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Contraception
Dr. Susheela Rani
PostgraduatesPostgraduates
WHO Recommendation criteria for safe contraceptive use (2009)
Category1Category1 = no restriction on use = no restriction on useCategory2 Category2 = the advantages of using the = the advantages of using the
method generally outweigh the theoretical method generally outweigh the theoretical or proven risksor proven risks
Category3Category3 = the theoretical or proven risks = the theoretical or proven risks usually outweigh the advantages of using usually outweigh the advantages of using the methodthe method
Category4Category4 = an unacceptable health risk = an unacceptable health risk
Outpatient yesterday
G3P1A1(MTP) with 7weeks amenorrhoea G3P1A1(MTP) with 7weeks amenorrhoea wants termination of pregnancy. wants termination of pregnancy.
Condom contraception all these days.Condom contraception all these days. Condom failure previous pregnancy, Condom failure previous pregnancy,
hence MTP hence MTP Present pregnancy resulted despite the Present pregnancy resulted despite the
use of double condoms!!!use of double condoms!!!
Have condoms failed?Have condoms failed?
Double bagging
It increases the friction It increases the friction
between the condoms duringbetween the condoms during
intercourse, making them intercourse, making them
more likely to tear – this is the same for the more likely to tear – this is the same for the both simultaneous use of male and female both simultaneous use of male and female condoms. When condoms do fail, it is most condoms. When condoms do fail, it is most often a result of human error, rather than often a result of human error, rather than defects in the condom themselvesdefects in the condom themselves
Case 1
Mrs G 28yr, P2 L2 A3 (all MTPs) wants Mrs G 28yr, P2 L2 A3 (all MTPs) wants contraceptioncontraception
Regular periods with moderate flowRegular periods with moderate flow Clinical Examination – Uterus normal size Clinical Examination – Uterus normal size
mobile, fornices freemobile, fornices free
Among contraceptives, which one of these is the Among contraceptives, which one of these is the most most cost - effective cost - effective
CondomsCondoms IUDIUD OCsOCs DMPADMPA Vaginal RingVaginal Ring
You are talking to her about effectiveness of You are talking to her about effectiveness of each method. She is worried that the IUD each method. She is worried that the IUD “will go into the abdomen”. “will go into the abdomen”. How would you How would you explain failure rate, perforation rate and explain failure rate, perforation rate and expulsion rate of IUD?expulsion rate of IUD?
Failure rateFailure rate<2 in 100 WY for CuT<2 in 100 WY for CuT<1 in 100WY for LNG IUS<1 in 100WY for LNG IUS
Perforation rate Perforation rate <2 in 1000 women getting inserted<2 in 1000 women getting inserted
Expulsion rateExpulsion rate1 in 20 and usually happens within first 1 in 20 and usually happens within first year particularly within 3 monthsyear particularly within 3 months
She says she is OK with the insertion of Cu She says she is OK with the insertion of Cu T and you get ready by wearing gloves for T and you get ready by wearing gloves for insertion. insertion.
Did we miss something here?Did we miss something here?
Informed (written)consentInformed (written)consent
Pt requests for a Cu IUCDPt requests for a Cu IUCD
However, examination reveals vulvo vaginitis suggestive of monilial However, examination reveals vulvo vaginitis suggestive of monilial infectioninfection
Would you still go ahead with with the insertion?Would you still go ahead with with the insertion?
You are ready for insertion. While the patient is You are ready for insertion. While the patient is
lying on the couch she gives history of lying on the couch she gives history of
gestational diabetes. Her FBS done a week back gestational diabetes. Her FBS done a week back
was 215mg/dLwas 215mg/dL
Would you still insert the IUD? Would you still insert the IUD?
Would you give prophylactic antibiotic? If Would you give prophylactic antibiotic? If so, what drug and what dosage?so, what drug and what dosage?
IUD & prophylactic antibiotics
Low risk women – no benefitLow risk women – no benefit
High risk women – single dose ofHigh risk women – single dose of
Doxycycline 200mg PO Doxycycline 200mg PO
Azithromycin 500mg POAzithromycin 500mg PO
Women with previous endocarditis or with a prosthetic
heart valve require intravenous antibiotic prophylaxis to
protect against bacterial endocarditis during intrauterine
contraception insertion or removal (Grade C).
