28. Contraception Flashcards
(277 cards)
1
Q
Why is family planning considered a critical health intervention?
A
Family planning is essential for achieving long-term sustainable development goals, combating HIV/AIDS, and improving the health and development of women, men, and children by allowing women to plan, space, and delay pregnancies.
2
Q
What guidelines is the South African National Contraception and Fertility Regulation Policy based on?
A
It is based on the 2012 SA National Contraception and Fertility Regulation Policy and Service Delivery Guidelines, which align with WHO recommendations.
3
Q
What are the cornerstones of family planning according to WHO?
A
The cornerstones include:
- Medical Eligibility Criteria (MEC) for Contraceptive Use
- Selected Practice Recommendations for Contraceptive Use
Both are evidence-based recommendations developed by WHO to improve quality and safety in family planning and undergo periodic expert reviews.
4
Q
What is the purpose of the WHO Medical Eligibility Criteria (MEC)?
A
MEC provides guidance on the safety of contraceptive methods in the context of specific health conditions and characteristics, such as HIV and tuberculosis.
5
Q
What are the four WHO MEC classification categories?
A
Category 1: No restriction; the method can be used in any circumstance.
Category 2: Advantages generally outweigh theoretical or proven risks; method can generally be used.
Category 3: Risks usually outweigh advantages; use is not recommended unless no other acceptable methods are available.
Category 4: Unacceptable health risk; method should not be used.
6
Q
What is the purpose of WHO’s Selected Practice Recommendations for Contraceptive Use?
A
It provides guidance on how to use contraceptives safely and effectively.
7
Q
What does “informed choice” mean in the context of family planning?
A
Informed choice means clients are provided with accurate, unbiased information about all available contraceptive methods to make a decision. They should receive their chosen method, subject to availability and meeting medical eligibility criteria.
8
Q
How does expanding contraceptive method choices impact family planning?
A
Expanding method choices improves satisfaction, increases acceptance, and raises the prevalence of contraceptive use (WHO MEC 2009).
9
Q
What aspects should be assessed prior to initiating contraception?
A
- Medical history
- Future fertility plans
- Contraceptive history
- STI/HIV risk assessment
- Promotion of dual protection/dual method use
- Blood pressure (BP)
- Pelvic exam (only for IUS/IUD fitting or female sterilization)
- Breast and cervical screening is not essential
- Pap smears per national guidelines or clinical indication
10
Q
When is it essential to measure blood pressure before initiating contraception?
A
- Essential prior to sterilization surgery
- Recommended before and during hormonal contraceptive use
- If not possible, hormonal methods can still be provided if there is no history of high BP, with BP measurement deferred to the next visit.
11
Q
When is a pelvic exam required before contraception use?
A
A pelvic exam is only required before:
- Fitting an intrauterine system (IUS) or intrauterine device (IUD)
- Performing female sterilization
12
Q
What is “dual protection” in the context of contraception?
A
Dual protection refers to using male or female condoms in combination with another contraceptive method to prevent both pregnancy and STI/HIV transmission.
13
Q
Why should correct and consistent condom use be emphasized?
A
Because condoms alone have a higher pregnancy rate compared to combined methods, and they provide protection against STIs and HIV.
14
Q
What is the current WHO classification for progestogen-only injectables among women at high risk of HIV?
A
Category 2: Women can use progestogen-only injectables but must be informed about:
- Potential increased risk of HIV acquisition
- Uncertainty of a causal relationship
- Ways to minimize HIV risk
15
Q
What findings have been observed about hormonal contraception and HIV acquisition risk?
A
- Injectable DMPA-IM increases the likelihood of HIV-1 acquisition in women.
- NET-EN and COCs containing LNG do not show the same risk.
- Differences arise from the biological effects of individual progestins and the protective effects of estrogen.
16
Q
Why is the relationship between DMPA-IM and HIV acquisition particularly important in sub-Saharan Africa?
A
Sub-Saharan Africa has high rates of both HIV and usage of DMPA injectable contraception, making this a critical public health concern.
17
Q
How does WHO stay updated on the evidence regarding hormonal contraception and HIV?
A
WHO continuously monitors evidence and commissions systematic reviews, such as the 2016 update, to provide the most accurate guidelines.
18
Q
Why might different progestins have varying effects on HIV risk?
A
Different progestins act via specific steroid receptors, and estrogen may have a protective anti-viral effect, leading to differential biological outcomes.zz
19
Q
What is a low-dose Combined Oral Contraceptive (COC)?
A
Low-dose COCs are pills containing 35 µg or less of synthetic estrogen (ethinyl estradiol) and a synthetic progestogen (e.g., levonorgestrel, desogestrel, gestodene). They are highly effective at preventing pregnancy when taken regularly and are safe for most healthy women.
20
Q
synthetic estrogen
A
ethinyl estradiol
21
Q
synthetic progestogen
A
levonorgestrel,
desogestrel,
gestodene
22
Q
List three examples of synthetic progestogens found in low-dose COCs.
A
Synthetic progestogens include:
Levonorgestrel
Desogestrel
Gestodene
23
Q
What is the main condition for the effectiveness of low-dose COCs?
A
They must be taken regularly to be highly effective at preventing pregnancy.
24
Q
Can breastfeeding women use COCs?
A
Breastfeeding women should avoid using COCs if they are less than 6 weeks postpartum (WHO Category 3/4).
25
Why should women who smoke more than 10-15 cigarettes per day and are over 35 years old avoid COCs?
Smoking combined with COCs significantly increases the risk of cardiovascular conditions, making it unsuitable for this group (WHO Category 3/4).
26
Which types of migraines are contraindications for COC use?
- Migraine with aura (any age)
- Simple migraines in women over 35 years
27
Name three cardiovascular-related conditions that are contraindications for COCs.
- Ischemic heart disease
- Stroke
- Complicated valvular heart disease
28
Why are women with VTE or known thrombogenic mutations advised against using COCs?
COCs increase the risk of blood clot formation, making them unsuitable for women with VTE or thrombogenic mutations.
29
Why are COCs contraindicated in women with diabetes lasting over 20 years or with vascular complications?
Long-term diabetes or vascular complications increase the risk of cardiovascular disease, which is exacerbated by COCs.
30
Which liver condition is a contraindication for COCs?
Liver tumors are a contraindication for COC use.
31
Why are enzyme-inducing drugs like rifampicin and ritonavir contraindicated with COCs?
These drugs reduce the effectiveness of COCs by increasing their metabolism.
32
Name a chronic autoimmune condition that is a contraindication for COCs.
Systemic lupus erythematosus (SLE) with positive or unknown antiphospholipid antibodies.
33
Why is prolonged immobilization a contraindication for COCs?
It increases the risk of venous thromboembolism (VTE), which is already a concern with COCs.
34
Mnemonic for contraindications of COC
"Breastfeeding Mothers Should Call Hypertension Clinics Before Liver Doctors See Acute Cases."
B - Breastfeeding (<6 weeks postpartum)
M - Migraine (with aura or simple migraine >35 years)
S - Smokers (>10-15 per day aged over 35)
C - Cardiovascular conditions / Complicated valvular heart disease
H - Hypertension
C - Cancer (breast)
B - Blood clots (VTE, thrombogenic mutations)
L - Liver tumors or severe liver disease
D - Diabetes (>20 years or with vascular complications)
S - SLE with antiphospholipid antibodies
A - Acute porphyria
C - CVD-related conditions (stroke, IHD, prolonged immobilization, etc.)
35
What should you do if one pill is missed (24–48 hours late)?
Take the missed pill as soon as it is remembered.
Continue taking the remaining pills at the usual time.
Key Point: No additional contraception is required.
36
What should you do if two or more pills are missed (>48 hours late)?
Take the most recent missed pill as soon as possible.
Discard any other missed pills.
Continue taking the remaining pills at the usual time.
