Family Planning

UNIT 26 HORMONAL CONTRACEPTION

Structure

26.0 Objectives
26.1 Introduction
26.2 Methods of Hormonal Contraception
26.2.1 Oral Contraceptive Pills (OCPs)
26.2.2 Implants
26.2.3 Injectibles
26.2.4 Progestasert and Vaginal Rings
26.3 Emergency Contraceptive Pills (ECP)
26.3.1 Pharmacology of ECP
26.3.2 Counselling for ECP
26.3.3 Client Selection
26.3.4 Guidelines for Instruction and Follow Up
26.4 Newer Methods of Hormonal Contraception
26.5 Methods Under Special Circumstances
26.6 Let Us Sum Up
26.7 Key Words
26.8 Answers to Check Your Progress
26.9 Further Readings

26.0 OBJECTIVES
After reading this unit, you will be able to:

l list the various methods of hormonal contraception;

l describe the mode of action, advantages and disadvantages of above methods;

l select the client and provide the chosen method;

l schedule follow up visits and provide follow up services;

l treat side effects/change to other methods if required; and

l select appropriate method for special circumstances.

26.1 INTRODUCTION
One of the widely used methods of contraception is hormonal and the synthetic
version of two female sex hormones i.e. oestrogen and progesterone. Hormones can be
provided through many routes, the most common being oral pills. The selection of
clients, advantages and disadvantages, mode of action, side effects and their
management and providing various methods of hormonal contraception are discussed
in this unit.

26.2 METHODS OF HORMONAL CONTRACEPTION

Contraception is provided by synthetic version of two female sex hormones —
oestrogen and progesterone. Hormonal contraception includes:
36
l Oral Contraceptive Pills Hormonal Contraception

l Implants
l Injectables
l Others — Progestasert and Vaginal Rings

26.2.1 Oral Contraceptive Pills (OCPs)

In oral pills, the doses of the hormones have been progressively decreased over the
last 20 years to the very minimum needed to prevent pregnancy. Hence many side
effects have been reduced. Oral pills are of two types:

1) Combined Oral Contraceptive Pills (COC): These pills contain combination of both
hormones oestrogen and progestogen.

2) Progestin only pill (Minipill): Pills contain progestogen only.

The birth control pill (COC or OCP) is an effective reversible method of contraception
and has been used for the last 30 years. It is extensively used in developed countries
and is a suitable method for developing countries too.

1) Combined Oral Contraceptive Pills (COC)

The COCs have been part of the National Family Welfare Programme since early 1960.
In spite of safety and high efficacy, the percentage of currently married women using
‘the pill’ is low. The National Family Health Survey (NFHS) II (1998- 99) showed that
only 2.1% of currently married women, aged 15-45 years, is using ‘the pill’. The
rumours and myths about ‘the pill’ and the side effects of ‘the pill’ are reported to be
the two major reasons for such low usage. To promote the sustained use of the COC, it
is important to counsel clients to clarify rumours and to provide reassurance/treatment
in case of side effects. Selection of clients is another important factor in ensuring
sustained use of the method. Considering the advantages of the method, it is important
to improve the quality of care to increase the acceptability and continuation of the
method especially when the felt need for spacing among the younger age group is
increasing (NFHS II).

A) Pharmacology of Combined Oral Contraceptive

Based on the results of several clinical trials conducted in India and elsewhere, the
National Family Welfare Programme introduced the low dose COC in the eighties. The
COC used in the National Family Welfare Programme contains:

l Norgestrel 0.30 mg per tablet

l Ethinyl Estradiol 0.03 mg per tablet

The COCs used in the National Family Welfare Programme are available under two
brand names — Mala N under the free distribution scheme and Mala D under the social
marketing programme (at a subsidised price). These are monophasic combination pills
containing the same amount of oestrogen and progestogen in each pill. Each packet of
Mala N and Mala D contains 21 contraceptive pills and 7 iron tablets. Other types of
COCs are commercially available.

Mechanism of Action

COCs provide effective protection against pregnancy by:

i) Inhibition of ovulation by suppressing Follicular Stimulating Hormone (FSH), thus

suppressing the release of ovum from ovaries

ii) Preventing implantation by altering endometrium so that it is not conducive for

implantation

iii) Reducing transportation of sperms by making cervical mucus thick.

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Family Planning l Continuous taking of the COC for 7 days is critical for suppressing the ovulation.
l Each tablet’s effect lasts only for 48 hours.

Effectiveness

It is very effective when taken correctly and consistently and the failure rate is 0.2 - 1
per 100 women years.

Advantages of COC

a) Contraceptive Benefits

i) Very effective when taken correctly and consistently and protects against both
uterine and ectopic pregnancy.

ii) Safe for most women

iii) Easy to use

iv) Reversible (can stop the COC whenever desired by the client on her own and
immediate return of fertility is experienced)

v) Non-invasive

vi) Unrelated to sexual activity

b) Health Benefits

i) Menstrual cycle

l Decreases menstrual blood loss and the duration

l Decreases menstrual cramps and pre-menstrual tension as cycles are
anovulatory due to suppression of ovulation
l Eliminates mid-cycle ovulation pain as no ovulation
l Ensures regular 28 day menstrual cycle

ii) Does not worsen anaemia due to less menstrual blood loss

iii) Reduces incidence of severe Pelvic Inflammatory Disease (PID) as compared to

nonusers. The mechanisms contributing to less severity of PID in women who
are COC users are the following: Decreased chances of growth of micro-
organisms due to decreased menstrual blood, reduced chances of the organisms
entering the uterus through thickening of cervical mucus and reduced chances of
spread due to less stronger uterine contractions.

Although the COC reduces the chances of severe PID, it does not offer
protection against all types of PID such as that caused by Chlamydia.

iv) Protection from ovarian and endometrial cancers and functional ovarian cysts

v) Protection from benign breast tumours such as fibroadenoma and fibrocystic

disease

vi) Used in treatment of endometriosis and abnormal bleeding

vii) Relief from acne especially pre-menstrual type due to the oestrogen

viii) Decreases incidence of rhuematoid arthritis

Disadvantages

a) Limitations

i) Has to be taken every day and depends on the motivation of the user

38 ii) Does not protect against Sexually Transmitted Diseases (STDs)/ HIV/AIDS
 iii) Not appropriate for mothers who are breast feeding infants less than six months Hormonal Contraception
old

iv) Effectiveness of the COC may be decreased in women who are taking the
following drugs:

l Anti epileptic drugs

l Anti tuberculosis drugs
l Antibacterial drugs
l Anti fungal drugs

It also interferes with the effectiveness of certain drugs. The list of drugs that
affect the effectiveness of COC and those affected by the COC are given in
Annexure 1.

b) Side Effects

i) Minor side effects listed below are most common during the first three months of
use of COC and these usually disappear with continued use.

l Amenorrhoea

l Inter-menstrual bleeding or spotting (breakthrough bleeding)

l Nausea

l Headache

l High blood pressure

l Weight gain

l Breast tenderness

Minor side effects are most common in the first three months of COC use. These
disappear with continued use of the COC.

ii) Serious side effects such as heart attack or stroke are rare with low dose COCs.
However, the risk is high among women who smoke, particularly those above 35
years, Women who smoke, irrespective of whether they use COC are at increased
risk for the above complications.

