DR AKISEKU A.K

LONG ACTING HORMONAL CONTRACEPTIVES

IntroductionLong acting reversible contraceptivesLong acting hormonal contraceptives

OUTLINE

There are about 1.2 billion women of

reproductive age world wideAn estimated 1.5 million unplanned

pregnancies occur in Nigeria every year and about half of these result in elective abortion.

Bankole A , Oye-Adediran. International Family Planning PerspectivesVolume 32, Number 4, December 2006

Introduction

Unexpected or unplanned pregnancy poses a major public health challenge in women

of reproductive age, especially in developing countries.

It has been estimated that of the 210 million pregnancies that occur annually worldwide, about 80 million(38%) are unplanned, and 46 million (22%) end in abortion.

Abortions account for 20%–40% of maternal

deaths in Nigeria.

Many factors contribute to unwanted pregnancy

in Nigeria, and a very important factor is the low

level of contraceptive use

Contraception a key strategy for the prevention

of unwanted pregnancy.

Open Access Journal of Contraception 2010: 19–22

The current prevalence rate for contraceptive

use in Nigeria is approximately 11%–13%.

The Nigeria’s family planning commitments is

to achieve a contraceptive prevalence rate of

36% by 2018.

National Strategy and implementation plan (2013-

2015)

The low prevalence of contraceptive use in Nigeria and indeed in the Sub‑Saharan region is due to interplay of many factors:

Socio‑cultural, economic, political, religious, and demographic.

Contraceptive prevalence= Women of reproductive age (15-49) who are

married or in a union and who are currently using any method of contraception

x 100  Total number of women of reproductive age

(15-49) who are married or in a union

Family planning programs have yielded positive gains over the past decade

Like all aspects of medicine, contraception is also witnessing advances, changes, improvements.

LARC is defined as contraceptive methods that require administration less than once per cycle or month.

Included in the category of LARC are:copper intrauterine devicesprogestogen-only intrauterine systemsprogestogen-only injectable contraceptives

Nice clinical guideline 30. 2014

LONG ACTING REVERSIBLE CONTRACEPTIVES

progestogen-only subdermal implants

Progesterone Vaginal Ring (PVR)

The uptake of LARC is low in Great Britain, at around 12% of women aged 16–49 in 2008–09, compared with 25% for the oral contraceptive pill and 25% for male condoms

Are the most effective reversible methods available Have high rates of user satisfaction as indicated

by high continuation rates Are set and forget methods that do not require

daily adherence Require fewer visits to health services than many

other methods Are cheaper than using the pill over 12 months Are easily reversible Are suitable for women of all ages Do not affect fertility after removal

BENEFIT OF LARC

A lack of familiarity with, or misperceptions about, the

methods

High upfront costs

Lack of access to insertion services

Health care providers’ concerns about the safety of IUD

use, especially in nulliparous ,younger women and

teenagers

Patient barriers, including a general lack of awareness of

LARC methods and information about their safety and

effectiveness

Barriers to LARC use

progestogen-only intrauterine systems

progestogen-only subdermal implants

progestogen-only injectable contraceptives

Progesterone Vaginal Ring (PVR)

Long acting hormonal contraceptives

Progestogens in Long acting ContraceptionSynthetic progesterone preps for

long acting contraception.Adminstered largely as depots,

implants, and as intra-uterine systems.

Contraceptive efficacy relies on daily slow release of progestogen

Mechanisms of action are largely:Centrally inhibiting ovulationThickening of vaginal and

cervical mucusThinning of endometrium

Is a levonorgestrel-releasing intrauterine device

Is T-shaped with reservoir on the vertical arm

Releases progestin levonorgetsrel 20ug daily Has 2 monfilament string attached to the

vertical arm.Life span is 5years

PROGESTOGEN INTRAUTERINE SYSTEM(MIRENA)

Thickening of cervical mucus impeding sperm acsent.

Alteration in uterotubal fluid that interferes with sperm migration

Anovulation in 10-15% of cycles.Thinning of endometrium to reduce likelihood

of implantation.FR: 0.1-0.7 preg/100 WYr

Mechanism of action

Risks50% of pregnancy as a result of failure are ectopic

preg.Irregular bleeding common in the initial 3-4

months of use.About 25% of users become amenorrhoeic after

the 2nd year of useBenefitsImprovement in dysmenorrhoea.Used for Rx of Menorrhagia Reduced incidence of PID.Reduces risk of endomitral carcinoma

Progesterone Vaginal Ring (PVR)(Progesterone-Only)

Progesterone diffuses at a continuous flow of 10mg per day through the siliconeProlongs lactation amenorrhoeaUsed for Postpartum contraceptionAfter 6 weeks of delivery and for 3 months

Progesterone Vaginal Ring

A vaginal ring is inserted at postnatal visit (6 weeks)

Once inserted, the Ring is worn for 3 months At end of 3 months, it is removed and another

replacedFor now, use is stopped when menstruation

returns, or for a maximum of 1 yearMeant for breastfeeding women only

How the Ring is Used

Types: Progestin-OnlyDepo Medroxy Progesterone Acetate (DMPA)

150 mgMicrocrystalline suspension3 monthly

Norethisterone Enanthate (Net-En) 200 mgIn oil2 monthly

progestogen-only injectable contraceptives

Inhibition of ovulation by suppressing gonadotropinns.