Precaution: Use condoms or avoid sexual intercourse until seven consecutive active pills have been taken.
37
What should you do if two or more pills are missed in Week 1 (Pills 1–7)?
Use emergency contraception if unprotected sex occurred during the missed pill window or the first week of pill-taking.
Resume taking pills as usual.
Use additional contraception (e.g., condoms) for seven days.
38
What should you do if two or more pills are missed in Week 2 (Pills 8–14)?
No emergency contraception is needed if pills were taken correctly before the missed days.
Resume taking pills as usual.
Ensure seven consecutive active pills are taken.
39
What should you do if two or more pills are missed in Week 3 (Pills 15–21)?
Omit the pill-free interval.
Finish the active pills in the current pack and discard all the placebos and start the next pack the following day without a break.
40
What is the effectiveness of COCs?
92% during the first year as commonly used.
Up to 99.7% effective when used correctly and consistently.
41
Are there any age or parity limitations for COC use?
Age Limitations: No restrictions from menarche to age 40; after 40, more careful follow-up may be required.
Parity Limitations: No restrictions
42
What is the primary mode of action of COCs?
COCs primarily prevent ovulation. Secondary mechanisms include thickening cervical mucus and altering the endometrium.
43
What are the common side effects of COCs?
Nausea and inter-menstrual spotting/bleeding (common in the first 3 months).
Mild headaches, dizziness, breast tenderness, light periods, breakthrough bleeding, or occasional amenorrhea may occur.
Usually, no medical management is required, but side effects should be discussed.
44
What are the non-contraceptive benefits of COCs?
COCs offer several non-contraceptive benefits, including:
- Regular, lighter, and less painful menstruation.
- Prevention or improvement of iron-deficiency anemia.
- Decreased incidence of PID, ectopic pregnancy, ovarian and endometrial cancers, and benign breast disease.
- Reduced symptoms of endometriosis and PCOS.
- Acne improvement, especially with preparations containing cyproterone acetate or drospirenone.
- Protection from risks associated with pregnancy.
45
Do COCs provide protection against HIV/STIs?
No, COCs do not protect against HIV or other STIs.
46
How long can COCs be used, and is there any delay in fertility return after discontinuation?
COCs can be safely used throughout the reproductive years; periodic discontinuation is not necessary.
Fertility returns without delay after discontinuation.
47
When can COCs be initiated, and is extra protection required?
If started on Day 1–5 of the cycle, protection is immediate.
If initiated at any other time, ensure the client is not pregnant and use extra protection for 7 days.
48
How should nausea, dizziness, moodiness, mild headaches, or tender breasts be managed in COC users?
1. Exclude pregnancy.
2. Reassure that these side effects are common and usually diminish within 3 months.
3. Advise to take pills with meals or before bed.
4. If problems persist:
- Try a different pill.
- Switch to a COC with less than 35 micrograms of oestrogen (if available).
- Help her choose another contraceptive method.
5. For cyclical pre-menstrual mood swings or breast tenderness with triphasic pills, consider switching to a monophasic pill.
49
What is the management for breakthrough bleeding or spotting that persists beyond 3 months of COC use?
1. Ask about missed pills.
2. Exclude concomitant drug use and severe diarrhea or vomiting (D&V).
3. Examine to exclude pregnancy or genital tract pathology (e.g., infection or cancer).
- If pathology is identified, manage appropriately.
4. Switch to a different brand of low-dose pills.
5. If low-dose pills fail:
- Switch to a higher-dose pill (if available) for 3 cycles for better cycle control, then revert to a low-dose pill.
- Alternatively, help her choose another contraceptive method.
50
What are the severe adverse events associated with COCs?
1. Venous Thromboembolism (VTE):
- Rare but occurs more frequently in COC users than non-users (though less frequently than during pregnancy).
2. Arterial Events:
- Myocardial infarction, haemorrhagic stroke, and ischaemic stroke are extremely rare during reproductive years.
- Associated with risk factors such as hypertension, smoking, diabetes, and migraine with aura.
51
How can the risk of severe adverse events with COCs be minimized?
- Apply the Medical Eligibility Criteria (MEC) carefully to screen users.
- Identify and address risk factors such as smoking, hypertension, diabetes, and migraine with aura.
52
What do progestogen-only pills (POPs) contain?
POPs contain very low doses of synthetic progestogen.
53
How should POPs be taken?
A POP should be taken approximately at the same time every day. There are no inactive pills in the POP pack, and no break is required between packs.
54
Are POPs suitable for breastfeeding women?
Yes, POPs are appropriate for breastfeeding women as they do not affect breastfeeding.
55
Why are POPs used in women who experience side effects from COCs (combined oral contraceptives)?
POPs are used in women who experience oestrogen-related side effects with COCs or have health conditions that preclude safe use of COCs.
56
How effective are POPs in preventing pregnancy compared to COCs?
POPs are slightly less effective than COCs in non-breastfeeding women, but when compliance is good, they are highly effective. They are also highly effective in breastfeeding women.
57
Are POPs safe for most women?
Yes, POPs are safe for most women.
58
What conditions preclude the use of POPs?
Conditions that preclude the use of POPs include current breast cancer, acute porphyria, and the use of enzyme-inducing drugs.
59
What is the effectiveness of POPs in non-breastfeeding women?
In non-breastfeeding women, POPs are 90-97% effective as commonly used. When used consistently and correctly, they are more than 99% effective.
60
How effective are POPs in fully breastfeeding women?
POPs are ≥99% effective in fully breastfeeding women.
61
Are there age restrictions for using POPs?
No, there are no age restrictions for women from menarche to menopause.
62
Are there any parity restrictions for using POPs?
No, there are no parity restrictions.
63
What is the primary mode of action of POPs?
POPs primarily thicken cervical mucus to prevent sperm penetration (after 2 days of use) and also inhibit ovulation in 60% of cycles.
64
What are the common side effects of POPs?
ommon side effects include changes in menstrual bleeding (irregular bleeding, spotting, or amenorrhoea), mild headaches, nausea, dizziness, mood changes, and breast tenderness.
65
Do POPs offer non-contraceptive benefits?
POPs provide no non-contraceptive benefits other than protection from risks associated with pregnancy.
66
67
Does using POPs protect against HIV or other STIs?
No, POPs do not provide protection against HIV or other STIs.
68
How long can POPs be used?
POPs can be used throughout the reproductive years.
69
How quickly does fertility return after stopping POPs?
Fertility returns without delay once POPs are discontinued
70
When can POPs be started?
POPs can be started at any time, provided it is reasonably certain that the client is not pregnant. If pregnancy is a possibility, a pregnancy test must be done, or the client should avoid sex or use condoms until her next period, and then begin taking the pills from Day 1.
71
What should a client do if she is more than 3 hours late in taking a POP?
If more than 3 hours late, take the missed pill as soon as possible, continue taking one pill each day as usual, and use condoms or avoid sex for the next 48 hours.
72
What should be done if a client experiences irregular bleeding or spotting while using POPs?
Reassure the client that irregular bleeding or spotting is common with POPs. Ask if she takes the pills on time, had vomiting or diarrhea, or started any medications that could affect POP effectiveness. If necessary, exclude pregnancy or other conditions. If no pathology is found, reassure the client and advise continuing with POPs. For short-term relief, offer ibuprofen 800 mg three times a day for 5 days. If bleeding persists and is unacceptable, consider changing methods.
73
What should be done if a client using POPs experiences amenorrhoea (absence of menstruation)?
Reassure the client that amenorrhoea is not uncommon with POPs. If pregnancy is suspected, perform a pregnancy test. If pregnant, stop the POPs and discuss management options, including termination of pregnancy (TOP). If not pregnant, continue using POPs with reassurance.
74
What is a Long Acting Reversible Contraceptive (LARC)?