If this patient had a cardiac disease instead If this patient had a cardiac disease instead of Diabetes, what caution would you of Diabetes, what caution would you exercise?exercise?
Vasovagal reaction may occur as a result Vasovagal reaction may occur as a result of cervical stimulation during insertion or of cervical stimulation during insertion or removal of IUD. removal of IUD.
Inj Atropine IM 10mins before the Inj Atropine IM 10mins before the procedure or use a short GA procedure or use a short GA
Is it true?
IUD use IUD use Cleaning the vagina with Povidone Iodine before Cleaning the vagina with Povidone Iodine before
insertion decreases the risk of infectioninsertion decreases the risk of infection Increased risk of infection is related only to the Increased risk of infection is related only to the
insertion process and not to IUDinsertion process and not to IUD Doubles the incidence of tubal infertilityDoubles the incidence of tubal infertility Increases the risk of ectopic pregnancy Increases the risk of ectopic pregnancy
Is it true?IUD use Cleaning the vagina with Povidone Iodine before
insertion decreases the risk of infection. Iodine preparation is of little benefit. No touch technique is more important
Increased risk of infection is related only to the insertion process and not to IUD True
Doubles the incidence of tubal infertility – No increased incidence
Increases the risk of ectopic pregnancy - No increased incidence
Patient comes back within 3 days saying that Patient comes back within 3 days saying that
she cannot feel the threads. Ultrasound reveals she cannot feel the threads. Ultrasound reveals
an empty uterus. IUCD on the antero superior an empty uterus. IUCD on the antero superior
surface of uterussurface of uterus
Patient is asymptomatic & not keen on surgeryPatient is asymptomatic & not keen on surgery
Perforated IUD
Is it best left alone if the woman is Is it best left alone if the woman is asymptomatic?asymptomatic?
Is it best removed soon after it is located? Is it best removed soon after it is located?
Perforated IUD
Copper can lead to adhesion formation. Copper can lead to adhesion formation. It is best removed soon after it is located – It is best removed soon after it is located –
before adhesion formation can occurbefore adhesion formation can occur It is left alone ONLY if the risk of surgery is high It is left alone ONLY if the risk of surgery is high
AND if the woman is asymptomaticAND if the woman is asymptomatic
Say this woman had an uneventful period after Say this woman had an uneventful period after insertion of Cu380A and comes for removal and insertion of Cu380A and comes for removal and reinsertion of a new one after 10years. She has a reinsertion of a new one after 10years. She has a Multi loadCu 375 inserted this time. When does Multi loadCu 375 inserted this time. When does she need to come for removal and insertion of she need to come for removal and insertion of another one?another one?
Women who have a Cu-IUD inserted at the age of 40 years or over can retain the device for 1 year after the last menstrual period if aged over 50 years (or 2 years if under 50 years) or until contraception is no longer required
Mr & Mrs P visit your clinic because Mrs P has Mr & Mrs P visit your clinic because Mrs P has
missed her period and is worried she could be missed her period and is worried she could be
pregnant. They have not used contraception so pregnant. They have not used contraception so
far. She has a regular 30days cycle far. She has a regular 30days cycle
Case 2
She is found to be not pregnant. She is found to be not pregnant.
They have 2 children, 3 and 2 yrs old and are They have 2 children, 3 and 2 yrs old and are
keen to postpone the third. However, they are a keen to postpone the third. However, they are a
religious couple and are not keen on using any religious couple and are not keen on using any
barriers / IUD or any medications. They have barriers / IUD or any medications. They have
heard of the (safe) Standard method and want to heard of the (safe) Standard method and want to
know what days are safe to have UPSIknow what days are safe to have UPSI
Safe period
Works best for women with cycles Works best for women with cycles
between 26 and 32 daysbetween 26 and 32 days
It identifies days 8-19 as fertile days It identifies days 8-19 as fertile days
Avoid UPSI from days 8 through 19Avoid UPSI from days 8 through 19
Failure rate 20%Failure rate 20%
Case 3
Mrs D 28yrs, software professional, often travels overseas on work
Married for 1 year Irregular periods cycle 45- 90days with
flow for 15-30days BMI 26, BP 120/70mmHg, pallor + Ut normal size, mobile, fx free
What would you advice?What would you advice?
