1. Contraception in Special Situations
Experts
Dr Jaya Narendra
Dr Arulmozhi Ramarajan
Dr Shubha Rao
Dr Jayanthy
Dr Ashakiran

2. What are special situations for contraception?
Adolescence
Following pregnancy and lactation
Peri-menopausal women
designated as “special population”
Women with gynaecological problems
Women with medical disorders & others

3. WHO Recommendation criteria for safe contraceptive use (2009)
Category1 = no restriction on use
Category2 = Advantages of using the method generally outweigh the theoretical or proven risks
Category3 = Theoretical or proven risks usually outweigh the advantages of using the method
Category4 = Unacceptable health risk

4. Case 1
An 18 year old adolescent with irregular periods and acne comes for treatment.
What are your options?

5. Choices are COCs with EE and DSPR COCs with Cyproterone acetate & EE
COCs with Desogestrel/Norgestrel
Life style modifications of course

6. Cyproterone acetate 2mg with EE 35 ugm
Drospirenone, due to its anti-androgenic action will help counteract the androgen induced hyperactivity of the Pilosebaceous glands
Cyproterone acetate 2mg with EE 35 ugm
Prescribed for a minimum of months
After 9 RCT treatment cycles, the median total acne lesion count was reduced by 62.5% in the EE/DRSP group and 58.8% in the EE/CPA
Cutis Apr;69(4 Suppl):2-15

7. Reduction in acne lesions with DSPR
-60 50
-40
-30
-20
-10
Cycle 11
Cycle 3 3
Cycle 6
Percentage reduction in total lesion count from baseline
DSPR was associated with a greater reduction from baseline in total lesion counts versus placebo  
In a pooled analysis of the data from the two studies, DSPR was associated with a greater reduction from baseline in inflammatory, non-inflammatory and total lesion counts.
Koltun W, Maloney M, Marr J, Kunz M. Ethinylestradiol 20 mcg/drospirenone 3 mg oral contraceptive administered in 24/4 regimen in the treatment of moderate acne vulgaris: a pooled analysis of two randomized, double-blind, placebo-controlled studies. Int J Gynecol Obstet 2009; 107(suppl 2): s620. 
*p< vs. placebo
DSPR
Placebo
Koltun W, et al. Int J Gynecol Obstet 2009;107(suppl 2):s620 7

8. What about COCs and Acne?
COC with Desogestrel & EE:
In comparison with the LNG+EE COC, the DSG+EE OCP significantly decreases the severity of acne and hirsutism, without any significant change in weight
Saudi Med J Jan;32(1):23-6.

9. Supposing an adolescent with regular cycles had a medical abortion and comes to you for contraceptive advice. What will you give? When will you start?

10. The Options
DMPA
LDOCP
Ring
IUCD

11. The Options Ring: can be inserted after the abortion is completed
Low dose oral contraceptives: have many benefits but compliance is an issue
Ring: can be inserted after the abortion is completed

12. Contraception in adolescents
Inj. DMPA: It temporarily interferes with calcium deposition in bones Both Cu IUD and LNG IUD are Category 1 for women > 20yrs and Category 2 for women < 20yrs

13. Contraception in adolescents
Adolescents are eligible for all contraceptives which are suitable for adults Proper counseling regarding use is important, especially for Emergency contraception
Dual protection to be stressed upon
Abstinence can be promoted as a method

14. Contraception after medical abortion
COC on the day of Mifepristone
Condoms, after bleeding stops
Sterilization, IUD, POP only after completion of abortion
Natural methods, DMPA & Ring, only after the next period

15. Special Situations - Procedures & Infections
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Post Abortion
First trimester 1
Second trimester 2
Pelvic Infection
Post abortion infection
Puerperal infection 4
Ectopic Pregnancy
DSG 1
Pelvic Surgery

16. Case 2
Mrs Just Delivered is being discharged today after a FTND of a healthy baby 3 days back. Both the mother and the baby are in good health and she is breast feeding the baby.
When would you schedule her postpartum visit for contraceptive advice?

