Contraception in Special Situations

Experts

Dr Jaya Narendra

Dr Arulmozhi Ramarajan

Dr Shubha Rao

Dr Jayanthy

Dr Ashakiran

What are special situations for contraception?

Adolescence Following pregnancy and lactation Peri-menopausal women

designated as “special population” Women with gynaecological

problems Women with medical disorders &

others

WHO Recommendation criteria for safe contraceptive use (2009)

Category1 = no restriction on useCategory2 = Advantages of using the

method generally outweigh the theoretical or proven risks

Category3 = Theoretical or proven risks usually outweigh the advantages of using the method

Category4 = Unacceptable health risk

Case 1

An 18 year old adolescent with irregular periods and acne comes for treatment.

What are your options?

Choices are

COCs with EE and DSPR

COCs with Cyproterone acetate & EE

COCs with Desogestrel/Norgestrel

Life style modifications of course

Reduction in acne lesions with DSPR

*p<0.0001 vs. placebo

Koltun W, et al. Int J Gynecol Obstet 2009;107(suppl 2):s620

-60

50

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-10

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DSPR Placebo

DSPR was associated with a greater reduction from baseline in total lesion counts versus placebo

Supposing an adolescent with regular cycles had a medical abortion and comes to you for contraceptive advice.

What will you give?

When will you start?

The Options

LDOCP

IUCD

DMPA

Ring

The Options

Low dose oral contraceptives: have many

benefits but compliance is an issue

Ring: can be inserted after the abortion is completed

Inj. DMPA: It temporarily interferes with calcium deposition in bones

Both Cu IUD and LNG IUD are

Category 1 for women > 20yrs and

Category 2 for women < 20yrs

Contraception in adolescents

Contraception in adolescents

Adolescents are eligible for all contraceptives which are suitable for adults Proper counseling regarding use is important, especially for Emergency contraception

Dual protection to be stressed upon

Abstinence can be promoted as a method

Contraception after medical abortion

COC on the day of Mifepristone Condoms, after bleeding stops Sterilization, IUD, POP only after

completion of abortion Natural methods, DMPA & Ring, only after

the next period

Mrs Just Delivered is being discharged today

after a FTND of a healthy baby 3 days back.

Both the mother and the baby are in good health

and she is breast feeding the baby.

When would you schedule her postpartum visit

for contraceptive advice?

Case 2

3 weeks after delivery 6 weeks after delivery 3 months after delivery 6 months after delivery

i

Most studies have shown that many

women ovulate before the 6th week (before

the traditional postpartum visit)

A 3 week visit would be ideal for

contraceptive advice

As advised, Mrs. Just Delivered visits after 3 weeks. She is partially breast feeding her baby

What are her contraceptive options?

COCs POPs LNG IUD Cu IUD DMPA

Mr J.D. considers Cu IUD and asks

“What would be the ideal time to insert the

Cu IUD, Doctor”

At 4 weeks?

At 6 months?

Postpartum visit at 3 weeks

Postpartum insertion of a Cu IUD is best

done within 48hours or AT or AFTER 4

weeks (Category 1)

It is not inserted between 48 hrs to 4 weeks

(Category 4)

WHO eligibility criteria 2008

What about Breast feeding and COCs?

There are 3 issues here

Risk of Thromboembolism Estrogen in doses more than 30 ugm

inhibits lactation and can lead to a shorter period of breast feeding

Estrogen can induce reversible increase in breast size of the mother and the infant, male or female

The risk for VTE within the first 42 days postpartum is 22-fold to 84-fold greater than the risk among non-pregnant, non-postpartum women.

The risk is highest immediately after delivery, declining rapidly during the first 21 days, but not returning to baseline until 42 days postpartum.

Use of COCs, which can cause a small increased risk for VTE, might theoretically pose an additional risk if used during this time.

Systematic review, CDC, WHO

Breast-feeding and combined hormonal contraception

COCs have Minor effects on quantity and quality of

breast milk No effect on infant growth

OB-GYNs=obstetricians and gynecologists; WHO=World Health Organization.1. Truitt ST et al. Cochrane Database Syst Rev. 2003;(2):CD003988.

Special Situations - Postpartum Contraception

COC POP

INJ IMP Cu IUD

LNG IUS

Breastfeeding

<3weeks postpartum

4 3 3 3 > 48 hr3

> 48 hr3

3 weeks - < 6 weeks postpartum if risks for VTE present

3 1 1 1 > 4 wks

1

> 4 wks1

> 6 months postpartum

2 1 1 1 1 1

Non Breastfeeding< 21 days 3 1 1 1 > 48

hr3

> 48 hr3

> 21 days 1 1 1 1 > 4 wks

1

> 4 wks1

She chooses to use Inj DMPA

What would you counsel her about?

