Session 1: Introduction to Family Planning Methods

TYPES OF FAMILY PLANNING METHODS AVAILABLE IN UGANDA

  1. Hormonal contraceptive method
  2. Oral pills
  • Combined Oral Contraceptives (COC) examples are; Lo-feminal, Microgynon and Pill Plan
  • Progestin only Pills (POP) examples; Overette and Microval

b.Injectables: - Depo Medroxy Progesterone Acetate (DMPA/Depo Provera) and Nerethisterone Enanthate (NET – EN) FPAU clinic only)

c.Implants: -Norplant, Jadelle, Implanon

  1. Intra-Uterine Device (IUD): - Copper T380A

3.Barrier Methods: - Condoms – female, male, Spermicides – foams, jellies, creams

4.Natural Family Planning: - Lactational Amenorrhoea Method (LAM) Fertility awareness methods, Moon beads

  1. Voluntary Surgical Contraception (VSC) : -Tubal Ligation, and Vasectomy

GUIDE FOR DESCRIBING FAMILY PLANNING METHODS

  • What it is
  • Effectiveness in preventing pregnancy including the user’s role
  • Mechanism of action
  • Advantages and non contraceptive benefits
  • Protection against STIs/HIV/AIDS
  • Common side effects and disadvantages
  • Who can use the method
  • Who cannot use
  • Signs of problems that require urgent medical attention

WHO Medical Eligibility Criteria for starting or continuing to use Family Planning methods

World Health Organization (WHO) has outlined the medical eligibility criteria for starting and using contraceptive methods. This criterion has been put in the following categories:

WHO Category 1 / No restriction on contraceptive use. The client can use the contraceptive
WHO Category 2 / Client can generally use the method. Advantages of using the method outweigh proven or theoretical risks. If a client chooses the method more than usual follow up is needed
WHO Category 3 / Client should not use the method. Proven or theoretical risks outweigh advantages of using the method.
WHO Category 4 / Client should not use the contraceptive. Client’s condition represents an unacceptable health risk if method is used.

Scenario I:

A 42 year old woman with 2 children requests COCs. She has a history of diabetes which was first diagnosed when she was 18 years old.

  1. Is this client a good candidate for receiving COCs during today’s visit?
  2. Explain your reasons
  3. What course of action would you suggest next for client?

Scenario II:

A 28 year old woman has 3 children. She and her husband consider their family complete, do not want any more children, and would like to use an effective contraceptive method. After counseling session woman decided that she wants to use DMPA. She is healthy, but for the past two months noticed light bleeding/spotting every time she had intercourse. She meant to go to the doctor, but didn’t get round to it.

  1. Is this client a good candidate for receiving COCs during today’s visit?
  2. Explain your reasons
  3. What course of action would you suggest next for client?

Session 1.1. Description of FP Methods

  1. Combined Oral Contraceptives

Description of COCs

Combined oral contraceptives are pills that contain 2 hormones i.e. Synthetic estrogen and progestin. They are taken orally and daily to prevent pregnancy.

Currently Uganda has only low oestrogen dose COCs (30 mcg instead of 50mcg that was responsible for oestrogen related effects in the previous years). The COC used in this country come in 28 Day Pill Cycles with 21 Active or Hormonal Pills and 7 Placebos or Ferrous Femurate to allow for withdrawal bleeding.

Types:Lo-feminal and Microgynon are found in the public sector health facilities whereas Duofem (Pilplan) is found in the private sector.

Microgynon: / Lo-Feminal: / Duofem
21 hormonal pills containing 0.03 mg of ethinyl estradiol and 0.15 mg Levonorgestrel and 7 brown pills containing Ferrous Femurate. / 21 White pills containing 0.03 mg ethinylestradiol (estrogen) and Norgestrel (progestin) 0.3 mg and 7 brown pills containing Ferrous Femurate. / (Marketed as New Pilplan): 21 White pills containing 0.03 mg ethinyl estradiol (estrogen) and Norgestrel (progestin) 0.3 mg and 7 brown pills containing Ferrous Femurate.

NB. Please note that though all the COCs have same type and amount of oestrogen in them, they sometimes differ in the type and amountof progestin e.g. Microgynon has a different type of progestin which is (Levonorgestrel 0.15 mg) whereas Lofeminal and Duofem have (Norgestrel 0.3 mg) as the progestin. The significance is that sometimes you may have to switch clients from one COC to another because the clients may respond differently to either. An example is a client may respond better to Microgynon than Lofeminal and Duofem.