LARCs are contraceptive methods that require administration less than once per cycle, offering high effectiveness without relying on daily compliance or correct use like pills or barrier methods
75
What are the different types of LARC methods?
LARC methods include:
- Intrauterine Contraception (IUD/IUS):
* Copper T 380 IUD (10 years)
*Nova T IUD (5 years)
*Levonorgestrel releasing Intrauterine System (LNG-IUS) (5 years)
- Progestogen-only Injections:
* DMPA (12 weekly)
*NET-EN (8 weekly)
- Sub-dermal Progestogen Implants:
*Single rod (3 years)
*Two rods (4 or 5 years depending on type)
76
How do LARCs compare to short-term contraceptive methods?
LARCs generally have superior continuation rates compared to short-term methods because they don't rely on user compliance. They are highly effective and cost-effective, even though the initial costs are higher.
77
Are LARCs cost-effective?
Yes, despite their higher initial costs, LARCs are more cost-effective within one to two years. Male and female sterilization only become more cost-effective than LARCs after 15 years.
78
What are progestogen-only injectables?
Progestogen-only injectables are highly effective, reversible contraception methods containing synthetic progestogens administered by deep intramuscular injection. The two main types are depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN).
79
How effective are progestogen-only injectables?
When used as commonly prescribed, progestogen-only injectables are 93% effective. However, if used correctly (e.g., reinjection on time), their effectiveness can be as high as 99.7%.
80
Are there any age restrictions for using progestogen-only injectables?
There are no strict age restrictions. However, caution is advised for adolescents under 18 and women over 45 due to concerns about bone mineral density. There is no data supporting the choice of injectable based on age alone.
81
Are there any restrictions for women based on parity (number of children) when using progestogen-only injectables?
No, there are no restrictions related to parity.
82
How do progestogen-only injectables work?
Progestogen-only injectables primarily inhibit ovulation, but they also thicken cervical mucus, which prevents sperm penetration.
83
What are common side effects of progestogen-only injectables?
Common side effects include changes in menstrual bleeding (irregular, prolonged, heavy bleeding, or amenorrhoea), weight gain, headaches, dizziness, mood changes, and decreased sex drive.
84
What non-contraceptive benefits do progestogen-only injectables offer?
Non-contraceptive benefits include:
- Prevention or improvement of iron deficiency anaemia
- Decrease in ectopic pregnancy, pelvic inflammatory disease (PID), uterine fibroids, and endometrial cancer
- Reduction in sickle cell crises in women with sickle cell anaemia
- Reduction in severity of endometriosis symptoms
85
Do progestogen-only injectables protect against HIV or STIs?
No, they do not protect against HIV or STIs. Some studies suggest that DMPA might increase the risk of HIV acquisition. It's important to emphasize the use of condoms along with hormonal or non-hormonal contraception for HIV prevention. Alternatives like Cu IUDs or lower-dose hormonal options should be explored with clients.
86
How long can progestogen-only injectables be used?
Progestogen-only injectables can be used throughout the reproductive years. However, for perimenopausal women, switching methods after age 45 may be considered to allow time for bone density recovery.
87
How long does it take for fertility to return after using progestogen-only injectables?
Fertility typically returns within 4-6 months, depending on the injectable type. There is no permanent damage to fertility.
88
When can progestogen-only injectables be initiated?
- If the first injection is given within the first 7 days of the menstrual cycle, protection is immediate, and no backup contraception is needed.
- If started after day 7, avoid sex or use condoms for 7 days.
- Injectables can be given immediately after childbirth, miscarriage, or termination of pregnancy (TOP). For breastfeeding women, initiation is suggested to be delayed until 6 weeks post-delivery.
89
What are common side effects of progestogen-only injectables?
Common side effects include:
- Irregular bleeding, prolonged spotting, or heavy bleeding: Especially in the first few months of use. Frequency decreases with duration.
- Amenorrhoea (absence of menstruation): Increases with use; about 80% of users experience it by the end of the second year.
- Weight gain: Caused mainly by increased appetite. Monitoring diet can help manage this.
- Acne, headaches, mood changes, bloating, and dizziness may also occur.
90
How long does it take for fertility to return after stopping progestogen-only injectables?
After discontinuation, the average delay in return to fertility is about:
4 to 6 months for NET-EN and DMPA, respectively.
It’s important to discuss this delay with clients when they plan to stop the method.
91
What should be done if a NET-EN injection is late?
A NET-EN injection can be safely given if it is less than 2 weeks late. If more than 2 weeks have passed:
- If pregnancy can be reasonably excluded (e.g., no sex since the grace period, consistent condom use, or LAM), the injection can be given.
- If pregnancy cannot be excluded, use condoms, abstain, or use POP for 3 weeks. If a pregnancy test is still negative, give the injection and advise continued protection for 7 days after the injection.
92
What should be done if a DMPA injection is late?
A DMPA injection can be safely given if it is less than 4 weeks late. If more than 4 weeks have passed:
- If pregnancy can be reasonably excluded (e.g., no sex since the grace period, consistent condom use, or LAM), the injection can be given.
- If pregnancy cannot be excluded, use condoms, abstain, or use POP for 3 weeks. If a pregnancy test is still negative, give the injection and advise continued protection for 7 days after the injection.
93
What should be done if the possibility of pregnancy cannot be excluded after a late injection?
If pregnancy cannot be excluded, the injection may still be given with the understanding that it will not harm an existing pregnancy. Advise the following:
- Use condoms or abstain from sex for the first 7 days after the injection.
- Schedule an early follow-up appointment in 4-6 weeks to confirm there is no pregnancy.
- Do not simply tell the client to wait for their next period; ensure they are given a method to use until their next period.
94
Are there any significant drug interactions with progestogen-only injectables?
There are few significant drug interactions. It is not necessary to shorten injection intervals when using enzyme-inducing drugs.
95
How should amenorrhoea (absence of menstruation) be managed in users of progestogen-only injectables?
Explain to the client that amenorrhoea is common and normal with progestogen-only methods and is not harmful.
Reassure the client that it does not indicate a problem, and it is a typical side effect of the method.
96
What should be done if a client experiences spotting or light irregular bleeding while using progestogen-only injectables?
Reassure the client that spotting or light bleeding is very common during the first few months of use, and it is usually not harmful.
Examine the client to exclude any underlying gynaecological pathology.
For light bleeding, a low-dose combined oral contraceptive (COC) for 7 days may help control it.
If oestrogen is contraindicated, consider using a non-steroidal anti-inflammatory drug (NSAID) like ibuprofen (400 mg three times a day for 3 days).
97
How should very heavy, prolonged, or frequent bleeding be managed in users of progestogen-only injectables?
- Examine to rule out any underlying gynaecological pathology.
- Reassure the client that some injectable users experience heavy or prolonged bleeding, but it usually diminishes over time and is not harmful.
- However, it may require attention, especially in women with anaemia.
- If pathology is excluded and oestrogen is not contraindicated, prescribe a high-dose COC, such as Biphasil®, to be taken daily for 21 days, followed by 7 placebo pills to allow for a normal withdrawal bleed (this can be repeated for up to two cycles if needed).
- If oestrogen is contraindicated, consider using an NSAID or Tranexamic acid to help reduce bleeding.
98
What should be done if bleeding remains unacceptable or persists despite treatment?
If bleeding remains unacceptable or continues after the prescribed treatments, advise the client to switch to another contraceptive method.
99
What are progestogen subdermal implants?
Progestogen subdermal implants are long-acting, highly effective, and safe contraceptives. The most common type, Implanon Next, consists of a single rod containing etonorgestrel, and it can be used for 3 years. The small rod, about the size of a matchstick, is inserted just under the skin of the upper arm, releasing a small amount of progestogen into the body.
100
How effective are progestogen subdermal implants?
Progestogen implants are the most effective form of contraception with extremely low failure rates and good continuation rates. They are highly reliable for contraception.