OC pillsOC pills
Progesterone only pillsProgesterone only pills
LNG IUSLNG IUS
IUCDIUCD
Mrs D opts to use OC pills, the low dose variety. In Mrs D opts to use OC pills, the low dose variety. In
fact, OC pills have been advised to her even fact, OC pills have been advised to her even
before her marriage for regularization of periods. before her marriage for regularization of periods.
Can you add value to your prescription of OC pills? Can you add value to your prescription of OC pills?
Extended OC pills for 3or more months Extended OC pills for 3or more months
6 RCTs show similar efficacy and safety for
continuous dosing and 28 day combination
contraceptive pills
Adv - convenience, reduction of menorrhagia, Adv - convenience, reduction of menorrhagia,
dysmenorrhoea and premenstrual syndrome, dysmenorrhoea and premenstrual syndrome,
improvement in Hb, general wellbeing. improvement in Hb, general wellbeing.
Disadv – Breakthrough bleeding in first few cyclesDisadv – Breakthrough bleeding in first few cycles
What is LARC?What is LARC?
LARC is defined as
Methods that require administering less than Methods that require administering less than once per cycle or monthonce per cycle or month
Miss K,18yrs, student, has irregular periods, Miss K,18yrs, student, has irregular periods, 4days /2-3 months. She has undergone medical 4days /2-3 months. She has undergone medical TOP 6months back. TOP 6months back.
She seeks consultation for irregular bleeding since She seeks consultation for irregular bleeding since 18days18days
She gives history of having used She gives history of having used ‘‘II’’ pills twice pills twice since her LMP since her LMP
You find her 6weeks pregnant and have provided You find her 6weeks pregnant and have provided medical TOPmedical TOP
What contraceptive advice would you now give her?What contraceptive advice would you now give her?
Case 4
AbstinenceAbstinence COCsCOCs POPsPOPs IUDIUD Injectable contraceptionInjectable contraception
You educate her about the correct method of You educate her about the correct method of use of Emergency Contraception. You advice…use of Emergency Contraception. You advice…
She does not want to take OCs because she She does not want to take OCs because she fears she may forget taking during her exams & fears she may forget taking during her exams & also fears that her parents will find out. also fears that her parents will find out. She is not sure if she can abstain from SI She is not sure if she can abstain from SI
What would you advice? What would you advice?
This girl needs regular contraception. This girl needs regular contraception.
LARC – user friendly, convenient, discreetLARC – user friendly, convenient, discreet
Long acting Injectable Progesterones need to be Long acting Injectable Progesterones need to be
used with caution in adolescents because of used with caution in adolescents because of
possible effect on Bone mineral densitypossible effect on Bone mineral density
Both Cu IUD and LNG IUD are Category 1 for Both Cu IUD and LNG IUD are Category 1 for
women >20yrs and Category 2 for women <20yrswomen >20yrs and Category 2 for women <20yrs
Why would you think twice before offering Cu IUD to Why would you think twice before offering Cu IUD to
a nulliparous woman?a nulliparous woman?
Why would you think twice before offering Cu IUD to Why would you think twice before offering Cu IUD to
a nulliparous woman?a nulliparous woman?
Because the risk of expulsion is higherBecause the risk of expulsion is higher
Mrs KS, 34yr, presented with migraine without
aura associated with COC use. Migraine occurs
during the pill-free week. Her BP is 120/70
mmHg and BMI 26 kg/m2. There has been no
weight gain or any other side effect. There is no
family or personal history of diabetes, hepatic
disease, migraine, cardiovascular disease or
cancer.
Case 5
Would you recommend a change of Would you recommend a change of contraceptive?contraceptive?
There is a 2–4-fold increased risk of stroke in women who experience migraine (with or without aura) while using COCs compared with those who experience migraine but do not use COCs
Mrs KS is < 35 years old and did not have the migraines until she started the new COC, the risk of stroke outweigh the advantages
Alternatives include CuT, POPs, Inj DMPA, LNG IUS, Barrier methods
Case 6
Keerthi, 22yr, delivered normally a healthy female baby today. She has a 1 year old daughter and is demanding Tubectomy. Her husband has decided to go with her wishes.
Is she an eligible candidate for Tubectomy?