Mechanism of action of COCs

The COC Pills prevent pregnancy by:

  • Suppressing ovulation
  • Thickening the cervical mucus thus making sperm entry difficult

Effectiveness of COCs

The effectiveness of the method depends on user compliance. It is very effective when used properly; about 3 in 1,000 women (0.3%) who use COC correctly and consistently get pregnant in the first year of use. When pill taking mistakes are made among the real users, the failure rate may be as high as 8%; this means that 1 woman in 12 will become pregnant in the first year of life as the hormone-free interval is lengthened (Contraceptive Technology 18th Revised Edition)

The failure rates decline as duration of use increases; and also as age of user increases; Failures may be due to:

  • Client error;
  • Service provider not giving complete and/or correct information;
  • Drug interactions
  • Severe vomiting/diarrhoea;
  • Expired pills

The continuation rate among COC users is low (25 – 50% of women will stop the COC within one year), most will stop for non-medical reasons. In cultures where bleeding may exclude women from some family activities, break through bleeding/spotting can be major reason to stop the pill. If client does not have or use another (back-up) method, unintended pregnancy can result;

It is important to counsel and reassure about potential side effects, and that break-through bleeding/spotting will decrease after first 3 to 4 months or can be managed. The client should be cautioned not to stop taking the COC unless she has another method to use, or has access to ECP at hand/has the method on hand, and knows how to use it.

Advantages and non-contraceptive benefits of COCs

  • Cause periods to be regular and predictable;
  • Reduces menstrual blood loss which prevents anaemia
  • Reduces dysmenorrhoea and premenstrual tension
  • Can be used an emergency contraception
  • Are very effective if taken correctly
  • Are easily reversible
  • Are safe for most women
  • Are independent of coitus
  • Protect against ovarian and endometrial cancer, and PID
  • Reduce risk of functional ovarian cysts, benign breast cysts, fibro-adenoma, and ectopic pregnancy

Disadvantages and common side effects of COCs

  • Effectiveness depends on client remembering to take pill everyday; strong motivation needed to take pills correctly/daily;
  • Require regular and dependable supply;
  • Reduces breast milk, especially in the first 6 months after delivery and is, therefore, not the most appropriate choice for lactating women (unless no other method is available and there is a high risk of getting pregnant);
  • Minor side effects which are common in first three months may include: spotting, amenorrhea, nausea, breast tenderness, headaches, weight gain, depression, and/or acne;
  • May cause circulatory complications though very rare. Increased risk is related to women over 35 who smoke and have other health problems.

Protection of COCs against STD/HIV infection

Some protection against pelvic inflammatory Disease (PID) but does not protect against other STIs, including HIV.

Who can use COC?

  • All women of reproductive age who desire to use COCs
  • Women with:
  • anaemia, but the basic problem causing anemia must be evaluated and treated
  • dysmenorrhoea
  • irregular cycles
  • history of ectopic pregnancies
  • Diabetics lasting less than 20 years or without evidence of hypertension
  • BP less than 160/100 mm Hg
  • trophoblastic disease (on treatment and follow –up)
  • Varicose veins or superficial thromophlebitis
  • Unexplained vaginal bleeding (although evaluation should be done as soon as possible)
  • Benign ovarian tumours (including cysts)
  • Ovarian cancer awaiting definitive treatment
  • Thryoid disease
  • Benign breast disease
  • Depressive disorders
  • Undergoing treatment with the antibiotic griseofulvin
  • Undergoing treatment with ARVs (although effectiveness may be reduced)
  • STIs, including HIV/AIDS
  • If a client is taking ARVs which include Niverapine and wants to use COCs, it is important that she takes the pill daily at the same time otherwise she is likely to get pregnant.

Who should not use COC?