101
What are the non-contraceptive benefits of progestogen implants?
In addition to providing effective contraception, progestogen implants offer some non-contraceptive benefits, although these were not specified in the provided information. They also do not affect bone mineral density, unlike some other hormonal methods.
102
How do the hormone levels from implants compare to other methods, and what side effects might occur?
The hormone levels from implants are constant and much lower than with injections. As a result, side effects, while similar to those of other progestogen methods, are generally less frequent, less pronounced, and rapidly reversible once the implant is removed.
103
Are progestogen implants cost-effective?
Despite high initial costs, progestogen implants are cost-effective compared to pills and injections, especially after one year of use.
104
Are there any women who should not use progestogen subdermal implants?
Women who should not use progestogen implants are those with the same contraindications as for injections, such as certain health conditions like severe cardiovascular disease, acute porphyria, and current breast cancer.
105
How effective are progestogen-only implants?
Progestogen-only implants are almost 100% effective. For example, with Implanon®, only 1 pregnancy occurs in 1,000 women over a 3-year period.
106
Are there age restrictions for using progestogen-only implants?
No, there are no age restrictions for progestogen-only implants, from menarche to menopause. Additionally, they do not affect bone mineral density (BMD).
107
Are there any restrictions based on parity (number of children) for using progestogen-only implants?
No, there are no parity limitations for using progestogen-only implants.
108
How do progestogen-only implants work?
Progestogen-only implants primarily inhibit ovulation and thicken cervical mucus, preventing sperm from penetrating the cervix.
109
What are common side effects of progestogen-only implants?
A: Common side effects include:
Changes in menstrual bleeding: Lighter bleeding, irregular bleeding, infrequent bleeding, and amenorrhoea.
Other side effects: Headaches, nausea, dizziness, breast tenderness, mood changes, and abdominal pain due to enlarged ovarian follicles.
110
What are the non-contraceptive benefits of progestogen-only implants?
Progestogen-only implants provide the following non-contraceptive benefits:
-Prevention of symptomatic pelvic inflammatory disease (PID)
- Prevention of iron-deficiency anaemia
111
Do progestogen-only implants protect against STIs?
No, progestogen-only implants do not protect against STIs.
112
How long can progestogen-only implants be used?
Progestogen-only implants can be used throughout the reproductive years, with no specific age limit.
113
How quickly does fertility return after discontinuation of progestogen-only implants?
Fertility returns without delay once the implant is removed.
114
When can progestogen-only implants be inserted?
If inserted within the first 5 days of the menstrual cycle, protection is immediate and no backup contraception is needed.
If inserted after day 5, the client should avoid sex or use condoms for 7 days.
Implants can also be inserted immediately after childbirth, miscarriage, or termination of pregnancy (TOP).
In breastfeeding women, it's recommended to wait 3 weeks before insertion.
115
Management of Side Effects
Side effects are similar to those of progestogen-only injections but tend to be less severe with implants. Side effects rapidly disappear once the implant is removed, and there is no delay in return to fertility.
116
How does Efavirenz affect the effectiveness of Implanon?
Efavirenz can potentially interfere with the efficacy and action of Implanon (progestogen-only implant). Due to this interaction, the National Department of Health advises against the use of Implanon for women on Fixed-Dose Combinations (FDC) that include Efavirenz.
117
What do the WHO and CDC say about using Implanon with Efavirenz?
According to WHO/CDC, Implanon is still classified as Category 2 for patients on ART containing Efavirenz. This means that while it can be used, there are considerations regarding effectiveness.
118
What does research show about pregnancy rates in women using Implanon and Efavirenz?
Studies show that women using Implanon with Efavirenz have higher pregnancy rates compared to women not on ART. However, despite the higher rates, the absolute pregnancy rates with Implanon are still lower than those seen with other hormonal contraceptives.
119
Is Implanon still effective in the later years of use, especially with Efavirenz?
There is no data to assess the effectiveness of Implanon during the later years when progestin levels are lower, and the risk of failure due to drug interactions might be higher. This raises concerns about the long-term effectiveness of Implanon for women on ART containing Efavirenz.
120
How should women using Implanon and Efavirenz be counselled?
Women should be counselled on the reduced effectiveness of Implanon when used with Efavirenz. It is crucial to advise dual-method use—using condoms alongside Implanon to ensure additional protection against both pregnancy and sexually transmitted infections (STIs).
121
What is a Copper Intrauterine Device (Cu IUD)?
A Cu IUD is a small, flexible device made of plastic and copper. It is inserted into the uterus to prevent pregnancy. It is a safe and highly effective method of long-acting reversible contraception
122
Who is a Cu IUD suitable for?
The Cu IUD is suitable for most women, including women at risk of or infected with HIV/AIDS. It is an excellent option for long-term contraception.
123
Are there any contraindications for using a Cu IUD?
Yes, women with certain gynaecological conditions should not use a Cu IUD. These include:
- Conditions that distort the uterine cavity (e.g. fibroids)
- Puerperal sepsis
- Pelvic tuberculosis (TB)
- Current pelvic inflammatory disease (PID)
- Cervical infections
124
Does the Cu IUD affect breastfeeding or intercourse?
No, the Cu IUD does not affect breastfeeding, interfere with intercourse, or cause hormonal side effects.
125
How long can a Cu IUD be used?
The CuT380A is registered in South Africa for 10 years of use. However, many regulatory bodies consider it effective for up to 12 years of continuous use.
126
Who can insert and remove a Cu IUD?
The Cu IUD must be inserted and removed by doctors or nurses who are specifically trained in the procedure.
127
Does the Cu IUD interact with medications or cause hormonal side effects?
No, the Cu IUD is not affected by drug interactions and does not have hormonal side effects. It is a non-hormonal form of contraception.
128
How effective are Cu IUDs?
Cu IUDs are 99.2-99.4% effective in the first year of use. This makes them one of the most effective forms of long-acting reversible contraception.
129
Are there age limitations for using Cu IUDs?
No, there are no age restrictions for Cu IUD use. Women of any age can use a Cu IUD.
130
Are there any restrictions based on parity for using Cu IUDs?
No, there are no parity limitations for Cu IUD use. It can be used by women regardless of whether they have had children.
131
How do Cu IUDs prevent pregnancy?
Cu IUDs primarily prevent fertilisation by inhibiting sperm migration into the upper female genital tract. A secondary action is to prevent implantation through changes in the endometrium.
132
What are the common side effects of Cu IUDs?
Common side effects include menstrual changes such as:
- Heavier bleeding
- Longer periods
- Increased cramps
133
Are there any non-contraceptive benefits to using Cu IUDs?
Yes, Cu IUDs provide some protection from endometrial cancer.
134
Do Cu IUDs protect against HIV or STIs?
No, Cu IUDs are not protective against HIV or STIs.
135
Do Cu IUDs interact with any medications?
No, Cu IUDs have no known drug interactions.
136
How long is the Cu IUD effective, and when should it be replaced?
The CuT380 is currently registered for 10 years of use in South Africa. After this period, the IUD needs to be replaced.
137
How quickly does fertility return after the Cu IUD is removed?
Fertility returns immediately upon removal of the Cu IUD.
138
When can a Cu IUD be inserted?
Within the first 12 days of the menstrual cycle (Day 1 is the first day of menstruation).
At any other time if it is reasonably certain the client is not pregnant.
If pregnancy cannot be excluded, postpone insertion until the next menstrual cycle.
Immediately after switching from an effective contraception method (if compliance was good).
Immediately or within 12 days after a miscarriage or termination of pregnancy (TOP).
6 weeks postpartum after a normal vaginal delivery; however, it may be inserted up to 48 hours post-delivery by specially trained providers.
After a Caesarean section, Cu IUD insertion should be done by experienced providers, typically at 6 weeks postpartum or immediately if necessary.