Eligibility for female sterilization
Should be married (including ever-married) Should be below 49yr and above 22yr Should have at least one child >1year unless the
sterilization is medically indicated Clients or their spouses/partners must not have
undergone sterilization in the past (not applicable in cases of failure of previous sterilization)
Must be in a sound state of mind
Sterilization Regret
Nationally, 5% of sterilized women aged 15–49 reported sterilization regret.
Women sterilized before age 25 were more likely to express regret
Compared with women having only sons, those who had only daughters were more likely to express regret
Encouraging couples to delay sterilization and increasing the availability of highly effective reversible contraceptives are options that India may consider to avert sterilization regret.
International Perspectives on Sexual and Reproductive Health, 2012, 38(4): 187–195
Sterilization Regret
Despite counselling, Keerthi undergoes Despite counselling, Keerthi undergoes Tubectomy.Tubectomy.
15months later she returns with missed 15months later she returns with missed periodperiod
Examination reveals a live Intrauterine Examination reveals a live Intrauterine pregnancy of 6weekspregnancy of 6weeks
What was the reason for failure of Tubectomy? What was the reason for failure of Tubectomy?
Factors Contributing to Failure
Operator Error Ligating the wrong Ligating the wrong
structurestructure Failure to Failure to
systematically systematically check the processcheck the process
Not ligating due to Not ligating due to technical technical problems and not problems and not informing the informing the womanwoman
Failures Independent of Operator
Tuboperitoneal fistulaTuboperitoneal fistulaRecanalaisationRecanalaisation
Tuboperitoneal fistula
Spontaneous Ectopic Pregnancy after tubal ligationSpontaneous Ectopic Pregnancy after tubal ligation
Progress 2015Progress 2015
Spontaneous Tubal Recanalisation
Progress 2015Progress 2015
Case 6
Mrs G 32yrs, P2 L2 Mrs G 32yrs, P2 L2 Irregular heavy periodsIrregular heavy periods Clinical Examination – 10wks size uterusClinical Examination – 10wks size uterus Ultrasound examination – Bulky uterus with Ultrasound examination – Bulky uterus with
multiple intramural fibroids, largest measuring multiple intramural fibroids, largest measuring 3cmX2cm. The endometrial cavity is not 3cmX2cm. The endometrial cavity is not distorted distorted
Endometrial thickness 11mm, contour - normal Endometrial thickness 11mm, contour - normal
Which one of these would be appropriate? Which one of these would be appropriate?
IUDIUD
OCsOCs
DMPADMPA
LNG IUD LNG IUD
OC pills & Fibroids
The administration of low dose OC pills to The administration of low dose OC pills to women with leiomyomas does not stimulate women with leiomyomas does not stimulate fibroid growth and is associated with decreased fibroid growth and is associated with decreased bleedingbleeding
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995
LNG IUS & Fibroids
In studies of the levonorgestrel device in women In studies of the levonorgestrel device in women with troublesome bleeding associated with with troublesome bleeding associated with fibroids, the size of the uterus and the largest fibroids, the size of the uterus and the largest individual tumors diminished slightly. individual tumors diminished slightly.
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995
Mrs G chooses to get an LNG IUS inserted. She Mrs G chooses to get an LNG IUS inserted. She
comes back to you after 3yrs for a check up. comes back to you after 3yrs for a check up.
She reveals that she was recently hospitalized She reveals that she was recently hospitalized
for a bad lung infection. She is presently for a bad lung infection. She is presently
undergoing treatment for tuberculosis and is on undergoing treatment for tuberculosis and is on
a 4 drug regime. a 4 drug regime.
Would you like to suggest a change in her Would you like to suggest a change in her contraceptive method?contraceptive method?
Data shows no reduction in the efficacy of LNG-Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugsIUS with liver enzyme-inducing drugs
Current WHO-MEC recommendations Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver enzymes, prescribed drugs which affect liver enzymes, such as rifampicin and anti-epileptic drugssuch as rifampicin and anti-epileptic drugs
Case 7
Mrs D 38yrs, P3 L3 TOP 3, is planning to undergo Mrs D 38yrs, P3 L3 TOP 3, is planning to undergo
Incisional hernia repair and Tubectomy. She is Incisional hernia repair and Tubectomy. She is
on low dose OC pills for contraception. on low dose OC pills for contraception.