17. 3 weeks after delivery 6 weeks after delivery 3 months after delivery

18. A 3 week visit would be ideal for contraceptive advice
Most studies have shown that many women ovulate before the 6th week (before the traditional postpartum visit)
A 3 week visit would be ideal for contraceptive advice

19. As advised, Mrs. Just Delivered visits after 3 weeks
As advised, Mrs. Just Delivered visits after 3 weeks. She is partially breast feeding her baby
What are her contraceptive options?
COCs
POPs
LNG IUD
Cu IUD
DMPA

20. Postpartum visit at 3 weeks
Mr J.D. considers Cu IUD and asks
“What would be the ideal time to insert the
Cu IUD, Doctor”
At 4 weeks?
At 6 months?
Cu 380A CAN BE INSERTED WITHIN 10 MINS OF DELIVERY OF THE PLACENTA UPTO 48 HOURS

21. It is not inserted between 48 hrs to 4 weeks (Category 4)
Postpartum insertion of a Cu IUD is best done within 48hours or AT or AFTER 4 weeks (Category 1)
It is not inserted between 48 hrs to 4 weeks (Category 4)
WHO eligibility criteria 2008

22. Post-placental IUD insertion
Within 10 min of delivery of placenta
Within 48 hrs of delivery
Special forceps for insertion
Antenatal counseling must
Expulsion rate ~ 3.7%
Acceptance good

23. What about Breast feeding and COCs?

24. There are 3 issues here
Risk of Thromboembolism
Estrogen in doses more than 30 ugm inhibits lactation and can lead to a shorter period of breast feeding
Estrogen can induce reversible increase in breast size of the mother and the infant, male or female

25. The risk for VTE within the first 42 days postpartum is 22-fold to 84-fold greater than the risk among non-pregnant, non-postpartum women.
The risk is highest immediately after delivery, declining rapidly during the first 21 days, but not returning to baseline until 42 days postpartum.
Use of COCs, which can cause a small increased risk for VTE, might theoretically pose an additional risk if used during this time.
Systematic review, CDC, WHO

26. Breast-feeding and combined hormonal contraception
COCs have
Minor effects on quantity and quality of breast milk
No effect on infant growth
OB-GYNs=obstetricians and gynecologists; WHO=World Health Organization.
1. Truitt ST et al. Cochrane Database Syst Rev. 2003;(2):CD

27. Special Situations - Postpartum Contraception
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Breastfeeding
<3weeks postpartum 4 3
> 48 hr
3 weeks - < 6 weeks postpartum if risks for VTE present 1
> 4 wks
> 6 months postpartum 2
Non Breastfeeding
< 21 days
> 21 days

28. She chooses to use Inj DMPA What would you counsel her about?
Can be given soon after delivery as it increases milk secretion especially in areas where pregnancy morbidity and mortality is high. What is the risk of pregnancy?
Ranges from 0 to 1 per 100 women years

29. She takes Inj DMPA and is quite happy with it
She takes Inj DMPA and is quite happy with it. Her periods are irregular with spotting on & off but since she has been counseled, she is not unduly disturbed by it and the bleeding settles down Following the second injection, she returns to the clinic only after 4 months

30. What would you do now?
Check for pregnancy. If negative give the injection and ask her to use additional method for the next 7days
Check for pregnancy and if negative give the injection without any additional advice about contraception
Give the injection

31. Late for an injection?? Grace period extended!
The repeat injection of
DMPA can be given up to 4 weeks late
NET-EN can be given up to 2 weeks late
without requiring additional contraceptive protection
Selected Practice Recommendations for Contraceptive Use 2008 update

32. What are the demerits of DMPA?
Irregular bleeding in the 1st 3-4 months
Interferes with Calcium deposition in bones
Fertility returns 8-10 mths after the last dose

33. Case 3 F, 32yrs, P2 L2 Regular heavy periods
Clinical Examination – 14wks size uterus
Ultrasound examination – Bulky uterus with multiple intramural fibroids, largest measuring 4cmX4cm.
Endometrial thickness 11mm, contour - normal

34. OC pills & Fibroids
The administration of low dose OC pills to women with leiomyomas does not stimulate fibroid growth and is associated with decreased bleeding
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

35. LNG IUS & Fibroids
In women with fibroids & troublesome bleeding, the size of the uterus and the largest individual tumors diminished slightly with LNG-IUS.
Friedman AJ Thomas PP, Does low dose OC pill use affect uterine size or menstrual flow in premenopausal women with leiomyomas Obstet Gynecol85: 631, 1995

36. Special Situations - Genital & Breast Conditions
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Fibroids
Cavity non distorting 1
Cavity distorting 4
Endometriosis 2
Benign Ovarian Tumors
Benign Breast Disease
Ectropion

37. Mrs F chooses to get an LNG IUS inserted
Mrs F chooses to get an LNG IUS inserted. She comes back after 3yrs for a check up. She reveals that she was recently hospitalized for a bad lung infection and is presently undergoing treatment for tuberculosis with a 4 drug regime.

