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WHO MEC: Special situations MAR-2011-AP-(IN)-3627-SS 30-Aug-2012.

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Presentation on theme: "WHO MEC: Special situations MAR-2011-AP-(IN)-3627-SS 30-Aug-2012."— Presentation transcript:

1 WHO MEC: Special situations MAR-2011-AP-(IN)-3627-SS 30-Aug-2012

2 Efficacy of methods Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year. United States of America.

3 Contraceptive revolution – reversible methods

4 WHO medical eligibility criteria for contraceptive use: classification Condition:Category For which there is no restriction on use of the method1 Where the advantages generally outweigh the theoretical or proven risks 2 Where the theoretical or proven risks usually outweigh the advantages of using the method 3 Represents an unacceptable health risk of the contraceptive method if used 4 Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

5 WHO medical eligibility criteria for contraceptive use: classification CategoryWith clinical judgementWith limited clinical judgement 1use method in any circumstances Yes (use the method) 2generally use the method 3use of method not usually recommended unless other more appropriate methods are not available or not acceptable No (do not use the method) 4method not to be used Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

6 Contraceptive Methods Available in India. Abbreviations mentioned in WHO MEC Low-dose combined oral contraceptives: COCs Progestogen-only Pills: POPs Intrauterine devices IUDs Depot medroxyprogesterone acetate : DMPA Norethisterone enantate : NET-NE Copper-bearing IUD: Cu-IUDs Levonorgestrel-releasing IUD (20 g/24hours): LNG-IUD Combined contraceptive Vaginal Ring: R Implant IMP Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

7 Case 1 A 18 year old unmarried woman, seeking contraception advice She also c/o; constant pelvic pain worsening during menses Medical History: None Family History: No reports of bleeding disorder Obstetrical History: G 0 P 0 A 0 Investigations: USG-NAD

8 WHO Guidelines ConditionCategory COC Dysmenorrhea1 Evidence: There was no increased risk of side-effects with COC use among women with dysmenorrhoea compared with women not using COCs. Some COC users had a reduction in pain and bleeding 1 1.Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

9 Case-2 A 24 year old married woman, seeking contraception advice She also C/O: constant pelvic pain worsening during menses Medical History: None Family History: No reports of bleeding disorder Obstetrical History: G 0 P 0 A 0 Investigations: USG- free fluid in the cul-de-sac

10 WHO Guidelines ConditionCategory COC Endometriosis1 Evidence: A Cochrane Collaboration Review identified one randomized controlled trial evaluating the effectiveness of COC use compared with a GnRH analogue in treating the symptoms of endometriosis. Women with endometriosis did not report worsening of the condition or any adverse events related to COC use 1. 1.Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotrophin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertility and Sterility 1993;60(1):75–9.

11 Case 3 A 35 year old female patient seeking advice on contraception C/O: heavy menses Family history: Mother underwent surgery for hysterectomy at the age of 45 due to uterine fibroids Obs/Gyn History: G 1 P 1 A 0 Investigations: USG- 4 heterogeneous structures, in the muscular layer without distortion of uterine cavity suggestive of leiomayomata.

12 WHO Guidelines ConditionCategory COC Uterine Fibroids (With or without distortion of uterine cavity) 1 Comments: COCs do not appear to cause growth of uterine fibroids Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

13 Case 3 A 30 year old female patient complaining about irregular bleeding pattern seeks advice on contraception Family history: unknown Physical examinations: mild acne lesions on face and hirsutism on face and limbs Obs/Gyn History: G 1 P 0 A 1

14 WHO Guidelines ConditionCategory COC Irregular pattern without heavy bleeding Heavy or prolonged bleeding (includes regular and irregular patterns) 1 Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

15 MEC use in women with different patterns of vaginal bleeding (WHO MEC 2009 ) Vaginal Bleeding patterns Hormonal contraceptives Progesterone only Pills Progesterone only injections Irregular bleeding without heavy bleeding 1 22 Heavy or prolonged bleeding (includes regular or irregular) 1 22 Unexplained vaginal bleeding (suspicious of serious pathology) before evaluation 2 23 Medical Eligibility criteria (MEC) 1: A condition for which there is no restriction for the use of the contraceptive method 2: A condition for which the advantages of using the method generally outweigh the theoretical or proven risks 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method 4: A condition that represents an unacceptable health risk if the contraceptive method is used.

16 DSG+EE Vs LNG+EE: Which one has better affect on acne hirsutism and weight change Sanam and Ziba, Saudi Med J 32:23-26, 2011

17 Design and Method Amir hospital & Family Planning Clinic Health Centers, Samnan, Iran Women ranging from years with no contraindication to OCs and have not used hormonal contraception in past 6 months Baseline analysis: weight, acne, number of leisions, hirsutism evaluation, SHBG levels and free testosterone DSG+EE Grp n=50 LNG+EE Grp n=50 n=100 Outcome analysis: weight, acne, number of leisions, hirsutism evaluation, SHBG levels and free testosterone 0 months 1months 2 months 3 months 4 months 5 months6 months Randomization

18 The effect of the pill on weight, hirsutism and acne Sanam and Ziba, Saudi Med J 32:23-26, ± ±4.2 Terminal hirsutism severity ± ±1.8 Hirsutism severity changes ± ±4.3 Base hirsutism severity Hirsutism ± ±3.3 Number of acne changes ± ±6.7 Terminal number of acne ± ±7.0 Base number of acne Acne ± ±3.6 Weight Changes (Kg) ± ±15.6 Terminal Weight (Kg) ± ±15.6 Base Weight (Kg) Weight P-Value DSG+EE LNG+EE Parameters

19 Case 4 A 28 year old female patient seeking advice on contraception C/O: constant lower abdominal pain and lower back pain Obs/Gyn History: G 0 P 0 A 1. (Surgical abortion of an unplanned pregnancy at a local clinic, two months ago.) Investigations: USG- Relevant findings in transvaginal sonogram shows normal ovary close to thickened fallopian tube in right adnexa

20 WHO Guidelines ConditionCategory COC Pelvic Inflammatory Disease (PID-Current) 1 Comments: COCs may reduce the risk of PID. Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

21 A summary of a few more situations where COC are favorable… ConditionCategoryAdditional Notes (Evidence/Comments) COC Gestational Trophoblastic Disease (decreasing or undetectable levels of β-HCG/ persistently elevated β-HCG levels or malignant disease) 1 Evidence found COC use did not increase the risk of postmolar trophoblastic disease and some COC users experienced a more rapid regression in hCG levels, compared with non-users. Endometrial Cancer1 COC use reduces the risk of developing endometrial cancer. While awaiting treatment, women may use COCs. In general, treatment of this condition renders a woman sterile. Ovarian Cancer1 COC use reduces the risk of developing ovarian cancer. While awaiting treatment, women may use COCs. In general, treatment of this condition renders a woman sterile. Cervical Ectropion1 Cervical ectropion is not a risk factor for cervical cancer, and there is no need for restriction of combined hormonal contraceptive use Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone MAR-2011-AP-(IN)-3627-SS 30-Aug-2012


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