F.

03 FAMILY PLANNING SIMPLIFIED MEC CATEGORIES

Dr. Ursua | December 05, 2018 With Limited
Category With Clinical Judgment Clinical
OUTLINE Judgment
I. Introduction Use method under any Yes, use the
1
II. WHO - Medical Eligibility Criteria circumstance method. There
III. DOH Family Planning Made E-A-S-I-E-R 2 Generally, use the method are no risks.
IV. Types of Contraception Use of method is not usually
V. Concepts and Considerations in OCPs recommended unless other
3 No, do not use
more appropriate methods
the method
are not available
I. INTRODUCTION 4 Method not to be used
THE FAMILY PLANNING POLICY
 Respect to life WHO CATEGORIES FOR PERMANENT METHODS (e.g.
 Birth Spacing tubal ligation and vasectomy)
o Gives the mother recovery time from previous Accept: there is no medical reason to deny sterilization
pregnancy to replenish vital nutrients that were lost A
to a person with this condition
during child birth or else the mother will be pushed to
Cautious: the procedure is normally conducted in a
have diseases such as anemia etc.
C routine setting, but with extra preparation and
 Informed Choices
precautions
o Elements of informed choice
Delay: the procedure is delayed until the condition is
 Voluntary decision D
evaluated and/or accepted
 Based on accurate information
Special: The procedure should be undertaken in a setting
 Range of contraceptive options S
with an experienced surgeon or staff, equipment
o Ethicality of family planning
o In the legal age, they call this the RESPONSIBLE
PARENTHOOD WHO CATEGORIES FOR FERTILITY AWARENESS-
BASED METHODS
THE BEST METHOD OF CONTRACEPTION SUITS: Accept: there is no medical reason to deny the
A
 Goals particularly FAB to a woman with this circumstance
 Health Cautious: the procedure is normally conducted in a
 Lifestyles C routine setting, but with extra preparation and
precautions
CONTRACEPTIVE CHOICES Delay: use of this method is delayed until the condition
D
 Hormonal Contraceptives is evaluated and/or corrected
 Intrauterine Device NA Not Applicable
 Male Condom
 Spermicides WHO CAN USE COC? WHO CANNOT USE COC?
 Vaginal Barriers (Categories 1 and 2 – WHO (Categories 3 and 4 – WHO
 Fertility Awareness Based Methods Medical Eligibility Criteria) MEC)
 Male and Female Sterilization Women with: Women with:
1. varicose veins 1. Breastfeeding less than
II. WHO - MEDICAL ELIGIBILITY CRITERIA 2. non-migrainous 21days post-partum
WHO CATEGORY FOR TEMPORARY METHODS (e.g. headache 2. smokers
condoms, IUDs, etc.) 3. depressive disorders 3. 35 years or older
1 Can use the method in any circumstances 4. trophoblastic diseases 4. hypertension 140/90 or
Generally, can use the method, advantages generally 5. benign ovarian tumors above
2
outweigh theoretical or proven risks 6. family history of breast 5. history of stroke
Should not use the method, unless other, or more CA 6. current/history of
appropriate methods are not available. 7. benign breast diseases ischemic heart disease
3 EXAMPLE: A 50 yr. old women should not take morning 8. epilepsy 7. diabetes more than 20
afterpill due to its high estrogen content that could put 9. thyroid disease years
her at risk of thromboembolism 10. uterine fibroids 8. Diabetes with
Should not use the method, condition represents an 11. history of gestational neuropathy,
acceptable health risk if method is used diabetes nephropathy, retinopathy
4 12. tuberculosis 9. gallbladder disease
EXAMPLE: The use of OCPs in males to be feminine will
impose them in having health risks 13. intake of antibiotics 10. active viral hepatitis
except rifampicin 11. cirrhosis
14. PID 12. liver tumors
15. STI 13. intake of rifampicin and
16. non- complicated anticonvulsants
valvular heart disease