The following contra-indicate administration of COC:

  • Pregnancy (although there is known harm to the woman or the foetus if COCs are accidentally used during pregnancy)
  • Complications or side effects that a service provider is not capable of handling:
  • Breast feeding mothers less than 6 months
  • Women due for major surgery within four weeks;
  • Women with:

-history of current deep vein thrombosis;

-Vascular disease;

-Migraine with focal neurological symptoms;

-Liver disease e.g. Hepatitis, cancer, cirrhosis

-Jaundice

-women with Active viral hepatitis

  • Women undergoing treatment with drugs that affect the liver enzymes (rifampicin and certain anticonvulsants such as phenytolin, carbamazipine, barbiturates, primidone, topiramate, oxcarbazepine)
  • Women with:

History of all ischemic heart disease;

-Stroke or history of stroke;

-Major surgery with prolonged immobilization;

-Hypertension greater than 160/100 mmhg;

-Known thrombogenic mutations (e.g. factor V leiden: prothrombin mutation: Protein S. Protein C and antithrombin deficiencies) due to higher risk of thrombosis

History of:

-Diabetes with vascular complications or diabetes of more than 20 years duration

-Smoking more than 15 cigarettes a day whatever the age

-Smoking when older than 35 years

Women judged to be forgetful or mentally retarded

To date there is no concrete evidence that oral contraceptives have any effect on the transmission of HIV or the course of AIDS once a person is infected

Signs of problems that require urgent medical attention

  • Severe headaches with blurred vision
  • Severe constant pain the chest with difficulty in breathing
  • Acute abdominal pain
  • Pain in the calf muscle
  • Eyes or skin become unusually yellow
  • COC signs that require urgent medical attention are rare in low-dose sub – 50 mcg danger signs, and what to do if she should experience any one of these. Care should be taken by the provider to present these in a non-alarming way to the client. Providers should question for these at each follow up visit. Heavy smoking appears to be the most significant risk factor for development of major cardiovascular disease.

Progestin only contraceptives (POP, Injectables, Implants)

For effectiveness of each method in preventing pregnancy and contributing factors, service providers during counseling clients, should emphasize the following to them:

  • POPs are effective after swallowing for seven days and the effectiveness is maintained by swallowing every day at the same time.
  • Injectables are effective within 48hrs. specifically for DMPA, effectiveness will last 12 weeks and NET EN for 8 weeks

Providers are also reminded that the effectiveness of the contraceptive in particular injectables and implants depends on giving the injection following the correct procedure and infection prevention protocols.

Implants:

The new implants (Jadell and Implanol) are different from the Norplant Implants was effective within 48 hours and used for 5 years whereas the new ones and are effective for 3 years. The effectiveness depends on proper insertion under the skin (subdermally)

The side effects are temporally and that they wear out (usually within 3 months) when the body gets used to the method. The side effects which are specific for each group (POP, Injectables, and Implants) are discussed in this handout.

All contraceptives which contain only one hormone; Progestin are referred to as Progestin Only Contraceptives (POCs). In Uganda, the major types available include oral pills, injectables and implants:

Type of POC / Name / Description
Oral pills / Progestin Only Pills (POP) / The one found in the health units in Uganda is Overette. Overette contains Norgestrel 0.075mg and is supplied in 29 pill packs.
Injectables / Depo Medroxy Progesterone Acetate (DMPA) / Each vial contains Medroxy Progesterone Acetate 150mg (DMPA). The common name is Depo Provera. It is marketed as Inject–Plan. It is found in the public sector health facilities.
NET– EN (Noristerat) / It is found in the private sector and supplied in 200mg vials.
Implants / Implanon / A single rod (capsule) which contains Etonorgestrel 68mg. within eight hours of after sub dermal insertion, etonogestrel levels are sufficient to provide contraceptive protection. A continuous release of etonogestrel is maintained for 3 years and within one week after removal, etonogestrel is no longer detectable in human serum.
Jadell / consists of two (2) rods (capsule) and each rod contains Levonorgestrel 75mg
Norplant Implants / FP method which contains six (6) small plastic capsules that are inserted under the skin of the woman’s upper arm. Each capsule contains only progestin hormone and lasts for 5 years.