She takes Inj DMPA and is quite happy with it.

Her periods are irregular with spotting on & off

but since she has been counseled, she is not

unduly disturbed by it and the bleeding settles

down

Following the second injection, she returns to

the clinic only after 4 months

What would you do now?

Check for pregnancy. If negative give the injection

and ask her to use additional method for the next

7days

Check for pregnancy and if negative give the

injection without any additional advice about

contraception

Give the injection

Late for an injection??Grace period extended!

The repeat injection of

DMPA can be given up to 4 weeks late

NET-EN can be given up to 2 weeks late

without requiring additional contraceptive

protection

Selected Practice Recommendations for Contraceptive Use 2008 update

What are the demerits of DMPA?

Irregular bleeding in the 1st 3-4 months

Interferes with Calcium deposition in bones

Fertility returns 8-10 mths after the last dose

Case 3

F, 32yrs, P2 L2 Regular heavy periods Clinical Examination – 14wks size uterus Ultrasound examination – Bulky uterus with

multiple intramural fibroids, largest measuring 4cmX4cm.

Endometrial thickness 11mm, contour - normal

OC pills & Fibroids

The administration of low dose OC pills to women with leiomyomas does not stimulate fibroid growth and is associated with decreased bleeding

Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

LNG IUS & Fibroids

In women with fibroids & troublesome bleeding, the size of the uterus and the largest individual tumors diminished slightly with LNG-IUS.

Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

Special Situations - Genital & Breast ConditionsCOC POP INJ IMP Cu

IUDLNG IUS

Fibroids

Cavity non distorting

1 1 1 1 1 1

Cavity distorting 1 1 1 1 4 4

Endometriosis

1 1 1 1 2 1

Benign Ovarian Tumors

1 1 1 1 1 1

Benign Breast Disease

1 1 1 1 1 1

Ectropion 1 1 1 1 1 1

Mrs F chooses to get an LNG IUS inserted. She

comes back after 3yrs for a check up. She

reveals that she was recently hospitalized for a

bad lung infection and is presently undergoing

treatment for tuberculosis with a 4 drug regime.

Would you like to suggest a change in her contraceptive method?

Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugs

Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver enzymes, such as rifampicin and anti-epileptic drugs

LNG IUS and Anti-TB Drugs

Special Situations - Miscellaneous Issues

COC POP

INJ IMP Cu IUD

LNG IUS

Anemias Iron deficiency anemia & thalessemia

1 1 1 1 2 1

Sickle cell 2 1 1 1 2 1

Liver TumorsBenign adenoma Malignant hepatoma

4 3 3 3 1 3

Liver Enzyme Affecting Drugs

Rifampicin, phenytoin, barbiturate, carbamezipine

3 3 2 3 1 1

33yr old with a BP of 150/100 needs contraception. She is on medication for Hypertension and does not have any other medical problem. What contraceptives would be safe for her?

Oral contraceptives (including newer agents), increase

systolic BP by 8 mm Hg and diastolic by 6 mm Hg

Special Situations - Hypertensive Conditions

COCR/P

POP DMPA

IMP Cu IUD

LNG IUS

Arterial CVD Risk Age, smoking, DM, HT

3/4 2 3 2 1 2

Hypertension

Adequate control 3 1 2 1 1 1

140 – 159 / 90 – 99 mm Hg

3 1 2 1 1 1

> 160 / > 100 mm Hg

4 1 3 2 1 2

Vascular disease 4 2 3 2 1 2

History of HT during pregnancy

2 1 1 1 1 1

35yr old woman with 3 children and diabetic since 1yr needs contraception. Her BMI is 28 and she is not hypertensive.

COC & Diabetes… COC in type I DM – Studies find no change in

HbA1c, development or progression of nephropathy or retinopathy

Nonsmoking, <35yrs, otherwise healthy diabetics, no end-organ disease – COC safe

LNG-IUS – Safe in diabetics

Past h/o GDM – COC does not accelerate or precipitate development of type II DM

ACOG Practice bulletin no:18, Obst & Gynecol. 2006

A 24-year old woman, with no concomitant diseases, was admitted with epigastric pain and vomiting. A provisional diagnosis of Acute Pancreatitis was made. On further questioning, she gave a h/o having taken Diane 35 in the previous 4 months. Her LMP was 5 days back.

