Advantages and disadvantages

Advantages and non-contraceptive benefits of Depo Provera_/Injectaplan

- Client only has to remember the return date for subsequent injections;

- It is highly effective (99.9%);

- Decreases risk of developing endometrial or ovarian cancer;

- Long-acting: injection required once every 12 weeks. Is reported to remain effective for up to an additional 4 weeks if a woman is late for her "shot" (injection);

- Appropriate for women over 35 years with estrogen precautions, and/or those who do not want more children but don't want VSC;

- May be used by women taking rifampicin; (continue)

- Does not significantly alter breast milk supply or quality, so may be used by lactating women after six weeks postpartum;

- Unrelated to coitus: provides privacy and convenience;

- Does not have serious cardiovascular effects sometimes associated with the COC;

- Hemoglobin levels often rise in women using DMPA, reducing anaemia;

- Reduces some pain and abnormal red blood cells in women with sickle cell disease;

- Does not require refrigeration and has a shelf life of 2-5 years;

- Prolonged absence of menses is an advantage for many women;

- Provides immediate Postpartum or Postabortion contraception;

- It is completely reversible (2-4 months delay in return to fertility).

 

Disadvantages and side-effects of Depo Provera_/Injectaplan

- Amenorrhoea often occurs after the 2nd or 3rd injection. Over half of the women using DMPA will experience amenorrhea by 12 months of use. Amenorrhea can be an advantage if women are fully informed that this is natural and not harmful;

- Can cause heavy prolonged irregular vaginal bleeding during the first 2 to 6 weeks after the first injection;

- May cause loss of libido; Delays return to fertility since it is long acting (delay may be 6 to 12 months after stopping injection). Pregnancy is delayed 2-4 months longer than after discontinuing

other contraceptives, such as COCs or IUDs. (continue)

 

DMPA is completely reversible and does not cause infertility. Residual levels of DMPA can be detected for 1- 4 months after the end of the contraceptive protection from the last injection;

- Increased appetite causing weight gain for some women (.5 kg, on average, in first year);

- Since they are long acting they cannot easily be discontinued or removed from the body if a complication occurs or if pregnancy is desired.

Protection against STI/HIV from Depo Provera_/Injectaplan

- Some protection against Pelvic Inflammatory Disease (PID);

- No protection against other STIs, including HIV. (continue)

Who should use Depo Provera_/Injectaplan?

- Breastfeeding Postpartum women (as early as 6 weeks Postpartum);

- Women who desire long-term contraception;

- Women who are or are suspected to be HIV-positive and want an effective method (although they will still need to use condoms as well);

- Women with sickle cell disease;

- Women who cannot use COCs due to estrogen content;

- Women who do not want to have any children but are not yet ready for voluntary surgical contraception;

- Women waiting for surgical contraception;

- Women who prefer a method that does not require any preparation before intercourse;

- Women who desire the convenience of not having to keep contraceptive methods at home;

- Women who have problems of compliance with oral contraceptives. (continue)

Who should not use Depo Provera_/Injectaplan?

- Women who are known or suspected to be pregnant. Because no method is indicated during pregnancy, any health risk is considered unacceptable. However, there is no harm to mother and foetus if DMPA is used;

- Women with unexplained vaginal bleeding (before evaluation): If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and eligibility adjusted after evaluation.

Provision guidelines for Depo Provera_/Injectaplan

- The first injection may be given any time in the menstrual cycle, provided the clinician is reasonably certain the client is not pregnant. However, DMPA offers greatest protection from pregnancy if given in the first 7 days (as client may ovulate after that). If administered after day 7, it may not prevent ovulation and client must use back-up method for the first 24 hours following the first injection (provide condoms);

- Standard regime is 150 mg of DMPA every 12 weeks (or 3 months), in the deltoid or gluteal muscle, deep intramuscular; (continue).

- Vial must be shaken vigorously before drawing solution into syringe;

- As with all injections, infection prevention technique and use of sterile needle and syringe for each client is mandatory;

- Injection site should not be massaged after injection as it may speed up the release of progestin and shorten period of efficacy.