139
What is the procedure for initiating Cu IUD use?
Full history-taking: To understand patient’s medical history, menstrual cycle, and risk factors.
Abdominal and pelvic exam: Perform both bimanual and speculum exams to assess the uterus and reproductive organs.
Prophylactic antibiotic use: Given the high prevalence of gonorrhoea and chlamydia in South Africa, administer a single dose of azithromycin 500mg or doxycycline 200mg at the time of insertion to prevent infection.
Discuss common side effects: Explain that side effects may include heavier menstrual bleeding, irregular bleeding, and more cramping during monthly bleeding. These side effects usually subside within 3-6 months.
Warn about potential problems: Explain warning signs such as missed periods (rare), possible pregnancy, expulsion of the IUD, pelvic pain, purulent discharge, fever, or abnormal bleeding that require immediate medical attention.
140
What is the follow-up schedule for Cu IUD users?
6 weeks post-insertion: This is the first follow-up visit to check for any complications or concerns.
Thereafter: Follow-up visits are on a prn (as needed) basis, unless the patient has specific issues.
When is the only essential follow-up visit? The only essential visit is when the Cu IUD is due for replacement.
141
How should common side effects like irregular or heavy vaginal bleeding be managed?
Reassurance: Inform the patient that irregular or heavy bleeding is common and usually reduces after a few months.
Examine for pathology: Exclude infection, partial expulsion, intrauterine pregnancy, ectopic pregnancy (rare), or other causes.
Treatment: If no pathology is found, counsel the patient and treat with NSAIDs for pain or discomfort. If the bleeding becomes unacceptable, offer an alternative form of contraception and consider IUD removal.
142
How should cramping and pain during menses be managed in Cu IUD users?
Reassurance: Let the patient know that increased cramping is common and typically lessens over time.
Examine for issues: Check for partial expulsion or uterine perforation and evaluate for other underlying problems.
Treatment: If no issues are found, offer NSAIDs for pain relief. If the pain remains intolerable, discuss other contraception options and consider removing the Cu IUD.
143
What are the warning signs that require immediate medical attention for Cu IUD users?
- Missed menstrual period/possible pregnancy (rare).
- Possible expulsion of the Cu IUD.
- Pelvic pain, purulent vaginal discharge, and/or fever.
- Excessive or abnormal bleeding.
144
What is the management for pregnancy in a Cu IUD user?
Exclude ectopic pregnancy: This is crucial as ectopic pregnancies are a serious complication.
Options for management if pregnancy is not desired:
- Termination of pregnancy (TOP): Discuss the option of TOP if the pregnancy is unwanted.
If pregnancy is desired:
- Remove the Cu IUD if the strings are visible and the pregnancy is <12 weeks.
- If strings are not visible or pregnancy is >12 weeks, refer for further management, including:
* Increased antenatal surveillance.
* Risk of miscarriage, which could be septic, or premature delivery.
145
What should be considered if the strings of the Cu IUD are missing?
Missing strings may be due to several factors:
- Threads cut short or drawn up into the uterine cavity.
- Expulsion of the IUD (3-5%).
- Pregnancy (<1%).
- Perforation (<0.1%).
Management:
- Exclude pregnancy: This is the first step.
- Ask about expulsion: Inquire if the patient has noticed any signs of expulsion.
- Further investigation: Refer for an ultrasound and/or X-ray to determine the position of the device.
- Advise condom use until the investigation is completed.
146
What should be done if there is vaginal discharge or lower abdominal pain suggesting a suspected pelvic inflammatory disease (PID)?
Examine for genital tract infection: Conduct a thorough examination to identify any infection in the genital tract.
Treatment: PID can be managed with the IUD in situ, so continue with the IUD while treating the infection appropriately.
147
What is the Levonorgestrel Releasing Intrauterine System (LNG-IUS)?
LNG-IUS is an intrauterine contraceptive device that releases a small, constant amount of progestogen (levonorgestrel) directly into the uterine cavity.
It is highly effective with a failure rate of 0.2%.
The continuation rate at one year is 80%.
It has fewer systemic hormonal effects than most other hormonal contraceptive methods.
148
What are the common side effects and changes associated with LNG-IUS use?
Irregular, light bleeding is common during the initial phase of use.
Amenorrhoea (absence of menstruation) is often seen with continued use in the majority of women.
Over time, menstrual bleeding tends to become lighter or stop altogether.
149
What is the WHO MEC (Medical Eligibility Criteria) classification for LNG-IUS?
The WHO MEC 3 / 4 classification for LNG-IUS is similar to that of the Cu IUD.
MEC 3: Conditions where the advantages of using the method generally outweigh the risks.
MEC 4: Conditions where the method is not recommended due to high risks.
150
What is the effectiveness of the Levonorgestrel Releasing Intrauterine System (LNG-IUS)?
Failure rate: 0.2%, making it highly effective.
Continuation rate: 80% at one year.
Comparison: As effective as male sterilization and more effective than female sterilization.
151
What are the age and parity limitations for using LNG-IUS?
Age limitations: LNG-IUS is safe for most women, regardless of age.
Parity limitations: No parity limitations, meaning it is suitable for both women who have had children and those who have not
152
What is the mode of action of the LNG-IUS?
Thickens cervical mucus, making it difficult for sperm to enter the uterus.
Suppresses endometrial development, preventing implantation of a fertilized egg.
153
What are the common side effects of LNG-IUS?
Initial side effects: Light irregular bleeding and infrequent bleeding are common in the first months of use.
Long-term side effects: Most women develop amenorrhoea (no menstruation) after continued use.
At 12 months, there is typically a >90% reduction in menstrual blood loss.
154
What are the non-contraceptive benefits of LNG-IUS?
Reduces menstrual blood loss, protecting against iron-deficiency anaemia.
Provides protection against ectopic pregnancy.
May reduce the risk of PID (Pelvic Inflammatory Disease) in women exposed to STIs.
Reduces menstrual cramps and alleviates symptoms of endometriosis, such as pelvic pain and excessive bleeding.
Practical uses include:
- Management of heavy menstrual bleeding (after evaluation).
- Hormone therapy in peri-menopausal women (in combination with systemic oestrogen).
155
What is the effect of LNG-IUS on HIV/STI risk?
LNG-IUS has no effect on the risk of HIV or other STIs.
156
Are there any drug interactions with LNG-IUS?
No known drug interactions with LNG-IUS.
157
What is the duration of use for LNG-IUS?
Duration of use: LNG-IUS can be used for up to 5 years.
158
What is the return to fertility after using LNG-IUS?
No delay in return to fertility once the LNG-IUS is removed.
159
When should LNG-IUS be fitted for immediate effectiveness?
It should be fitted before day 7 of the menstrual cycle to be immediately effective.
If fitted at another time, ensure there is no pregnancy, and 7 days of abstinence or barrier protection should be advised before it becomes effective.
160
What problems are managed similarly to Cu IUD with LNG-IUS?
Management of issues such as pregnancy, missing strings, PID, and other complications is similar to that for Cu IUD, as outlined in previous sections.
161
What is LNG-IUS registered for in South Africa?
- Contraception.
- Management of heavy menstrual bleeding.
- Endometrial protection during hormone therapy in menopause.
162
Is LNG-IUS suitable for emergency contraception?
No, LNG-IUS is not suitable for emergency contraception.
163
What is Emergency Contraception (EC)?
- Emergency Contraception (EC) is the use of a contraceptive method after unprotected sexual intercourse (before pregnancy is established) to reduce the risk of pregnancy.
- EC can be used at any time during the menstrual cycle, but must be taken within 5 days (120 hours) of unprotected sex.
- Goal: Prevent unwanted pregnancies by acting quickly after the event.
164
What are the two main types of Emergency Contraception (EC) methods available in South Africa?