B) Method-specific Counselling for COC

Once a client has chosen COCs for family planning, then method specific counselling
is done as follows. Counselling is done every time a client comes for re-supply. Ensure
that privacy and confidentiality are maintained all the time.

i) Establish rapport with the client.

ii) Ask the client what she knows about COC, rumours (if any) and past experience with
COC (in case of clients who have used ‘the pill’). (Refer to Annexure 2 for common
rumours).

iii) Provide information as relevant and clarify doubts. If the client is new, repeat the
information on the following. Show a packet of COC.

l Mechanism of action

l Advantages, disadvantages

l Effectiveness

l When to start taking the COC (in relation to menstrual period)

l The importance of taking the COC everyday and what to do if the pill is missed 39
Family Planning iv) If the client is still convinced about the decision to use COC, conduct an assessment
of the client for medical eligibility as detailed below. Record history and findings in the
client record.

v) If found eligible, demonstrate the use of the COC as mentioned in guidelines below.
Ask the client to repeat instructions. Record the supply of the COC.

vi) Tell the client about likely problems /side effects in the first few months and what to
do in such situations.

vii) Tell the client about likely serious problems (warning signs) when the client must
contact the Medical Officer /health worker and assure that care will be provided.

viii) Tell the client to use condoms (by spouse/partner) if the COC is missed, in case of
severe vomiting or diarrhoea and if there is any chance of exposure to STDs and
demonstrate how to use condoms. Ask the client to repeat the instructions.

ix) Tell the client to inform the health provider if started on treatment for tuberculosis or
epilepsy.

x) Tell the client to inform the health provider about taking COC when seeking medical
consultation.

xi) Tell the client how to store the COC.

xii) Tell the client to return for follow up in a month’s time and to bring the used packet of
COC.

xiii) Provide three packets of COC. Tell the client about other sources of COC, which she
can use if needed.

xiv) Provide a packet of condoms for use in conditions listed above (see viii).

Counselling on Return Visit

Every time a client comes for follow-up, it is important to counsel the client to ensure
continuation of the method.

i) Ask the client whether she and her spouse/partner are satisfied with the method

ii) Ask about problems and reassure as required.

iii) Ask about any history of pelvic pain or discharge per vagina or any history
suggestive of STDs in the spouse/partner

iv) Assess the client by history and examination to confirm problems or for any new
conditions that are contra-indications for use of COC. Record findings.

v) Manage problems as discussed later in this Section.

vi) If the client has developed conditions that are contra-indications for COC use,
counsel for other methods of family planning.

vii) If the client is still eligible for continuing with COC, ask to repeat how to take the COC.

viii) Repeat reasons for contacting the health worker and when to return for follow up.

ix) Provide supplies of COC and record the same.

Counselling a Client Who Wants to Stop Using the COC

It is important to counsel a client who wants to stop using the COC because of request
by the client or because of contra-indications/complications. It is important to tell
clients about immediate return of fertility after stopping the COC.

i) If the client wants another child, tell about immediate return of fertility. Provide
information on antenatal care, care during delivery and about post-partum family
planning.
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ii) If the client is stopping the COC due to side effects, which have persisted in spite of Hormonal Contraception
management of the problem, counsel for other methods of family planning.
iii) If the client is stopping the COC because of dissatisfaction with the method, counsel
(repeat benefits, side effects and their duration). If still not convinced, counsel about
other methods of family planning.

iv) If the client develops conditions that are contra-indications for use of COC, counsel
about other methods of family planning.

v) Record findings, reasons for stopping the use of COC and advice.

C) Client Selection

Eligibility Criteria for Use of COC

a) Indications

Appropriate for:

i) Any woman in the reproductive age group, who desires a highly effective
contraceptive

ii) Immediately after abortions

iii) Women with menstrual problems such as severe cramps, heavy bleeding or has
irregular cycles
COC decrease cramps, bleeding and regularises cycles.

iv) Has moderate to severe anaemia

Less menstrual blood loss occurs with COC and, therefore, it does not worsen the
anaemia.

v) History of functional ovarian cysts and family history of ovarian cancer COC provides
protective effect against the above conditions.

b) Precautions

Absolute Contraindications

COC should not be prescribed in the following conditions/ situations:

i) Pregnancy

ii) History of thromboembolic disorders in the present or past:

l Deep vein thrombosis

l Stroke
l Oestrogen promotes blood clotting and adds to the existing predisposition to
thrombosis.

iii) History of heart disease

l Ischaemic heart disease

l Heart problems such as angina, cardiac failure, valvular heart disease and others
l The increased risk of thrombosis with the oestrogen adds to the predisposition
to thrombosis in the above conditions.

iv) High blood pressure 160 mm of Hg + /100 mm of Hg +

Oestrogen increases the blood pressure slightly and thus adds to the existing risk
situation.

v) Severe headache or migraine with focal neurological symptoms

This may be an indication of increased risk of stroke, a condition in which the COC is
contraindicated. 41
Family Planning vi) Long standing diabetes or diabetes with vascular disorders such as retinopathy,
nephropathy or neuropathy

The COC adds to the increased risk of cardiovascular disease and thrombosis.

vii) Is above 35 and is a heavy smoker (15 cigarettes/‘bidis’ a day)

Smoking as such is a risk factor for cardiovascular problems and oestrogen adds to
the risk. Smoking and oestrogen promote blood clotting.

viii) Has a known carcinoma of breast or has history suggestive of carcinoma or

undiagnosed lump

The risk for progress of the condition may be increased. In case of an undiagnosed
lump, indication for use is based on confirmed diagnosis.

ix) Has severe or active liver disease, gall bladder disease or history of jaundice in the
previous six months or recurrent jaundice during pregnancy

The COC is metabolised in the liver and its use may adversely affect women whose
liver function is already compromised. COC may affect the prognosis of the existing
liver tumours. It may worsen the existing gall bladder disease.

x) Breast feeding less than six weeks postpartum

Oestrogen increases the risk of thrombosis (adds to the existing risk of thrombosis
during early post-partum period). There is also the risk of neonates getting a dose of
oestrogen through breast milk.

xi) Known carcinoma of the cervix or history suggestive of carcinoma (unexplained

vaginal bleeding: intermenstrual or post-coital)

There is minimal chance of carcinoma in situ progressing to invasive disease and the
progression of existing carcinoma. The risk is increased with smoking and unsafe
sexual practices.

