or people under age 18.) D Ceftriaxone, 125 mg intramuscular injection as a single dose. D Cefixime, 400 mg by mouth as a single dose. D Azithromycin, 2 g by mouth as a single dose. D Spectinomycin, 2 g intramuscular injection as a single dose. Treatments that may be useful in countries where the disease is not commonly resistant to these medications: D Kanamycin, 2 g intramuscular injection as a single dose. D Trimethoprim, 80 mglsulphamethoxazole, 400 mg; 10 tablets by mouth daily for 3 days. (Do not give to pregnant women. OK for breastfeeding women if infants are healthy, full-term, and more than one month old.) In most areas of the world, penicillin and tetracycline are no longer effective against gonorrhea . . Tell patient to avoid sex until treatment is completed and symptoms are gone. Urge that sex partner(s) get treated. Treatments for chlamydial infection (choose ONE) D Azithromycin, 1 g by mouth as a single dose. TREATMENTS for Common SIDs and Other Genital Infections 16-17 o Doxycycline, 100 mg by mouth 2 times daily for 7 days. (Do NOT give to pregnant or breastfeeding women.) o Amoxicillin, 500 mg by mouth 3 times daily for 7 days. o Erythromycin, 500 mg by mouth 4 times daily for 7 days. o Ofloxacin, 300 mg by mouth 2 times daily for 7 days. (Do NOT give to pregnant or breastfeeding women.) o Tetracycline, 500 mg by mouth 4 times daily for 7 days. (Do NOT give to pregnant or breastfeeding women.) Treatment for pregnant or breastfeeding women: o Amoxicillin, 500 mg by mouth 3 times daily for 7 days. o Erythromycin, 500 mg by mouth 4 times daily for 7 days . . Tell patient to avoid sex for 7 days after treatment starts. Urge that sex partner(s) get treated. Trichomoniasis/Bacterial vaginosis treatment o Metronidazole, 2 g by mouth as a single dose, or 400 or 500 mg by mouth 2 times daily for 7 days. (Do NOT give metronidazole to pregnant women during the first three months of pregnancy. Use the single-dose treatment after the third month.) . Tell patient not to drink alcohol while taking metronidazole. It may cause nausea and vomiting. Urge that sex partner(s) get treated. Tell patient to avoid sex until treatment complete, symptoms are gone, and partners' symptoms are gone. Pelvic inflammatory disease treatment Treat for a range of pathogens: Any single-dose treatment for gonorrhea (see page 16-17); AND doxycycline, 100 mg by mouth 2 times daily for 14 days, or tetracycline, 500 mg by mouth 4 times daily for 14 days; AND metronidazole, 400 or 500 rng by mouth 2 times daily for 14 days. (See also pages 12-19 to 12-20.) (See instructions for doxycycline, tetracycline, and metronidazole above.) Candidiasis treatments (choose ONE) For women: o Miconazole. 200 mg suppository inserted in vagina once daily for 3 days. o Clotrimazole, 500 mg tablet inserted in vagina as a single dose; or two 100 mg tablets inserted in vagina once daily for 3 days. 16-18 Essentials of Contraceptive Technology o Fluconazole, 150 mg by mouth as a single dose. (Do NOT give to pregnant women.) o Nystatin, 100,000 unit tablet inserted in vagina once daily ror 14 days. For men: o Nystatin, miconazole, or dotrimazole cream or ointment, applied to infected atea 2 times a day for 7 days. Syphilis treatments For early disease - primary , secondary, or latent syphilis of 2 years or less (choose ONE) For anyone without penicillin allergy: o Benzathine penicillin G, 2.4 million units total, in 2 intramuscular injections during 1 dinic visit; give 1 injection in each buttock. o Procaine penicillin G, 1.2 million units in 1 intramuscular injection once daily for 10 consecutive days. Allergic to peniciUin* (men and nonpregnant women only): o Doxycycline, 100 mg by mouth 2 times daily for 15 days. o T etracydine, 500 mg by mouth 4 times daily for 15 days. Allergic to peniciUin (pregnant women only): o Erythromycin, 500 mg by mouth 4 times daily for 15 days. Not highly effective. Urge these women to bring their babies within 7 days after birth for treatment for congenital syphilis . . Urge that sex partner(s) get treated. Late latent syphilis or latent syphilis of unknown duration (choose ONE) For anyone without penicillin allergy: o Benzathine penicillin G, 7.2 million units total, administered as intramusculat injections in 3 doses of2.4 million units each at I-week intervals. o Procaine penicillin G, 1.2 million units in 1 intramusculat injection once daily for 20 consecutive days. Allergic to penicillin (men and nonpregnant women only): o Same as for early disease but treat for 30 days rather than 15 days. Allergic to peniciUin (pregnant women only): o Same as for eatly disease but treat for 30 days rather than 15 days. *Typical symptoms of true allergy to penicillin are the symptoms of anaphylaxis, including severe fucial swelling, widespread itching and hives, difficulty breathing and swallowing, sudden drop in blood pressure, weak and rapid pulse, nausea, vomiting, abdominal cramp" diarrhea, confusion, dizziness, and possible loss of ronsciousness. Symptoms occur within 20 minuteS after penicillin injection. In gene.ra/, tteatment involves maintaining an airway and giving oxygen and epinephrine. TREATMENTS for Common SIDs and Other Genitollnfecfions 16-19 Early congenital syphilis - up to 2 years of age (choose ONE) D Procaine penicillin G, 50,000 units per kg of body weight, as one intramuscular injection daily for 10 days. D Aqueous benzylpenicillin, 100,000 to 150,000 units per kg of body weight per day, given as 50,000 units/kg intravenously every 12 hours for the first 7 days of life and every 8 hours thereafter for the next 3 days. If more than 1 day of treatment is missed, the entire course should be resrarted. Chancroid treatment (choose ONE) D Azithromycin, 1 g by mouth as a single dose. D Erythromycin, 500 mg by mouth 4 times daily for 7 days. D Ciprofloxacin, 500 mg by mouth 2 times daily for 3 days. (Do NOT give to pregnant or breastfeeding women or people under age 18.) D Ceftriaxone, 250 mg intramuscular injection as a single dose . . Re-examine in 3 to 7 days. Sex partner(s)--even those with no symptoms-- should be treated if they had sex: with patient within 10 days before patient's symptoms srarted or since symptoms started. Lymphogranuloma venereum treatment (choose ONE) D Doxycycline, 100 mg by mouth 2 times a day for 14 days. (Do NOT give to pregnant Of breastfeeding women.) D Erythromycin, 500 mg by mouth 4 times a day for 14 days. D Tetracycline, 500 mg by mouth 4 times a day for 14 days. (Do NOT give to pregnant or breastfeeding women.) . Urge that sex partner(s) be tested and treated. Genital herpes treatment . Clients should not have sex when blisters are present-not even with a condom. Herpes can be spread even when no blisters are present, but a condom may provide some protection. No cure available. The client should keep the infected area clean and try not to touch the sores. Antibiotic ointments may help. Duration of symptoms can be shortened if treatment begins early in an outbreak. If not started early, treatment may be ineffective. 16-20 Essentials of Contraceptive Technology For a first outbreak give (choose ONE) o Acyclovir, 200 rng by mouth 5 times daily ror 7 days, or 400 rng 3 times daily ror 7 days. o Famciclovir, 250 mg by mouth 3 times daily for 7 days. o Valaciclovir, 1 g by mouth 2 times daily for 7 days. For recurrences of blisters, give (choose ONE) o Acyclovir, 200 mg by mouth 5 times daily for 5 days, or 400 mg 3 times daily for 5 days, or 800 mg 2 times daily for 5 days. o Famciclovir, 125 mg by mouth 2 times daily for 5 days. o Valaciclovir, 500 mg by mouth 2 times daily for 5 days, or 1000 mg as a single dose for 5 days. If the client has outbreaks 6 or more times a year, give (choose ONE) o Acyclovir, 400 mg by mouth 2 times daily. o Famciclovir, 250 mg by mouth 2 times daily. o Valaciclovir, 500 mg by mouth daily as a single dose, or 1000 mg daily as a single dose. Treat for 1 year and then reassess. ~ Urge that sex partners be evaluated and counseled and, if they have symptoms, treated. ~ A woman with herpes can infect her baby during childbirth. This is very dangerous for the baby and requires medical attention. Granuloma inguinale (donovanosis) treatment (choose ONE) o Azithromycin, 1 g by mouth on the first day, then 500 mg daily as a single dose until sores heal. o Doxycycline, 100 mg by mouth 2 times daily until sores heal. (Do NOT give to pregnant or breastfeedingwomen.) o Erythromycin, 500 mg by mouth 4 times daily until sores heal. o Tetracycline, 500 mg by mouth 4 times daily until sores heal. (Do NOT give to pregnant or breastfeeding women.) o Trimethoprim, 80 mglsulfamethoxawle, 400 mg, 2 tablets by mouth twice daily until sores heal (at least 14 days). (Do not give to pregnant women. OK for breastfeeding women if infants are healthy, full-term, and more than one month old.) ~ Urge that sex partner(s) with symptoms get treated. Human papilloma virus (HPV) treatment No cure available. Can be treated chemically or surgically for cosmetic purposes. If warts grow rapidly, check for HN infection. TREATMENTS for Common SIDs and Other Genital Infections 16-21 16-22 Essentials of Contraceptive Technology WHO Medical Eligibility Criteria for Starting Contraceptive Methods The table on the following pages summarizes World Health Organization (WHO) medical eligibility criteria for starting contraceptive methods. These criteria are the basis for the Medical Eligibility Checklists in Chapters 5 through 15. WHO Categories for Temporary Methods WHO 1 Can use the method. No restriction on use. WHO 2 Can use the method. Advantages generally outweigh theoretical or proven risks. Category 2 conditions could be considered in choosing a method. If the client chooses the method, more than usual follow-up may be needed. WHO 3 Should not use the method unless a doctor or nurse makes a clinical judgement that the client can safely use it. Theoretical or proven risks usually outweigh the advantages of the method. Method of last choice, for which careful follow-up will be needed. WHO 4 Should not use the method. Condition represents an unacceptable health risk if method is used. Simplified 2-Category System Where a doctor or nurse is not available to make clinical judgements, the WHO 4-category classification system can be simplified into a 2-category system as shown in this table: WHO Category With Clinical Judgement With Limited Clinical Judgement Use the method NOTE: In the table that follows, Category 3 and 4 conditions are shaded to indicate the method should not be provided where clinical judgement is limited. WHO Categories for Female Sterilization and Vasectomy Accept No medical reason prevents performing the procedure in a routine setting. Caution The procedure can be performed in a routine setting but with extra preparation and precautions. Delay Delay the procedure. Condition must be treated and resolved before the procedure can be performed. Provide temporary methods. Refer Refer client to a center where an experienced surgeon and staff can perform the pro- cedure. Setting should be equipped for general anesthesia and other medical support. Provide temporary methods. (WHO calls this category "Special.") NOTE: In the table that follows, "Delay" and "Refer" conditions are shaded. Appendix WHO MEDICAL ELIGIBILITY CRITERIA A-l t m Cl> Cl> (I) a cl" u;- a. () o :::l a- n (I) "£. ~. ~ n ::r :::l o c8 '< » "0 "0 (I) :::l 0. x' W H O M ed ic al E lig ib ili ty C rit er ia fo r St ar tin g Co nt ra ce pt iv e M et ho ds Zl g > - z j c . . . . . ~ . . . . 5 c 1l . . .,g > - z "E E c ~ ~ . " ' :l ~ :s "' I - ;;= E " " '" l: ~ ~ il: C O N D IT IO N 0 ,n~ . !! ~ U C Z . . '" 2 2 2 I C au tio n A cc ep t C :J , '" - rl §, ~ - < = B E = 0 '" .~ l] . . . '? c " i" ~ 0 U . . . . - "' U . . '" C U ~i . ~ ~. c l. f~ - < il ~l : .