When would you ask her to stop the OC pill?When would you ask her to stop the OC pill? 4weeks before the planned surgery 4weeks before the planned surgery 2weeks before the planned surgery2weeks before the planned surgery The day before the planned surgeryThe day before the planned surgery
Data shows that high dose OC pills carry a risk Data shows that high dose OC pills carry a risk
of postoperative thrombosis of postoperative thrombosis
Low dose OC pills have not shown similar riskLow dose OC pills have not shown similar risk
Stopping OC pills well before the procedure is Stopping OC pills well before the procedure is
recommended only when prolonged recommended only when prolonged
immobilization is required following surgeryimmobilization is required following surgery
Mrs C is being discharged today after a FTND of Mrs C is being discharged today after a FTND of
a healthy boy baby 3 days back. Both the a healthy boy baby 3 days back. Both the
mother and the baby are in good health and she mother and the baby are in good health and she
is breast feeding the baby.is breast feeding the baby.
When would you schedule her postpartum visit When would you schedule her postpartum visit
to provide contraception?to provide contraception?
Case 8
6 weeks after delivery6 weeks after delivery 4 months after delivery4 months after delivery 3 months after delivery3 months after delivery 3 weeks after delivery3 weeks after delivery
ii
Most studies have shown that half the women Most studies have shown that half the women
ovulate before the 6ovulate before the 6thth week week (before the (before the
traditional postpartum visit) . traditional postpartum visit) . A 3 week visit A 3 week visit
would be idealwould be ideal
Rule of 3’s
Beginning of postpartum contraceptive useBeginning of postpartum contraceptive use
Full breast feeding – 3Full breast feeding – 3rdrd month month
Partial or No breast feeding – 3Partial or No breast feeding – 3rdrd week week
Mrs C and her husband visit after 3weeks. She Mrs C and her husband visit after 3weeks. She is partially breast feeding her baby.is partially breast feeding her baby.
What are her contraceptive options?What are her contraceptive options? COCsCOCs POPsPOPs LNG IUDLNG IUD Cu IUD Cu IUD Injectable progesteronesInjectable progesterones
Mr CMr C considers Cu IUD and asks considers Cu IUD and asks
““What would be the ideal time to insert CuIUD?What would be the ideal time to insert CuIUD?
””
ImmediatelyImmediately
At 4weeksAt 4weeks
At 6weeksAt 6weeks
Postpartum visit at 3 weeks
At 4weeksAt 4weeks
Is it true about IUD in breast feeding Is it true about IUD in breast feeding
women…..women…..
Insertion is easierInsertion is easier
Rate of expulsion is higherRate of expulsion is higher
Rate of perforation is higherRate of perforation is higher
Postpartum visit at 3 weeks
Postpartum insertion of either a Cu IUD or LNG Postpartum insertion of either a Cu IUD or LNG
IUD is best done within 48hours or AT or IUD is best done within 48hours or AT or
AFTER 4weeks . It is not inserted between AFTER 4weeks . It is not inserted between
48hrs to 4weeks. 48hrs to 4weeks.
WHO eligibility criteria 2008WHO eligibility criteria 2008
Postpartum visit at 3 weeks
Despite allaying her fears of IUD, Mrs C is Despite allaying her fears of IUD, Mrs C is
unwilling to consider it. She is doubtful of taking unwilling to consider it. She is doubtful of taking
pills regularly. What are her options now?pills regularly. What are her options now?
She chooses to use Inj DMPA. When would you She chooses to use Inj DMPA. When would you
start her on the injection?start her on the injection?
ImmediatelyImmediately
Later….if so when?Later….if so when?
She takes Inj DMPA. Her periods are irregular with She takes Inj DMPA. Her periods are irregular with
spotting on & off despite the non steroidal anti- spotting on & off despite the non steroidal anti-
inflammatory drugs prescribed. She is disturbed inflammatory drugs prescribed. She is disturbed
by it because she cannot say her prayers when by it because she cannot say her prayers when
she has bleeding. What would you do now? she has bleeding. What would you do now?
Discontinue injectable straight awayDiscontinue injectable straight away
If no gynaec problems are found treat with If no gynaec problems are found treat with
ethinyl estradiol, short termethinyl estradiol, short term
She takes Inj DMPA and is quite happy with it. Her She takes Inj DMPA and is quite happy with it. Her
periods are irregular with spotting on & off but periods are irregular with spotting on & off but
since she has been counselled, she is not since she has been counselled, she is not
unduly disturbed by it and the bleeding settles. unduly disturbed by it and the bleeding settles.