Routine follow-up for Depo Provera-Injectaplan

- Subsequent injections are given every 12 to 14 weeks but client has a 2 week grace period as DMPA provides protection up to 4 weeks after last injection. In addition, subsequent injections may also be given up to two weeks early.

Signs of problems from Depo Provera_/Injectaplan warranting immediate return to clinic

- Uncontrollable heavy vaginal bleeding;

- Excessive weight gain;

- Severe abdominal pain after the first injection.

 

Counselling on Norplant

Description of Norplant

       Norplant comes in 6 small flexible plastic capsules that are inserted under the skin of the woman's upper arm. Each of the capsules is 3.4 cm long with a diameter of 2.4 mm and contains an average of 36 mg of Levonorgestrel. Norplant provides protection from pregnancy for up to 5 years.

Mechanism of action of Norplant

- Inhibits ovulation so that eggs will not be released regularly;

- Thickens cervical mucus to prevent sperm from entering.

Effectiveness of Norplant

- Very effective (more than 99%)

 

Advantages and disadvantages

Advantages and non-contraceptive benefits of Norplant

- Highly effective with failure rate of less than 1%;

- No delay in return to fertility after removal,

- Decreased risk of developing endometrial or ovarian cancer,

- Long acting: needs replacement only after 5 years;

- Low user-responsibility: Once Norplant_ is inserted, the woman only has to return to the clinic for follow up visits and to have the implant removed;

- Convenient (does not interfere with normal activities, sexual desire, or intercourse);

- Decreases menstrual cramps and pains;

- Comfortable and usually not visible under the skin.

 

Disadvantages and side-effects of Norplant_

- May cause irregular bleeding, spotting, or heavy bleeding in the first few months;

- May cause amenorrhoea in the first few months;

- Must be inserted and removed by trained service provider and thus it is not available everywhere;

- Effectiveness is lowered by drugs like rifanpicin, barbiturates and phenyntion;

- Risk similar to any minor surgery (infection, bleeding, or hematoma)

- Woman cannot stop whenever she wants a baby unless implants are removed

- Does not protect against STI/HIV.

Protection of Norplant_ against STI/HIV

- Some protection against Pelvic Inflammatory Disease (PID);

- No protection against other STIs, including HIV.

Who should use Norplant?

- Women who want a method that does not require much user responsibility;

- Women who want long-term birth spacing (two years or more);

- Women who have the number of children they want but do not want a permanent method (voluntary sterilsation) at this time;

- Women who are breastfeeding;

- Women who prefer not to use contraceptives that contain estrogen or have developed estrogenrelated complications while taking combined oral contraceptives (COCs);

- Young women, as it offers some protection against PID;

- Women who prefer a method that does not require taking contraceptive action daily or before sexual intercourse. (This includes women who have trouble using barrier methods or remembering to take Pill everyday).

Who should not use Norplant?

- Women who are known or suspected to be pregnant;

- Women with breast or genital cancer.

Provision guidelines for Norplant

- Anytime you can be reasonably sure that client is not pregnant;

- Days 1-7 of the menstrual cycle;

- Post-partum:

- after 6 months of using lactational amennorhoea;

- after 6 weeks of breast feeding but not using LAM;

- immediately within 6 weeks if not breast feeding.

- Post-abortion care-immediately or within the first 7 days.

Routine follow-up for Norplant_

- One week after insertion to check on insertion;

- Anytime if there is a problem.

Signs of problems from Norplant_ warranting immediate return to clinic

- Uncontrollable heavy vaginal bleeding;

- Excessive weight gain;

- Severe abdominal pain after the first insertion;

- Pus, bleeding, or pain at the insertion site.

 

Counselling on Emergency Contraceptive Pills

Description

      Emergency Contraceptive Pills (Pack of Vikela) is a hormonal method of preventing pregnancy resulting from unexpected unprotected act of sexual intercourse.

- Locally marketed through the commercial sector as Vikela

- ECPs should not be used as routine contraceptions.

Effectiveness

      ECPs reduces the risk of pregnancy by approximately 75% if taken within 72 hours of last intercourse.     Effectiveness is higher when emergency contraceptive is taken immediately at last intercourse.