Relative Contraindications

COC should be considered more carefully in the following conditions:

i) Breast feeding six weeks to six months post-partum

COC may decrease quantity of breast milk.

ii) Age over 40 years

Risk of cardiovascular disease increases and COC may add to the risk.

iii) Smoker and age above 35 years

iv) History of hypertension or current blood pressure above 140/90 mm of Hg

It is advisable to consult a specialist before starting the COC in the following

conditions.

v) Known hyperlipidemia

Oestrogen may add to the existing risk.

vi) Unexplained vaginal bleeding

It may be due to pregnancy (tubal or uterine) or pelvic pathology such as malignancy,

ovarian cysts, PID or fibroids. COC has a protective effect in case of ovarian cysts,
endometrial and ovarian cancers. It is important to diagnose the cause before
prescribing COC.

vii) On treatment for tuberculosis or epilepsy or on antibiotics for more than a week

42 These drugs reduce the efficacy of COC.

Special Circumstances when COC should not given Hormonal Contraception

i) Planned surgery: COC should be discontinued at least four weeks in advance of the
surgery because of its effect on increasing coagulation of blood.

ii) Adolescents who have not reached menarche

Client Assessment

a) History taking

History should be taken very carefully. The history should include the following:

l Age, smoker (if smoker: number of cigarettes per day)

l Date of last menstrual period and details of menstrual cycle
l Parity, date of last child birth/abortion
l Whether breast feeding (if breast feeding, age of the child and whether breast feeding
is exclusive or partial)
l History of hypertension, heart problems, breathlessness, deep vein thrombosis
(severe pain and swelling in the calf) and stroke
l History of severe headaches
l History of jaundice (including during pregnancy) and liver disease
l History of lumps in the breast or breast cancer
l History of cancer of the cervix and uterus
l Any bleeding between periods or after intercourse
l History of pelvic infections or sexually transmitted diseases (abnormal vaginal
discharge, lower abdominal pain)
l Whether on treatment for tuberculosis or convulsions or taking antibiotics for long

b) General and Systemic Examination

General physical: Weight, pallor, jaundice, cyanosis, pulse, blood pressure.

Heart: Rate

Breast: Lumps, ulcer (see Annexure 3 for breast examination)

Abdomen: Liver (whether enlarged, tender), any mass, tenderness in the lower
abdomen

c) Pelvic Examination

Conduct the following examinations:

i) Examination of external genitalia for evidence of Reproductive Tract Infections (RTIs)/

STDs

ii) Speculum examination for evidence of vaginal and cervical infection, and cervical
growth/ulcers

iii) Bimanual examination for determining the uterine size, consistency, mobility,
tenderness and adenexal mass (ovarian cyst/cancer) and for ruling out PID

Laboratory Examination

It is advisable to get the haemoglobin and urine for sugar checked.

Do a Pap smear if possible and a vaginal smear for infections if indicated.

If any contraindication present, do not provide COC.

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Family Planning D) Guidelines for Instruction and Follow Up

Guidelines for Instructing a Client on Use of COC

i) Show the packet of COC to the client as instructions are being given.

ii) Explain the timing of starting ‘the pill’.

Start ‘the pill’ on the fifth day of menstruation (explain that the first day of
menstruation is the day when bleeding/spotting starts). Explain that it is important to
start ‘the pill’ on day five as by then menstrual flow will be full and one can be sure of
not being pregnant.

iii) It can also be on day 1 of MTP/abortion, 6 weeks post partum if breastfeeding and 6
months after delivery for breastfeeding mothers.

iv) Explain how to take ‘the pill’

l Show the client where to start ‘the pill’ (where it is marked START) and to
follow the arrow to decide which pill to take next and follow the arrow till the
last pill.
l Show how to take out the pill from the packet.
l Emphasise the importance of taking ‘the pill’ everyday even during
menstruation and even when there is no sexual intercourse.
l Explain that ‘the pill’ must be taken at a fixed time, preferably at night before
going to sleep. This will help to prevent the feeling of nausea, which is
common in the early months of taking the pill.
l Tell that the day after the packet is over, the next packet should be started
with ‘the pill’ where it is marked START.
l Explain that ‘the pill’ has to be taken continuously for 7 days for it to be
effective in preventing pregnancy.

v) Explain that the client may suffer from spotting or bleeding between periods and
nausea during the first three months. Tell the client that taking ‘the pill’ at night helps
to avoid nausea. Emphasise that the problems usually disappear after the first three
months.

vi) Tell the client what to do in case ‘the pill’ is missed. Emphasise that each day of
missing ‘the pill’ increases the risk of pregnancy

l If one pill is missed, take it as soon as you remember it.

l The next pill should be taken at the same time as usual (two pills may have to be
taken on one day).
l If the pill is missed for two days or more:

— Take the pills as soon as possible and continue with the packet. Two tablets
should be taken for the number of days the pill has been missed. (Although
the pill is not effective if missed for 48 hours (2 days). the continuation of
the pill is being advised to maintain the routine.)

— Use condoms for 7 days, till the pill has been taken for 7 continuous days
(for the pill to be effective).

vii) Advise use of condoms:

l If ‘the pill’ is missed for two or more days

l If the packet of COC is finished and she has no new packet
l If risk of exposure to STDs
l In case of diarrhoea or vomiting when the chances of absorption of the pill are
less and the risk of pregnancy is increased
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viii) Instruct the client to inform about the use of ‘the pill’ during every medical Hormonal Contraception
consultation to prevent prescription of drugs that have interactions with the COC.

ix) Advise the client to contact for advice if started on treatment for tuberculosis,
epilepsy or on long term antibiotics as these drugs decrease the effectiveness of the
COC.

x) Advise to keep the COC in a cool, dry place, away from the reach of children.

xi) Give instructions for follow up.

l Return to the clinic within three months of starting the COC. Advise to bring the
used packets (even the empty ones to be sure that the pills are being taken
regularly).
l Return to the clinic before the scheduled date if:
l not satisfied with the method
l develops jaundice
l pregnancy suspected
l at risk of STD/HIV
l develops lumps in the breast
l has inter-menstrual or post-coital bleeding

xii) Contact immediately if any of the following as they are life threatening conditions:

l Severe abdominal pain (probably gall bladder disease, blood clot or pancreatitis)
l Severe chest pain, cough, breathlessness (probably blood clot in the lungs or
heart attack)
l Severe headache, dizziness, weakness, numbness (probably due to stroke,
hypertension or migraine)
l Eye problems (loss of vision or blurring), speech problem (probably due to stroke
or temporary vascular problem)
l Severe pain in calf or thigh (probably blood clot in the leg)

xiii) Provide a packet of condoms. Demonstrate the use of condoms if the client does not
know and ask to repeat the same.

Warning signs

The following acronym will help to remember the warning signs.

A—Abdominal pain

C—Chest pain

H—Headache

E—Eye problem

S—Severe leg pain

Follow up Schedule
During each follow up visit the client should be counselled.

The Medical Officer should instruct the HW(F) that during her routine field visits she
should enquire about any problems and advise clients for follow-up.
The recommended schedule for follow-up assessment is as follows:

l First visit - Within three months of prescribing the COC

l Subsequent visits - Yearly 45
Family Planning Do a complete assessment during the yearly visits. Record findings.

Do haemoglobin and urine for sugar.

The client must be instructed about taking ‘the pill’ regularly.