~ g] = 1 'E u "' - ~' " .!3 ~~ N A : n o t a pp lic ab le to de ci si on to u se m e th od . a St er ili za tio n is a pp ro pr ia te fo r w o m e n a n d m e n o f a n y ag e, bu t o n ly if th ey a re su re t he y w ill n o t w a n t ch ild re n in th e fu tu re . b Th is c o n di tio n m ay a ffe ct o v a ria n fu nc tio n a n d/ or c ha ng e fe rti lit y sig ns a n d sy m pt om s a n d/ or m a ke m et ho ds d iff ic ul t t o le ar n a n d u se . c Sh or tly a fte r m e n a rc he (a ge a t fir st m en st ru al b le ed in g) a n d as m e n o pa us e a pp ro ac he s, m en st ru al c yc le s m ay b e irr eg ul ar . d H ig he r ty pi ca l f ai lu re r at es o f t hi s m e th od m ay e x po se th e u se r to a n u n a c c e pt ab le ri sk o f da ng er ou s u n in te nd ed pr eg na nc y. e W ith o r w ith ou t v as cu la r di se as e. B re as tfe ed in g m ay n o t be re c o m m e n de d w ith d ru gs u se d to t re at th is c o n di tio n. - Co nd iti on n o t lis te d by W H O fo r th is m et ho d; d oe s n o t af fe ct e lig ib ili ty fo r m e th od u se . ~ "U <D ::s a. x' ~ o ~ III Si! n ~ III ~ i! !: ~ n ~ =i III ~ • t w Ca te go ry 3 o r 4, d ep en di ng o n t he s ev er ity o f t he c o n di tio n. Ri sk f ac to rs fo r ar te ria l di se as e, s u ch a s ag e, sm o ki ng , d ia be te s, hi gh bl oo d pr es su re . Ci rc ul at or y di se as e du e to bl oo d cl O Is . LA M h as n o im pa ct o n t hi s co n di tio n, b ut th e co n di tio n m ay r u le o u t b re as tfe ed in g. k U _ . . ,. !'s ea se d ue to al te rie s. m n Fo ca l n eu ro lo gi ca l sy m pt om s = bl ur re d v isi on , te m po ra ry lo ss o f v isi on , se e s fla sh in g lig ht s o r z ig za g lin es , o r ha s br ie f tr ou bl e sp ea ki ng o r m o v in g. o R eg ar dl es s o f a ge . P Th is co n di tio n m ay m a ke th e c a le nd ar m et ho d di ffi cu lt o r im po ss ib le to u se e ffe ct iv el y. :r J:>,. m Cl> Cl> (1) ::::I g- iP Q. () o ::::I a- n (1) - q ~. ~ n ~ ::: :I o c8 "< » -0 "R ::::I 0. x· W H O M ed ic al E lig ib ili ty C rit er ia fo r St ar tin g Co nt ra ce pt iv e M et ho ds (c on tin ue d) :l ~ c g > - z . 0 c '" . ~ c . . . is . :2 , . . . . ~" 8 ~ I- . § c Kl !i - " ' < 1 . . . . 2 > - ~ :> ! 5, ~ ~ " f:: :!- ~ ] ~~ E E c .~ = u l!" 'B &1 ~g -g :s tl = . . .~ ~" : 1 9 e- " ' ii: i ! . . . '? 1-. ~ - e" 'o C C O N D IT IO N :I! E ~ c " 8- . € = " , 2 = ~ . - '" j~ j 0 z . . '" v '" Q v . f . . . ev id en ce o f d is ea se in b Th is co n di tio n m a y a ffe ct o v a ria n fu nc tio n a n d/ or ch an ge fe rti lit y sig ns a nd sy m pt om s a n d/ or m a ke m et ho ds d iff ic ul t t o le ar n an d us e. d H ig he r t yp ic al fa ilu re ra te s o f t hi s m e th od m ay ex po se th e us er t o an u n a cc e pt ab le ri sk o f da ng er ou s u n in te nd ed pr eg na nc y. Br ea st fe ed in g m ay n o t b e re co m m e n de d w ith d ru gs us ed to tr ea t t hi s co n di tio n. LA M h as n o im pa ct o n th is co n di tio n, b ut th e co n di tio n m ay r u le o u t br ea st fe ed in g. r Ce rv ica l c ap n o t re co m m e n de d. s In cl ud in g e n do m et rit is (in fla mm ati on o f t he lin in g o f t he u te ru s) fo llo w in g ch ild bi rth o r a bo rti on . C on di tio n do es n o t a ffe ct va gi na l b le ed in g pa tte rn s; c a le nd ar m e th od c an b e us ed . U Ba rri er m e th od s, e sp ec ia lly c o n do m s, a re a lw ay s re co m m e n de d fo r pr ev en tio n o f S TD s, in cl ud in g H IV /A ID S. v Pu ru le nt c er vi ci tis = a pu s- lik e di sc ha rg e fro m th e o pe n i ng o f t he c e rv ix . - Co nd iti on n o t l ist ed b y W H O fo r t hi s m e th od ; do es n o t a ffe ct e lig ib ili ty fo r m e th od u se . » " tl al ;, c. x· ~ o ~ III g n ~ III ~ Ci) ii ~ :i n 2!! RI ~ t W In a re as w he re S TD in ci de nc e is hi gh , v ag in itis m ay in di ca te a n S TD . x Fo r e x a m pl e, c u rr e n tly ha s o r w ill h av e m o re th an o n e s ex p ar tn er o r a pa rtn er w ho h as m o re th an o n e p ar tn er . y Th er e is a po te nt ia l in cr ea se d ris k o f u rin ar y tr ac t in fe ct io n w ith di ap hr ag m s an d sp er m ic id es . z Fo r IU D s, H IV ·in fe ct ed o r a n y o th er m ed ic al c o n di tio n o r m e di ca tio n th at m ak es th e bo dy le ss a bl e to fi gh t i nf ec tio n. aa I n ar ea s w he re in fe ct io us di se as e is th e m a in c au se o f i nf an t d ea th , H IV - in fe ct ed w o m e n s ho ul d be a dv is ed to b re as tfe ed . In o th er a re as , if af fo rd ab le a lte rn at iv es to br ea st m ilk a re a v ai la bl e, H IV -in fe ct ed w o m e n sh ou ld n o t br ea st fe ed . ab H ig h do se o f n o n o x yn ol ·g s pe rm ic id e m a y ca u se v ag in al a br as io ns , w hi ch m ay in cr ea se ri sk o f H IV in fe ct io n. ac U te rin e fib ro id s di sto rti ng th e u te rin e c a v ity ; o th er w is e ca te go ry 1 . ad S ev er e o be si ty m ay m a ke di ap hr ag m o r c a p pl ac em en t d iff ic ul t. - Co nd iti on n o t lis te d by W H O fo r t hi s m et ho d; do es n o t af fe ct e lig ib il ity fo r m e th od u se . :r I W H O M ed ic al E lig ib ili ty C rit er ia fo r St ar tin g Co nt ra ce pt iv e M et ho ds (c on tin ue d) 0- m Cl> Cl> ID a ,r u ;- Q. n o a a o ID - g. ~. ~ o ~ :::l o c8 -< » " 0 ~ :::l CL x' C O N D IT IO N Th yr oi d Si m pl e go ite r H yp er th yr oi d H yp ot hy ro id Th al as se m ia < in he rit ed a n em ia ) Tr op ho bl as t d ise as e Be ni gn M al ig na nt Si ck le ce ll di se as e Co ag ul at io n <b loo d cl ot tin g) di so rd er s Iro n de fic ie nc y an em ia H em og lo bi n 7 g/ dl -l O g /d l H em og lo bi n les s th an 7 g /d l Ep ile ps y Sc hi sto so m ia sis W ith ou t c o m pl ic at io ns W ith fi br os is o f t he li ve r W ith s ev er e fib ro si s o f t he li ve r M al ar ia g -g C :s E Q v 1 1 1 1 1 1 2 - 1 1 1 1 1 • 1 II C >- z . c . . . C . ~ t;; . E C Q z C - ::: .~ ~ ~. ~ . . !! '" e- n s: : O Il" , ~ ~ ~ ,n~ Q "- ~ c z 1 1 1 Ac ce pt 1 1 1 f~ f~ 1 1 1 Ca uti on 1 1 1 Ca uti on 1 1 1 Ac ce pt 1 1 1 ~~ f 1 1 1 Ca uti on - - - • 1 1 1 Ca uti on 1 1 1 f~ {~ l 1 1 1 Ca uti on 1 1 1 Ac ce pt 1 1 1 Ca uti on ~ • • 1 Ac ce pt 11 c . ~ :J . i" - I) . . . . c - " ' < >- §,V ~' t iH :e E E ~ ~ ~ '" ~] ~ , B ls l Q .~ fl . . . '" tl c . c ~ c :. i" ~ " ' - Q ~ c- . - '" !I ~~ v '" c v of . . . - 1 1 1 1 1 1 - 1 1 1 1 lb , t 1 - 1 1 1 1 lb ,t l' - 1 2 1 1 1 1 - 1 ~;% ~~ 1 1 1 1 - ld ~f, ~f; : ld ld ld l' ii ld 2 ld ld ld 1 - - - - - - - 1 2 1 1 1 1 - 1 2 1 1 1 1 - 1 1 1 1 1 l' - 1 1 1 1 1 1 - ld 1 ld ld lb ,d. t l' - ld 1 ld ld lb ,d. t l' - 1 1 1 1 1 1 b Th is co n di tio n m a y af fe ct o va ria n fu nc tio n a n d/ or c ha ng e fe rti lit y sig ns a nd s ym pt om s a n d/ or m ak e m e th od s di ffi cu lt to le ar n an d us e. d H ig he r t yp ic al fa ilu re ra te s o f t hi s m e th od m a y ex po se th e us er to a n u n a cc e pt ab le ri sk o f da ng er ou s u n in te nd ed pr eg na nc y. Br ea st fe ed in g m a y n o t be re co m m e n de d w ith dr ug s us ed to tr ea t t hi s co n di tio n. Co nd iti on d oe s n o t af fe ct v ag in al b le ed in g pa tte rn s; c a le nd ar m e th od c an b e us ed . - Co nd iti on n o t l ist ed b y W H O fo r t hi s m e th od ; do es n o t a ffe ct e lig ib ili ty fo r m e th od u se . » Dr ug in ter ac tio ns ae A nt ib io tic s o th er th an " U " U Ta ki ng th e a n tib io tic s ri fa m pi n rif am pi n an d (I) Ca ut io n gr ise of ul vi n. = :) (ri fa mp ici ne ) o r gr is eo fu lv in C L af Ba rb itu ra te s, ph en yt oi n, X· T ak in g o th er a n ti bi ot ic s· e A cc ep t ca rb am ez ap in e. pr im id on e. ag A lle rg y tn la te x is n o t a pr ob le m w ith p la sti c co n do m s. if av ai la bl e. ah I n o rd er to p ro te ct in fa nt h ea lth , br ea stf ee di ng is n o t re co m m en de d. ai Co un se lin g re qu ire s sp ec ia l c a re to e n su re a n in fo rm ed c ho ic e is m ad e. aj M en str ua tio n in di ca te s n ee d fo r a n n th er co n tr ac ep tiv e m et ho d . I . . ;n ;Y C IC U I3 tl lc n " ,I .l Ic (I ' tJ' CI IU U U II I1 5 1 1 1 1 A cc ep t _ a j m en str ua tio n) 1 2 1 1 1 ok D ec is io n to b re as tfe ed Tu be rc ul os is sh ou ld ta ke in to 0 co n sid er at io n th e ri s ks ~ N on pe lv ic 1 1 1 1 A cc ep t 1d 1 Id 1d 1d 1a x an d be ne fit s to t he in fa nt . In D . I~. ~ . . . i i i i . d ,,~ ",1 'i . d . d . d . a k al !Cl ~ r- In D is to rt ed u te ri ne c a v ity ~it' 1~ is - - - - - - _ c U ll - am D ia ph ra gm c a n n o t b e O th er a bn or m al iti es n o t di st or tin g th e u se d in ce rt ai n ca se s o f iii u te ri ne c a v ity a n d n o t in te rf er in g w it h - - - - 2 - - - pr ol ap se ; c a p n o t ~ I U D i ns e rt io na n ac ce pt ab le fo r c lie nt s • w ith s ev er el y di sto rte d Pa st to xi c sh oc k sy nd ro m e - - - - 1 - 1 - - ce rv ic al a n at om y. n Br ea stf ee di ng an I nc lu di ng u te rin e ~ I ~ fib ro id s, ce rv ic al le ss th an 6 w e e ks a ft er c hi ld bi rt h A cc ep t - 1 - 1 _ 8 0 1b 1 st en os is, o r ce rv ic ai In 6 w e e ks to 6 m o n th s a ft er c hi ld bi rt h la ce ra tio ns . ~ (fu lly o r a lm os t f ul ly b re as tf ee di ng ) 1 1 1 A cc ep t - 1 1 1 lb 1 - Co nd iti on n o t W H O fo r t hi s 6 m o n th s o r m o re a ft er c hi ld bi rt h 2 1 1 1 A cc ep t - 1 - 1 1 ID do es n o t a ffe ct fo r m et ho d u se . t '" 1> (X) m Cl> Cl> ID a o· u;- Q., n o a Cl n ID " ~ ~ n ::r ::J Q. c8 '< » " " ID ::J Cl. x' W H O M ed ic al E lig ib ili ty C rit er ia fo r St ar tin g Co nt ra ce pt iv e M et ho ds (c on tin ue d) S f z . t:i 1 ~ i :is ~ IS :!; C O N D IT IO N Q Po st pa rtu m (n on br ea sif ee din g w o m e n ) ~ Le ss th an 2 1 da ys a fte r c hi ld bi rth 1 1 21 o r m o re d ay s af te r c hi ld bi rth 1 1 Po st ab or tio n Fi rs t t rim es te r Se co nd tr im es te r Af te r s e pt ic a bo rti on aq • A dd iti on al c o n di tio ns re la te d to fe m al e st er ili za tio n: Co nd iti on s th at re qu ire d ela y: ab do m in al s ki n in fe ct io n; a c u te br on ch iti s o r pn eu m on ia ; e m e r- ge nc y su rg er y; s u rg er y fo r a n in fe ct io us c o n di tio n; sy st em ic in fe ct io n o r se v e re g as tro en te rit is . Co nd iti on s t ha t r eq ui re re fer ral to a sp ec ia l e en te r: c hr on ic a st hm a, br on ch iti s, e m ph ys em a, o r lu ng in fe ct io n; fi xe d u te ru s du e to p re - v io us su rg er y Or in fe ct io n; a bd om - in al w al l o r u m bi lic al h er ni a. Co nd iti on s t ha t di ap hr ag m at ic I di se as e; e le ct iv e su rg er y; s ev er e n u tr iti on al d ef ic ie nc ie s. Co nd iti on s t ha t p os e n o s pe ci al re qu ire m en ts: c e sa ria n se ct io n. 1 1 1 1 1 1 1 1 1 Po stp ar tu m s te ril iza tio n co n di tio ns tha t r eq ui re d ela y: 7 d ay s 1 0 42 d ay s af te r c hi ld bi rth ; s ev er e pr ee eJ am ps ia ! e c la m ps ia ; p ro lo ng ed ru pt ur e o f m e m br an es (2 4 ho ur s o r m o re ); se v e re h em or rh ag e; fe ve r d ur in g o r rig ht a fte r d el iv er y; s ep si s; s e v e re tr au m a to th e ge ni ta l t ra ct (c erv ica l o r v ag in al te ar a t de liv er y). Po stp ar tu m s te ril iza tio n co n di tio ns th at re qu ire re fer ral to a s pe ci al ce n te r: u te rin e ru pt ur e o r pe rf or at io n. Po stp ar tu m s te ril iza tio n co n di tio ns th at p os e n o s pe ci al re qu ire m en ts: le ss th an 7 d ay s a fte r c hi ld bi rth ; m o re th an 4 2 da ys af te r c hi ld bi rth ; m ild pr ee cl am ps ia . Po sta bo rti on st er ili za tio n se v e re h em or rh a! le : tr au m a 10 th e ge ni ta l he m at om et ra (e xc ess th e u te ru s). Po sta bo rti on st er ili za tio n co n di tio ns th at re qu ire re fer ral to a s pe ci al ee n te r: u te rin e pe rf or at io n. :l . - a Q :2 E . - . 2 > - i i .!L ~ ~ 8 ~ I] ~ '\' ! = c I:! z . . '" 1 . . . 1 t 1 . . . 1 t 1 - - 1 1 1 - - 1 2 la . . :5! . . i! ti .