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Contraceptive Options for Women and Couples with HIV Combined Oral Contraceptive Pills (COCs)

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Presentation on theme: "Contraceptive Options for Women and Couples with HIV Combined Oral Contraceptive Pills (COCs)"— Presentation transcript:

1 Contraceptive Options for Women and Couples with HIV Combined Oral Contraceptive Pills (COCs)

2 Types of COCs 21: all active (7 days break between packs) 28: 21 active + 7 inactive pills (no break between packs) Pills per pack Low-dose (most common): µg of estrogen or less High-dose: 50 µg of estrogen Dose Monophasic, biphasic, triphasic Phasic Combination of two hormones: estrogen and progestin Content

3 Effectiveness Source: CCP and WHO, Oral contraceptives Percentage of women pregnant in first year of use Rate during typical use Rate during perfect use Female condom Female sterilization Implants DMPA Spermicides Standard Days Method Male condom IUD (TCu-380A)

4 COCs – Mechanism of Action Primary mechanism: suppression of ovulation Other mechanism: fertilization prevention –thickened cervical mucus makes it difficult for sperm to enter uterus and unite with egg COCs have no effect on an existing pregnancy.

5 COCs – Characteristics Common side effects (serious complications rare) Non-contraceptive health benefits No STI/HIV protectionProtection from symptomatic PID Require daily uptakeReversible Not as effective in typical use (92%) Safe and more than 99% effective if used correctly DisadvantagesAdvantages

6 COCs – Common Side Effects Non-menstrual Nausea Weight change Dizziness Mild headaches Breast tenderness Mood changes Bleeding Breakthrough light bleeding and spotting Amenorrhea Side effects are not experienced by all users. They are not harmful but may be unpleasant. Source: Ory, 1982; CCP and WHO, 2007.

7 Non-contraceptive Health Benefits of COCs: Overview Reduced risk of: Ovarian and endometrial cancer Functional ovarian cysts Ectopic pregnancy Symptomatic PID Improvement of: Menstrual problems Some gynecologic conditions Source: CCP and WHO, 2007.

8 Non-contraceptive Health Benefits of COCs: Menstrual and Other Improvements Decreased amount of flow and days of bleeding Reduced risk of anemia Decreased symptoms of dysmenorrhea Decreased symptoms of endometriosis Reduced symptoms of premenstrual syndrome Source: Belsey, 1988; Davis, 2005; Davis, 2007.

9 Adverse Effects of COCs: Overview Severe adverse effects rare Slight increase in risk concentrated among a subgroup of women with particular characteristics Some effects immediate, some long term

10 Adverse Effects of COCs: Cardiovascular Disease (CVD) COCs may slightly increase risk of heart attack, stroke, and thromboembolism –lower estrogen dose in newer pills make CVD risk minimal –women who develop CVD have other risk factors (e.g. smoking, hypertension, diabetes) In rare event CVD conditions develop: –they begin soon after initiation –pills must be discontinued Source: WHO, 1998.

11 Adverse Effects of COCs: Breast Cancer No overall increase in breast cancer risk among women who had ever used COCs Very slight risk increase in current COC users and within 10 years after discontinuation –may be due to accelerated growth of already existing tumors Absolute number of breast cancer cases attributable to COCs is very small Source: WHO Collaborative Study of Neoplasia and Steroid Contraceptives, 1989; Collaborative Group on Hormonal Factors in Breast Cancer, 1996.

12 Adverse Effects of COCs: Cervical and Liver Cancer Cervical cancer Small increase in risk among COC users –other factors may play a role –association is not clear Liver cancer Countries with low incidence – no increased risk Countries with high incidence – small increase among COC users Source: WHO Collaborative Study of Neoplasia and Steroid Contraceptives, 1985 and 1989.

13 Category 1 and 2 Examples (not inclusive): Who Can Use COCs ≥40 years; breastfeeding ≥6 months postpartum; superficial thrombophlebitis; uncomplicated diabetes; cervical cancer; unexplained vaginal bleeding; undiagnosed breast mass Category 2 menarche to 39 years; endometriosis; endometrial or ovarian cancer; uterine fibroids; family history of breast cancer; varicose veins; irregular, heavy, or prolonged bleeding; anemia; STI/PID; hepatitis (chronic/carrier) Category 1 Conditions WHO Category Source: WHO, 2004; updated 2008.