Management of Side Effects and Other Complications

Always counsel clients who have side effects and other complications. If the COC is
stopped, counsel for other methods of family planning.

a) Amenorrhoea

i) Ask the client to explain how she has been taking ‘the pill’ (see the used packet if
available, to be sure that no pill has been missed).

ii) Ask for history of diarrhoea and vomiting, whether started on treatment for
tuberculosis, epilepsy or any antibiotics.

iii) Rule out pregnancy by history and examination.

l If pregnant and does not want to continue with the pregnancy, refer for
Medical Termination of Pregnancy (MTP).
l If pregnant and wants to continue with the pregnancy, reassure that ‘the
pills’ taken so far won’t affect the foetus. Advise about antenatal care.

iv) If ‘the pill’ is being taken regularly and if the client is not pregnant, reassure the
client. Explain that no menses is due to lack of build up of the uterine lining.

l If the client is reassured, advise to complete the second packet of ‘the pill’
and report for follow up.
l If the amenorrhoea continues after the second packet is over, refer to a
specialist.

b) Spotting or bleeding between periods

i) Ask the client to explain how she has been taking ‘the pill’ (see the used packet if
the client has brought it).

ii) Ask for history of diarrhoea and vomiting, whether started on treatment for
tuberculosis, epilepsy or any antibiotics.

iii) Rule out pregnancy and other gynaecological problems such as tumours, PID or
cervical infection by history and examination.

iv) If pregnant, advise according to intentions of continuing with the pregnancy

(see iii under Amenorrhoea as mentioned above).

l If evidence of infection, take smears and treat.

l Take pap smear if possible and send it to an appropriate facility for

diagnosis and refer to a specialist if required.

v) If ‘the pill’ is being taken regularly and she is not pregnant, reassure the client.

l If the client is reassured, advise to complete the second packet and report
for follow up.

l If the spotting persists even after the second cycle, refer to a specialist.

c) Nausea

i) Ask the client to explain how she has been taking ‘the pill’ (see the used packet if
the client has brought it).

ii) Find out the timing of taking ‘the pill’.

iii) Rule out pregnancy by history and examination.

46
 If pregnant, advise according to intentions of continuing with the pregnancy (see Hormonal Contraception
iii under Amenorhhoea).

iv) If not pregnant, rule out other causes of vomiting such as jaundice.

v) If ‘the pills’ are not taken at night, advise to do so.

vi) If the client wants to continue with ‘the pill’, reassure and explain that the
symptoms generally disappear after three months.

vii) If on high dose oestrogen or progestogen, prescribe low dose pills.

d) Headaches

i) Rule out causes of headache such as sinusitis and eye problems. Treat
accordingly and continue with the COC.

ii) Check blood pressure. If blood pressure is high. manage as described under High
Blood Pressure.

iii) Rule out migraine. Ask for history of blurring of vision, numbness and speech
problems. If history suggestive of migraine, stop the COC and counsel for other
methods of family planning.

e) High Blood Pressure

i) Ask for history of high blood pressure prior to starting ‘the pill’.

ii) If blood pressure is higher than 160/100, stop the COC. Advise for treatment (if
not already on treatment). Counsel for another method of family planning.

iii) If between 140/90 and 160/100, counsel about the potential danger, of rise in
blood pressure due to the pill. If wants to continue with the pill, advise to get
blood pressure checked every month and to get treatment for high blood
pressure (if not already on treatment). Put on a low dose pill (if on high dose pill).

f) Weight Gain

i) Check whether the weight gain is after the COC has been started.

ii) Find out about eating habits.

iii) If no reason for weight gain, rule out pregnancy. If pregnant, advise as in iii under
Amenorrhoea.

iv) If not pregnant, reassure that hormonal contraceptives do cause slight weight
gain. If weight gain is not acceptable, stop the COC and counsel for another
method.

g) Breast Tenderness

i) Rule out pregnancy and advise accordingly.

ii) Rule out breast lumps and in case of lumps, rule out cancer of the breast.

iii) If breast feeding, rule out infection.

iv) Reassure. Put on low dose pill (if on high dose) or switch over to progestogen
pill.

v) Reassure.

The drug interaction, rumours and facts about pills, COC screening and follow up
cards are given in Annexures 1, 2 and 3 respectively.

47
Family Planning 2) Progestin only Pill (Mini Pill, POP)

Progestin only pills contain synthetic progestogens but no oestrogen. These pills are
taken continuously. POP must be taken at the same time every day. Because the
hormone dose is small, forgetting one days pill can cause the method to be ineffective
that month. POPs are not a good choice for a client who is unwilling or unable to
obtain and consistently use them.

Mechanism of action: It causes cervical mucous to be become thick and impenetrable

to sperms. The endometrial lining becomes thin and atrophic, so not conducive to
implantation. Suppress ovulation in many cycles.

Effectiveness: 96.5 to 99.5%.

Indication: Breastfeeding woman; woman with high BP; woman more than 35 years and
smoking; where neither COCs are not suitable nor other effective methods are suitable;
women with sickle cell disease.

Advantages: Does not affect lactation; does not increase BP and headache;
theoretically less risk of cardiovascular side effects; decreases painful menses;
decreases menstrual blood loss there by decreases anaemia; does not increase blood
clotting; provides some protection against pelvic inflammatory disease because of
thick cervical mucous.

Disadvantages: POP has Ii high failure rate as compared to cars; relatively high rate
of ectopic pregnancy and more likely to cause menstrual irregularities and spotting/
heavy bleeding. It does not protect against development of ovarian cysts, SID and
AIDS. Occasional conditions which mayor may not be related to the use of POP use
are headache, mood changes, weight gain, breast tenderness, nausea, dizziness, acne
and hirsutism.

Selection of clientele: Can be given to woman in whom COC is contraindicated. It

can be used by lactating women and should not be used by women who experience
abnormal genital bleeding and who has had ectopic pregnancy. It is not a good choice
for those women who are unable or unwilling to obtain the pill and use them
consistently.

Selection of drug: There is no important difference between mini pill preparations.

Warning signals that a clientele should know is to seek medical care to check for
pregnancy and ectopic pregnancy (if there is more than 45 days of amenorrhoea).

26.2.2 Implants (Norplant)

Norplant is currently the only implementable contraceptive implant in wide use. It
consist of 6 tiny silicone rubber capsules containing the progestogen DL Norgestrel.
They are surgically inserted under the skin on the inside of the upper arm by a
trained medical personnel. The tubes allow a steady diffusion of drug into the blood
stream. The implants must be surgically removed when the steroid is used up (i.e. after
5 years) or when woman wishes to discontinue the method. It is very effective in
preventing pregnancy.

Mechanism of action: It makes the cervical mucous thick and thus impenetrable to
sperms. It makes the endometrium thin and atrophic, thus not conducive to
implantation and also inhibits ovulation in many cycles. The contraceptive effects start
24 hours after insertion if inserted within 7 days of menstrual cycle. Effect continue for
7 years and need to be replaced if the woman wants to continue the method.

No contraceptive effect remains after the removal of implant. The woman can become
pregnant during the next menstrual cycle.

Effectiveness: 99.7%.

Advantages: As effective as surgical contraception but still reversible; provides

definite birth control for 5 years; decreases blood loss during periods thus prevents
and improves anaemia; does not interfere with sexual intercourse and can be used in
48
breastfeeding women. The acceptors of implant do not have to remember dates except Hormonal Contraception
follow up visits.

Disadvantages: Does not protect against STDs and AIDS; require minor surgical
procedure for insertion and removal; provider dependent; very small risk of infection at
the site of insertion; causes menstrual irregularities and spotting. In occasional
women, it causes heavy and prolonged bleeding that decrease over time and
amenorrhoea may occur for several months.