~ i.: i: . . i:: l . - . Q u 1 - 1 _ a ~ 1 1 1 la p 11 :!; ~1 i! .2: . lb lb lb lb -~~ g - := fj1 ,g . . - e ~. i~ - - - b Th is c o n di tio n m ay a ffe ct o v ar ia n fu nc tio n a n d/ or c ha ng e fe rti li ty s ig ns a n d sy m pt om s a n d/ or m a ke m e th od s di ffi cu lt to le ar n a n d u se . ao C an s ta rt d ia ph ra gm u se 6 w e e ks a fte r c hi ld bi rth . di ao hr a2 m u se aq T ha t i s, im m ed ia te ly a fte r a bo rti on in vo lv in g ge ni ta l tr ac t in fe ct io n. 1 - - 1 n'f: '~~ 1 1 lb - C on di tio n n o t lis te d by W H O fo r t hi s m et ho d; do es n o t a ffe ct e lig ib ili ty fo r m e th od u se . • • A dd iti on al c o n di tio ns re la te d to v a se c to m y: Co nd iti on s th at re qu ire sc ro ta l s ki n in fe ct io n; a c tiv e ba la ni tis ; e pi di dy m iti s o r o re sy st em ic in fe ct io n o r se v er e ga st ro en te rit is ; f ila ria sis o r e le ph an tia si s; in tra sc ro ta l m as s. Co nd iti on th at re qu ire s r efe rra l to a s pe ci al ce nr er : in gu in al h er ni a. Co nd iti on s th at re qu ire c a u tio n: pr ev io us s cr o ta l s u rg er y o r in jur y; la rg e v ar ic oc el e, la rg e hy dr oc el e; cr yp to rc hi di sm . ( In so m e ci rc um st an ce s, c ry pt or ch id is m m a y re qu ire re fe rra l.) t A dd iti on al c o n di tio ns re la te d to TC u- ]8 0A IU D , p ost pa rtu m in se rti on (b re as tle ed .ng or n o n br ea st fe ed in g) : Co nd iti on th at re pr es en ts an u n a cc ep ta bl e he al th ri sk (W HO 4) : se ps is du rin g af te r c hi ld bi rth }. Co nd iti on th at re qu ire s a do cto r o r n u rs e to m a ke a c lin ica l ju dg em en t th at th e cl ie nt ca n s a fel y u se a n lU D (W HO 3) : 4 8 ho ur s to 4 w ee ks p os tp ar tu m . Co nd iti on fo r w hi ch a dv an ta ge s o f I UD u se g en er al ly o u tw ei gh th eo re tic al o r pr ov en r isk s (W HO 2) : le ss th an 4 8 ho ur s af te r c hi Id bi rth . Co nd iti on th at re qu ire s n o re st ric tio n: M or e th an 4 w e e ks af te r c hi ld bi rth . tt A dd iti on al c o n di tio ns r e la te d to L AM : Co nd iti on s th at re pr es en t a n u n a cc ep ta bl e he al th ri sk to th e in fan t: u se o f r es er pi ne , er go ta m in e, a n tim et ab ol ite s, cy cl os po rin e, c o rt is on e, br om oc rip tin e, r ad io ac tiv e . o r an tic oa gu la nt s. w hi ch L A M h as nO e ffe ct o n th e co n di tio n, b ut th e co n di tio n m a y pr ev en t br ea stfe edi ng : s o re n ip pl es ; m as tit is (b rea st in fla m m at io n); c o n ge ni ta l d ef or m ity o f i nf an t's m o u th , j aw or p al at e; in fa nt sm a ll fo r a ge , p re m at ur e bi rth , o r n e o n a ta l in te ns iv e c a re ; pa st br ea st su rg er y; c er ta in in fa nt m et ab ol ic d is or de rs . Co nd iti on th at re qu ire s n o re st ric tio ns (W HO I) : b re as t e n go rg em en t. Suggested Reading Angle, M. Guidelines for clinical procedures in family planning, a reference for trainers, 2nd ed. Chapel Hill, North Carolina, Program for International Training in Health (INTRAH), 1992. Angle, M. Guidelines for clinical procedures in family planning, a reference for trainers. 2nd ed., revised (chapters 3-7). Chapel Hill, North Carolina, Program for International Training in Health (INTRAH),1993. AVSC International. Safe and voluntary surgical contraception: Guidelines for service programs. New York, AVSC International, 1995. Blumenthal, P.D. and McIntosh, N. PocketGuide for family planning service providers, 1996-1998. 2nd edition. Baltimore, Johns Hopkins Program for International Education in Reproductive Health OHPIEGO), 1996. Cooperating Agencies Informed Choice Task Force. Informed choice: Report of the Cooperating Agencies Task Force. Baltimore, Johns Hopkins School of Public Health, Center for Communication Programs, 1989. Hatcher, R.A., Trussell, J., Stewart, E, Stewart, G.K, Kowal, D., Guest, E, Cates, W, and Policar, M. Contraceptive technology. 16th ed. New York, Irvington, 1994. Huezo, C.M. and Carignan, C.S. Medical and service delivery guidelines for family planning. London, International Planned Parenthood Federation (IPPF) in collaboration with AVSC International, 1997. Suggested Reading A-9 Labbok, M., Cooney, C., and Coly, S. Guidelines: Breastfeeding, family planning, and the Lactational Amenorrhea Method-LAM. Washington, D.C., Georgetown University, Institute for Reproductive Health, 1994. McCann, M.F. and Potter, 1.S. Progestin-only oral contraception: A comprehensive review. Contraception 50(6): S9-S195. December 1994. McIntosh, N., Kinzie, B., and Blouse, A. IUD guidelines for family planning service programs, a problem-solving reference manual. 2nd ed. Baltimore, Johns Hopkins Program for International Education in Reproductive Health OHPIEGO), 1993. McIntosh, N., Blouse, A., and Shaefer, 1. Norplant® guidelines for family planning service programs, a problem-solving reference manual. 2nd ed. Baltimore, Johns Hopkins Program for International Education in Reproductive Health OHPIEGO), 1995. Moreno, 1. and Goldman, N. Contraceptive failure rates in developing countries: Evidence from the Demographic and Health Surveys. International Family Planning Perspectives 17(2): 44-49. 1991. Murphy, E. M. and Steele, C. Client-provider interactions in family planning services: Guidance from research and program experience. In: Technical Guidance/Competence Working Group. Recommendations for updating selected practices in contraceptive use. Vol. 2. Chapel Hill, North Carolina, University of North Carolina, Program for International Training in Health, 1997. p. 187-194. Population Council (PC). Norplant contraceptive subdermal implants: Guide to effective counseling. New York, PC, 1990. Shelton, J.D., Angle, M.A., and Jacobstein, RA. Medical barriers to access to family planning. Lancet 340(8831): 1334-1335. November 28, 1992. Solter, C. Comprehensive reproductive health and family planning training curriculum, module 6: DMPA injectable contraceptive. Watertown, Massachusetts, Pathfinder International, August 1996. A-10 Essentials of Contraceptive Technology Appendix Technical Guidance/Competence Working Group. Recommendations for updating selected practices in contraceptive use: Results of a technical meeting. Vols. 1 and 2. Chapel Hill, North Carolina, University of North Carolina, Program for International Training in Health, 1994 and 1997. (Condensed version published in Population Reports, Family Planning Methods: New Guidance. Baltimore, Johns Hopkins School of Public Health, Population Information Program, 1996.) Tietjen, L., Cronin, W. and Mclntosh, N. Infection prevention for family planning service programs, a problem-solving reference manual. Baltimore, Johns Hopkins Program for International Education in Reproductive Health OHPIEGO), March 1992. World Health Organization (WHO). Improving access to quality care in family planning: Medical eligibility criteria for contraceptive use. Geneva, WHO, Family and Reproductive Health, 1996. World Health Organization (WHO). Injectable contraceptives, their role in family planning care. Geneva, WHO, 1990. Population Reports, especially the following issues: Blackburn, RD., Cunkelman, J.A, and Zlidar, V.M. Oral Contraceptives - An Update. Population Reports, Series A, No. 9. Baltimore, Johns Hopkins School of Public Health, Population Information Program, Spring 2000. Church, CA. and Geller, J.S. Voluntary female sterilization: Number one and growing. Population Reports, Series C, No. 10. Baltimore, Johns Hopkins School of Public Health, Population Information Program, November 1990. Gardner, R, Blackburn, RD., and Upadhyay, U.D. Closing the Condom Gap. Population Reports, Series H, No. 9. Baltimore, Johns Hopkins School of Public Health, Population Information Program, April, 1999. Suggested Reading A-ll Lande, R. New era for injectables. Population Reports, Series K, No. 5. Baltimore, Johns Hopkins School of Public Health, Population Information Program, August 1995. Liskin, L., Benoit, E., and Blackhurn, R. Vasectomy: New opportunities. Population Reports, Series D, No. 5. Baltimore, Johns Hopkins School of Public Health, Population Information Program, March 1992. McCauley, AP. and Geller, J.S. Decisions for Norplant programs. Population Reports, Series K, No. 4. Baltimore, Johns Hopkins School of Public Health, Population Information Program, September 1992. Rinehart, W., Rudy, S., and Drennan, M. GATHER guide to counseling. Population Reports, Series J, No. 48. Baltimore, Johns Hopkins School of Public Health, Population Information Program, December 1998. Treiman, K, Liskin, L., Kols, A, and Rinehart, W. !lIDs-An update. Population Reports, Series B., No. 6. Baltimore, Johns Hopkins School of Public Health, Population Information Program, December 1995. A-12 Essentials of Contraceptive Technology Appendix Glossary abscess. Collection of pus surrounded by inflammation. acquired immune deficiency syndrome (AIDS). A progressive, usually fatal condition (syndrome) that reduces the body's ability to fight certain infections. Caused by infection with HIV (human immunodeficiency virus). acute purulent cervicitis. Inflammation of the cervix with a pus-like discharge. AIDS. See acquired immune deficiency syndrome. amenorrhea. Absence of meustrual periods (monthly vaginal bleeding). anemia. Low levels of the oxygen-carrying material in the blood. Anemia results in decreased oxygen to the tissues of the body. Symptoms are often vague and may include chronic fatigue, irritability, dizziness, memory problems, shortness of breath, headaches, and bone pain. Mild anemia may have no noticeable symptoms. Anemia may result from excessive blood loss, blood cell destruction, or decreased blood cell formation. (See hemoglobin, iron deficiency anemia.) anal fisrula. An abnormal opening at or near the anus. anus. The lower opening of the digestive tract (large intestine); the outlet of the rectum. backup method. A family planning method such as condoms or spermicide that can be used temporarily for extra protection against pregnancy when needed-for example, when starting a new method, when supplies run out, and when a pill user misses several pills in a row. bacterial vaginitis. Inflammation of the vagina caused by a bacterial infection. bacterial vaginosis. A common vaginal condition caused by overgrowth of bacteria normally found in the vagina. Not generally sexually transmitted. Can come from douching, pregnancy, or antibiotics. Causes fishy-smelling discharge. balanitis. Inflammation of the head (tip) of the penis and the mucous membrane beneath it. Note: Words in dark black type also are defined in this glossary. Glossary A-13 benign breast disease. A disease involving the presence of abnormal but not malignant (cancerous) breast tissue. blood pressure. The force (pressure) of the blood against the walls of blood vessels, created chiefly by the heart as it pumps blood through the body. As the heart beats, pressure increases. As the heart relaxes between beats, pressure decreases. Normal blood pressure varies from moment to moment within each petsOn. Generally, normal sysrolic (pumping) blood pressure is less than 140 mm HG, and normal diastolic (resting) blood pressure is less than 90 mm HG. (See hypertension.) breakthrough bleeding. Vaginal bleeding between menstrual periods. (See also spotting.) buboes. Bursting lymph nodes. (See lymphogranuloma venereum.) candidiasis. A common infection of the skin or mucous membranes caused by a yeast-like fungus (usually Candida albicans); the most common cause of vaginitis. In women, symptoms include intense vaginal burning and itching and a clumpy, white fluid in and around the vagina. In men, symptoms include itching genitals and white fluid under the fOreskin (if uncircumcised). Rarely sexually transmitted. cardiovascular disease (or problems). Any disease or abnormal condition of the heart, blood vessels, or blood circulation. (See cardiovascular system, circulatory system.) cardiovascular system. The system by which blood is circulated through the body. Consists of the heart and blood vessels. cerebrovascular disease. Any disease of the blood vessels of the brain. cervical mucus. A thick fluid plugging the opening of the cervix. Most of the time cervical mucus is thick enough to prevent sperm from entering the uterus. At midcycle, however, under the influence of estrogen, the mucus becomes thin and watery, and sperm can more easily pass into the uterus. cervicitis. Inflammation of the cervix. cervix. The lower portion of the uterus that extends into the upper vagina. chancroid. A sexually transmitted disease caused by the bacillus (rod-shaped bacteria) Hemophilus ducreyi. Symptoms include soft and painful sores on the penis, vagina, or anus, and swollen lymph nodes. Symptoms may not appear or may be difficult to notice in women, but both women and men can transmit the disease. chlamydia. A sexually transmitted disease caused by