38. Would you like to suggest a change in her contraceptive method?

39. LNG IUS and Anti-TB Drugs
Data shows no reduction in the efficacy of LNG-IUS with liver enzyme-inducing drugs Current WHO-MEC recommendations LNG-IUS - Category ‘1’ for women who are prescribed drugs which affect liver enzymes, such as rifampicin and anti-epileptic drugs

40. Special Situations - Miscellaneous Issues
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Anemias
Iron deficiency anemia & thalessemia 1 2
Sickle cell
Liver Tumors
Benign adenoma Malignant hepatoma 4 3
Liver Enzyme Affecting Drugs
Rifampicin, phenytoin, barbiturate, carbamezipine

41. 33yr old with a BP of 150/100 needs contraception
33yr old with a BP of 150/100 needs contraception. She is on medication for Hypertension and does not have any other medical problem. What contraceptives would be safe for her?

42. Oral contraceptives (including newer agents), increase systolic BP by 8 mm Hg and diastolic by 6 mm Hg

43. Special Situations - Hypertensive Conditions
COC
R/P
POP
DMPA
IMP
Cu IUD
LNG IUS
Arterial CVD Risk
Age, smoking, DM, HT
3/4 2 3 1
Hypertension
Adequate control
140 – 159 / 90 – 99 mm Hg
> 160 / > 100 mm Hg 4
Vascular disease
History of HT during pregnancy

44. 35yr old woman with 3 children and diabetic since 1yr needs contraception. Her BMI is 28 and she is not hypertensive.

45. COC & Diabetes…
COC in type I DM – Studies find no change in HbA1c, development or progression of nephropathy or retinopathy
Nonsmoking, <35yrs, otherwise healthy diabetics, no end-organ disease – COC safe
LNG-IUS – Safe in diabetics
Past h/o GDM – COC does not accelerate or precipitate development of type II DM
ACOG Practice bulletin no:18, Obst & Gynecol. 2006

46. Special Situations - Endocrine Disorders
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Diabetes Mellitus
History of GDM 1
Non vascular - insulin or non insulin dependent 2
Vascular disease
Nephropathy / retinopathy Over 20 years duration
I – 3
C - 4 3
Thyroid Disorders
Hyperthyroidism
Hypothyroidism

47. Contraception in Dyslipedemia
Contraception in a patient with a past h/o Obstetric Cholestasis
Contraception in a pt with cervical Dysplasia
Contraception in the peri-menopause
Contraception in a pt with Hypertension
Contraception in a pt with Diabetes
Contraception in a pt with Heart disease

48. Case 4
A 24-year old woman, with no concomitant diseases, was admitted with epigastric pain and vomiting. A provisional diagnosis of Acute Pancreatitis was made. On further questioning, she gave a h/o having taken Diane 35 in the previous 4 months. Her LMP was 5 days back.
Is there a connection between the OC Pill and
Acute Pancreatitis?

49. S Triglycerides, Cholesterol and FBS are increased when on the pill
Facts in favour of a connection
Acute pancreatitis occurred within 3months of starting estrogen therapy in most cases
Abdominal pain and pancreatitis ceased within 10 days of stopping estrogen
S Triglycerides, Cholesterol and FBS are increased when on the pill

50. Estrogen increases fasting Triglycerides by increasing the hepatic production of Triglycerides.
Estrogen also increases HD Lipoproteins and decreases LD Lipoproteins
Primary Dyslipidemia is a relative contraindication for Estrogen therapy

51. Take Home message
In young, healthy women taking oral contraceptives and presenting with acute abdominal pain, consider the diagnosis of Acute Pancreatitis
Lipid profile before starting OCPs not recommended
With no pre-existing Hyperlipidemia, S triglycerides increase is usually mild and does not lead to pancreatitis
If obese, with a family history of hyperlipidemia, lipid profile checked to prevent acute pancreatitis
Knehtl M, Journal of Disease Markers, Nov 2014

52. Case 5
A 28-year-old woman, P2+1, developed jaundice, pruritus, fatigue and anorexia. She gave a history of a single 28 day cycle of oral contraceptives (Ovral L), started shortly after a first trimester abortion. She was on no other medication and did not drink alcohol

53. Because of persistent jaundice, she underwent endoscopic retrograde cholangio-pancreatography which was normal. A liver biopsy showed intrahepatic cholestasis with minimal inflammation and bile duct proliferation

54. What could be the problem? Do you want to elicit any other history?

55. She gives a history of having pruritus and jaundice in her 2 previous pregnancies In the 5th month of her 1st and the 6th week of her 2nd pregnancy Bilirubin values of 3.5 and 3.8 mg/dl Severe pruritus Cause of jaundice not identified

56. What type of jaundice did she suffer from
What type of jaundice did she suffer from? Is there a connection between the jaundice she had in her 2 prior pregnancies and what she is suffering from now?