Mechanism of action of POCs

All POCs prevent pregnancy by mainly in two ways by thickening the cervical mucus within 24 hours making it difficult for sperm to enter the uterus and/or inhibiting ovulation

Method specific information:

a)Progestin Only Pills (POP)

Effectiveness

  • POPs are most effective when taken at the same time everyday. Delaying to take the pill for only three hours may result in pregnancy if the woman has unprotected sexual intercourse in that time.
  • For breastfeeding women, POP is very effective when taken correctly because breastfeeding itself provides much protection against pregnancy. Only one (1) pregnancy may occur per 100 women in the first year of use.
  • POPs are also very effective when used correctly and consistently in both breastfeeding and non breastfeeding women. 0.5 pregnancies (1 in every 200 women) may occur in the first year of use.
  • POPs are also very effective when used correctly and consistently in both breastfeeding and non breastfeeding women. 0.5 pregnancies (1 in every 200 women) may occur in the first year of use.

Advantages and non contraceptive benefits

  • Very effective if taken correctly
  • Can be very effective during breastfeeding start 6 weeks after delivery
  • Does not suppress lactation
  • No estrogenic side effects
  • Can take one pill of the same colour everyday with no break, so it is easier to understand
  • Suitable for those with hypertension or thromboembolic, cardiac, or sickle cell disease
  • Does not increase blood clotting
  • Reduces the risk of:
  • Benign breast disease
  • Endometrial and ovarian cancer
  • Pelvic inflammatory disease

Common side effects and disadvantages

For women who are not breastfeeding may have:

  • Spotting or bleeding between periods
  • Amenorrhea
  • Mild headache
  • Breast tenderness
  • If not breastfeeding, even taking a pill a few hours late increases risk of pregnancy
  • Does not project against other STIs or HIV

b)Depo Provera (DMPA) and Noristerat

Effectiveness:

  • Very effective – 0.3 pregnancies per 100 women in first year of use (1 in every 33.3 women) when injections are given regularly, every 12 weeks.
  • Pregnancy rates become higher for women who are late for an injection or who miss an injection or if there are stock outs.

Advantages and non contraceptive benefits

  • It is very effective
  • Does not suppress lactation
  • Client only has to remember the return date for subsequent injections i.e. it is private; no one can know that the woman is on it
  • Can be used at any age
  • No estrogen side effects
  • May reduce the frequency of epileptic and sickle cells crisis less frequent
  • Helps to prevent ectopic pregnancies and iron deficiency anaemia

Disadvantages and common side effects

  • The woman may experience the following changes in the menstrual bleeding:
  • Spotting (most common at first)
  • Amenorrhea (normal after first year of use)
  • Heavy bleeding (rare)
  • Weight gain
  • Delayed return of fertility, about 4 months longer wait for pregnancy after stopping use
  • Mild Headaches
  • Breast tenderness
  • Loss of libido
  • Moodiness
  • Nausea
  • Acne or hair loss
  • Requires injection every three months
  • Does to protect against other STIs or HIV

c)Implants

There are so far 3 types of Implants in Uganda i.e. Norplant Implant, Implanol and Jadell.

General information on Implants:

Effectiveness /
  • Implants are very effective, only 0.1 pregnancies per 100 women (1 in every 1,000) may occur in the first year of use.
  • Pregnancy rates have been slightly higher among women weighing more than 70 kgs.

Advantages and non contraceptive benefits /
  • Very effective even in heavier women
  • Effective within 24 hours after insertion
  • No delay in return to fertility after removal
  • Long acting; needs replacement after three years
  • No repeated clinic visits required
  • Helps to prevent: iron deficiency, anaemia, ectopic pregnancy, endometrial cancer
  • Makes sickle cell crisis less frequent and less painful
  • No effect on breast milk
  • No oestrogen side effects
  • Insertion involves only minor pain of anaesthesia needle. Not painful if anaesthesia is given properly.

Common side effects and disadvantages /
  • Changes in menstrual bleeding:
  • Spotting
  • Heavy bleeding (rare)
  • Amenorrhea
  • Minor surgical procedure required for insertion and removal
  • Discomfort in the arm after insertion
  • Does not protect against STIs including HIV/AIDS
  • While being on Implants, some women may develop:
  • Weight gain
  • Headaches
  • Dizziness
  • Breast tenderness
  • Moodiness
  • Nausea
  • Acne/skin rash
  • Change in appetite
  • Hair loss or more hair growth on the face
  • Client cannot start or stop using an implant on her own; the capsules must be inserted and removed by a specially trained health care provider.

SESSION: 1.3. SCREENING CLIENTS FOR CONTRACEPTIVES USE

Purposes of screening clients for FP method use