1. Hormonal Emergency Contraceptive Pills (ECPs):
- Taken within 120 hours (5 days) of unprotected intercourse.
- The earlier the better for effectiveness.
2. Copper Intrauterine Device (Cu IUD):
- Inserted up to 120 hours (5 days) after unprotected intercourse.
- The most effective method of EC available.
165
What are the advantages and limitations of ECPs and Cu IUD as Emergency Contraception?
ECPs:
- Advantages: Simpler and less invasive to provide.
- Limitations: Must be taken as soon as possible after unprotected sex for maximum effectiveness.
Cu IUD:
- Advantages: Most effective method of EC, remains effective throughout the 120-hour window.
- Limitations: Insertion is more invasive, requires a healthcare provider.
- Cu IUD is particularly indicated when a woman:
* Wishes to use it as ongoing contraception.
* Presents late in the 120-hour window.
Vomits after taking ECPs.
166
When should Cu IUD be offered for Emergency Contraception?
Cu IUD should be offered to all women as the most effective EC method.
Particularly useful when:
- The woman wishes to continue using the IUD for ongoing contraception.
- The woman presents late in the 120-hour window (after unprotected sex).
- The woman vomits after taking ECPs, reducing the effectiveness of the pills.
167
What should be done if a woman does not want to use the Cu IUD for ongoing contraception?
The Cu IUD can still be inserted with prophylactic antibiotics for EC use.
It can be removed at the next menstrual period, after which a more suitable, ongoing contraception method can be initiated.
168
What is the time frame for effectiveness of ECPs vs. Cu IUD?
ECPs: Efficacy decreases as time passes; the earlier they are taken after unprotected sex, the more effective they are. However, they remain effective within the 120-hour (5-day) window.
Cu IUD: Efficacy remains constant throughout the 120-hour (5-day) window, making it highly effective regardless of when it is inserted within that period.
169
What are the benefits of knowing about and using Emergency Contraception?
Knowledge of and access to EC can help prevent many unwanted pregnancies.
It offers women a second chance to prevent pregnancy after unprotected sex.
Provides an option when primary contraception fails or is not used.
170
What are Emergency Contraceptive Pills (ECPs)?
ECPs are oral contraceptive pills (COCs or POPs) taken at a higher dose and in a different regimen than for regular contraception.
They are used after unprotected intercourse to prevent pregnancy.
171
What is the difference between EC-POP and EC-COC regimens?
EC-POP (Emergency Contraceptive Progestogen-Only Pill) is more effective than the EC-COC (Emergency Contraceptive Combined Oral Contraceptive) regimen.
EC-POP also has fewer side effects compared to the EC-COC regimen.
172
Are there any contraindications to using Emergency Contraceptive Pills (ECPs)?
No absolute contraindications for ECP use.
Even women with medical conditions that would typically preclude the use of ongoing hormonal pills can generally take ECPs, as they are used for such a short period (only post-intercourse).
173
Can ECPs be accessed without a prescription?
Yes, ECPs are available without a prescription and can be purchased over-the-counter from pharmacies.
174
Why is the use of ECPs generally safe for women with medical conditions?
The hormone in ECPs is given for such a short duration that the risks typically associated with prolonged use of hormonal pills are minimized, making it generally safe for women with certain medical conditions.
175
What is the effectiveness of Emergency Contraceptive Pills (ECPs)?
POP regimen (Progestogen-Only Pill):
- 95% to 58% effective depending on how soon they are taken after unprotected intercourse.
- Most effective within the first 24 hours.
COC regimen (Combined Oral Contraceptive):
- 77% to 31% effective, with effectiveness decreasing over time.
- Most effective within the first 24 hours.
176
Are there age or parity limitations for using ECPs?
No age limitations for ECP use.
No parity limitations, meaning they are safe for both women who have had children and those who have not.
177
How do Emergency Contraceptive Pills (ECPs) work?
Primarily inhibit or delay ovulation to prevent the release of an egg.
May also interfere with implantation of a fertilized egg.
No evidence that ECPs cause an abortion or affect an already established pregnancy.
178
What are the common side effects of ECPs?
Nausea and vomiting (more common with the COC regimen).
Other side effects may include dizziness, headaches, fatigue, and cycle irregularities.
179
What are the non-contraceptive benefits of ECPs?
None. ECPs are intended solely for preventing pregnancy after unprotected sex.
180
Do ECPs provide protection against STIs?
No, ECPs are not protective against sexually transmitted infections (STIs).
181
Are there any drug interactions with ECPs?
If the patient is using enzyme-inducing drugs (e.g., rifampicin or ritonavir), the Cu IUD is the preferred emergency contraception method.
If the Cu IUD is not suitable, ECPs can be used, but the dose should be increased to 3mg LNG stat or 3 Ovral, followed by 3 tablets 12 hours later.
182
What is the duration of use for ECPs?
Intended for occasional "emergency" use only, not for regular contraception.
183
What happens to fertility after using ECPs?
Return to fertility is immediate after using ECPs. There is no delay in a woman’s ability to conceive once the pills are taken.
184
What is the first dose of the Yuzpe Regimen using 50 µgm ethinyloestradiol and 250 µgm levonorgestrel (e.g., Ovral®)?
2 pills
185
What is the second dose of the Yuzpe Regimen using 50 µgm ethinyloestradiol and 250 µgm levonorgestrel (e.g., Ovral®)?
2 pills, taken 12 hours after the first dose
186
What is the first dose of the Yuzpe Regimen using 30 µgm ethinyloestradiol and 150 µgm levonorgestrel (e.g., Nordette® or Oralcon®)?
4 pills
187
What is the second dose of the Yuzpe Regimen using 30 µgm ethinyloestradiol and 150 µgm levonorgestrel (e.g., Nordette® or Oralcon®)?
4 pills, taken 12 hours after the first dose
188
What is the first dose of the progestogen-only pill regimen using 1.5 mg levonorgestrel (e.g., Escapelle®)?
1 pill, single dose
189
What is the second dose of the progestogen-only pill regimen using 1.5 mg levonorgestrel (e.g., Escapelle®)?
No second dose needed; it's a single dose regimen.
190
What is the first dose of the progestogen-only pill regimen using 0.75 mg levonorgestrel (e.g., Norlevo®)?
2 pills, single dose
191
What is the second dose of the progestogen-only pill regimen using 0.75 mg levonorgestrel (e.g., Norlevo®)?
No second dose needed; it's a single dose regimen
192
What is the first dose of the progestogen-only pill regimen using 30 µgm levonorgestrel (e.g., Microval® or Hy-an®)?
50 pills as a single dose
193
What is the alternative first dose of the progestogen-only pill regimen using 30 µgm levonorgestrel (e.g., Microval® or Hy-an®)?
25 pills, followed by another 25 pills
194
Why should a request for emergency contraception (EC) be viewed as an opportunity?
It’s an opportunity to prevent an unwanted pregnancy and counsel about future use of regular contraception. Clients treated with respect are more likely to start long-term contraception.
195
What should clients be counselled about regarding the correct regimen for ECP use?
Clients should be informed about the specific regimen for the ECP they are using, including how many pills to take and when.
196
What are the possible side effects of ECPs and how can they be managed?
Possible side effects include nausea and vomiting. To manage these, clients can take the pills with food and repeat the dose if vomiting occurs within 2 hours of taking the pills. Alternatively, a copper IUD can be offered.
197
When should a client expect their next period after using ECPs?
The next period may come a few days earlier or later than normal.
198
What should clients do regarding condoms or abstinence after using ECPs?
Clients should use condoms or abstain from sex for the rest of the current menstrual cycle.
199
Why are ECPs not recommended for regular contraception?
ECPs are intended for emergency use only because they have a higher failure rate and more side effects compared to regular contraception.
200
What is "quick start" in relation to ECPs?
A regular method of contraception may be started at the same visit as ECPs. This reduces the chance of pregnancy while waiting for the next menstruation.