57. What are the features of Cholestatic jaundice?

58. Bland Cholestasis
Time of onset: 4 to 24 wks after starting pill Jaundice: mild, S Bil never > 7mgs% Pruritus: severe ALT: <200 U/L (<5 times ULN) Alkaline phosphatase: <230 U/L (<2 times elevated) Both may be normal too Resolves in 1-2 mths, rarely 6 mths Never associated with fatal liver disease
Alkaline phosphatase and aminotransferase levels are only modestly elevated, particularly in relationship to the degree of jaundice. ALT levels are usually <200 U/L (<5 times ULN), alkaline phosphatase <230 U/L (<2 times elevated). Both may be normal.
Drugs. Typical causative agents of bland cholestasis are the androgenic steroids, this pattern being almost pathognomic. Bland cholestasis can also occur with estrogen therapy, particularly in high doses and in women with a history of cholestasis of pregnancy

59. To avoid it, should you do a LFT for all women
To avoid it, should you do a LFT for all women before prescribing the pill?
Criteria for Definition. Elements important in diagnosis of bland cholestasis due to medications include:
Minimal elevations in ALT (<200 U/L or <5 times ULN) and alkaline phosphatase (<230 U/L or <2 times ULN)
Latency of 4 to 24 weeks
Insidious onset of symptoms of pruritus and jaundice
Bilirubin >2.5 mg/dL
Slow recovery of more than 4 weeks
Exposure to an agent known to cause bland cholestasis (anabolic steroids, estrogens)
If liver biopsy is obtained, changes of intrahepatic cholestasis with minimal inflammation or hepatocellular necrosis.

60. Can happen in men too after Anabolic steroids

61. Take home message Take a proper history before starting the pill
If woman complains of pruritus when on the pill, discontinue it
Do LFT. If elevated, treat symptomatically
Repeat LFT after 6 weeks
Use only those hormonal contraceptives that bypass the liver like LNG-IUS, Vaginal Ring, etc
Reassure the woman that it is not a serious condition
It has yet to be established whether it is progesterone or estrogen that 'triggers' the condition

62. Special Situations - Gastrointestinal Conditions
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Gall Bladder Disease
Symptomatic
Asymptomatic 3 2 1
Cholestasis
Pregnancy / COC related
Viral Hepatitis
Active disease
Carrier state 4
Cirrhosis
Mild – compensated
Severe - decompensated

63. Is it true? Taking oral contraceptives for five or more years is
associated with a doubling of cervical cancer risk
Is it true?

64. Women who use oral contraceptives have an increased risk of developing cervical cancer
The new analysis of data from 24 worldwide studies is one of the most rigorous examinations of cervical cancer risk in oral contraceptive users ever conducted
Lancet, Nov 2010

65. 16,500 cervical cancer patients and 35,500 women without the disease studied to quantify the risk associated with oral contraceptive use worldwide.
It was found that women who used the pill for 5 years or less had a 10% increased risk of cervical cancer when compared with women who had never taken it. This increased risk rose to 60% with 5-9 years of use and doubled with 10 years of use or over

66. Epidemiologist Jane Green, MD, who led the study team…
The risk starts to fall pretty quickly and has gone away 10 years later
- the findings should be seen as good news for women who take the pill or have taken it in the past. What we haven't known is what happens after they stop taking the pill.
Lancet, Nov 2010

67. The reasons for this risk from OC use are not entirely clear.
less likely to use a diaphragm, condoms, or other methods that offer some protection against STDs including HPV.
hormones in OCs might help the virus enter the genetic material of cervical cells.
Dr. Lesley Walker, director of information at Cancer Research UK says the question of a link between OCPs and cancer does not have a straightforward answer
For every 1,000 women on the pill, in more developed countries between the ages of 20 and 30, less than one extra cancer (4.5 instead of 3.8 for never-users) can be expected by the age of 50.
In less developed countries, the risk was estimated to be 8.3 cases per 1,000 decade-long OCP users, compared with 7.3 cases for every 1,000 never-users of the pill.

68. "Regular screening is important for all women, but especially for those taking oral contraceptives," Sasieni says.
"A woman who has regular screenings can basically forget about the increase in risk.“
Based on the most recent evaluation of several studies, the IARC has concluded that HC can be classified as carcinogenic to the cervix as well as to the breast.