Occasional conditions which may or may not be due to norplants are headache, mood
changes, weight gain or weight loss, breast tenderness, nausea, dizziness, acne and
hirsutism. It does not prevent ectopic pregnancy, ovarian cysts and may not be quite
effective for heavy weight women.

Selection of clientele: It should not be used in cases of suspected pregnancy;

abnormal genital bleeding; history of cardiovascular disease; malignancy; suspected
for breast cancer or if the client is taking drugs like rifampicin or anticonvulsants.

It is indicated when no more children are desired: where a risk of increased

cardiovascular complications with COC’s are present and where other methods
requiring dally use becomes difficult to use. It is also indicated when oestrogen related
complications develop during COC use (high BP, headache), in more than 35 years and
where contact with the service provider a regular basis is difficult.

Selection of method: Norplant is the only implant available currently. Warning signals
that a user should know is to seek medical care in case of dizziness; headache, heavy
bleeding and infection at insertion site.

26.2.3 Injectables
Injectable contraceptives are the synthetic hormone injected into the muscle. These are
available as 3 months, 2 months and also monthly injections. The synthetic hormone
progestion is used in all these injections. But the monthly injection also contains
oestrogen in addition.

The products available are:

l DMPA (Depot medroxy progesterone Acetate): Available as Depot Provera, 150 mg,
injected 1M every 3 months.

l NET-EN (Nor ethindrone enanthate): Available as Noristerat, 200 mg, injected IM

every 2 months.

l Cycloprovera/Cyclofem: A combination of 25 mg depot medroxy progesterone acetate

and 5 mg oestradiol cypionate injected monthly.

l Mesigyna: Available as HRP 102, a combination of 50 mg norethindrone enanthate

(NET-IN) and 5 mg oestradiol valerate, injected monthly.

Mechanism of action: It prevents pregnancy by making cervical mucous thick and

impenetrable to sperms and makes the endometrium thin and atrophic making it non-
conducive for implantation. It also suppresses ovulation.

Effectiveness: 99-99.5 %

Advantages: It is an effective reversible contraceptive and easy to use; convenient as

it requires injections once in 3 months/2 months/every month (depending on the
preparation); has no serious side effects; appeal to woman who feel confident about
injections, do not interfere with lactation and the return of fertility is not impaired
(though delayed by 3-4 months). It may have health benefits similar to oral
contraceptives. Does not require action before or after intercourse.

Disadvantages: Causes menstrual disturbances (up to 25% discontinue because of

this). Heavy bleeding in uncommon but inter menstrual bleeding and amenorrhoea after
delayed use occur in about half of the users. Return of fertility delayed by 4-8 months
after the last dose. 49
Family Planning Selection of clientele: One should not use injectables if pregnancy is suspected, in
case of undiagnosed vaginal bleeding, history of cardiovascular disease, known cancer
breast.

It is indicated for those, for whom, the timing of return of fertility is not important; who
do not desire more children and those, who have a risk of cardiovascular complications
from OCPs. It is also indicated where other methods requiring daily usage is difficult to
use; oestrogen related complications developed on OCPs (headache, high BP);
amenorrhoea is acceptable and contact with service provider on a regular basis is
difficult.

When to take injections: Contraceptive effect starts immediately if injection is given

between day 1 and day 5 of menstrual cycle. If injections are given from 6 days after
last period use abstinence or barrier method.

For client’s convenience, repeat injections can be given 2 weeks early or 2 weeks later
than the exact scheduled date. Deep intramuscular injections to be given. The site
should not be messaged after injection.

Selection of method: Of all injectables, DMPA is best tested, longer lasting and more
effective. Net-EN and monthly preparations have also proven reliable. Warning signals
that a user should know is that in case of dizziness, headache and heavy bleeding,
medical care is to be sought.

26.2.4 Progestasert and Vaginal Rings

Progestasert is an intrauterine device impregnated with. It is ‘T’ shaped and slowly
releases progestogen locally. Since it decreases menstrual bleeding, it is suitable for
woman with heavy vaginal bleeding. Progestasert needs to be replaced every year.
The progestogen acts locally and makes the endometrium not conducive to
implementation and makes cervical mucous impenetrable to sperms. The
disadvantages are intermenstrual spotting and increased risk of ectopic pregnancy as
with progestogen only contraceptives.

Vaginal rings are impregnated with or progesterone. Vaginal rings are different from
other long acting hormonal methods. Rings are placed ill the vagina by the client and
removed by herself. Thus it is not user dependent. The action is same as other
progestogen only methods. But rings are less effective than implants or injectables.
The other side effects are also like other progestogen only methods. Expulsion of ring
is an added problem. These rings can be used by lactating women and can remain ill
vagina for 3 months.

Check Your Progress 1

1) How does combined oral contraceptive pills act?

.........................................................................................................................................................

.........................................................................................................................................................

2) List three important non-contraceptive health benefits of OC’s.

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

3) What are the warning signals an OC user should know?

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................
50
4) Name the drug used in injectable contraceptives. Hormonal Contraception

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

26.3 EMERGENCY CONTRACEPTIVE PILLS

Emergency Contraceptive Pills (ECPs) are hormonal contraceptives that can be used to
prevent pregnancy following an unprotected act of sexual intercourse within the past
72 hours. It provides an important option to women who have had unprotected
intercourse due to non-use or a contraceptive accident. It is a very critical option for
preventing an unwanted pregnancy from sexual assault.

26.3.1 Pharmacology of ECP

All the hormonal oral contraceptive pills (combined as well as single) in varying doses
can be used as ECPs. However, the Drug Controller of India has approved only
levonorgestrel (LNG) (progestogen-only) for use as ECP. LNG is available in 0.75 mg
tablets. LNG is the ‘dedicated product’ for emergency contraception as it will be
specially packaged at the correct dosage for use as ECP. The guidelines are for
administration of LNG.

Mechanism of Action

The precise mode of action of ECPs is uncertain and may be related to the time it is
used in a woman’s cycle. ECPs are thought to prevent ovulation, fertilization and/or
implantation, depending on the phase of menstrual cycle, through the various
mechanisms listed below:

i) Inhibition or delay of ovulation when used prior to ovulation

ii) Thickening of cervical mucus

iii) Direct inhibition of fertilization

iv) Histological and biochemical alteration in endometrium leading to impaired

endometrial receptivity to implantation of the fertilised egg.

v) Alteration in transport of egg, sperm and embryo

vi) Interference with corpus luteum function and luteolysis

The mechanisms for prevention of pregnancy are thought to happen before

implantation takes place.

ECPs are not effective once the process of implantation has taken place. ECPs will
not cause an abortion.

Effectiveness

The efficacy of the ECP used correctly (time and dose as prescribed) after a single act
of unprotected sexual intercourse is about 98% (2% failure rate).