infection with the bacterium chlamydia trachomatis. Symptoms that women may notice include unusual vaginal discharge, irregular bleeding, bleeding after intercourse, or deep pain after and/or during sexual intercourse. Symptoms that men may notice include clear, mucus-like discharge from the penis and burning during urination. Chlamydia is dangerous because, if untreated, it can lead to pelvic inflammatory disease. cholestasis. Reduced flow of bile secreted by the liver. circulatory system. The system by which blood and lymph are circulated throughout the body. Includes the cardiovascular system and the lymphatic system. A-14 Essentials of Contraceptive Technology cirrhosis (of the liver). A disease of the liver involving destruction of liver cells and diminished liver function. Can block blood flow to the liver, causing high blood pressure or jaundice. conception. Union of an ovum, or egg cell, with a sperm. Also known as fenilization. coronary anery disease. Narrowing of the aneries that supply blood to the myocardium (muscular middle layer of the hean wall). May eventually result in damage to the hean muscle. cryptorchidism. Failure of one or both testes to descend into the scrotum. depression. A mental condition typically marked by dejection, despair, lack of hope, and sometimes either extreme tiredness or agitation. diabetes (diabetes mellitus). A chronic disorder caused by ineffective production or use of the hormone insulin secreted by the pancreas. People with diabetes (diabetics) are unable to use carbohydrates in food properly, causing glucose (sugar) to build up in the blood and urine. Symptoms include excessive urination and excessive thirst. Diabetics, especially if untreated, are at risk of developing serious long-term complications such as nephropathy, neuropathy, and retinopathy. disinfect (medical instruments). To destroy all living microorganisms except some forms of bacteria. Also called high-level disinfection. dysmenorrhea. Painful menstrual periods. eclampsia. A major toxic condition of late pregnancy, labor, and the period immediately after delivery, characterized by convulsions (involuntary muscle contractions, or seizures). In serious cases, sometimes followed by coma and death. Eclampsia occurs as a complication of preeclampsia. ectopic pregnancy. Pregnancy anywhere outside the uterus, such as in the fallopian tubes or ovaries. Ectopic pregnancy is an emergency since the fetus often grows to a size large enough to cause fatal internal bleeding in the mother's abdomen. ejaculation. The release of semen from the penis. elephantiasis. A chronic and often extreme swelling and hardening of skin tissue and tissue just beneath the skin, especially of the legs and scrotum, resulting from an obstruction in the lymphatic system. (See filariasis.) embryo. The product of conception (fenilization of an egg by a sperm) during the first 8 weeks of its development. During the remainder of pregnancy it is know as the fetus. emergency oral contraception. Combined oral contraceptives used soon after unprotected sexual intercourse to prevent pregnancy. endometrium. The membrane that lines the inner surface of the uterus. Glossary A-15 endometriosis. A condition where endometrial tissue is located outside the uterus. The tissue may attach itself to the reproductive organs or to other organs in the abdominal cavity. May cause pelvic adhesions in the abdominal cavity and in the fhllopian tubes. Endometriosis may also interfere with ovulation and with the implantation of the embryo. (See endometrium.) engorgement (breast engorgement). A condition resulting when more milk accumulates in the breasts than the inf.mt consumes. Engorgement may cause the breasts to feel hard, painful, and hot. Can usually be prevented (or relieved) by breastfeeding more often. epididymis. A coiled, tubular organ attached to and lying on the testicle. Developing sperm reach maturity and develop their swimming capabilities within this organ. The matured sperm leave the epididymis through the vas deferens. epididymitis. Inflammation of the epididymis. epilepsy. A chronic disorder caused by diSturbed brain function. Usually involves some disturbance of consciousness. May involve convulsions (involuntary muscle contractions, or seizures). estrogen. Natural estrogens, especially the hormone estradiol, are secreted by a mature ovarian follide, which surrounds the ovum, or egg. Responsible for female sexual development. The word estrogen is now used to describe synthetic drugs that have effects like those of an estrogen and are used in combined oral contraceptives and monthly injectable contraceptives. fallopian tube. Either of a pair of slender ducts that connect the uterus to the region of each ovary. It carries the ovum from the ovary to the uterus and carries sperm from the uterus towards the ovary. Fertilization of the ovum by sperm usually takes place in the fallopian tube. fertilization. See conception. fetus. The product of conception from the end of the eighth week until birth. (See embryo.) fibroid. A benign growth often found in or on the uterus. Fibroids are not harmful unless they cause pain or grow large enough to cause an obstruction. fibrosis. The excess formation of fibrous tissue, as in reaction to organ damage; for example, fibrosis of the liver. filariasis. A chronic parasitic disease caused by filarial worms. People usually become infected when they are bitten by mosquitoes that have been exposed to the worms. Living worms cause little tissue damage, but death of adult worms may lead to inflammation and permanent fibrosis clogging Channels in the lymphatic system. Serious infections may lead to elephantiasis. focal neurologic symptoms. Blurred vision, temporary loss of vision, seeing flashing lights or zigzag lines, or trouble speaking or moving. Occur with a type of migraine. follicle. A small round structure in the ovary. Each follicle contains an egg. During ovulation the follicle on the surface of the ovary opens and releases a mature egg. A-16 Essentials of Contraceptive Technology fully breastfeeding. Giving a baby no other food or liquid than breast milk. A woman described as nearly fi.dly breastfeeding gives the baby some additional liquid or food, but at least 85% of the baby's feedings are breast milk. gastroenteritis. Inflammation of the mucous membrane of both stomach and intestine. genital herpes. A disease caused by the virus herpes simplex. Usually spread by sexual contact. Symptoms likdy to be noticed include one or more very painful small blisters around the vagina. on the penis, or around the anus. These blisters may burst open and dry up to become scabs. Sores can last for 3 weeks or more and then disappear. New blisters usually appear from time to time because the virus stays in the body. genital warts. Cluster-like growths on the vulva, the vaginal wall, and the cervix in women, and on the penis in men. Caused by human papilloma virus. gestational diabetes. Diabetes that develops only during pregnancy. Occurs because the usual hormone production is changed and sugar is not utilized as efficiendy. gland. A cell or group of cells in the body that makes a substance (secretion) to be discharged and used in some other part of the body. goiter. A chronic, noncancerous enlargement of the thyroid gland. gonorrhea. A sexually transmitted disease caused by the bacterium Neisseria gonorrhea. It is transmitted by a person carrying the bacterium when one mucous membrane comes into contact with another's. Gonorrhea causes inflammation of the genital mucous membrane in both sexes. May also affect other parts of the body such as the anus and cervix. Symptoms include a pus-like discharge from the penis in men or the cervix in women and lower abdominal pain and fever in women. If not treated, gonorrhea can cause sterility. granuloma inguinale. A sexually transmitted disease that causes lumps under the skin in the genital region, most often between the scrotum and thighs on men or between the labia and vagina on women. groin. The depression between the thigh and the torso. heart attack. A heart attack occurs when the flow of blood in a coronary artery is blocked long enough to cause some heart muscle to die. Also called myocardial infarction. (See also ischemic heart disease.) heavy smoker. A person who smokes 15 or more cigarettes per day. hemoglobin. The iron-containing material in red blood cells. Hemoglobin carries oxygen from the lungs to the tissues of the body. hepatitis. Inflammation of the liver, usually caused by a virus but sometimes by a toxin. hernia. The projection of an organ, part of an organ, or any bodily structure through the wall that normally contains it. Glossary A-17 HIY. Human immunodeficiency virus, the cause of acquired immune deficiency syndrome (AIDS). HN can be rransmitted by sexual contact (heterosexual or homosexual), by contaminated blood products (especially blood transfusion), through contaminated needles or surgical instruments, and from mother to fetus or infant before or during birth. If the mother is infected with HIV; there is a small chance that the virus will be passed to the baby through breast milk. hormone. A chemical substance formed in one organ or part of the body and carried in the blood to another organ or part. Affects the activity of other organs or parts of the body through chemical action. human papillomavirus (HPV). A common, highly contagious sexually transmitted disease caused by a virus and spread by skin-ta-skin contact. Symptoms include warts on or near the penis, vagina, or anus. Warts may not appear or may be difficult to notice. Certain subtypes of HPV are responsible for most cases of cervical cancer. (See genital warts.) hydrocele. The collection of fluid in a body cavity, especially in the testes or along the spermatic cord. hypertension. Higher blood pressure than normal. Normal blood pressure in adults varies from moment to moment within each person, but generally diastolic (resting) blood pressure from 90 to 99 mm HG is considered mild hypertension; 100 to 109, moderate hypertension; and 110 or greater, severe hypertension. Systolic (pumping) blood pressure from 140 to 159 mm HG is considered mild hypertension; 160 to 179, moderate hypertension; and 180 or greater, severe hypertension. (See blood pressure.) hyperthyroid. Too much production of thyroid hormones. (See thyroid gland.) hypothyroid. Not enough production of thyroid hormones. (See thyroid gland.) implantation. The embedding of the embryo into tissue so it can establish contact with the mother's blood supply for nourishment. Implantation usually occurs in the endometrium; however, in an ectopic pregnancy it may occur elsewhere in the body. inguinal hernia. A hernia in the groin. iron deficiency anemia. Anemia resulting from a greater demand for iron than can be supplied. Commonly caused by chronic loss of blood, such as vaginal bleeding, or by poor diet. Usually successfully treated by iron supplements and a well-balanced diet. ischemic heart disease, ischemia. ischemia is reduced blood flow (and thus reduced oxygen) to tissues of the body. When this reduced flow is in the coronary arteries (arteries of the heart), it is called ischemic heart disease or myocardial ischemia. jaundice. A symptom of liver disease. A person with jaundice typically has abnormal yellowing of the skin and whites of the eyes. labia. The inner and outer lips of the vagina. laceration. A wound or irregular tear of the flesh. A-1 8 Essentials of Contraceptive Technology LAM (Lactational Amenorrhea Method). A family planning method that relies on breastfeeding as natural protection against pregnancy for up to 6 months after childbirth. Women who use LAM must fully or nearly fully breastfued to protect themselves from pregnancy. (See fully breastfeeding.) laparoscope. A device consisting of a tube containing an optical system for viewing the inside of an organ or body cavity. Used in diagnosis and in some female sterilization procedures. laparoscopy. A medical procedure petformed using a laparoscope to see the inside of an organ or body cavity. Also, a type of female sterilization procedure Oaparoscopic sterilization). lesion. A diseased area