Following the second injection, she returns to the Following the second injection, she returns to the
clinic only after 4months clinic only after 4months
What would you do now?What would you do now?
Check for pregnancy. If negative give the injection and Check for pregnancy. If negative give the injection and
ask her to use additional method for the next 7days ask her to use additional method for the next 7days
Check for pregnancy and if negative give the injection Check for pregnancy and if negative give the injection
without any additional advice about contraceptionwithout any additional advice about contraception
Give the injection without any additional advice about Give the injection without any additional advice about
contraceptioncontraception
Late for an injection?? grace period extended!
The repeat injection of The repeat injection of
DMPA can be given up to 4 weeks lateDMPA can be given up to 4 weeks late
NET-EN can be given up to 2 weeks late NET-EN can be given up to 2 weeks late
without requiring additional contraceptive without requiring additional contraceptive
protectionprotection
Selected Practice Recommendations for Contraceptive Use 2008 updateSelected Practice Recommendations for Contraceptive Use 2008 update
Thanks
Mrs A, 25yrs, married for 4 yrsMrs A, 25yrs, married for 4 yrsDetected HT soon after marriageDetected HT soon after marriageP2 L2, I – IUD at 28wks, II – LSCS for P2 L2, I – IUD at 28wks, II – LSCS for
twins, super added GDM twins, super added GDM Investigations after the I pregnancyInvestigations after the I pregnancyAPLA negativeAPLA negativeLipid profile – within normal limitsLipid profile – within normal limitsSugars – within normal limits Sugars – within normal limits
Case 4
Menorrhagia since 2yrs. Underwent D&C – Cystic glandular Hyperplasia
Amen 2months , UPT – Negative Ht 5’, Wt 102kg, BP- 190/100 No withdrawal bleeding with
medroxyprogesterone acetate 20mg for 7days Scan – Ovaries bulky, Uterus NS, End – 10mm,
Cholelithiasis + Needs regularization of periods and
contraception
Would you like to investigate her or Would you like to investigate her or prescribe contraception right away?prescribe contraception right away?
What investigations would you ask for?What investigations would you ask for?
Routine examinations / tests before contraception
WHO eligibility criteria 2004WHO eligibility criteria 2004
Lipid profile shows raised cholesterol. However Lipid profile shows raised cholesterol. However
HDL/VLDL ratio is within normal limitsHDL/VLDL ratio is within normal limits
SGOT, SGPT, Renal function tests are normalSGOT, SGPT, Renal function tests are normal
Ultrasound scan of the abdomen shows normal Ultrasound scan of the abdomen shows normal
uterus with polycystic ovariesuterus with polycystic ovaries
What would you advice? What would you advice?
OC pills?OC pills?
Progesterone only pills?Progesterone only pills?
LNG IUS?LNG IUS?
IUCD?IUCD?
Hypertension and OC pills
Low dose OC pills can be used in women less Low dose OC pills can be used in women less than 35yrs with HT.than 35yrs with HT.
Progesterone only pills are betterProgesterone only pills are better Low dose OC pills have negligible impact on the Low dose OC pills have negligible impact on the
lipoprotein levellipoprotein level However, BP & lipid levels need to be closely However, BP & lipid levels need to be closely
monitoredmonitored
What can a woman do if she vomits and / or has What can a woman do if she vomits and / or has
severe diarrhoea while using COCs or severe diarrhoea while using COCs or
progestogen-only pills (POPs)?progestogen-only pills (POPs)?
Continue taking it orally despite her discomfort Continue taking it orally despite her discomfort (consider like missing pills)(consider like missing pills)
Use the vaginal route at the same dosage as oral
Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive Coutinho EM et al, Comparitive study on the efficacy and acceptability of contraceptive pills administered vaginally, an international multicentrer clinical trial. Clinical pills administered vaginally, an international multicentrer clinical trial. Clinical PharamacolPharamacol
Ziaei et al, Compartive study and evaluation of side effects of low dose OC pills Ziaei et al, Compartive study and evaluation of side effects of low dose OC pills adminsrtered by the oral and vaginal route, Contraception 2002adminsrtered by the oral and vaginal route, Contraception 2002
THANK YOUTHANK YOU