Regular use of ECPs is not recommended due to the following reasons:

l Overall ECPs are less effective than regular contraceptives.

l Since ECPs are used only once, it cannot be directly compared to the failure rates of
regular oral contraceptives which are calculated based on use during a full year.

l With frequent use of ECPs, the failure rate would be higher than of regular hormonal
contraceptives.
51
Family Planning Advantages and Disadvantages of LNG

a) Advantages

i) Effective if taken correctly as prescribed.

ii) Safe for all women including those who have conditions, that are listed as
precautions in case of other hormonal contraceptives.

iii) Does not affect lactation.

iv) Use not associated with foetal malformation or congenital defects.

v) Does not increase the risk of ectopic pregnancy.

b) Disadvantages

Has to be used within 72 hours of the first act of sexual intercourse:

i) Second dose after 12 hours in mandatory

ii) Effectiveness decreases with frequent use

iii) Does not protect from STDs/HIV

iv) Side effects: Nausea, Vomiting, irregular bleeding per vagina, breast tenderness,
headache, dizziness, fatigue.

26.3.2 Conselling for ECP

Counselling is one of the critical activities when administering ECPs for the following
reasons:

i) Counselling would help to provide emotional support to a client/couple who is

worried about a pregnancy due to unprotected sexual intercourse.

ii) It establishes rapport and confidence in the provider as the provider is helping the
client/couple to meet a critical need, which is prevention of an unwanted pregnancy.

iii) It provides an opportunity to help the client/couple start using regularly a

contraceptive of their choice as well as ensure sustained correct use of the same.

Every client should be counselled to help decide to plan her/his family and to choose
a method based on informed choice. Wherever possible/spouse/partners should be
counselled.

The following are the critical steps in counselling for emergency contraceptive pills

i) Building a rapport with the client by greeting the client as this is critical in finding out
accurate information for effective use of ECP such as the timing of first unprotected
intercourse. It is also important for acceptance of a regular contraceptive.

ii) Make the client feel comfortable psychologically as well as physically. The former is
extremely important, as she may be very anxious. In case of sexual assault, the effort
has to be greater as the woman would be emotionally distraught.

iii) Be supportive and non-judgemental especially in cases of sexual assault.

iv) Identify the reason for wanting ECP and when the first unprotected sexual intercourse
happened. In case of a contraceptive accident, ask the client to describe the use of the
method.

v) Identify the client’s needs by asking relevant questions: personal, social, family,
medical, reproductive health including reproductive tract infections/STDs, family
planning goals and past/current use of family planning methods (if not found out
earlier).

vi) Using simple language, provide information on the following:

52
 l What is ECP Hormonal Contraception

l Timing of use

l Method of action
l Effectiveness in preventing pregnancy (especially if implantation is likely to have
taken place)

l Effectiveness in causing abortion

l Effect on the foetus if pregnancy continues
l Advantages, side effects

l Effect on preventing future pregnancies

l Importance of regular use of a contraceptive

l Various contraceptive methods including mechanisms of action of methods, their

benefits and disadvantages and timing for initiation of the method and where to
obtain the services.

iv) Once the client/couple is sure about using the ECP, do a client assessment as
described later, and if found eligible, provide the ECP. Record in the client card.

v) Instruct the client about taking the ECP, emphasising the need for second dose, likely
side effects and what to do in such situations.

vi) Discuss when to return for follow up and for initiating the use of a regular
contraceptive.

vii) Provide a packet of condoms in case of STDs/HIV if condoms have not been chosen
as the method.

viii) Maintain confidentiality and privacy must be ensured at all counselling sessions.

Confidentiality and privacy should be maintained during counselling.

Counselling on Return Visit After ECP

Every time a client comes for follow-up, it is important to counsel the client to ensure
continuation of the method.

i) Ask the client about any side effects

ii) Ask about her last menstrual period: flow, duration

iii) If not pregnant, counsel about family planning methods as described in the earlier
sections.

26.3.3 Client Selection

Eligibility Criteria for ECPs

a) Indications

Timing in relation to the first act of unprotected sexual intercourse is critical for
determining the eligibility for use of ECP.

Indicated in all cases within 72 hours of the first act of unprotected intercourse in the
following situations:

i) Non-use of any contraceptive

ii) Inconsistent use of contraceptive

iii) Contraceptive accident due to:

53
Family Planning l Rupture or slippage of condoms
l Failed coitus interruptus
l IUD expulsion
l Miscalculation of safe period days
l Failure to take oral pills for more than three days in a row

iv) Sexual assault

Timing of first act of unprotected sexual intercourse (within 72 hours) is critical in

determining eligibility for use of ECP.

b) Precautions

There are no known medical conditions that are precautions for the use of the ECP as
only small doses of the hormone is used for single course.

ECPs must not be prescribed in suspected/confirmed pregnancies. The reason is not

because the ECP will cause any malformation in the foetus, but because of its
ineffectiveness in terminating the pregnancy.

Any client who has had the first act of unprotected sexual intercourse more than 72
hours ago must not be prescribed ECPs as the failure rate is very high.

ECPs should not be advised in suspected/confirmed pregnancies. ECPs should not be

prescribed in any client who had the first act of sexual intercourse more than 72
hours ago.

Client Assessment

l Menstrual history should be taken carefully to exclude pregnancy and should include
the date of last menstrual period, whether the flow and duration was normal.

l Contraceptive history should be taken. If using any contraceptive, ask about the
method of use to find out whether it is correct and is being used consistently. In case
of Cu-T user, ask about history of expulsion.

l Ask carefully and sensitively questions to establish the timing of first act of
intercourse. Explain why the questions are being asked.

l Other health assessment such as laboratory tests or pelvic examination is

recommended unless indicated to rule out a suspected pregnancy or other conditions.

26.3.4 Guidelines for Instruction and Follow Up

Guidelines for Instructing Clients About ECPs

Steps for Instructing a Client

i) Make certain that the client does not want to become pregnant, but that she
understands that there is still a chance of pregnancy even after ECPs. Explain that the
ECP should not cause any harm to the foetus if it fails to prevent pregnancy.

ii) Ensure that the client understands the dosage schedule given below:

l First dose of a tablet of ECP (Levonorgestrel 0.75 mg) is taken as early as

possible within 72 hours of the first act of sexual intercourse.

l Second tablet to be taken within 12 hours of the first tablet.

Make sure that the client understands that the first tablet should be taken as early
as possible, within 72 hours of the first act of sexual intercourse. The timing of the
second tablet within 12 hours is also important.
54
iii) Explain that the pills can be taken with sips of water. Also explain that taking the pills Hormonal Contraception
with milk or with a snack helps to decrease the nausea that may be felt.

iv) Explain that taking additional pills, more than the two prescribed, do not increase its
effectiveness, but increase the side effects.

Additional pills (more than the two prescribed) will not increase effectiveness.

v) Explain the common side effects and what to do in such situations.

vi) Make sure that the client understands that if she vomits within two hours of taking
the pills, the dose must be repeated as she may have vomited the pills out.

vii) Explain that contrary to common belief, a woman taking ECP does not menstruate
immediately after taking ECP.

viii) Make sure that the client understands that the ECPs will not protect her from
pregnancies resulting from future unprotected intercourse.

l Advise a method such as condom till her next menstrual cycle after which a
method of client’s choice can be provided.

l Demonstrate the use of condoms and ask the client to demonstrate its use.