of skin or other body tissue. light smoker. A person who smokes, but fewer than 15 cigarettes per day. lymph. A fluid that is collected from the tissues throughout the body, flows through the lymphatic system, and eventually enters the bloodstream. Lymph removes bacteria and . cettain proteins from the tissues, carries fut from the intestines, and supplies white blood cells to the blood. lymph nodes. Enclosed masses of tissue that filter out foreign particles, such as bacteria, preventing them from entering the blood. Lymph nodes are spread throughout the body. lymphatic system. The system of structures that carries lymph from body tissues to the bloodstream. lymphogranuloma venereum. A sexually transmitted disease usually caused by chlamydia trachomatis. In men, symptoms include large dark lumps in the groin that open to drain pus, scar up, and open again. Women develop painful, oozing sores around the anus. Also called buboes. menopause. The time in a woman's life when menses (menstrual periods) stop. Occurs when a woman's ovaries stop producing eggs and monthly bleeding from the uterus stops. menses. Monthly flow of bloody fluid from the uterus through the vagina in adult women between puberty and menopanse. menstrual cycle. A repeating series of changes in the ovaries and endometrium that includes ovulation and about two weeks later the beginning of mensttual bleeding. In most women, cycles average about 28 days but may be shotter or longer. (See menses, menstrual period.) menstrual period, menstruation. Periodic discharging of the menses in response to stimulation from esttogen and progesterone. migraine. Severe, recurrent headache, usually accompanied by sensitivity to light and affecting only one side of the head, with sharp pain and sometimes nausea, vomiting, and trouble seeing. (See focal neurologic symptoms.) minilaparotomy. A female sterilization technique petformed by bringing the fallopian tubes through a small incision in the abdomen and then usually tying and cutting them. Glossary A-19 mucous membrane. The membrane lining all passages and cavities of the body that communicate with the air. Cells or glands in the surface layer of the mucous membrane secrete mucus. mucus. The fluid secreted by mucous membranes and glands. (See mucous membrane.) nearly fully breastfeeding. See fully breastfeeding. nephropathy. Any disease of the kidneys. neuropathy. Any disease of the nerves. orchitis. Inflatnmation of a testis. (See testes.) ovarian cyst. A cyst is an abnormal sac or cavity containing a liquid or semisolid material and enclosed by a membrane. On the ovary, often arising from a follicle. When a cyst occurs on the ovary, it may cause some abdominal pain but rarely requires any treatment. Ovarian cysts usually disappear on their own. ovary. Either of a pair of female sex glands that produce the reproductive egg cells, the ova (see ovum). The ovaries also produce the sex hormones estrogen and progesterone. These hormones contribute to the process of sexual development, regulation of the menstrual cycle, and the achievement and maintenance of pregnancy. ovulation. The release of an egg cell from an ovary. ovum. Egg cell, produced by the ovaries. partially breastfeeding. Less than fully or nearly fully breastfeeding. (See fully breastfeeding.) pelvic adhesions. Abnormal tough bands of tissue connecting internal body structures in the pelvis. Adhesions can interfere with movement of the egg and implantation of the embryo in the uterus. pelvic infection. See pelvic inflammatory disease. pelvic inflatnmatory disease (PID). Infection in the uterine lining, uterine wall, fallopian tube, ovary, uterine membrane, broad ligaments of the uterus, or membranes lining the pelvic wall. May be caused by a variety of infectious organisms including gonorrhea and chlamydia. pelvis. The skeletal structure located in the lower part of the human torso, resting on the legs and supporting the spine. In females, also refers to the hollow portion of the pelvic bone structure through which the fetus passes during birth. penis. The male organ for urination and sexual intercourse. placenta. The organ that nourishes a growing fetus. The placenta (also known as "afterbirth") is expelled from the uterus within a few minutes after the birth of a baby. postpartum. After childbirth; the first 6 weeks after childbirth. preedampsia. High blood pressure (hypertension) plus proteinuria (excess protein in the urine), or swelling, or both (but without convulsions) after 20 weeks of pregnancy. If not treated, may progress to eclampsia. Cause unknown. A-20 Essentials of Contraceptive Technology progesterone. A hormone secreted chiefly by the corpus luteum, which develops in a ruptured ovarian follicle during the luteal phase of the menstrual cycle (after ovulation). Progesterone prepares the endometrium for possible implantation of a fertilized egg. It also protects the embryo and enhances development of the placenta and aids in preparing the breasts for nursing the new infant. progestin. A word used to cover a large group of synthetic drugs that have an effect similar to that of progesterone. Progestins are used in oral contraceptives, injectables, and implants. puberty. The time oflife when the body begins making adult levels of sex hormones and the young person takes on adult body characteristics. puerperal sepsis. Infection of the reproductive organs during the puerperium (first 42 days postpartum.) pulmonary embolism. A blood clot formed elsewhere in the body that has traveled to the lung, causing shortness of breath and pain when taking a deep breath. Can be fatal. purulent cervicitis. Inflammation of the cervix accompanied by a pus-like discharge. pus. A yellowish-white fluid formed in infected tissue. rectum. The lower part of the digestive tract (large intestine). retinopathy. Any disorder of the retina (innermost part of the eye that receives images formed by the lens). schistosomiasis. A parasitic disease caused by a flatworm that spends part of its life in a freshwater snail host. Schistosomiasis is widespread in Asia, Africa, and tropical America. People become infected while wading or bathing in water containing larvae of the infected snails. scrotum. In the male, the pouch of skin behind the penis that contains the testes. semen. The thick, white fluid produced by a man's reproductive organs and released through the penis during ejaculation. Contains sperm. sepsis. The presence of various pus-forming and disease-causing organisms, or poisonous substances they produce, in the blood or body tissues. septic abortion. Abortion involving infection. sexually transmitted diseases (STDs). The term given to a group of diseases affecting both men and women and generally transmitted during sexual activity. These diseases usually cause discomfort, some may lead to infertility, and some may be life-threatening. sickle cell anemia, sickle cell disease. Hereditary, chronic form of anernia. Blood cells take on abnormal sickle- or crescent-shape when deprived of oxygen. Sickle cell anemia can cause various problems, including impaired growth and development and decreased resistance to infections. (See sickle cell crisis.) sickle cell crisis. Severe pain due to sickle cell anemia, particularly in the abdomen, chest, back, or joints. People with sickle cell disease are at risk of crises of unpredictable frequency and severity throughout their lives. Glossary A-21 sperm. The male sex cell. Sperm are produced in the testes of an adult male and released into the vagina during ejaculation. If conditions allow, sperm swim through the opening of the cervix, through the uterus, and into the fallopian tubes. If ovulation has recently occurred, sperm may then penetrate and join with the female's egg. (See conception.) spermatic cord. A cord consisting of the vas deferens and accompanying arteries, veins, nerves, and lymphatic vessels that passes from the groin down into the scrotum to the back of each testicle. spotting. Light vaginal bleeding at any time other than during a woman's menstrual period. (See also breakthrough bleeding.) sterilize (medical instruments). To destroy all microorganisms. stroke. A stroke occurs when there is a sudden disruption in the flow of blood to an area of the brain. Deprived of blood, the affected brain cells either become damaged or die. syndrome. A group of signs or symptoms that collectively indicate a particular disease or abnormal condition. syphilis. A sexually transmitted disease caused by the miaoorganism (spirochete) Treponema paUidum. The spirochete usually enters the body through invisible breaks in the skin or through intact mucous membranes lining the mouth, rectum, or genital tract. About 3 weeks later, sores containing large numbers of spirochetes develop at the entry site. Typically, the sores heal, but the spirochetes spread throughout the body. Ifleft untreated, syphilis may eventually progress to systemic infection and cause general paralysis. testes, testicles. The two reproductive glands, in the scrotum, that produce sperm and the male hormone testosterone. ("Testis" if referring to one of the testes.) thalassemia. An inherited type of anemia. thromboembolic disorder (or disease). Abnormal clotting in the blood vessels. thrombophlebitis. The fOrmation of blood clots (thrombi) causing pain and swelling in the leg. thrombophlebitis, superficial. Inflammation of a vein just beneath the skin. thyroid gland. A gland located in the lower part of the front of the neck. The thyroid gland produces hormones that are essential for life and have many effects on body growth and development. thyroid disease. Any disease of the thyroid gland. (See goiter, hyperthyroid, hypothyroid, thyroid gland.) toxic shock syndrome. A rare condition associated with infections by varieties of the common bacterium staphylococcus aureus. Apparently caused when a bacterial toxin enters the bloodstream of persons lacking antibodies against the toxin. Symptoms include sudden onset of high fever, vomiting, diarrhea, low blood pressure, and a sunburn-like skin rash. Has been reported in women who forget to remove menstrual tampons or, in a few cases, who leave diaphragms in place for several days. toxin. Poison; a poisonous substance of animal or plant origin. A-22 Essentials of Contraceptive Technology trauma. A wound, especially one caused by sudden physical injury. trichomoniasis. A sexually transmitted disease caused by Trichomonas vaginalis, a protozoan (microscopic organism). Symptoms in women include irritation, redness and swelling of the vulva, a bad-smelling vaginal discharge, and painful or difficult urination. Men often have no symptoms but may have a discharge from the penis and/or painful or difficult urination. trophoblast. The outermost layer of cells of the developing embryo through which the embryo receives nourishment from the mother. The cells of the trophoblast contribute to the formation of the placenta. trophoblast disease. Disease involving abnormal cell growth of the trophoblast during pregnancy. tuberculosis. A contagious disease caused by the microorganism Mycobacterium tuberculosis. Most commonly affects the respiratory system but may also infect other parts of the body including the pelvis. uterine fibroid. See fibroid. uterus. The hollow, muscular organ that carries the fetus during pregnancy. vagina. The passage leading from the external genital opening to the uterus in females. The vagina serves as a passage for discharge of menses, for reception of the penis during sexual intercourse, and for delivery of the fetus during childbirth. vaginitis. Inflammation of the vagina. May be caused by microorganisms such as gonococci, staphylococci, streptococci, spirochetes; chemical irritation from use of too strong chemicals in douching; fungus infection caused by Candidd albicans; protozoan infection; irritation from foreign bodies; vitamin deficiency as in pellagra; conditions involving the vulva and surrounding areas such as uncleanliness; or intestinal worms. valvular heart disease. Health problems associated with improperly functioning heart valves. varicocele. Enlargement of the veins of the spermatic cord. Symptoms include a dull ache along the cord and swollen tissue in the scrotum that feels like "a bag of worms." varicose veins. Enlarged, twisted veins. Most commonly seen in the legs. vas deferens (vas, vasa). One of the slim muscular tubes that transports sperm from the testes. These tubes are cut during a vasectomy. vascular disease. Any disease of the blood vessels. vulva. The exterior female genitals. Glossary A-23 A abdominal cavity . A-16 abdominal pain . 