 

Mechanism of Action

- The precise mode of action of ECPs is uncertain and may be related to the time it is used in a woman’s cycle;

- ECPs are thought to - prevent ovulation and implantation;

- ECPs are not effective once the process of fertilization has begun, and ECPS will not cause an abortion.

 

Advantages and disadvantages

Advantages and non-contraceptive benefits of Emergency Contraceptives

- Highly effective if used within the first 72 hours;

- Simple;

- Reduces the risk of unwanted pregnacy and likely to prepare for the first sexual encounter;

 

Disadvantages and side-effects of Emergency Contraceptives

- Causes nausea and vomiting;

- Reduces breastmilk particularly when COCs are used;

- May change the time of a woman’s next menstrual period or produce spotting;

- May cause breast tenderness, headache and dizziness Protection of emergency contraception against STI/HIV/AIDS

- No protection against STI/HIV;

- If at risk of STI/HIV condoms should be used as well.

Who should use emergency contraceptive?

- When there is a method failure or misuse like:

- condom rupture;

- failed coitus interruptus;

- IUD expulsion.

- If a woman has missed one or more progestin-only pills;

- In cases of sexual assault:

- Rape;

- Defilement.

- In case of intercourse without contraception.

Who should not use emergency contraceptive?

- there are no medical precautions to the use of ECPs;

- The dose of hormones used in ECP is relatively small and the pills are used for a short time. So the precautions associated with continuos use of COCs and POPs do not apply.

Dosage

- ECP should be initiated within the first 72 hours of unprotectd sex. The earlier the better.

- Vikela pre packed-ECP is Progestine only.

- The following Pill combination may be used as well:

- COC - High oestrogen: e.g. Ovral 2 pills start, then 2 pills after 2 hours

- COC - Low oestrogen e.g. Lofeminal: 4 pills start, then 4 pills after 2 hours

- POP - e.g. Ovrette - 20 pills start, then 20 pills after 12 hours Microval - 20 pills start, then 20 pills after 12 hours .

What client should do after using ECPs?

- No any immediate signs showing whether or not the ECPs has worked;

- The menstrual period should come on time (or few days early or late);

- If the period is more than a week later than expected, or if there is any cause for concern, client should see the health care provider.

If the ECPs do not work and pregnancy occurs

- Based on available information, there is no reason to believe that the pregnancy would be abnormal or the baby hurt in any way.

 

Counselling client on Intra Uterine Contraceptive Device (IUD)

Description of IUD

     The IUD is a plastic device which may have copper and is inserted in the uterine cavity to prevent pregnancy.

      The Copper T 380A (the most common IUD in Egypt) is a T-shaped device with Copper on the stem and the arms of the T.

Its duration of effectiveness is 10 years and its shelf life is 7 years. Multiload 375 lasts 5 years.

Mechanism of action of IUD

- Makes the endometrium unsuitable for implantation of fertilised ovum

- Copper emits metal ions that are spermicidal.

Effectiveness of IUD

- Very effective (96-99%).

 

Advantages and disadvantages

Advantages and non-contraceptive benefits of the IUD

- Easily reversible;

- Long-term Family Planning method;

- No hormone-related side effects;

- Only user-responsibility is to remember to check for the strings and check menstrual pads for expelled IUD before disposal;

- Can be inserted as early as six weeks Postpartum or immediately post delivery or up to 48 hours post delivery by trained provider;

- Safe for most women not at risk for STI/HIV;

- One visit for insertion and minimal followup required after first 3-6 weeks check-up (unless client has problems);

- Economical as it lasts a long time once it is inserted (continue)

- Long duration of use (up to 10 years for TCu 380A);

- Not related to coitus; allows woman privacy and control in regard to her fertility;

- Does not interact with medications woman may use.

Disadvantages and side-effects of the IUD

- Mild cramps during the first few 3-5 days post-insertion;

- Longer and heavier menstrual blood loss in the first 3 months;

- increased normal vaginal discharge in the first 3 months

- Spotting or bleeding between periods;

- Increased cramping pain during menses;

- May expose patient to infection during insertion where infection prevention practices are not followed

- It is trained provider dependent

- Does not protect against ovarian, endometrial cancer or cervical cancer. (continue)

- IUDs do not increase the risk of ectopic pregnancy. Since intrauterine pregnancy is uncommon in IUD users (less than 2%), the risk of an ectopic pregnancy is even rarer. (For most of the most widely used IUDs, there is less than 1.5 ectopic pregnancies per 1,000 women using IUD). However, since IUDs protect better against intra uterine pregnancy than against ectopic pregnancy, the pregnancy is more likely to be ectopic if the patient becomes pregnant.