Make sure that the client understands that the ECPs do not protect pregnancies as a
result of future unprotected sexual intercourse.

ix) Explain that ECPs do not protect from STDs/HIV and the need to use condoms if the
client or her partner is at risk.

x) Stress the importance of follow up:

l If delay in menstruation

l Immediately after menstruation for initiating regular use of a contraceptive

l If side effects are not controlled after following the advice.

Side Effects and Their Management

As explained earlier, there are very few minor side effects to ECP. Some of the common
side effects and their management is given below. Proper counselling clients prepares
the client for side effects and improves the tolerance.

i) Nausea

Nausea occurs is approximately 20 per cent of women using progestin—only ECPs.

Taking the pill with milk or snack may help reduce nausea.

ii) Vomiting

Vomiting occurs in approximately 5 per cent of women using progestin—ony ECPs.

l If vomiting occurs more than two hours of taking emergency contraceptive pill,
women should not worry as the pill is already in the system by that time.

l But if vomiting occurs within two hours of taking ECP, repeat another dose with an
anti emetic or ECP may be administered vaginally.

iii) Irregular Uterine Bleeding

Some women may experience irregular bleeding/spotting after taking ECPs. This should
not be understood as periods. The majority of the women will have their menstrual
period on time or slightly early.

Assess women having excessive/prolonged bleeding for pregnancy and its

complications or any other pelvic abnormalities. 55
Family Planning iv) Missed Period

A pregnancy test is mandatory if menstrual period is delayed for more than two weeks
than expected date.

There are no known teratogenic effects on the foetus if the pregnancy cannot be
prevented. This could be due to the fact that the ECPs are taken long before
organogenesis starts.

v) Other Side Effects

Other side effects are breast tenderness, headache, dizziness, and fatigue. These side
effects generally do not last more than 24 hours. Prescribe simple analgesics.

Timing for Initiating Regular Sse of Contraception

The table given below provides the appropriate timing for initiating regular use of
contraception:

Method Timing of Initiation

1) Condom Can be used immediately. If decided on another method,

the condoms should be used till the next periods.

2) Oral contraceptives If found eligible for use, start on fifth day of menstruation

3) IUCD If found eligible for use, insert within 7 days of

menstruation.

4) Female sterilisation If found eligible for use, admit for surgery within 7 days of
menstruation

5) Male sterilisation If found eligible for use, husband can go immediately for
surgery.

Check Your Progress 2

1) What do you understand by emergency contraceptive pills?

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

2) Name the drug approved for emergency contraceptive pills in India?

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

3) How do you prescribe ECP?

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................
56
 Hormonal Contraception
26.4 NEWER METHODS OF HORMONAL
CONTRACEPTION
The following newer methods are being tried for contraception.

1) Biodegradable Implants: Biodegradable implants deliver progestins from a carrier that

gradually dissolves in body tissue. Thus the carrier never has to be removed. Once
the carrier capsule starts getting dissolved it cannot be removed. Two types of
biodegradable implants are tested i.e. Caproner and Norethindrone pellets.

l Caproner: It contains 30-50 mg are released daily and is effective for 18 months.

l Norethindrone pellets: Each pellet contains 35 mg norethindrone and small

amount of cholesterol. 2-4 pellets are used and is effective for one year.

2) Injectable Microspheres and Microcapsules: These contain biodegradable copolymer

and one or more hormones at varying rates to achieve a fairly constant doze
(Hormones used are Norethindrone, Norgestimate Progesterone, combination of
Norethindrone and Ethinyl oestradiol). These are effective for 1, 2 or 6 months
depending on formulations. It can be administered like injections and once given
cannot be removed.

3) Hormonal Vaginal Rings: Vaginal rings containing both oestrogen and progestogen
have been tried. These vaginal rings are inserted for 3 weeks.

4) RU-486: RU-486 is an antiprogestational agent. It competes with progesterone for the

receptors in the uterus so that the progesterone is displaced and pregnancy cannot be
sustained. Thus it acts as a menstrual regulator/abortifacient. For the abortion
process to be complete, prostaglandin is given after RU-486 is taken. Prostaglandins
cause uterine contractions and complete the abortion. It is effective up to 6-8 weeks
only. The procedures take several days and requires 2 or more visits to service
provider. Bleeding or spotting may last up to 8-10 days. Cramping, nausea, diarrhoea
may occur. Heavy bleeding may occur in 2% of women and failed procedure need back
up. It is not marketed in India. To use RU-486, back up facilities to complete abortion
must be available. Success rate is claimed to be 90%.

26.5 METHODS UNDER SPECIAL

CIRCUMSTANCES
Suggested methods (even though all other options are available) for different special
circumstances are mentioned below:

a) Delaying first child: For delaying the first child after marriage, the first choice is
usually combined pill. This is very effective and not intercourse related. This is
followed by barrier methods for 1 month before attempting conception. Second choice
is barrier methods which is dependent on intercourse.

b) During breastfeeding: For first 6 months, exclusive breastfeeding alone is adequate if

periods have not returned. After 6 months of delivery/if menstruation returns earlier/if
exclusive breastfeeding not practiced, other methods have to be used. They are
barrier method that could be used till period returns, IUCD and progestogen only pills.

c) Spacing after breastfeeding: First choice is combined oral contraceptive pills for
greater effectiveness and regular period. IUCD is next choice.

d) After the last child till decision on permanent method:

l IUCD

l Barrier methods

l Progestogen only pill

57
Family Planning e) After family is completed: If the other methods are not acceptable, then vasectomy/
tubectomy be followed.

f) Adolescence: The best method is to say ‘No’ to sexual intercourse. Choice depends
on religious views, steadiness of relationship and frequency of intercourse.

l Barrier methods if possibility of multiple partners or partners having other

partners. Offers protection from STD’s and HIV. It requires high degree of
motivation and adequate knowledge about the method.

l In steady relationships COCs are preferred if regular menstruation has been

established.

Check Your Progress 3

1) Name one antiprogestational agent.

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

2) Enumerate the contraceptive methods available for a breastfeeding woman.

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

26.6 LET US SUM UP

After reading this unit, you should feel confident in providing hormonal contraception
especially oral contraceptive pills and injectable contraceptives. Selection of patients,
advantages, disadvantages, side effects, complications and how to deal with them
have been discussed in this unit.

26.7 KEY WORDS

Adolescence : Person between age 10-20 years

ECP : Emergency Contraceptive Pills

LNG : Levonorgestrel

Minipill : Progestogen only pill

NFHS : National Family Health Survey

Pill/OCP : Oral Contraceptive Pill

58
 Hormonal Contraception
26.8 ANSWERS TO CHECK YOUR PROGRESS
Check Your Progress 1

1) Inhibits ovulation; Makes cervical mucous thick and impenetrable to sperm; Induces
changes in endometrium not conducive to implementation.

2) The benefits are:

l Regularises menstrual cycle, relieves dysmenorrhoea and premenstrual tension,

decreases menorrhagia— reduces the chance of anaemia.

l Decreases risk of pelvic inflammatory disease.

l Reduces the incidence of ectopic pregnancy.