6-12, 6-18, 8-15, 9-17,12-16, 12-19 to 12-20,12-22, 16-12,A-17 abdominal skin infection . 9-9, A-8 abdominal surgery . 9-9 abdominal wall hernia •. .A-8 abnotrnal vaginal bleeding . 5-16,5-18, 6-13 to 6-14, 7-14, 7-17,8-16,8-18, 12-16 to 12-17, 12-19, 12-22, 16-12, A-3 abonion .• 2-1, 4-6,5-8,5-10,5-26,6-8,6-10, 7-7,7-9,7-21,8-9,8-11,9-7,9-13,9/10-2, 12-5,12-9,12-10, 12-19, 12-26, 13-8 to 13-9, 13-13 to 13-14, 14-8,A-8, A-21 abscess . 8-15, 8-19, 9-18,10-14 to 10-15, 16-15,A-13 abstinence . 3-5, ll-14, 11-16, 14-1. 16-11 acetaminophen . 9-16, 9-19, 10-12, 10-16. See also paracetamOl. acne . 6-5, 7-5, 8-5 acquired immune deficiency syndrome . 16-3, A-5, A-13, A-18. See also AIDS, HIV, HIV/AIDS. acyclovir .•. 16-21 adolescence . 5-4 adolescent . 5-8,6-8, 7-7, 8-9 age . 2-1,4-14,5-4,5-6,5-8,5-26,5-28,7-4, 7-15,7-20,8-1,8-22,9-10,9-12,9-22, 10-9 to 10-10, 10-18, 11-5, 12-26, 16-6, 16-20 AIDS . 4-10, 5-5, 5-10, 9-9, 10-9, 11-4, 11-16, 12-8,13-19,14-7,14-17,15-5 to 15-6, 15-15, 16-3,16-10, 16-21, 16-22, A-5, A-13, A-18. See also acquired immune deficiency syndrome, HIV, HIV/AIDS. allergic . 11-6, 11-14, 13-8, 16-19 allergic reaaion . 9-5, 11-7, 11-11, 13-6, 13-13, 13-15 Index Index allergy to latex . l1-6, 11-13 to 11-14, 13-S,A-7 alligator forceps . 12-13 amenonhea •. 5-4, 5-17 to 5-1S, 6-6, 6-12, 6-13 to 6-14. 7-1, 7-5, 7-9. 7-15. 7-18, 7-20, 8-1,8-5,8-14,8-17,12-22,15-3,A-13 amoxicillin . 16-18 ampicillin . 13-15 anal fistula . 16-15 anal intercourse . 11-16, 11-18, 16-10 anatomical abnormalities . A-7 anemia . 5-I, 5-4, 5-8, 5-27, 6-8, 6-14, 7-4, 7-7, 7-10,7-15,7-20,8-5,8-9,8-14,8-17 to 8-18, 9-9,9-10,10-9,12-6,12-9,12-18,12-22, 14-9, 15-7,A-3, A-6, A-13, A-IS, A-21, A-22 anesthesia . 8-5, 9-5,9-6,9-15,9-20 to 9-21, 10-7, 10-10, A-I anesthesia risk.9-5, 9-21 anestheric . 8-5, 8-12 to 8-14, 9-13 to 9-15, 9-20,10-11 anti-anxiety therapies . 14-9, A-7 anti-nausea medicine . 5-23 antibiotic.s . 8-19, 9-10, 9-lS, 10-15, 12-9, 12-20,12-26,13-11,13-15 to 13-16.15-13. 16-13. 16-20, A-7 anticoagulants . 15-6, A-3, A-7, A-8 anticonvulsants . 12-9, A-7 anrimetabolites . 15-6. A-8 antiseptic . 4-11, 7-12,8-19, 9-IS, 10-15, 12-12 anus . 16-10, 16-14 to 16-16, A-B, A-14, A-17, A-18,A-19 aspirin . 5-17. 7-16. 8-17 to 8-19, 9-16, 9-19, 10-12,10-16,12-14.12-18 azithromycin . 16-17, 16-20 to 16-21 1-1 B baby oil . 11-10 back-up method . 7-8, 8-10, A-l3. Seeatso condoms as back-up method, spermicide as back-up method. bacteria . 4-l0, 9-18, 10-15, 13-11, A-14, A-15, A-17, A-19,A-22 bacterial infection . A-l3 bacterial vaginiris . A-5, A-13 bacrerial vaginosis . A-5,16-13, 16-18 balanitis . A-8, A-13 barbiturates . 5-7,6-7,8-8,9-10, A-7 barrier methods . 4-13, 4-15, 4-16, 4-17, 4-18, 4-22, 6-1B, 11-1 to 11-IB, 13-1 to 13-19,14-1, 1S-12,A-4, A-13, A-14 basal body temperature . 14-3, 14-5, 14-8 to 14-9 14-10,14-12 to 14-13, 14-17. Seeatso BBT. BBT . 14-3, 14-1B. See also basal body temperature. benefits ofbreastfeeding . 4-8, 15-5 benefits of fumily planning . 1-4, 2-1 benign breast disease . 5-4, 5-8,6-5, 6-B, 7-7, 8-9,12-9,15-7,A-4,A-14 benzathine penicillin G . 16-19 benzylpenicillin . 16-20 bile . A-14 bipolar electrocoagulation . 9-21 birth defects . . 13-1B birth weight. . 7-21 bleeding . . See breakthrough bleeding. heavy bleeding, irregular bleeding, menstrual bleeding, sporting, vaginal bleeding. blisters . 16-15, 16-20 to 16-21 blocked arteries . 4-15, s-6, 5-16,6-13,6-14, 7-6,7-14,8-16,8-20,9-B,A-3,A-17 blood circulation . A-14 blood clots, bloodclotting . S-5, s-6, 6-7, 7-6, 7-14,8-7,8-16,B-20,9-9,9-16, 10-5, 10-9, 10-12,10-15, 12-9,A-21 toA-22 blood pressure . 4-14,4-22,5-6,7-6,9-8, A-2, A-14, A-1B, A-22 1-2 Essentials of Contraceptive Technology breakthrough bleeding . . Sce spotting. breast cancer . 4-8, 4-17, S-7, S-16, 6-7, 6-13, 7-6, 7-14,7-21,8-7.8-16.9-8. 12-9,1S-7,A-4 breast inflammation . . See mastitis. breast milk . 4-I, 4-8 to 4-9,6-3,6-5,7-4,7-20, 8-5,9-4.11-5. 12-S. I3-S. IS-I, 1S-3 to 1S-9, 1S-14 to IS-IS, 16-10,A-S,A-16,A-17.A-IB breast surgery . A-8 breast tenderness . 4-7, 5-4, 6-6. 7-S, 8-S, 9-17, 12-22, 1 S-13 breastfeeding . I-6 to 1-7,4-1, 4-S, 4-6, 4-8 to 4-9, 4-13 to 4-14, 4-1B. 4-19, 4-20, 4-22, S-l. S-5, 5-6, S-9, 6-1, 6-3 to 6-9, 6-11 to 6-14, 6-16 to 6-17, 7-1, 7-6 to 7-9, 7-20.8-1.8-7,8-9,8-10 to 8-11, 9-11.12-1, 12-9,14-1,14-8, IS-I to IS-15, 16-3, 16-10, 16-17, 16-18, 16-20, 16-21, A-7, A-8. A-16.A-17.A-19,A-20 breasts, enlarged . 4-7 breasts, sore . 1 S-13 bromocriptine . Is-6. A-8 bronchitis . 9-9, A-8 buboes . A-14. A-19 burrer . ll-l0, 11-15, 13-19 c calendar calculation . 14-3, 14-13, 14-17 calendar method . 4-6. 14-3. 14-S. 14-7, 14-B, 14-10.14-13 to 14-14, 14-17,A-4,A-6 Candida albicans . A-14, A-23 candidiasis . 16-13, 16-1B, A-14 carbamezapine . 5-7, 6-7, 8-8, 9-10, A-7 cefixime . 16-17 cefiriaxone . 16-17,16-20 cerebrovascular disease . A-3, A-14 cervical cancer . 4-22,5-26, 11-5, 12-8, 13-5, 13-18,14-8,16-16,A-4,A-IB cervical cap . 4-S, 4-6, 4-13, 13-3 to 13-9, 13-12 to 13-13. 13-17 to 13-19, 16-B, A-2,A-8 cervical cap removal . 13-13 Index cervical disease . A-4 cervical imraepithelial neoplasia . .A-4 cervical lacerations . A-7 cervical mucus . 5-3, 6-4, 7-3,8-4,14-7,14-8, 14-9, 14-17, A-14 cervical secretions . 14-3, 14-5,14-6, 14-10, 14-11 to 14-12,14-17 cervical stenosis . A-7 cervical tear •• .A-8 cervix . 4-11, 12-3, 12-12, 12-13, 12-15, 12-16, 12-19, 12-21, 12-26, 12-27,13-3, 13-8 to 13-13, 13-18, 16-21, A-13,A-14, A-17,A-21 chancroid . 16-14, 16-20, A-14 checking the IUD . 12-15 chest pain . 5-6, 7-6 childbirth . 4-8, 4-9,4-14,5-6. 5-9, 5-10, 6-5,6-8,6-9,6-17,7-1,7-4,7-6 to 7-9, 8-1,8-5,8-7,8-9 to 8-11, 9-13, 11-5, 12-1,12-5 to 12-8,12-10 to 12-12,13-5, 13-7 to 13-9,14-1, 14-7, 15-1, 15-4, 15-6, 15-7,15-9,15-12,16-3,16-10,16-21,A-8, A-19,A-20,A-23 children . 2-1, 2-2, 4-14,5-1,5-4,5-8,5-27, 6-8,7-1,7-7,7-20,8-1,8-9,8-22,9-1,9-3, 9-6,9-11,9-12,9-19,9-22 to 9/10-2, 10-1, 10-3,10-6,10-7,10-9, 10-10, 10-11, 10-16, 10-17, 10-18, 11-10, 12-25, 13-4, 13-5, 14-9, 16-21,A-7 chills . 9-18, 10-15 chlamydia . 11-4, 16-3, 16-12, 16-17,A-14, A-19, A-20 cholestasis . A-5, A-14 cigarettes .• 5-5,5-6,5-8,6-8,7-7,8-9, 12-9, 14-9, 15-7, A-2, A-17, A-19 ciprofloxacin . 16-17, 16-20 circulatory system . A-14 cirrhosis . 5-7, 6-7, 7-6, 8-7, 9-9, 9-10, A-5,A-15 clip . 9-14, 9-22,10-11 clotrima:zole . 16-18 to 16-19 coagulation disorders . 9-9, 10-9, A-6 cocoa butter . 11-10, 13-19 Index coconut oil . 11-1O cold cream •. 11-10 combined oral contraceptives . 1-5,4-3,4-9,4-13 to 4-18, 4-20,5-1 to 5-28, 6-3 to 6-6, 7-5, 7-18,7-20.8-6.8-17.8-18.11-5, A-2 to A-8. A-15. A-16 communiry-based distributor . 4-3. 5-8, 13-7 complications . 3-5. 4-15,5-15.6-5,6-12,7-4. 7-11,8-15.9-1,9-5,9-7,9-8.9-18,10-5, 10-14, 12-6, 12-16,A-3,A-15 conception . A-15, A-16 condom breaks . 5-21, 11-11, 11-18 condoms . 2-1.3-5.4-4,4-7,4-9,4-13,4-20, 4-22,5-5 to 5-7,5-9 to 5-11, 5-13, 5-14, 5-18.5-19.5-21 to 5-22, 5-24 to 5-25. 6-7, 6-9,6-10,6-12,6-16,6-17.7-5,7-6. 7-8 to 7-10,7-19.8-6,8-8,8-10,8-11,8-21. 9-5,9-19. 10-1, 10-4 to 10-6, 10-11, 10-12, 10-16. 10-18, 11-1 to 11-18. 12-7. 12-8, 12-24,13-4, 13-9, 13-17. 13-19, 14-17. 15-5,15-11, 15-12, 15-14, 16-1. 16-5, 16-8. 16-9,16-11,16-20,16-22,A-2toA-8,A-13 condoms as backup method . 5-7, 5-9, 5-10. 5-11.5-13.5-14,5-18.6-7.6-10.6-12, 6-17,7-8.7-10.8-8.8-10,10-1,10-4, 10-11, 10-12. 10-16, 14-4, 14-16. 14-17, 15-12 conAdentiality . 3-6, 12-8 congeniral defurmity, infimt . A-8 cooking oil . 11-1 ° copper T . 12-3. 12-11 coronary artery disease .•• A-15 cortisone . 15-6 counseling . 3-1 to 3-8. 4-3. 4-21. 4-22, 5-5. 5-10,5-17.6-6,6-15,7-1,7-5.7-9.7-15. 8-1,8-6,8-12,8-15.8-17,8-20.8-23,9-6, 9-12.9-21.9-23,9/10-1 to 9/10-2. 10-7, 10-10.10-15.10-18.11-8.11-13,12-7, 12-11, 12-18, 12-23, 12-26. 13-7. 13-9, 13-15,14-7.14-15,15-5,15-8,15-12,16-6 cream, spermicidal . 13-3 cryptorchidism •. .A-8, A-IS crysralline penicillin G . 16-19 CycJofom •. 7-3 Cyc/oprovera . 7-3 1-3 cyclosporine . 15-6. A-8 D decision table . 1-4 Depo-Provera . 7-3 depot-medroxyprogesterone acetate ••• 7-3 depression . A-15 diabetes . 4-16. 5-6, 5-8, 7-6, 7-18, 8-9, 9-8 to 9-10, 10-9, 12-9, 12-28, 15-7, A-2 toA-3,A-15.A-17 diaphragm . 4-5, 4-13. 4-18, 4-20, 4-22,13-1, 13-3 to 13-9, 13-11 to 13-19, 14-17, 16-8, A-2 to A-8, A-22 diaphragm insertion . See inserting a diaphragm. diaphragm removal . I3-6, 13-11, 13-16, 13-18 diaphragmacic hernia . 9-10, A-8 diarrhea . 4-8, 5-14,5-18,9-17,13-11,13-16, 15-5,16-9,16-10,A-22 diet . 7-5, 15-3. 15-9, 15-15,A-18 discharge, vaginal . 4-7, 5-24, 12-8, 12-14, 12-19, 12-21 to 12-22, 12-24, 13-15, 13-16, 16-7, 16-12,16-13,A-14,A-23 disinfect . 4-10 to 4-12,7-12,7-13, A-15 disposable needles . 7-13 disposal . 4-10.7-13 dizziness . 8-5,9-17, 13-11, 13-16 DMPA injectable contracepcive . 4-13 to 4-17, 4-20.4-22,5-6,5-21,7-1 to 7-21, 15-12, A-2toA-8 doctor . 1-3, 3-5, 5-15. 5-27, 6-12, 7-11, 8-14. 8-15.9-16. 10-13. 11-11, 12-16. 12-21 to 12-22. 12-27 donovanosis . 16-15.16-21 douche.douching . 13-10.13-17.16-13,A-23 doxycycline . 16-18 to 16-21 Dramaminl' .• 5-23 drug interactions . 5-7,5-16,6-7,6-13,8-8. 8-16, A-7. A-8 dysmenorrhea . A--7, A-15 1-4 Essentials of Contraceptive Technology E eclampsia . 9-7, A-8. A-15. A-20 ectopic pregrumcy . 5-5, 5-8, 5-24, 6-6, 6-12. 6-14,6-17.7-4,8-5.8-15,8-18,8-22,9-5, 9-11.9-17.9-21.9-22.10-5,11-5,12-5. 12-6. 12-9, 12-16. 12-1S, 12-20, 12-22. 13-5, A-5, A-15, A-18 effectiveness . 1-5.3-4,4-1.4-19 to 4-20,5-3, 5-4,5-5,5-23,6-1,6-4,6-6,6-11,6-16, 7-1.7-4,7-18,8-1,8-4,9-1.9-4,9-21, 10-1, 10-4, 10-5, 11-1, 11-4, 11-7, 12-1, 12-4. 12-16. 13-1, 13-4, 13-6, 14-1, 14-4, 14-5, 15-1, 15-4, 15-5, 16-17, 16-20 ejaculacion . 9-22, 10-1, 10-4, 10-5, 10-12, 10-16,10-17,11-5,11-10,11-17,13-10, 13-11, 13-13, A-15, A-21 , A--22 electrocoagulacion . 9-14,9-21 elephantiasis . 10-9. A-8, A-15, A-16 eligibility crireria . . See medical eligibility criteria. embtyo . A-15, A-18, A-20, A-21,A-23 emergency oral contraception . .5-1, 5-20 to 5-25, 5-28,6-1,6-1S,l1-11,A-15 emphysema . A-8 EngenderHealth (AVSC Intemacional) . 9-23, 10-19 endometrial cancer . 1-6, 5-4, 5-26, 6-5, 7-4, 7-21,8-5,8-22,12-8,12-17,12-21,A-4 endometriosis . 5-8, 6-8, 8-9, 9-7, 14-9, A-7, A-16 endometricis . A-4 endometrium . A-15,A-19, A-21 engorgement . 15-13, A-8. A-16 epididymis . A-16 epididymitis . .A-8, A-16 epidural anesthesia . 9-15 epllepsy . 6-8, 7-4, 7-7, 8-9, 9-10, 12-9,A-6, A-7,A-16 ereccion . l0-4, 10-17, 11-10, 11-14. 11-16 ergotamine . 15-6, A-8 erythromycin . 16-1S to 16-21 Index estrogen . 4--9,5-3,5-5,5-6,5-7,5-23,6-1,6-3, 6-5,6-6,7-3,7-4,7-5,7-16,8-3,8-5,8-6, 8-17,8-18,A-14,A-16,A-19,A-20 ethlnyl estradiol.5-23, 7-16 Eugynon 50 •. .5-23 F fainting, faintness . 6-12, 6-16, 8-15, 8-21, 9-17, 9-19,10-5,10-11,12-16,12-23 @1opian rube . 9-4, 9-13, 9-14, 9-22,12-19, A-15 toA-16,A-19,A-20,A-22 f.amcidovir . 16-21 family planning counseling . 1-4, 3-1 to 3-8 family planning method . 1-2 to 1-7, 4-1 to 4--5, 4-8 to 4--9,4--19 to 4-22, A-13, A-19 family planning providers . 1-2,2-1,3-3,9-23, 10-11,10-18,12-12,12-24,13-6,16-4,16-6 fat . 5-8,6-8,7-7,8-9, 14-9, 15-7, A-19 fatigue . 15-13 female condom . 11-3, 11-7 female srerilization . 1-5, 3-2, 3-5, 4-4,4-9,4-11, 4-13,4-20,4-22,9-1 to 9-23, 10-5, 10-17, A-2toA-8,A-19 FemenaI . 5-23 fertility . 9-23, 10-18, 14-8 to 14-9. See also return of fertility. fertilityawareness . 1-5, 4-5, 4-9, 4-13 to 4-18, 4-20,4-22,14--1 to 14-18, A-2 toA-8 fertilization . A-15, A-16 fetus . 4-6, 5-26, 7-21, 8-22,16-10,16-14, A-15, A-16, A-18, A-20, A-23 fever . 9-17, 9-18, 9-19,10-13,10-15,10-16, 12-8, 12-16, 12-21, 12-22, 12-24, 13-11,13-16, 14--1,14-7, 15-13, 16-14,A-8,A-17,A-22 fibroid . A-16, A-23. See also uterine fibroids. fibrosis . A-6, A-16. See also liver fibrosis. fdaria1 worms . A-16 fliariasis . l0-9, A-8, A-15 to A-16 film. spermicidal . .13-10, 13-17 fixed uterus . 