69. When women who had used DMPA were compared to women who had never used this method, there were also significant differences in presence of and severity of disease
There are several studies which have reported that hormonal contraception (HC) - pills and injectables - moderately increase the risk of cervical cancer as well as being a risk for all stages of cervical cancer particularly in human papilloma virus (HPV)-positive women thus suggesting that oral contraceptives may act as a promoter for HPV-induced carcinogenesis. Norma McFarlane-Anderson etal, BMC Womens Health, 2008

70. Contraception in the peri-menopausal period
Do we need it?

71. No more
Surprise periods
No more
Hot Flushes
No more
Surprise Babies
No more
Diaper duty

72. Issues with Peri-Menopause
Need for effective contraception
Menstrual cycle abnormalities
Vasomotor instability
Need for osteoporosis and cardiovascular disease prevention
Increased risk of gynecological cancer
Kailas NA, Reprod Health Eur J Contracept Care. 2005

73. The choices are
Oral Contraceptives-highly effective contraception, non-contraceptive benefits, improve QOL
POPs.. Excellent safety profile
IUCDs
DMPA.. No evidence about # due to bone loss
Barrier
Combined Vaginal Ring, Skin Patches.. Risks same as OCPs
Natural Estrogens.. safer

75. A woman had a Cu 380 A inserted at 38 years
A woman had a Cu 380 A inserted at 38 years. 10 years later, at the age of 48, she has irregular cycles. Should the IUD be removed?

76. Keeping the IUD for a few more years may be indicated
Studies from the United Nations and Brazil indicate high efficacy of copper IUD after the 10-year window
Spontaneous fertility beyond age 45 is rare and the IUD becomes even more effective
Keeping the IUD for a few more years may be indicated
1. Bahamondes L et al. Contraception. 2005;72: United Nations (UN) Development Programme, UN Population Fund, WHO and World Bank, Special Programme of Research, Development and Research Training in Human Reproduction. Contraception. 1997;56:

78. When on COC, how does a woman know that she has reached menopause?

79. Stop the pills for a month or more
Check her FSH
Testing FSH a second time one month later will provide a more reliable result

80. Case 6
Mrs M, just married, had an open heart surgery for ASD repair 2months back. She is on oral anticoagulants. Wants contraception for at lease one year.

81. ↑ Menorrhagia, corpus luteum hematoma, hemoperitoneum
Women on anticoagulant Rx
↑ Menorrhagia, corpus luteum hematoma, hemoperitoneum
COC, DMPA, Mirena - Appropriate
COC – Do not ↑ risk of thrombosis if well anticoagulated
DMPA – Not much injection site problems

82. Special Situations - Heart Disease
COC
POP
INJ
IMP
Cu IUD
LNG IUS
Ischemic Heart Disease
History of IHD 4
I - 2
C - 3 3 1
Current IHD
Valvular Heart Disease
Uncomplicated 2
Complicated - Pulmonary HT & atrial fibrillation
Complicated - SBE

83. To sum up

84. Ideal Contraceptive in a woman with Hypertension If < 35 years Non-smoking No end organ disease Well controlled Hypertension Low dose COC ..OK If not POPs or LNG-IUS
Oral contraceptives (including newer agents), increase systolic
blood pressure by 8 mm Hg and diastolic by 6 mm Hg

85. Ideal contraceptive in a woman with Dyslipidemia If dyslipidaemia is well controlled, COCs with <35 ugms of EE can be used Serum lipids monitored regularly If LDL > 160 mgs%- POPs safer Type of Progesterone is the deciding factor
Estrogens increase HDL, Triglycerides and lower LDL
Progesterone opposes this action. Androgenic Progestogens like Norethisterone,
LNG, increase LDL, lower HDL and Triglycerides.

86. Ideal contraceptive in a woman with Diabetes COCs do not increase a woman's risk of developing type 2 diabetes In type 1 diabetes, COCs do not impair metabolic control or accelerate the development of vascular disease BUT, ACOG recommends COCs only If <35 yrs No HT, Nephropathy, Retinopathy or other vascular disease LNG IUS.. safe

87. What about in Obesity? COCs and Transdermal patch less effective Obesity and COCs independent risk factors for VTE DUB and Endo Ca more common in obese
LNG-IUS safe and effective

89. A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload 375 inserted this time. When does she need to come for removal?

90. A 42yr old P4L4 has just got a Multiload 250 removed and a Multiload 375 inserted this time. When does she need to come for removal?
She need not get it removed till after menopause.
Women 40 years or older at the time of IUD insertion may retain the device until they no longer require contraception, even if this is beyond the duration