Is there a connection between the OC Pill and Acute Pancreatitis?

Case 4

Acute pancreatitis occurred within 3months of starting estrogen therapy in most cases

Abdominal pain and pancreatitis ceased within 10 days of stopping estrogen

S Triglycerides, Cholesterol and FBS are increased when on the pill

Facts in favour of a connection

Estrogen increases fasting Triglycerides by increasing the hepatic production of Triglycerides.

Estrogen also increases HD Lipoproteins and decreases LD Lipoproteins

Primary Dyslipidemia is a relative contraindication for Estrogen therapy

In young, healthy women taking oral contraceptives and presenting with acute abdominal pain, consider the diagnosis of Acute Pancreatitis

Lipid profile before starting OCPs not recommended

With no pre-existing Hyperlipidemia, S triglycerides increase is usually mild and does not lead to pancreatitis

If obese, with a family history of hyperlipidemia, lipid profile checked to prevent acute pancreatitis

Take Home message

Knehtl M, Journal of Disease Markers, Nov 2014

Case 5

A 28-year-old woman, P2+1, developed jaundice, pruritus, fatigue and anorexia. She gave a history of a single 28 day cycle of oral contraceptives (Ovral L), started shortly after a first trimester abortion. She was on no other medication and did not drink alcohol

Because of persistent jaundice, she underwent endoscopic retrograde cholangio-pancreatography which was normal. A liver biopsy showed intrahepatic cholestasis with minimal inflammation and bile duct proliferation

What could be the problem? Do you want to elicit any other history?

She gives a history of having pruritus and jaundice in her 2 previous pregnancies

In the 5th month of her 1st and the 6th week of her 2nd pregnancy

Bilirubin values of 3.5 and 3.8 mg/dl

Severe pruritus

Cause of jaundice not identified

What type of jaundice did she suffer from?

Is there a connection between the jaundice she had in her 2 prior pregnancies and what she is suffering from now?

What are the features of Cholestatic jaundice?

Bland Cholestasis

Time of onset: 4 to 24 wks after starting pill

Jaundice: mild, S Bil never > 7mgs%

Pruritus: severe

ALT: <200 U/L (<5 times ULN)

Alkaline phosphatase: <230 U/L (<2 times elevated) Both may be normal too

Resolves in 1-2 mths, rarely 6 mths

Never associated with fatal liver disease

To avoid it, should you do a LFT for all women before prescribing the pill?

Can happen in men too after Anabolic steroids

Take home message Take a proper history before starting the pill If woman complains of pruritus when on the

pill, discontinue it Do LFT. If elevated, treat symptomatically Repeat LFT after 6 weeks Use only those hormonal contraceptives

that bypass the liver like LNG-IUS, Vaginal Ring, etc

Reassure the woman that it is not a serious condition

Special Situations - Gastrointestinal ConditionsCOC PO

PINJ IMP Cu

IUDLNG IUS

Gall Bladder Disease

SymptomaticAsymptomatic

32

22

22

22

11

22

Cholestasis Pregnancy / COC related

23

12

12

12

11

12

Viral Hepatitis

Active diseaseCarrier state

41

31

31

31

11

31

Cirrhosis

Mild – compensatedSevere - decompensated

34

23

23

23

11

23

Taking oral contraceptives for five or more years is

associated with a doubling of cervical cancer risk

Is it true?

Women who use oral contraceptives have an increased risk of developing cervical cancer

The new analysis of data from 24 worldwide studies is one of the most rigorous examinations of cervical cancer risk in oral contraceptive users ever conducted

Lancet, Nov 2010

16,500 cervical cancer patients and 35,500 women without the disease studied to quantify the risk associated with oral contraceptive use worldwide.

It was found that women who used the pill for 5 years or less had a 10% increased risk of cervical cancer when compared with women who had never taken it. This increased risk rose to 60% with 5-9 years of use and doubled with 10 years of use or over

Epidemiologist Jane Green, MD, who led the study team…

The risk starts to fall pretty quickly and has gone away 10 years later

Lancet, Nov 2010

The reasons for this risk from OC use are not entirely clear. less likely to use a diaphragm, condoms,

or other methods that offer some protection against STDs including HPV.

hormones in OCs might help the virus enter the genetic material of cervical cells.

"Regular screening is important for all women, but especially for those taking oral contraceptives," Sasieni says.

"A woman who has regular screenings can basically forget about the increase in risk.“

Based on the most recent evaluation of several studies, the IARC has concluded that HC can be classified as carcinogenic to the cervix as well as to the breast.