9-7. A-8 fluconazole . 16-19 Index foam, spermicidal . 13-3, 13-10 fuamingtablets, spermiddal . .13-3, 13-6, 13-10, 13-17 fucal neurologic symptoms . A-3, A-16 follide . 6-18, 8-18, A-16 lO11ow-up . 3-7,4-22, 5-16 to 5-18, 6-13 to 6-15, 7-14 to 7-17, 8-16 to 8-20,8-23,9-16,9-18, 10-7,10-13 to 10-15,11-12 to 11-14, 12-17 to 12-23, 13-14 to 13-16, 14--8, 14--15 to 14--16,15-11 to 15-13 fungus infection . 15-13, A-23 G gallbladderdisease . 5-7, 5-16, 9-9, 12-9, 15-7,A-5 gastroenteritis . 9-9, 10-9, A-8, A-17 genital exam . 4--22 genital herpes . 16-15, 16-20, 16-21, A-17 . .5t!!aIiohelpes. genital tract infection . 12-8, 16-12 to 16-22, A-8 genital warts •• .see human papilloma virus (HPV). gestational diabetes . A-17 gloves . 4-10, 4-11, 4-12, 7-12 glucose . 7-18, A-15 glucose tests . 4-22 goiter . A-6, A-17 gonorrhea . ll-4, 12-19, 16-3, 16-12, 16-17, 16-18, A-17, A-20 granuloma ingoinale . 16-15, 16-21, A-17 griseofulvin . 5-7, 5-16, 6-7, 6-13, 8-8, 8-16, 9-10,A-7 H hair growth . 8-5 hair 1055 . 7-5,8-5 hand lotion . 13-19 hand washing . 4-11 headache . 4-16, 5-4, 5-7, 5-8, 5-14 to 5-17, 5-19,6-6,6-8,6-12,6-13,6-15,6-16,7-5, 7-7,7-11,7-14,7-17,7-19,8-5,8-15,8-16, 8-20,8-21, 12-9,14-9, 15-7,A-3,A-19. See also lOcal neurologic symptoms, migraine. 1-5 health care provk!ers . l-l to 1-2,4-5 to 4-6, 4-22, 5-2S, 8-5, 8-12 to 8-13, 8-22 to 8-23, 9-4, 9-12,9-15, 9-1S, 9-20 to 9-23, 9/10-2,10-4, 10-11 to 10-12, 10-14 to 10-15, IO-IS to 10-19, 11-5, 11-15, 12--6, 12-12 to 12-15, 13-5, 14-6, 14-10, 15-6, 16-1, 16-4, 16-9 health risk. . 9-4, 10-5 heart attack . 5-5, 5-6, 6-5, 7-4, 7-6, A-I 7. See also ischemic heart disease. heart disease . 4-15, 5-6, 5-16,6-13,6-14,7-6, 7-14,8-16,8-20,9-8, 1001S, 12-9, 16-14,~3 heavybleeding . 6-12, 7-5, 7-11, 7-16, 7-19, 8-lS,12-13, 12-1S, 12-24,A-3 hematometta . A-S hemoglobin . 4-22, 9-9, 9-10, A-17 hemorrhage . 9-7, A-S hepatitis . 4-IO, 4-IS, 16-3, A-5, A-17 hernia . 9-7, 10-8, A-8, A-17 to A-IS. See also abdominal wall hernia, diaph.ragmatic hernia, inguinal hernia, umbilical hernia. herpes . 11-4, 16-3, 16-9, 16-15, 16-20, 16-21. See also genital herpes. high blood pressure . 4-14, 4-15,5-5 to 5-6, 5-16,7-6,7-7,7-14,8-9,9-8,12-9,14-9. 15-7, A-2, A-14, A-15, A-IS, A-20 high.J.evel disinfection . 4-10 to 4-12, 7-12, 7-13,A-15 HIV . 4-lO, 4-17, 9-11,10-9,11-1,11-4.11-8, 11-16,12-8,13-6,1.3-19.15-5,15-6,15-15, 16-3, 16-8, 16-10. 16-11. 16-21. A-5, A-13. A-IS. See also acquired immune deficiency syndrome. AIDS. HIV/AlDS. HIV/AlDS . I-4, 2-1, 3-5,5-19,6-16.7-5, 7-13,7-19,8-6,8-21,9-5,9-19,10-6, 10-16,11-1,11-4 to 11-8, 11-12, 11-14 to 11-17, 12--6, 12-16. 12-24, 13-4. 13-5,1.3-19,14-17,15-5,15-14,16-1. 16-3, 16-S, 16-11 to 16-12, 16-22,A-5. See also acquired immune deficiency syndrome, AlDS,HIV. hormone . 4-9, 5-3, 5-5 to 5-7, 5-12, 5-22, 6-3, 6-7,6-14,6-15,6-17,6-1S,7-3,7-6,7-14, 7-17,8-3,8-7,8-S, 8-20, 10-17,12-3, 12-5 to 12--6, 12-13, 13-5. 14-6, 15-4, A-IS HPV . . See human papillomavirus (HPV). 1-6 Essentials of Contraceptive Technology Human Immunodeficiency Virus . . See HIV. human papillomavirus (HPV) . l1-4, 16-16, 16-21,A-17,A-lS hydrocele . 10-8, A-8, A-IS hypertension . . See high blood pressure. hyperchyroid . 9-9,14-8,A-6,A-1S hypothyroid . 9-10, 14-8, A-6, A-IS ibuprofen . 5-17, 7-16, 8-17, 9-16, 9-19,10-12. 10-16,12-12.12-14 immuuities . 4-8, 15-5, 15-15 implantation . A-16, A-IS. A-20, A-21 impotence . 10-15,11-16 infection . 4-IO. 7-6. 7-13. 8-15, 8-19, 8-21, 9-5. 9-7. 9-9,9-11,9-17,9-1S, 10-5, 10-8, 10-9, 10-13 to 10-15, 11-4, 11-5, 11-8, 11-13, 12-5, 12--6, 12-8 to 12-11, 12-14, 12-20 to 12-22, 12-25 to 12-27, 13-15, 14-9, 14-17,15-13,16-1 to 16-22,A-5,A-8,~13, A-14,A-16,A-20 toA-22 infection-prevention . 4-I, 4-4,4-5, 4-10 to 4-12, 4-22, 9-3, 9-13, 9-14, 10-3, 10-11, 12-1, 12-12, 12-13, 16-5 infertility and sexually transmitted diseases (STDs) . 11-5, 12-6, 12-8, 13-5, 16-3. 16-9,A-21 informed choice . 1-6, 3-2 to .3-3, 3-7 informedconsent . 9-12, 9-23, 9/10-1,10-10, 10-1S inguinal hernia . A-8, A-IS injectable contraceptives . See DMPA injectable conttaceprives, NET EN. injection . .3-5, 4-3, 4-11, 5-21, 8-4, 8-12 to 8-13,10-11,16-17,16-19,16-20. See also DMPA injectable conttaceptives, NET EN. insetting a cervical cap . 13-1, 13-12, 1.3-16 inserting a diaphragm . 13-1, 13-11, 13-16 inserting an IUD . 12-7, 12-12, 16-4 inserting Norplant® capsules . 8-12 insulin . A-3, ~15 Index interval procedure for female sterilization . 9-13 intrauterine device . See lUDo intrascrotal mass . A-8 intravenous antibiotics . 9-18, 10-15, 16-19 iron deficiency anemia . . See anemia. irregular bleeding . .5-8, 5-12, 5-14, 6-13 to 6-14, 7-16, 12-18, A-14 irregular menstrual cycles and fertility awareness-based methods . 14-7, 14-8 irritation . 11-11, 13-6, 13-13 ischemic heart disease . 6-14, 8-20, A-3, A-18 itching . I1-6, 11-11, 11-13 to 11-15,13-13, 13-15, 16-7, 16-13 IUCD . 12-3. See also lUD. IUD . 1-5, 3-5 to 3-6, 3-8,4-3,4-5,4-6,4-9, 4-11,4-13,4-15 to 4-18, 4-20, 4-22,5-21, 9-20,12-1 ro 12-27,15-12,16-4, A-2 toA-8 lUD insettion . 4-11, 12-1, 12-6, 12-7,12-14, 12-26, 12-27, 16-4. See also insetting an lUD. IUD removal . 12-1, 12-3, 12-5, 12-6, 12-10 to 12-11, 12-13, 12-14, 12-16 to 12-18, 12-20, 12-21, 12-23 to 12-27 lUD strin~ . 12-6, 12-13, 12-16, 12-21. 12-24 J jaundice . 5-7, 5-15, 5-19,6-7,7-6,8-7, A-5, A-15,A-18 jelly, spermicidal . 13-3, 13-11, 13-12,13-17 JHPIEGO . 4-10, 9-23,10-19 Johns Hopkins Program for International Education in Reproductive Health . See JHPIEGO. K kanarnycin . 16-17 kidney disease . 5-6, 5-8,7-6,9-10, A-8, A-20 L lactational arnenormea method . . See LAM. LAM . 1-5, 1-7,4-5,4-8 to 4-9, 4-13, 4-15 ro 4-20, 4-22, 15-1 to 15-15, A-2 roA-8, A-19 Index laparoscope, laparoscopy . 4-4, 9-3, 9-6, 9-14, 9-16,9-20, A-19 latex . 11-3, 11-16, 11-18, 13-19. See also allergy ro latex. Uppes Loop . 12-3 lithium . 14-9, 15-6, A-7, A-8 liver disease . 5-7.5-16,6-7,6-13,7-6,7-14, 8-7,8-16,A-5 liver fibrosis . 9-9 to 9-10, A-6. See also fibrosis. liver infection . 5-7,6-7,7-6.8-7 liver tumors . A-5 LNG-20 . 12-3 ltJ.Fer1U1I4l . • 5-23 LoIOvral.5-23 Ioca1 anesthesia . 4-22.9-1,9-3.9-5,9-15.9-21 lubricant . 11-3. 11-6. 11-10, 11-13 ro 11-15, 11-18,13-19 lung disease . 9-9, A-8 lymph . A-19 lymph node . 16-14 ro 16-15, A-14, A-19 Iymphogranulana venereuro . 16-15, 16-20 M MAla-D . 5-23 malaria . 5-8. 6-8. 7-7, 8-9. 9-11. 12-9, 14-9. 15-7, 16-3. A-6 male sterilization . . See vasectomy. malignant trophoblast disease . 9-7. 12-8. A-6 Marezinif ' •.• 5-23 margarine . 11-10. 13-19 mastitis . A-8 measles . 4-8.15-5 medical eligibility chc:cklist . 1-3. 1-6 to 1-7. 5-5. 6-6.7-5,8-6,9-6 to 9-10, 10-7, 12-7. 13-7, 14-7, 15-5 medical eligibility criteria . 1-4. 1-7,3-7,4-3, 4-13, 5-20, A-I to A-8. See also medical eligibility checklist. Megmron . 7-3 1-7 menopause . 5-4, 5-26, 7~15, 12~5, 12-13. 12-26, A-2, A-19 menses . 4-22, 6-12. A-19 menstrual bleed.ing . 4--8, 4-22. 5-9. 6-6, 6-10. 7-5,7-8,7-10,7-15,7-18,7-20.8-5,8-10, 8-14 to 8-15, 9-20. 12~, 12-10, 12-18, 14--8 to 14-9, 14-17, 15-3. 1~, 15-9, A-2.A-19 menstrual b100d . 5-27 menstrual cramps . 5-4, 12~ menstrual cycle . 5-9, 6-4, 6-9 to 6-10, 6-18, 7-7 to 7-8,8-4,8-10,12-10,12-13,12-26, 14-1,14--8,A-2,A-19 menstrual period . H to 4--8, 5-4. 5-8. 5-10, 5-12.5-18.5-19,5-26.6-8 to 6-10. 6-14. 7~ to 7-8. 7-16. 7-19. 8-5. 8-7. 8-9 to 8-11. 8-17.9-4.9-17.9-20,10-13,12-1,12-5. 12~, 12-7, 12-14 to 12-16, 12-19, 12-24, 12-26.14--8,15-1.15-3 to 15-4. 1~, 15-8 to 15-9. 15-11. 15-14. 15-15, A-19 menstruation . 5-1, 9-11,12-10,12-13.12-26. A-7.A-19 Mmgyna . 7-3 mesuanol. . 5-23 metabolic disorder. inf.mt . l~. A-8 metronidazole . 16-18 miconazole . 16-18 to 16-19 Microgynon •.• 5-23 midwives . 4-3 to 4-5 migraine . 4-16. 5-7, 5-18,6-15,7-17.8-20. A-3. A-16. A-19. See also 6xaI neurologic symptoms, headache. milk production . 6-3, 6-5,15-15 mineral oil . 11-10. 13-19 minilap . 9-3. See also minilaparotomy. minilaparotomy . 9-3. 9-5, 9~, 9-13 to 9-14, 9-16,9-20,A-19 minipill . 6-3. See also progestin-only oral contraceptives. miscarriage . H, 5-8. 5-10.6-8,6-10,7-7.7-9. 8-9,8-11,12-9,12-10.12-25,13-9 missed pills . 4-22. 5-11. 5-13, 5-19, 6-12. 6-17 MLCu-375 . 12-3, 12-4 1-8 Essentials of Contraceptive Technology mobile team . 10-7 moodchanges . 4-7. 5-5,5-14.5-19,7-5. See also depression. mood-alteringdrugs . 14-9.1~,A-7.A-8 mucous membrane . 4-12, A-20 MuIti«wJ . 12-3. See also MLCu-375. muscle ache . 13-11, 13-16 myocardial infarction . .A-17 N nausea . 4-7, 5-4, 5-10, 5-14, 5-17, 5-19. 5-23. 7-5.8-5.9-17,12-22,16-18 needles . 4-IO to 4-12. 7-12 to 7-13, 8-5. 9-14. 10-10,16-10,16-11.16-12 Neisseria gonorrhea . A-I7 neonatal intensive care . A-8 nephroparhy . A-20. See also kidney disease. nerve disease . 5-8. See also neuroparhy. ncrvousness . 8-5 NET EN . 4-13 to 4-17. 4-20, 4-22,~, 7-3, 7-18 neuropathy . .A-20 noncancerous cervical lesions . A-4 nonmed1ca1 providm . 5-8, 10-7, 13-7 nonpelvic ruberculosis . 9-II, 12-9, A-7 nonsteroidal anti-inflamrnarory drugs . .5-17.7-16, 8-17 co 8-19,12-19 Nordette . 5-23 Nordiol . 5-23 Norimrat . 7-3 NO'1'ktnt implanrs . 1-5,~, 3-8. 4-4, 4-9, 4-11 to 4-13, 4-15, 4-17. 4-20, 4-22. 8-1 to 8-24.15-12, A-2 toA-8 no-scalpel vasectomy . 10-10 no-touch IUD insertion technique . 4-11, 12-12 N01Ja 7: . 12-3 NSAID . See nonsteroidal anti-inflammatory drugs. nulliparous . A-7 Index nUISe . 1-3, 3--5, 4-3 [04-5,5-15,5-27,6-12, 7-11,8-14,8-15,9-16,10-13,11-11,12-16, 12-21 to 12-22, 12-27 nurse-midwife . 4-3 to 4-5 nurse-practitioners . 4-3.4-4 nutrition . 4-8 to 4-9,9-10, 15-9, A-8 nystatin . 16-19 o obese, obesity . 9-10, A-S. See also fat. ofloxacin . 16-18 oral contraceptives . . S~ combined oral contraceptives, progestin-only oral contraceptives. oral intercoUISe . 11-16, 11-18 orchitis . .A-8, A-20 ovarian cancer . 1-6, 5-4, 6-5,7-4,7-21,9-5, 12-8, 12-17, 12-21, A-4 ovarian CYSIS •.• 5-4, 6-18, 8-5, 8-18 [0 8-19,8-22, 14-9, A-4, A-20 ovarian tumor . S-8, 6-8, 8-9.8-18,9-11 ovary, ovaries . 5-3, 5-20, 5-26, 6-4, 6-18, 7-3, 8-4,8-S,9-4,12-19.14-8.15-4,A-20 overdose, anesthesia . 9-5.9-21 Ovral . S-23 ovulation . 5-3,5-20,6-4,7-3,8-4, 14-3. 14-5, 14-11 to 14-13, 15-4, A-16, A-20 ovum . A-20 p Panadol® . 9-19,10-16 pa=etanlol.5-17, 9-16, 9-19,10-12,10-15, 10-16, 12-14 parity . A-7 Pathfinder International . 9-23 peak day ( of cervical secretions) •. I4-11, 14-13, 14-17 pelvic adhesions . .A-20 pelvic cancers .•. 9-7 Index pelvic exam, pelvic examination . 4-5,4-11,4-12, 4-22,5-27,8-22,9-13,9-14,12-6,12-7, 12-12,12-14,12-17,12-19,12-22, 13-6 to 13-8 pelvicinfection •. 12-1 0, 12-25, A-20 pelvic inflamma[Oty disease .• 5-4,5-8,6-5,6-8, 7-16,8-9,8-18,9-7 to 9-8, 11-5, 12-1, 12-6, 12-8,12-13,12-16 to 12-18, 12-19, 12-20, 12-25,12-26,13--5,14-9,16-18,A-4,A-20 pelvic tuberculosis . 9-9, 12-8, A-7 pelvis . .A-20 penicillin . 16-17, 16-19 penis .•. 10-S, 11-3, 11-4, 11-6, 11-7. 11-9 [011-11,11-14,11-15,11-18,14-4, 14-17. 16-7, 16-12 to 16-16. A-20 perforation . 12-6, 12-13 petroleum jelly . 11-10, 11-18, 13--19 pharmacist . 4-3,4-S phenytoin . 5-7, 6-7, 8-8, 9-10, A-7 physical exam, physical examination . 4-1, 4-6, 4-7, 5-5,5-7,6-6,6-7,7-5,7-6,8-6,8-7,9-5, 9-13,9-14,12-20,13--7,15-5,16-22 PID . See pelvic infIamma[Oty disease. placenta . 12-10, 12-12, A-20 plastic condom . 11-14 plugged milk duCts . 15-13 pneumonia . 9-9, 15-5, 16-10,A-8 postabortion . l4-8, A-8 postabortion family planning . 5-1O, 6-10, 7-10, 8-11,13-8,I4-8,14-10,A-8.seeabo postabortion female sterilization, postabortion IUD insertion. postabortion female sterilization . 9-4,9-7,9-13, A-8 postabortion IUD insertion . 12-5, 12-11 postcoital contraception . . see emergency oral contraception. Postiwr-2 . 5-23,6-18 postpartum . 14-8, A-8, A-20 postpartum family planning . 5-9, 6-9, 7-8, 7-9,8-10,8-11, 11-5, 13-8, 14-8, 14-10, 15-1 to 15-1S,A-7 [OA-8. seeabo postpartum female sterilization, postpartum IUD insertion. 1-9 postpartum female sterilization . 9-7, 9-13, A-8 postpartum IUD insertion . 12-5, 12-7 to 12-8, 12-12,12-15,A-8 preeclampsia . 9-7, 9-11, A-8, A-20 pregnancy . 