Thickening of cervical mucus.Thinning of the endometrium.

Mechanism of action

During 1 year of use, the perfect use failure rate is 0.3 pregnancies per 100 woman-years, whereas the failure rate with typical use is 3 pregnancies per 100 woman-years.

The risk of ectopic pregnancy is significantly lower among users compared to women who do not use contraception.

The risk of endometrial cancer is reduced by as much as 80%, an effect that is long term and increases with duration of use.

Studies have shown as much as a 70% reduction in the frequency of sickle cell crises; the mechanism for this effect is not known.

Some women with endometriosis have improvement of symptoms with use of DMPA.

BENEFIT

Decrease in bone mineral density, hence, encourage calcium intake.

Irregular bleeding & prolonged menstrual flow

Amenorrhoea in prolonged usersMood swing & Depression.?Wt gain, about 5Ib(2.2kg) in 1 yr of use.Delayed return to fertility when discontinued,

≥10 months.

Disadvantages

Depo-subQ Provera (DMPA-SC)Contains 104 mg Depo-medroxy

progesterone acetateIn micro-crystalline suspension formNow Subcutaneous unlike Intramuscular in

DMPAAlso every 12 weeksShould not be used continuously for ˃2 years

Newly approved Depo-provera

Preferred injection Sites

Upper Thigh

Abdomen

Initially Six Rods, Norplant (now discarded)Two rod Jadelle (levonorgestrel) – 5 yearsOne rod Implanon (etonogestrel) – 3 yearsBio-degradable (Capronor) that does not

require removal (2 years) – Developed by Research Triangle Institute

Implants

[Levonorgestrel Implant]1st generation of implantsConsists of 6 rods, each measuring 34mm in

length & 2.4mm in diameter

NORPLANT

Each rod contains 36mg levonorgestrel.Approximately 80mcg of levonorgestrel is

released daily during the first 6-12 months after insertion.

Rate of release gradually declines to 30-35ug/day.

LH surge necessary for ovulation is suppressed in approximately 50% of cycles

Are mainly irregular bleeding pattern, which normalises over long term use.

HeadachesAcne, Weight gain/loss, mastalgia, mood

cahnge or depression.Hyperpigmentation over site of implantHirsuitism.Galactorrhoea.Symptomatic functional cyst occasionally

occur.

Side effects

Insertion is by special troca, subdermally on the inner surface of the left upper arm under local anaesthesia.

JADELLE [NORPLANT-2]Levonorgestrel preparationContains 2 non-biodegradeable silicone

elastomer capsule.Each capsule is 43mm in length & 2.5mm in

diameter.Each capsule contains 75mg Levonorgestrel.Insertion is effective for 5yrs.

Newer generation of Implants

Jadelle Implants (2 capsules)

Implanon: Non biodegradable

Single rod

Contain 68mg of etonogestrel active metabolite of desogestrel.

The hormone is released at an initial rate of 60mcg per day decreasing to 30mcg per day after 2years.

Duration of action is 3years

Nexplanon identical to Implanon except for containing 15mg Barium sulphate, added to the core to make it detectable by x-ray.

Rod is 4cm in length & 2mm in diameter.

Shld be removed after 3yrs, or earlier if

preg is desired .When the rod is removed, the return to

fertility is rapid, with the return of ovulation within 3 weeks

Apart form its effect on cervical mucus, it

also inhibits ovulation.

Compared with the Norplant system,

Implanon is associated with a higher

frequency of amenorrhea and

oligomenorrhea, a decrease in the prevalence

of frequent and prolonged bleeding, and a

decrease in the frequency of adverse effects

such as weight gain, headache, and acne.

Implanon Implant

Implanon insertion kit.

Nexplanon

Uniplant is a single implant contraceptive containing 38mg nomegestrel acetate in a 4cm silastic tube with a 100ug per day release rate

It provide contraception for 1year.

UNIPLANT

CAPRONOR, NORETHINDRONE PELLETSCAPRONOR: is a single capsule,

levonogestrel releasing subdermal implant2.4mm in diameter and 40mm in lengthIt provide contraception for 1year.Capsule remain intact for the first 12 months

allowing for easy removal then begins to disappear after 12months

Biodegradable implant

NORETHINDRONE PELLETS or anuelleIs injected subdermally and maintain

circulating contraceptive level of progestin for up to 3years.

This pellet is compose of 10% pure cholesterol and 90% norethindrone

This method is currently under development.

Expert clinical opinion is that LARC methods may have a wider role in contraception and their increased uptake could help to reduce unintended pregnancy

Enabling women to make an informed choice about LARC and addressing women's preferences is an important objective.

CONCLUSION

SH&FPA statement on LARCs: October 2013. Nice clinical guideline 30. 2014. Long acting reversible contraception (C-Gyn 34) New

statement july 2014. Increasing access to long acting reversible contraceptives in

nigeria: National strategy and implementation plan (2013-2015)

Open Access Journal of Contraception 2010:1 9–22 Kigbu J H, Daniyan A B C. UPDATES ON CONTRACEPTION.

Ibom Medical Journal.2008;3: 4-12 Current Concepts In Contraception. Text of Presentation at

the MDCAN, OOUTH Sagamu, CPD LECTURE SERIES. By Dr. Peter O. Adefuye.

Current Diagnosis & Treatment Obstetrics & Gynecology, Eleventh Edition.2013

Reference

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