When women who had used DMPA were compared to women who had never used this method, there were also significant differences in presence of and severity of disease

There are several studies which have reported that hormonal contraception (HC) - pills and injectables - moderately increase the risk of cervical cancer as well as being a risk for all stages of cervical cancer particularly in human papilloma virus (HPV)-positive women thus suggesting that oral contraceptives may act as a promoter for HPV-induced carcinogenesis. Norma McFarlane-Anderson etal, BMC Womens Health, 2008

Contraception in the peri-menopausal period

Do we need it?

No more Surprise periods

No more Surprise Babies

No more Diaper duty

No more Hot Flushes

Issues with Peri-Menopause

Need for effective contraception Menstrual cycle abnormalities Vasomotor instability Need for osteoporosis and cardiovascular

disease prevention Increased risk of gynecological cancer

Kailas NA, Reprod Health Eur J Contracept Care. 2005

The choices are

Oral Contraceptives-highly effective contraception, non-contraceptive benefits, improve QOL

POPs.. Excellent safety profile IUCDs DMPA.. No evidence about # due to bone loss Barrier Combined Vaginal Ring, Skin Patches.. Risks

same as OCPs Natural Estrogens.. safer

A woman had a Cu 380 A inserted at 38 years. 10 years later, at the age of 48, she has irregular cycles. Should the IUD be removed?

Studies from the United Nations and Brazil indicate high efficacy of copper IUD after the 10-year windowSpontaneous fertility beyond age 45 is rare and the IUD becomes even more effectiveKeeping the IUD for a few more years may be indicated

1. Bahamondes L et al. Contraception. 2005;72:337-341. 2. United Nations (UN) Development Programme, UN Population Fund, WHO and World Bank, Special Programme of Research, Development and Research Training in Human Reproduction. Contraception. 1997;56:341-352.

When on COC, how does a woman know that she has reached menopause?

Stop the pills for a month or more Check her FSHTesting FSH a second time one month later will provide a more reliable result

Case 6

Mrs M, just married, had an open heart surgery for ASD repair 2months back. She is on oral anticoagulants. Wants contraception for at lease one year.

Women on anticoagulant Rx

↑ Menorrhagia, corpus luteum hematoma, hemoperitoneum

COC, DMPA, Mirena - Appropriate COC – Do not ↑ risk of thrombosis if well

anticoagulated DMPA – Not much injection site problems

Special Situations - Heart Disease

COC POP INJ IMP Cu IUD

LNG IUS

Ischemic Heart Disease

History of IHD 4 I - 2C - 3

3 I - 2C - 3

1 I - 2C - 3

Current IHD 4 I - 2C - 3

3 I - 2C - 3

1 I - 2C - 3

Valvular Heart Disease

Uncomplicated 2 1 1 1 1 1

Complicated - Pulmonary HT & atrial fibrillation

4 1 1 1 2 2

Complicated - SBE 4 1 1 1 2 2

To sum up

Ideal Contraceptive in a woman with Hypertension

If < 35 years

Non-smoking

No end organ disease

Well controlled Hypertension

Low dose COC ..OK

If not POPs or LNG-IUS

Oral contraceptives (including newer agents), increase systolic blood pressure by 8 mm Hg and diastolic by 6 mm Hg

Ideal contraceptive in a woman with

Dyslipidemia

If dyslipidaemia is well controlled,

COCs with <35 ugms of EE can be used

Serum lipids monitored regularly

If LDL > 160 mgs%- POPs safer

Type of Progesterone is the deciding factor

Estrogens increase HDL, Triglycerides and lower LDLProgesterone opposes this action. Androgenic Progestogens like Norethisterone,LNG, increase LDL, lower HDL and Triglycerides.

Ideal contraceptive in a woman with Diabetes

COCs do not increase a woman's risk of developing type 2 diabetes

In type 1 diabetes, COCs do not impair metabolic control or accelerate the development of vascular disease

BUT, ACOG recommends COCs only

If <35 yrs

No HT, Nephropathy, Retinopathy or other vascular disease

LNG IUS.. safe

What about in Obesity?

COCs and Transdermal patch less effective

Obesity and COCs independent risk factors for VTE

DUB and Endo Ca more common in obese

LNG-IUS safe and effective

A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload

375 inserted this time. When does she need to come for removal?

A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload

375 inserted this time. When does she need to come for removal?

She need not get it removed till after menopause.

Women 40 years or older at the time of IUD insertion may retain the

device until they no longer require contraception, even if this is beyond

the duration