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11.8 Contraception

Table of Contents

11.8.1 Combined Oral Contraceptives (COS) and Injectables

Before initiating oral contraceptive pills:

  • Check blood pressure
  • Perform vaginal examination (to check normal size of uterus)
  • Check for contraindications like deep vein thrombosis

Follow up:

  • Instruct women always to inform the doctor or nurse that they are on contraceptives while attending clinic or hospital.
  • Women on oral contraceptives need regular physical check-ups including blood pressure measurement every six months
  • Need to withdraw COCs or Progesteron Only Contraceptives (POPs) in:
    o Pregnancy
    o Severe headaches especially associated with visual disturbances
    o Numbness or paresis of extremities
    o Unexplained chest pain or shortness of breath o Severe leg pains etc.

The recommended oral contraceptives are:

A: Ethinyloestradiol + Norgestrel Tablets 0.03mg + 0.3mg

OR

A: Ethinyloestradiol + Levonogestrel Tablets 0.03mg + 0.15mg

OR

A: Ethinyloestradiol + Desogestrell Tablets 0.03mg + 0.15mg

OR

A: Medroxyprogesterone acetate IM 150 mg every three months

Note

Take the first pill on the 5th day of menstruation and then continue every day without any interruptions
Check blood sugar and hypertension after every 6 months


Caution!
 Avoid use in women with severe hypertension and women without proven fertility

Post-coital contraception (“morning-after pill”)

The method is applicable mostly after rape and unprotected sexual intercourse where pregnancy is not desired. Within 3 days (72 hours) of unprotected sexual intercourse, give:

A: Combined oral Contraceptive ethinyloestradiol 100 µg and levonorgestrel

500 µg (2 high dose COC tablets)

OR

A: Ethinyloetradiol 30–35 µg and levonorgestrel 150–250 µg –3 tablets (3 low dose COC tablets).

  • Repeat this dose after twelve hours
  • Advice to return to physician if menstruation does not occur within 3 weeks; give advice on contraceptive use

11.8.2 Implant Contraceptives

Implants are contraindicated to:  Severe hypertension

  • Thromboembolism
  • Active liver disease
  • Sickle cell anaemia
  • Genital bleeding
  • Severe headaches

The following are the recommended implants:

B: “Implanon 68mg “containing etonogestrol in single silastic capsules is implanted in the left upper arm with local anesthesia. Is effective for 3 years

OR

B: Implanon NXT, 68mg is an implant containing etonogestrel in single silastic capsule with applicator is implanted in the left upper arm with local anesthesia. Is effective for 3 years

OR

B: Jadelle, “containing levonogestrel 75mg in two silastic capsules is implanted subdermal in the left upper arm with local anesthesia. Is effective for 5 years and is recommended for women who have completed their family or not ready for sterilization or those not able to take estrogen containing contraceptives.

NOTE:Use the WHO Medical eligibility criteria (MEC) wheel on providing FP methods

11.8.3 Infertility

Infertility is a condition of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.12

Investigation: Not every fertility test will be done for every case.

WOMEN: For women, fertility testing may include basic gynaecologic examination  VDRL tests

  • Urine routine and microscopic
  • Cervical mucus examination
  • Abdominal pelvic USS-to look for polycystic ovaries, larger ovarian cysts, fibroids, and, sometimes, to confirm ovulation is taking place.
  • HSG (hysterosalpingogram) to check that the fallopian tubes are open and not blocked, as well as to evaluate the shape of the uterus.
  • Hysteroscopy- This is done if an HSG examination showed potential abnormalities or was inconclusive.
  • Diagnostic laparascopy- This test is only done when symptoms point to possible endometriosis, as part of treatment for blocked fallopian tubes, or in some cases of unexplained infertility.
  • Hormonal profile- FSH, LH,T3 & T4,Testosterone, prolactin, estradioland progesterone

MEN: Perform the following

  • Semen analysis
  • VDRL tests
  • Hormonal profile-FSH,Testosterone, but sometimes also LH, estradiol, or prolactin

Treatment will depend on the underlying cause

Non-pharmacological treatment

  • Weight reduction in obese clients.
  • Educate the couple on the importance of having sexual intercourse during the fertile window
  • Try to avoid smoking/excessive drinking

Pharmacological treatment

Ovulation stimulation;

C: Clomiphene citrate 50mg (PO) once per day for seven days from the 2nd–5th day of menstruation.(maximum 6 cycles)

Polycystic Ovarian Syndrome (PCOS)

A: Metformin 500mg 8 hourly (sometimes used during PCOS treatment, alone or along with fertility drugs)

Hyperprolactinemia

B: Bromocriptine 2.5–5mg once per day until the prolactin level is within the normal range Surgeries:

  • Tubal surgery for Tubal blockage
  • Myomectomy for uterine fibroids
  • Ovarian drilling is a possible surgical infertility treatment for PCOS–related infertility

Referral

Refer all patients with infertility to a gynecologist.

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