201
What should be done if a normal period doesn't occur after using ECPs?
A pregnancy test should be advised if the period does not occur within a week of when it was expected.
202
Can ECPs be used repeatedly?
While not ideal, ECPs can be given repeatedly if requested within 120 hours. However, clients should be counselled that repeat use is less effective than regular contraception and may result in more side effects. The reasons for repeated requests should also be investigated.
203
What makes the Cu IUD the most effective form of emergency contraception (EC)?
The Cu IUD provides highly effective EC, with treatment failure in less than 0.1% of cases.
204
How does the Cu IUD work as emergency contraception?
The Cu IUD can prevent fertilization or prevent implantation, depending on the timing of insertion in relation to ovulation.
205
Does the Cu IUD provide protection against sexually transmitted infections (STIs)?
No, the Cu IUD does not protect against STIs. Consider post-exposure antiretroviral therapy (ART) and prophylactic antibiotics if necessary.
206
How long does the Cu IUD provide contraception once inserted for emergency use?
The contraceptive effect lasts as long as the device remains in place. If used long-term, it can continue to provide contraception. Otherwise, it can be removed at the next menstruation, and an alternative contraceptive method can be started.
207
What is the ideal timing for Cu IUD insertion after unprotected intercourse?
It can be inserted within five days (120 hours) of a single episode of unprotected intercourse.
It can be inserted up to 5 days after the estimated date of ovulation in a regular cycle (up to Date 19 of a 28-day cycle).
It can be inserted any time within the first 12 days of the menstrual cycle, regardless of the cycle length or how many days have passed since unprotected sex.
208
Does the Cu IUD cause abortion if used for emergency contraception within the recommended time frame?
No, the Cu IUD does not cause abortion if used within the recommended time frame.
209
Can the LNG-IUS be used as emergency contraception?
No, the LNG-IUS (Levonorgestrel Intrauterine System) is not suitable for use as emergency contraception.
210
What is the male condom and how does it work?
The male condom is a sheath that covers the erect penis, preventing sperm from entering the female genital tract. It is typically made of latex.
211
How effective is the male condom in preventing pregnancy?
The male condom can be effective in preventing pregnancy when used correctly and consistently.
212
How effective is the male condom in preventing STIs and HIV?
The male condom provides the best protection against STIs and HIV, second only to abstinence and mutual faithfulness with an uninfected partner.
213
Can the male condom be used for both pregnancy and STI prevention?
Yes, the condom can be used alone for dual protection against both pregnancy and STIs, or it can be combined with another more effective method of contraception (dual-method use).
214
What should be considered if a condom is not used or there is method failure (e.g., breakage or slippage)?
Emergency contraception (EC) can be used to address concerns about contraceptive efficacy if condoms are occasionally not used or fail. Consider providing an advance supply of EC for patients.
215
What is the female condom and how does it work?
The female condom is a sheath made of thin, transparent, soft synthetic rubber inserted into the vagina before or at the time of intercourse. It prevents pregnancy and the transmission of STIs/HIV. It has two flexible rings—an inner ring to assist with insertion and an outer ring to cover the vulva and hold the condom in position.
216
How effective is the female condom in preventing pregnancy and STIs/HIV?
When used correctly and consistently, the female condom provides effective dual protection against both pregnancy and the transmission of STIs, including HIV.
217
Who might benefit from using the female condom?
The female condom may be a good option for women whose partners refuse to use male condoms or for couples with latex allergies who are unable to use male condoms.
218
How does the typical use method failure rate of the female condom compare to other contraceptive methods?
The typical use failure rates for the female condom are higher compared to many other contraceptive methods.
219
How can emergency contraception help with the use of female condoms?
Promotion and easy access to emergency contraception (EC) can help address accidental pregnancies when the female condom is not used or is incorrectly used.
220
How can the effectiveness of the female condom be improved?
The female condom may be used together with a more effective method of contraception (dual-method use) to increase protection against pregnancy.
221
What is the effectiveness of male and female condoms during the first year of use?
Male condom: 85-98% effective, depending on correct and consistent use.
Female condom: 79-95% effective, depending on correct and consistent use.
222
Are there any age limitations for using male or female condoms?
No, there are no age limitations for either male or female condoms.
223
Are there any age limitations for using male or female condoms?
No, there are no age limitations for either male or female condoms.
224
Are there any parity (number of children) limitations for using male or female condoms?
No, there are no parity limitations for either male or female condoms.
225
How do male and female condoms work as contraception?
Both male and female condoms create a physical barrier that prevents sperm (or infections, including HIV) from entering the female genital tract.
226
How effective are condoms at reducing the risk of STIs/HIV?
Male condom: About 80% effective in protecting against STIs, including HIV. Most effective for STIs transmitted through bodily fluids (e.g., HIV, gonorrhea, chlamydia).
Female condom: Similar effectiveness. May be better at protecting against STIs transmitted through skin-to-skin contact (e.g., genital herpes, HPV) because it covers a larger area.
227
What are the common side effects of using male and female condoms?
There are no common side effects. However, latex allergies may occur, but this is extremely rare.
228
What are the non-contraceptive benefits of using male and female condoms?
Both provide significant protection against STIs (including HIV and HPV) and the potential consequences of STIs.
229
Can male and female condoms interact with other products?
Male condoms should not be used with oil-based lubricants or vaginal/rectal creams, as these can damage the latex.
Female condoms are not affected by oil-based lubricants.
230
How long can male and female condoms be used for?
Condoms can be used safely throughout the reproductive years and beyond, as long as protection from infections is required.
231
How quickly do fertility and normal cycles return after using condoms?
There is immediate return to fertility once condoms are no longer used.
232
What is female sterilisation and how is it performed?
Female sterilisation, also known as tubal occlusion or tubal ligation (TL), is a permanent contraceptive method where the fallopian tubes are blocked. It is typically performed through mini-laparotomy, laparoscopy, or during a Caesarean Section, under general, local, or spinal anaesthesia.
233
What is the Essure® technique for female sterilisation?
Essure® involves inserting a small device into each fallopian tube via hysteroscopy, which causes fibrosis and tubal occlusion. A follow-up at 12 weeks with X-ray and possibly an HSG is required to confirm the success of the procedure.
234
Does female sterilisation affect menstruation or hormone production?
No, female sterilisation does not affect hormone production or sexual desire, and women continue to menstruate. The procedure does not interfere with sexual intercourse.
235
Is female sterilisation the same as a hysterectomy?
No, female sterilisation is not the same as a hysterectomy. In sterilisation, the uterus is not removed, and menstruation continues.
236
Are there any medical conditions that make a woman ineligible for female sterilisation?
There is no medical condition that automatically makes a woman ineligible for sterilisation. However, in some cases, the procedure may need to be delayed, or special arrangements may be required.
237
What alternatives should be offered to women requesting sterilisation?
Long-acting reversible contraceptive (LARC) methods, such as the Cu T 380, LNG-IUS, and implants, should be offered as alternatives to female sterilisation, since they are as effective and do not require surgery.
238
What is male sterilisation (vasectomy) and how is it performed?
Male sterilisation, also known as vasectomy, is a permanent surgical procedure where the vas deferens (ejaculatory ducts) are closed to prevent sperm from mixing with the ejaculate. The procedure is typically done under local anaesthesia.
239
Is male sterilisation the same as castration?
No, male sterilisation is not the same as castration. The testes are not removed. The procedure only blocks the vas deferens to prevent sperm from being released with the ejaculate.
240
Does male sterilisation affect sexual function?
No, male sterilisation does not affect sexual desire, erections, or sexual function. The man will continue to ejaculate normally, but the semen will not contain sperm.
241
How long does it take for a vasectomy to be effective?
It typically takes about 20 ejaculations for the vasectomy to be fully effective. A semen analysis is recommended 12 weeks after the surgery to confirm the absence of sperm.