3) Warning signal an DC user should know are: ACHES (Abdominal pain, Chest pain,
Headache, Eye problems, Sever leg pain/swelling).

4) DMPA, NET-EN

Check Your Progress 2

1) Emergency contraceptive pills are hormonal contraceptives that are used to prevent
pregnancy following an unprotected act of sexual intercourse within the past 72
hours.

2) Levonorgestrel (LNG) progestin only pill is the drug approved for emergency
contraception in India.

3) Levonorgestrel (0.75 mg) pill is prescribed. First tablet is to be taken as early as

possible within 72 hours of the first act of sexual intercourse. The second tablet is
taken within 12 hours of the first tablet.

Check Your Progress 3

1) RU-486 (Mifipristone)

2) i) IUCD insertion at 6 weeks (during first postnatal check up)

ii) Condom

iii) Minipill (Progestin only pill)

iv) LAM (Lactational amenorrhoea method) for 6 months if she is exclusively

breastfeeding and has amenorrhoea.

26.9 FURTHER READINGS

Government of India: Guidelines for Oral Contraceptive Administration for Medical
Officers, Department of Family Welfare, Ministry of Health and Family Welfare.

Guillebaud, John, Contraception —Your Questions Answered, Churchill Livingstone,

second edition, 1993.

University of North Carolina, Guidelines for Clinical Procedures in Family Planning

Programme for International Training in Health (INTRAH), School of Medicine, 2nd
edition, 1993.

World Health Organisation, “Improving Acess to Quality of Care in Family Planning”,

Medical Eligibility Criteria for Contraceptive Use, Family and Reproductive Health
Division, 1996.

World Health Organisation, “Improving Access to Quality of Care in Family Planning”,

Medical Eligibility Criteria for Contraceptive Use, Second edition. Department of
Reproductive Health and Research, 2000. 59
Family Planning Annexure 1

Drug Interactions
A. Drugs that may reduce the efficacy of COCs
Antibacterial Anticonvulsants Antifungals
Rifampicin Barbiturates (Pheno- Griseofulvin
barbitone, Primidone
Penicillins
Chloramphenicol
Cephalosporins
Metronidazole
Sufonamides
Nitrofurantion

B. Drugs that are affected by COC

Antibacterials Anticonvulsants Anticoagulants

Trolengomycin Barbiturates:Phenytoin Warfarin

(increases toxicity) (increases toxicity) (decreases effect)

Antidepressants Antidiabetic agents Antihypertensive agents

Tricyclic:clomipramine, Insulin Methyl dopa

amitryptiline Oral hyoglycaemics (decreases effect)
(increases effect) (decreases effect) Beta blocking agents
(increases effect)

Antianxiety Theophylline preparations

Benzodiazepines: Aminophylline
Chlordiazepoxide, Theophylline
diazepam (increases risk of
(increaeses the effect of toxicity)
the above)
Lorazepam (decreases
effect)

Source : ICMR: Guidenes for family Planning Service including Counselling. Screening,
Procedure, Follow-up and Infection Control. Module for PHC Medical Officers
1996.

60
 Annexure 2 Hormonal Contraception

Rumours and Facts

One of the reasons for a smaller percentage of women using COC is the myths about
the COC. The following is a list of common myths and the facts. It is important to be
aware of these to effectively counsel the clients who opt for COC.

Myths Facts

1) Pill causes cancer. Pills offer protection against cancers of

the ovary and endometrium. There is no
demonstrated increase in risk of breast
cancer.

2) Pill causes infertility. Pills do not lead to permanent infertility.

After stopping the pill fertility returns
immediately in most women.

3) Pills cause heat in the body and need The pills do not cause any heat in the to
drink milk to decrease the effect. body. It does not cause hyperacidity.
Most clients cannot afford to buy milk. Milk has no effect on the side effects of
the pill.

4) Pill affects women’s health The low dose pills do not lead to major
permanently. complications, as the dose of hormones is
small.

Experiences from India and allover the

world have shown that if the women are
properly screened and the pill is given
only to the women who are eligible for
use, then there are no serious
complications.

The risk of dying from pregnancy and

childbirth is higher than the risk of dying
from complications of the pill.

5) Pills cause deformities in babies. There is no increased risk of giving birth

to deformed babies by women who have
taken COC. Even when the pill is taken
accidentally during pregnancy, there is no
risk of the baby being born deformed.

6) Pills must be discontinued for 2-3 The pills can be safely used continuously
months as continued use may cause as long as one desires. Fertility returns
ovarian dysfunction. immediately after stopping the pill in most
women. Discontinuation of use of pills
without using another method can lead to
an unwanted pregnancy. There is no need
to advice few months of ‘no pill’

61
Family Planning Annexure 3

COC Screening and Follow-up Card

Name of Health Centre: District: State: Registration number:

Name of the client: Age:

Address:
Menstrual history

Age at menarche: Date of last menstrual period

Menstrual cycle: regular/irregular Flow: Scanty/moderate/heavy

Duration: days Pain:

Obstetrical history

Total number of pregnancies: Total number of living children: female male

Number of abortions: Induced Spontaneous:
Date of last delivery/C-section/abortion:

History of jaundice during pregnancy:

History of ectopic pregnancy.

History of puerperal Infection after delivery or abortion:

Breast feeding

Currently breast feeding: Duration:

Gynaecological history

Inter-menstrual bleeding: Post-coital bleeding:

History of cancer of the cervix or uterus:

History of pelvic tuberculosis.

History of RTIs/STDs/HIV

. Discharge per vagina: Colour of discharge:

Itching Ulcers of the genitalia: Swelling of the genitalia or groin:

Lower abdominal pain: Abdominal mass:

Medical history
History of smoking: (mention number of cigarettes or bidis)

History of stroke/severe pain in calf muscle (deep vein thrombosis)/pulmonary

embolism
History of breathlessness/heart disease:

History of hypertension:
History of severe headache/ migraine

History of jaundice (specifically ask about jaundice during pregnancy)

History of liver disease or gall bladder disease:

History of diabetes: Years since diagnosed: Complications:

History of chronic cough/tuberculosis: On treatment:

History of epilepsy: On treatment:

62
History of lumps in the breast or cancer: Hormonal Contraception

General and systemic examination

Weight: Pulse: BP: Presence of anaemia:

Signs of jaundice:

Breast: Lumps/ulcer
Heart:
Abdomen: Liver palpable: Any mass: Any tenderness:

Pelvic examination
External genitalia: Normal

Abnormal discharge/redness/patches/ulcer/growth/warts/ swelling

Per speculum examination: Normal

Discharge/bleeding/ ulcer / growth

Bimanual examination

Cervix: Pointing backwards/ forwards Soft/firm/hard, tenderness on movement/ freely

mobile, smooth/irregular surface, bleeds to touch
Uterus: Normal

Anteverted/retroverted
Normal/bulky/small, smooth/irregular surface, soft/firm, mobile/fixed

Adenexa: Normal
Tenderness, mass

Laboratory examination:
Haemoglobin: Urine sugar:
Vaginal smear: Pap smear:

Details of COC administration

Type of COC prescribed: Date of starting the COC:

Date advised for follow up:

Follow Up

Date Menstrual history BP Pelvic examination Remarks

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