1-3, 1-5, 1-7,2-1,3-4,4-1, 4-6 to 4-9, 4-13 to 4-20, 5-3 to 5-4, 5-10, 5-12 to 5-15, 5-16 to 5-18, 5-20 to 5-22, 5-24, 5-26 to 5-28, 6-3 to 6-4,6-6,6-9, 6-11 to 6-14,6-18,7-3 to 7-8, 7-14 to 7-15, 7-17,7-18,7-20,7-21,8-3 to 8-8, 8-10, 8-1~8-16,8-18,8-22,8-23,9-4,9-5,9-7, 9-8,9-17,9-21 to 9-22, 9/10-2, 10-4, 10-5, 10-17,11-1, 11-4 to 11-8, 11-11, 11-15, 11-17,12-4 to 12-6,12-10,12-13,12-17, 12-19,12-21 to 12-22, 12-27, 13-4 to 13-5, 13-8,13-14, 14-1, 14-4 to 14-5, 14-8, 14-16, 14-18,15-1,15-3,15-4,15-6 to 15-8, 15-12,15-14,16-3,16-4, 16-10,16-13, 16-14,16-17 to 16-21, A-2, A-4, A-5, A-6,A-15 pregnancy rate . 1-5, 3-4,4-19,5-3 to 5-4, 6-4, 7-4,7-18,8-4,9-4, 10-4, 11-4, 12-4, 13-4, 14-4 to 14-5, 14-18, 15-4, 15-8 pregnancy test . 4-1, 4-6 to 4-7, 6-17 premature birth . A-8 premature ejaculation . 11-5 pressure on bladder, pain from . 13-16 primidone . 5-7, 6-7, 8-8, 9-10, A-7 procaine penicillin G . 16-19 to 16-20 procedures . 4-1, 4-4. 4-5. 4-21 to 4-22, A-I classification fur providing liuniIy planning methods . 4-22 devdoping IiuniIy planning policy . 1-1 infection p.revention . 4-10 to 4-12 providing liuniIy planning methods . 4-21 to 4-22, 5-10 to 5-11, 6-10, 7-9, 8-12 to 8-13, 9-13 to 9-15,10-11,11-8,12-11 to 12-13, 13-9, 15-8 ProgestllSm . 12-3 progesterone . 12-3, A-21 progestin . 5-3, 6-3, 7-3, 7-21,8-3,8-17, 8-24,12-3 progestin-only injectables . 1-6, 7-1 to 7-21 1-10 Essentials of Contraceptive Technology progestin-only methods . 4-13 to 4-18. See also DMPA, Norplant implants, progestin-only oral contraceptives. progestin-onlyoral contraceptives . 1-5, 4-3, 4-6, 4-9,4-13,4-15,4-17,4-20,4-22,5-18,5-21 to 5-23, 5-27, 6-1 to 6-18, 15-10, 15-12, A-2toA-8 progestins . A-21 prophylactics . 11-3. See also condoms. prostate cancer .• 10-18 pubeny . A-21 puerperal sepsis . 12-8, A-8, A-21 pulmonary embolism . 9-8, 14-9, A-21 purulent cervicitis . 4-17, 9-11, 12-21, A-21 pus . 8-15, 8-19, 9-17 to 9-19, 10-13 to 10-16, 12-21,16-7, 16-12,16-14,16-15,A-21 R radioactive drugs . 15-6, A-8 rape . 5-21 rash . 8-5, 11-11, 11-13 to 11-14, 13-11, 13-13, 13-16,16-9 recrum . 13-16, 16-15, A-21 regret fullowing sterilization . . 9/10-2 removing Norplant capsules . 8-13 reserpine . 15-6, A-8 retinopathy . A-21 return offertility . 5-4, 6-9, 7-1, 7-5, 7-8, 7-18, 7-20,8-1,8-5,8-10 return visit . 1-3, 3-5 to 3-7,5-11,5-16,6-13, 6-17,7-4,7-9,7-14,8-16,9-18,10-14, 11-12,12-14,12-17,13-9,13-14, 15-11 to 15-12 reusable needles . 4-11, 7-13 .reversa1,sterilization . 9-5,9-22,I0-6,10-17 thythm method . 14-13 to 14-14, 14-17. See also calendar method. rif.unpin, rif.unpicin . .s-7, 5-8, 5-16, 5-18, 6-7, 6-8,6-13, 8-8,8-9,8-16, 9-10,A-7 ring . 9-14 Index risk . 9/10-1 rupture of membranes . A-8 5 scalpel.4-12,10-11 schistosomiasis . 5-8, 6-8, 7-7,8--9,9-9 to 9-11, 12-9, A-6, A-21 scrotal injury . A-8 scrotal skin infection . 10-8, A-8 scrotal surgery . A-8 scrorum . 10-3 to 10-6, 10-8, 10-10 to 10-12, 10-15,16-15,A-21 seizure . 5-7,5-16,5-18,6-7,6-13,7-4,8-8, 8--16,9-10 semen . 4-lO, 10-4, 10-8, 10-14, 10-17, 10-18, 16-10 sepsis . A-8. See also puerperal sepsis. septic abortion . A-8, A-21 sexual ability . 9-20, 10-3, 10-17 sexual behavior . 16-8,16-11 sexual contact . 14-16, 14-17. 16-3, 16-10, 16-11 sexual desire . 10-15 sexual enjoyment . 5-4, 7-4,8-4,9-4, 10-5. 11-5, 11-6,12-5 sexual intercourse . 11-8,11-17. 16-10, 16-11 sexual perfurmance . l0-1, 10-12.10-15 sexual pleasure . 1 0-15 sexual sensarion . l0-1, 11-1, 11-6, 11-14 sexually transmitted disease . 2-1, 3-5, 3-7, 4-6, 4-17,4-22,5-5,5-19,5-20,5-24,5-25,6-8, 6-16,7-5,7-16,7-19,7-21,8-6,8--9,8--18, 8--21,9-5,9-7,9-11,9-19,10-6,10-8,10-9, 10-16,11-1,11-4 to 11-9,11-11 to 11-18, 12-1,12-6,12-8,12-16,12-17,12-20, 12-21, 12-24, 12-25, 12-26, 12-27. 13-1, 13-4 to 13-6, 13-17, 13-19, 14-7, 14-9. 14-17,15-5,15-14,16-1 to 16-22, A-4 to A-5, A-8, A-21 shopkeeper . 4-3, 5-8, 16-5 shortness of breath . 5-6, 7-6 sickle cell crisis . 7-4, 8--5, A-21 Index sickle ceU disease •.• 6-8. 7-7,8--9,9-10, 10-9, 15-7, A-6, A-21 side effect . 3-5,5-1,5-4,5-14,5-17 to 5-19, 6-5,6-6,7-4,7-5,7-10,7-15,8--5, 8--14 to 8--15,8-17, 12-6, 12-13, 12-18, 13-6,16-9 signs ofpregnancy . 4-7, 6-12, 6-17, 8--15, 9-17, 12-23 skin cream . ll-lB skin lorion . ll-10 skin rash . 8--5, 11-11, 11-13 to 11-14, 13-11, 13-13, 13-16, 16-14. See also rash. smoking . 4-14, 4-15,5-5,5-6,5-8,5-26 to 5-28, 6-8,7-7,8--9, 12-9, 14-9, 15-7, A-2, A-17, A-19 soap and water. . 4-11, 7-12, 8--19, 9-18, 10-15,11-11 social marketing programs . 5-28, 16-5 sores . 16-14, 16-15, 16-20 sore nipples . A-8 sore throat . 16-14 spectinomycin . 16-17 sperm . l0-4, 10-5, 10-11, 10-14,10-18,11-4, 12-4, 13-4, A-22 sperm duct . 10-8 spermatic cord . 10-8, A-18. A-22 spermicide . 4-5,4-7.4-20.4-22,5-6,5-22, 5-24,6-7,6-9,7-6,7-9,7-21,8-8,8-11, 11-3, 11-8,11-10 to 11-13, 12-7, 13-1, 13-19,14-17,15-11,16-1,16-5,16-6, 16-8, 16-9, A-2 to A-8 spermicide as back-up merhod-5-7, 5-9, 5-10, 5-11,5-13,5-14,5-18,6-10,6-12,6-17, 7-8,7-10,8--10, 15-12,A-13 spinal anesrhesia . 9-15 spontaneous abortion . . See miscarriage. sporring . 5-4, 5-14, 5-18, 6-6, 6-12, 6-13 to 6-14, 7-1, 7-5, 7-16, 8--1, 8--5, 8--14, 8--17 to 8--18,12-6,12-24, A-22 spring clips . 9-21 "standard-dose" oral conrraoeprives . .5-22,5-23 staphylococcus . 4-10, A-22 to A-23 1-11 STD-See sexually transmitted disease. STD risk assessment . 16-1, 16-6 to 16-7 sterile . 4-11, 5-26,7-12,7-13, 12-12 sterilize . 4-10 to 4-12, 16-11, A-22 stitches . 8-12, 8-13, 9-14, 9-16, 9-18, 10-13, 10-14 storingrondoms, diaphragm . 11-11, 11-15, 13--7 Stteptococcus . .A-23 Sttoke . 4-15, 5-5, 5-6, 5-16, 6-5, 6-14, 7-6, 7-14,8-20,9-8,12-9,14-8,A-3,A-22 subacute bactetial endocarditis . A-3 sulfumetboxazole . 13--15, 16-17, 16-21 superficial thrombophlebitis . A-3, A-22 suppositoty . 13--3, 13--10, 13--17, 16-18 surgety . 5-7, A-3, A-S surgical procedure . 8-6, 8-12 to 8-13, 9-13 to 9-14, 91l0-1, 10-11 syndrome . A-22 syphilis . 4-17, Il-4, 16-3, 16-14, 16-19, 16-20,A-22 syphilis test . 16-22 syringe . 4-1O to 4-12,7-12 to 7-13 systemicinfection . 9-9, 10-9, A-8 T TCu-380A . 1-5,4-20, 12-1, 12-3 to 12-5, 12-11,12-14, 12-22,12-24,12-27,A-2toA-8 tender breasts . .see breast tenderness. testes, testicles . 10-3, 10-8, 10-17, 16-7, A-22 testis . A-22 tetraeyeline . 16-17 to 16-21 thalassemia . A-6, A-22 thromboembolic disorder . A-3, A-22 thrombophlebitis . .A-3, A-22 thrush . 15-13 thyroid disease . 5-8, 6-8, 7-7, 8-9, 12-9, 15-7, A-6,A-22 thyroid gland ••. A-22 1-12 Essentials of Contraceptive Technology toxic shock syndrome . l3-8, 13--11, 13--13, 13--14,13--16, 13--18,A-7,A-22 toxin . A-22 training . 9-13,9-23, 10-11, 10-19, 12-12, 12-25 trauma . A-8, A-23 Trichomonas vaginalis .•• A-23 trichomoniasis . 16-13, 16-18, A-23 tricyclic anti-depressants . 14-9, A-7 trimerhoprim . 16-17,16-21 trocar . 4-12 trophoblast, trophoblast disease . A-6, A-23 tubal abscess . 12-20 tuballigation . 9-3,9-4 tuberculosis . 4-18, 5-8, 6-8, 7-7, 8-9. 9-11, 12-9. 16-10,A-7,A-23 tying the tubes . 9-3,A-19 Tylenol® . 9-16, 9-19,10-12,10-16. Seelllso acetaminophen. paracetamol. u umbilical hernia . .A-8 uncircumciserl . 1l-9, 16-13 undescended testes . 1 0-8 unintended pregnancy . 2-1, 4-19, A-2, A-4, A-6 United States Food and Drug Adrninistration . 7-21,12-27 upser stomach . 5-1, 5-19 urinary tract infection . 13-6, 13--14, 13-15, 13--1S, A-5 urination . 12-8, 13-6, 13--15, 16-7, 16-12, 16-13 urine sugar . 4-22 uterine cavity . A-5, A-7 uterine elevator . 9-13 uterine evacuarion . 7-17, 8-18 uterine fibroids . .5-8,6-8, 7-4, 7-7, 8-9, 9-8, 14-9,15-7,A-5,A-7,A-23 uterine involution . A-8 uterine perforation . 9-7, A-8 Index uterine rupture . 9-7, A-8 uterinesound . 4-12,12-13 uterus . 9-13,9-20, 12-1, 12-3, 12-4, 12-10, 12-12,12-13,12-25,13-8,13-9,A-4,A-8, A-23 v vaginal abrasions . A-5 vaginal bleeding . 3-8, 4-17, 5-1, 5-17 to 5-18, 6-1,6-14,6-16,7-1,7-7,7-10,7-17,7-19, 8-1, 8-8, 8-1B, 8-21,9-7,9-11,9-17, 9-19, 12-7, 12-9, 12-19, 14-8, 16-12, A-3. A-4, A-6 vaginal discharge . . See discharge, vaginal. vaginal exam . 4-11 vaginal infection . 14-1, 14-7, 14-9, 14-17, A-5 vaginal intercourse . 14-4, 14-12, 14-16, 14-17,16-10 vaginal itching . . See itching. vaginal lesion . 13-16 vaginallubricant . 13-19 vaginal lubrication . 11-1B. 13-5 vaginal method . 4-6. 4-9.5-25, 13-1 to 13-19 vaginal sec.retions . 4-1 ° vaginal specu1urn . 4-12, 12-12 vaginal tear •. A-B vaginal wetness . 11-1B, 14-17 vaginal yeast cream . 13-19 vaginitis . 4-17, 9-11, 13-16, A-5, A-23 valaciclovir . 16-21 valproic acid . . 5-lB. A-7 valvular heart disease . 4-15. 6-8, 7-7, 8-9. 9-8, 15-7,A-3,A-23 varicocele . 10-8, A-8, A-23 Index varicoseveins . 5-8, 6-8, 7-7, 8-9, 9-11,12-9, 14-9,15-7,A-3,A-23 vas, vas deli:rens . lO-11,A-16, A-23 vasa . A-23 vascular disease . 4-15, 5-8,7-18,9-8,9-10, A-2, A-3,A-23 vasectomy . 3-2, 3-5, 4-4, 4-9, 4-13, 4-20, 4-22, 9-3.9-5,9-22,10-1 to 10-19,A-2 toA-8,A-23 Vaseline® . 11-10, 11-15, 13-19 vegetable oil . 13-19 viral hepatitis . 4-18, 5-7, 6-7, 7-6, 8-7, 9-9. 14-9,15-6,15-11,A-5 vitamin C . 13-15 voluntary surgical contraception . 9-3 vomiting . 4-7, 5-10, 5-14, 5-lB, 5-23, 13-16, 16-9,16-18 vulva . 13-15,A-23 w wall chart . 1-4 wasre . 4-10.4-12 weakness . 5-27,9-20, 10-17, 11-16 weight . 4-7, 8-23, 9-15 weight gain . 5-4, 6-5,7-1,7-5,7-10,7-19,8-5 WHO . See World Health Organization. withdrawal . 14-1, 14-4, 14-5, 14-10 to 14-14, 14-17 woman-controlledmethod . 11-7, 13-1, 13-4, 13-5, 13-17, 13-19 World Health Organization . I-6, 1-7,4-13, 7-20,7-21,9-6,10-7,15-15,16-17, A-I toA-8 y yeast-lilre fungus . A-14 1-13 Illustration Credits Page 6-5: Bolivia National Reproductive Healtb Program, IEC Subcommission Page 7-12: Johns Hoplcins Population Communication Services Page 8-11: template: Wyeth.Ayerst; photo: JHPIEGO Page 8-13: JHPIEGO Page 9-15: Johns Hopkins Population Communication Services Page 10-3: EngenderHealtb (AVSC International) Page 10-6: Hatcher. RA., et al. Family planning metbods and practice: Africa. Atlanra, US DHHS. COC, 1983. Page 11-7: The Female Healtb Company Page 11-9: Asociaci6n Demognlfica Salvadorena Page 11-10: le&: Asociaci6n Demognlfica Salvadorena; right: Asociaci6n Hondurena de Planificaci6n de Familia Page 14-11: Georgetown Universiry Institute fur Reproductive Healtb Page 15-10: left: WHO; right: World Bank Production Credits Supervision: Stephen M. Goldstein and Uncia D. Sadler, Population Infurmation Program, Center for Communication Programs, Johns Hoplcins Bloomberg School of Public Healtb Design and typesetting: Dayman, Christina M. Whittington, and Mary Pat Peabody. Prographics Printing: Mail-Well Mid-Atlantic Print Group How to Obtain More Copies of The Essentials of Contraceptive Technology The Essentials of Contraceptive Technology in English, Spanish, and French is available free of charge to health care professionals and programs in developing countries, USAID Collaborating Agencies, and other organizations working to promote reproductive health in developing countries. For developed-country orders, the price is US$5 per copy, postage and handling included. (Developed-country orders should be sent to the Population Information Program at the address below. Please pay with order.) Only for those in the regions or countries listed, please send orders for 30copies or fewer to one of the addresses listed under each country on the opposite page. (For orders of 30 copies, see below.) 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Box 37230 Old Red Cross Building Los Angeles Boulevard Long Acres. Lusaka 10 10 1 Zambia TeI: 260-1-254-555 Fax 260-1-253-839 E-mail: elizabeths@zihp.org.zm or graceS@zihp.org.zm Zimbabwe Executive Director Zimbabwe National Family Planning Council Harare Hospital Grounds 1'.0. Box 51220 Southerton, Harare, Zimbabwe TeI: 263-04-621-909/620-281-5 Fax: 263-04-620-280 E-mail: znfpC@ecoweb.oo.zw ® Vasectomy Population Information Program Center for Communication Programs The Johns Hoplcins Bloomberg School of Public Health III Market Place, Baltimore, MD 21202, USA The Essentials of Contraceptive Technology How to use the thumb index: To find a chapter quickly, match the chapter title on this cover with the brown block on the page edges at left. Chapters listed in the left column are in the front of the book. Chapters listed on the right are in the back. 1885960018_eng 1885960018_eng_part2 1885960018_eng_part3

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