242
How does male sterilisation compare to female sterilisation?
Male sterilisation is generally safer, somewhat more effective, and less expensive than female sterilisation.
243
What should be considered if a man is not certain about ending fertility?
If a man is unsure about ending fertility, alternative highly effective reversible methods (LARC) for his partner should be discussed. These methods should be considered before making a final decision about vasectomy.
244
What should be considered before making a final decision on vasectomy?
Informed decision-making is important. Alternative long-acting reversible contraception (LARC) methods should be considered (depending on availability) before deciding on male sterilisation.
245
What is the effectiveness of female sterilisation (tubal ligation) and male sterilisation (vasectomy)?
Female sterilisation (TL): 99.5-99.8% effective in the first year after the procedure; 98.2% effective over 10 years.
Vasectomy: Over 99.8% effective in the first year after the procedure.
246
Are there age limitations for female and male sterilisation?
From a medical perspective, there are no age or parity restrictions.
However, regret is most common among clients under age 30 and/or those with low parity (few or no children), so careful counselling is essential.
247
What is the mode of action for female sterilisation and vasectomy?
Female sterilisation (TL): Blocking the fallopian tubes prevents the ovum and sperm from uniting, making the woman sterile immediately after the procedure.
Vasectomy: Surgical closure of the vas deferens (ejaculatory duct) prevents sperm from mixing with the ejaculate. It is not effective immediately; it takes about three months for the ejaculate to be sperm-free.
248
What are the immediate problems or complications associated with female sterilisation and vasectomy?
Female sterilisation: Post-operative pain, wound infection, and haematoma. Chronic scrotal pain is rare.
Vasectomy: Typically involves post-operative pain, wound infection, haematoma, and rarely chronic scrotal pain
249
What are the non-contraceptive benefits of female sterilisation and vasectomy?
Female sterilisation: May offer some protection against PID (Pelvic Inflammatory Disease) and ovarian cancer.
Vasectomy: Provides protection for the man’s partner from the risks associated with pregnancy.
250
Do female and male sterilisation offer protection against STIs?
No, both **female and male sterilisation are not protective against STIs.
251
Are there any drug interactions with female or male sterilisation?
No, there are no drug interactions with either procedure.
252
What is the duration of use for female sterilisation and vasectomy?
Both are considered to be permanent and irreversible.
253
What is the return to fertility after female sterilisation and vasectomy?
Female sterilisation: Return to fertility is impossible unless the tubes are reconnected (which can be expensive and success is not guaranteed).
Vasectomy: Return to fertility is not possible without surgical reconnection of the vas deferens, which is also expensive and not always successful.
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When can female sterilisation and vasectomy be performed?
Female sterilisation: Can be performed at any time during a woman's reproductive life. Common times include:
- Immediately postpartum or up to 7 days after delivery.
- During a Caesarean section (if the decision was made in advance).
- Immediately after an induced or spontaneous abortion.
- At least 6 weeks after a delivery, once the uterus has returned to normal size, and if it is reasonably certain the woman is not pregnant.
Vasectomy: Can be performed at any time.
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What should be reviewed during counselling for sterilisation?
Counselling should include:
- A review of the reasons for choosing sterilisation.
- Ideally, both partners should be involved in the counselling process.
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What alternative methods should be discussed during sterilisation counselling?
Counselling should provide information about other highly effective reversible methods, such as:
- Cu T 380 IUD,
- LNG releasing IUS,
- Sub-dermal implants.
These methods offer equivalent protection from pregnancy but are reversible and do not require surgery.
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What should be explained about male and female sterilisation during counselling?
Vasectomy should be explained as a safer, simpler, and more effective permanent procedure than female sterilisation.
Information about both male and female sterilisation should be provided to ensure clients make an informed decision.
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Why is it important to discuss feelings about not having more children?
This is particularly important for:
- Clients who are young, have few or no children, or are not in a stable relationship.
- Clients who may not be in complete agreement with their partner or who show excessive interest in reversal procedures.
Discussing these feelings helps ensure clients are fully prepared for the emotional aspects of the decision.
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What other factors should be considered when counselling about sterilisation?
Clients should be helped to consider future possible changes, such as:
- Loss of existing children,
- Loss of partner through death or divorce,
- The possibility of wanting more children with a new partner.
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What should clients be informed about regarding the surgical procedure for sterilisation?
Clients should be provided with detailed information about:
- The surgical procedure,
- Risks and possible complications of the procedure.
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How should misconceptions about sterilisation be addressed during counselling?
It is important to clarify any misconceptions about both male and female sterilisation to ensure the client has accurate information.
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What should be emphasized regarding protection from STIs during sterilisation counselling?
Clients should be reminded that sterilisation offers no protection from STIs, including HIV. Therefore, condom use should still be recommended to protect against STIs.
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What should be done after the counselling session?
After counselling:
Couples should be given the opportunity to think about the information before making a decision.
There should be no coercion, and clients should not be offered incentives to agree to sterilisation.
Written informed consent must be obtained prior to sterilisation.
Partner's consent is not a legal requirement for the procedure.
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What are Fertility Awareness-Based (FAB) methods?
FAB methods are used for both planning and avoiding pregnancy. They rely on identifying signs and symptoms of the fertile and infertile phases of the menstrual cycle. Abstinence during the fertile phase (typically 10-12 consecutive days) is required.
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How effective are FAB methods?
FAB methods are 95% effective when used correctly and 75% effective among typical users in the first year of use.
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What are some commonly used FAB methods in South Africa?
In South Africa, the Billings Ovulation Method (based on cervical mucus changes) and the Sympto-Thermal Method (which combines cervical mucus changes, temperature monitoring, and other fertility indicators) are most commonly used.
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What are the advantages and limitations of FAB methods?
Advantages: No side effects, no medical restrictions, and no need for hormones or devices.
Limitations: Requires motivation from both partners, correct and consistent use, and full training. Certain conditions, like adolescence or peri-menopause, can make it harder to use FAB effectively.
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Who should not rely on FAB methods for contraception?
Clients for whom pregnancy is contraindicated for medical reasons should consider more effective contraception options.
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What type of training is required for using FAB methods?
Effective use of FAB methods requires specialized training. Both partners should ideally be trained together, but the woman can be taught alone. Training includes identifying fertile and infertile phases, using a thermometer, and graphing temperature readings to identify the fertile window.
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What is the Lactational Amenorrhoea Method (LAM)?
LAM is a temporary method of natural family planning used by fully breastfeeding women to avoid pregnancy. It relies on the natural effects of breastfeeding to suppress ovulation.
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What are the criteria for LAM to be effective?
LAM is 98% effective when the following three criteria are met:
1. The woman is amenorrhoeic (no menstruation).
2. She is fully breastfeeding (no supplementary feeds).
3. The baby is less than six months old.
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When should a woman switch from LAM to another method?
Women should switch to another method of contraception if any of the LAM criteria expires or if they no longer want to rely on it for contraception.
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Can LAM protect against STIs?
While LAM is effective for contraception, it does not protect against STIs. Condoms should be used to prevent HIV/STI transmission or acquisition.
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What is the withdrawal method?
Withdrawal, or coitus interruptus, involves the male partner removing the penis from the vagina before ejaculation, thus preventing sperm from entering the female genital tract.
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How effective is the withdrawal method?
Perfect use: 95% effective.
Typical use: 73% effective in the first year, as it is difficult to practice consistently and correctly.
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Are there any medical restrictions for using the withdrawal method?
No medical conditions restrict a client's eligibility for the use of withdrawal. It is also free of side effects, always available, and cost-free.
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Should withdrawal be used as a standalone method?
Withdrawal is often less effective when used alone. Providers should offer clients reliable backup contraceptive options, like condoms and emergency contraception, in case of method failure.