14 Category 3 and 4 Examples (not inclusive): Who Should Not Use COCs breastfeeding <6 weeks postpartum, hypertension (≥160/≥100), migraines with aura, deep venous thrombosis (history or acute), ischemic heart disease or stroke, complicated diabetes, breast cancer, acute/flare hepatitis, severe liver disease and most liver tumors Category 4 breastfeeding between 6 weeks and 6 months postpartum; non-breastfeeding <21 days postpartum; hypertension ( /90–99); migraine without aura (<35 years/continue use); gall bladder disease; use of rifampicin, rifabutin Category 3 Conditions WHO Category Source: WHO, 2004; updated 2008.

15 COC Use by Women with HIV Women with HIV or AIDS can use without restrictions Women on ARVs other than ritonavir can use COCs safely Should not be used by women who take ritonavir Using low-dose COCs is appropriate Dual method use should be encouraged Source: WHO, 2004, updated 2008; Sekar, WHO Eligibility Criteria ConditionCategory HIV-infected 1 AIDS 1 ARV therapy (which does not contain ritonavir) 2 Ritonavir/ ritonavir- boosted PIs (as part of ARV regimen) 3

16 How to Take COCs: When to Initiate Anytime provider is reasonably sure woman is not pregnant First 5 days of menstrual cycle After 5 th day, use backup method for 7 days Postpartum: –not breastfeeding: delay 3 weeks –breastfeeding: delay 6 months or until breastfeeding is discontinued Source: WHO, 2004; updated 2008.

17 How to Take COCs: Schedule and Missed Pills Schedule: Take one pill every day 21-day packs  7-day break 28-day packs  no break between packs Missed pill: Missed 1 or 2 active pills in a row Take missed pill as soon as remembered Keep taking other pills on schedule No backup method needed Source: WHO, 2004; updated 2008.

18 How to Take COCs: Missed Pills Miss 3 or more active pills in a row or start pack 3 or more days late Take first missed pill as soon as you remember Continue daily pill taking as usual and use backup method or abstain for next 7 days Count number of active pills remaining in pack 7 or more active pills left in the pack Finish active pills Take hormone-free break Fewer than 7 active pills left in the pack Finish active pills Discard inactive pills Start new pack immediately Source: WHO, 2004; updated 2008.

19 Management of COC Side Effects: Non-Menstrual Problems Counsel about healthy eating habits and exercise Take pills with food or at bedtime Reassure client: usually diminish over time Provide counseling Weight change Nausea and vomiting Dizziness, nausea If side effects persist and are unacceptable to client: if possible, switch pill formulation or switch to another method Any client concerns Action/ManagementProblem Source: CCP and WHO, 2007.

20 Management of COC Side Effects: Bleeding Problems Reassure client: no medical treatment necessary Amenorrhea Administer non-steroidal anti-inflammatory Use pills with more potent progestin (if available) Prolonged bleeding If side effects persist and are unacceptable to client: switch to another method Reassure client: reinforce correct pill taking Breakthrough bleeding Action based on assessment Assess cause (consider pregnancy or disease) Unexplained vaginal bleeding or amenorrhea Action/ManagementProblem Source: CCP and WHO, 2007.

21 Key Counseling Topics for COC Users Safety and efficacy (depends on woman’s ability to take pills on time) How COCs work Possible side effects How to take pills; what to do if pills are missed No protection from STIs/HIV When to return

22 When to Return: Warning Signs of COC Complications Return immediately if experiencing ACHES: Abdominal pain (sharp) Chest pain (severe) Headache (severe) Eye (blurred vision, brief loss of vision) Sharp leg pain Advise to stop taking pills, use a backup method, and return to the clinic immediately. Source: Pathfinder International, 2006.

23 When to Return: Follow-up for COCs No fixed schedule Return anytime if any questions or concerns and for resupply; give more than one cycle of pills if possible During follow-up visit: –assess for method satisfaction and any health problems that may restrict COC use –manage and reassure about side effects –reinforce correct pill taking and what to do when pills are missed


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