Protection against STI/HIV from IUD

- No protection against STI/HIV;

- If at risk of STI/HIV, there is an increased risk of PID and subsequent infertility and therefore should not be used.

Who should use IUD?

- Breastfeeding mothers;

- Women who have a healthy reproductive tract;

- Women who are in a mutually faithful sexual relationship and who are not at risk or have a low risk for STI/HIV. (IUD users with STIs are at risk of PID with its consequences of chronic pain, ectopic pregnancy, and infertility);

- Women who have completed childbearing and do not want VSC or long term hormonal methods (IUDs very suitable for older women until menopause);

- Women who want long-term, reversible method and have children. (Excellent return to fertility; IUDs are better tolerated by women who have carried at least one pregnancy to term); (continue) .

- Women who want an effective method but precaution(s) exist for hormonal method such as COCs. (IUD has little/no effect on body systems other than the reproductive tract);

- Women who are immediate Postpartum and want effective method that won't interfere with breastfeeding. (IUD does not affect lactation; may be inserted immediately post placental or within first 48 hours Postpartum.) This requires special training;

- Women who have successfully used IUD in past. Users with positive past experience tend to tolerate IUDs well.

Who should not use IUD?

- Women who are known or suspected to be pregnant. As no method is indicated, any health risk is considered unacceptable. With IUD use during pregnancy, there is greatly increased risk of spontaneous abortion. If the IUD is in situ, there is a risk of septic abortion;

- Women with active PID, within 6 months of treatment for PID, or with risk of PID (purulent cervicitis);

- Women with undiagnosed abnormal uterine bleeding. If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation; (continue)

- Women who have a history of having STIs within the last 3 months, or who are at risk of exposure to STIs including HIV (those with or whose partners have multiple sexual partners). In women with increased risk of STIs, IUD insertion poses a risk of PID;

- Women with lowered resistance to infection, for example, with Diabetes Mellitus, HIV infection, or AIDS;

- Women with known or suspected genital cancer (cervical, endometrial, or ovarian cancer). There is a concern about increased risk of infection and bleeding. This may make the condition worse.

Provision guidelines for IUD

- during menstruation;

- anytime when sure client is not pregnant;

- anytime when switching from hormonal method;

- as early as six weeks post partum or can be inserted immediately post delivery or up to 48 hours post delivery by trained provider.

Routine follow-up for IUD (4 - 6 weeks after insertion)

- Ask the client:

- How she has been;

- Whether she is feeling the strings;

- If she has had her monthly period.

- Review the client’s knowledge on side effects and danger signs then ensure her understanding;

- Tell the client that she should return to the clinic if she feels the strings or in case of a problem.

Signs of problems from IUD warranting immediate return to clinic

- Pain in the lower abdomen;

- Pain with intercourse;

- Foul-smelling vaginal discharge;

- Fever;

- Missed period;

- Missing strings;

- Prolonged vaginal bleeding;

- Spotting.

Where IUD is obtainable?

- Vikele cms health units, private sector.

Summary of crucial factors for safe IUD use

- Careful screening and assessment of STI/HIV risk;

- Provider skill proficiency in IUD insertion and infection prevention practices;

- Reliable back-up services;

- Careful and complete client counselling.

 

Counselling on Spermicides

Description of spermicide

- Vaginal spermicides come in the form of foam, cream, jelly, tablet or suppository and is inserted into the vagina just before sexual intercourse to prevent pregnancy.

Mechanism of action of spermicide

- Inactivates and kills sperm;

- Blocks path of sperm to the uterus.

Effectiveness of spermicides

- Fairly effective, depending on the user (79-97%);

- If used with condom, effectiveness is 99%;

- Effectiveness lasts only 30 to 40 minutes after insertion.

 

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