OB 1 | 1 of 6 FERIA, BASTIAN, IMPERIAL

17. history of hypertension o Fertilization and Ovulation is important processes to be
in pregnancy understood and informed to the patient for family
18. healthy women of any planning to be effective and safe
age or parity  Voluntary Surgical Sterilization
19. diabetes less than 20 o Bilateral tubal ligation is basically blocking the
years and without passage way and once there is recanalization, they can
complications still get pregnant
o Vasectomy
III. DOH FAMILY PLANNING MADE E-A-S-I-E-R  Hormonal: Supress ovulation
 E: effective o May have extra-organ added benefits such as lowering
 A: accessible incidence of ovarian and breast cancer but cannot
 S: safe prevent STIs
 I: ideal o Blocking the Hypothalamo-pituitary-gonadal axis
 E: exciting  IUD: prevention of fertilization
 R: rewarding o Can have mechanical effect (somehow block the
passage) and toxic/foreign body effect (copper can
A. EFFECTIVE cause death of sperm)
 Refers to typical and perfect use efficacy rate
 Perfect use efficacy rate EVIDENCE-BASED: CONTINUOUS RESEARCH
o Refers to the efficacy of a “CORRECT USE” of a  High dose to low dose monophasic, biphasic & triphasic OCPs
contraceptive that reflects what happens IF o Lesser side effects and more beneficial
contraceptive method is USED CORRECTLY EVERY o Monophasic: pills deliver the same amount of estrogen
TIME. and progestin each day.
 Typical use efficacy rate o Biphasic: deliver one strength for 7-10 days and second
o Refers to the efficacy of the “ACTUAL USE” of strength (different concentration as the first one) for 11-
contraceptive that reflects WHAT HAPPENS IN THE 14 days. In the final days, take placebos or none at all.
REAL WORLD WHEN WE FACTOR IN HUMAN o Triphasic: Each dose is administered in a three-phase
ERROR in the first year of use of a contraceptive method birth control base on the normal cycle of progesterone
and estrogen. If the OCP is marked by three colors, it is
EFFICACY RATE (%) triphasic.
CONTRACEPTIVE METHOD PERFECT TYPICAL  IUD: from iron ring to plastics to medicated (with hormone)
USE USE IUDs
Condom 98% 85 %  Calendar method to Cycle Beads
Intrauterine device (IUD) 99.9% o This are natural family planning
Oral contraceptives/Pills (contains  Female condoms: from diaphragms to shields and sponges
99.7 % o Prevents penetration of the sperm
progesterone and estrogen)
Injectable (same components as o Blocks the female reproductive tract
OCPs. E.g. Depot  For endometriosis and preventing pregnancies
99.7% o DMPA
Medroxyprogesterone
acetate/DMPA)  Progesterone can cause depression
 Male contaceptive pills
Bilateral Tubal Ligation (BTL) 99.5%
Vasectomy () 99.9%
D. IDEAL
Natural Family Planning Method
95-99%  A method will always be available for special purpose
(NFP)
NOTE: Efficacy rate is computed by = (100 %) - (% of women
METHODS
experiencing unintended pregnancy within 1st year of use of
 Breastfeeding/Lactational amenorrhea method (LAM)
contraceptive)
o Can cause amenorrhea for 4 months because
breastfeeding stimulates the secretion of prolactin that
B. ACCESSIBLE
suppresses the process of ovulation
 Government funded and promoted (Free!)
o The following family planning methods may be used
o No Scalpel vasectomy, tubal ligation in goverment
after delivery:
hospitals
 IUD and condom
o OCPs, DMPA, IUD, condom, NFP
 Injectibles and OCPs
 Accessible through drugstores, supermarts, online
 Progesterone: ONLY pills for lactating women
 Do not give Estrogen OCPs as this
C. SAFE
DECREASE milk production
SCIENTIFIC
 Two day contraceptive method
 Male and Female Reproductive System
 Uses cervical secretion
o You can well inform your patient about safety if you go
 SPINNBARKEIT MUCUS which is stringy,
back to the concept of the reproductive system. If you
stretchy in quality which indicates time of
know about all of this, you can inform your patient the
ovulation
mechanism and right use of family planning methods

OB 1 | 2 of 6 FERIA, BASTIAN, IMPERIAL

 Barrier methods for the “UNPREPARED”  Given as a treatment for endometriosis/
 Reversible methods (IUD) for the “UNDECIDED” dysmenorrhea because it suppresses
 Spacing with added benefits natural ovulation thus bypassing
o Cyproterone acetate menstrual cycle.
 Has testosterone effect  NET – EN (norethindrone enthanate)
 Benefits: Smooth skin o Given every 2 months
 Pills for the “NOT TOO BUSY” o Oil based
 Implants for the “TOO BUSY”  Noristerat
 Female condoms for those ”WHO CANNOT SUSTAIN o Causes depression in women and water retention
ERRECTION” causing them feeling of bloatedness.
 On-going research: Male contraceptives pills and tubal
implants COMBINED INJECTABLES
 Spray on condoms “COMING SOON!”  Contain estrogen and progesterone
 Given monthly
E. EXCITING  Lunelle, Mesigyna
 Abstinence to Schedule (base it on the Basal Body
Temperature, cervical mucus method, sympathothermal
chart, cervical mucus method)
 Variety of condoms SUBDERMAL IMPLANTS

F. REWARDING
 Achieve or prevent pregnancy
 Prevent STI’s, HIV and AIDs using condoms
 Noncontraceptive benefits from contraceptives: Clear
skin
 Benefits family to their goals and career
 Plastic capsules or rods inserted underneath the skin
IV. TYPES OF CONTRACEPTION  Contain progestin only
A. HORMONAL CONTRACEPTIVES o Norplant
ORAL COMBINED CONTRACEPTIVES (OCP)  Releases levonorgestrel
 Simulates the natural hormone cycle of  Six capsules
women  Effective for 5 years
 Contain estrogen and progestin o Jadelle
 Marvelon, Lady Pill, Nordette, Seif, Micropil  Releases levonorgestrel
 DO NOT give to lactating women. It  Two rods
prevents production of milk (because of  Effective for five years
estrogen) o Implanon
 Non – contraceptive benefits of combined oral contraceptives  Releases etonorgestrel
o Help prevent or reduce:  One rod
 Ovarian Cancer  Effective for three years
 Breast Cancer
 Iron- deficiency anemia TRANSDERMAL CONTRACEPTIVE PATCH
 Endometrial CA  Contains Ethinyl Estradiol and Norelgestromin
 Ectopic pregnancy o Square patch (4.45 cm each side)
 Ovarian cyst o Applied on the buttocks, abdomen, upper torso and
 Benign breast disease upper arm
 PID o One patch applied each week for three weeks to simulate
 Endometriosis the 21-day cycle
 Dysmenorrhea o Fourth week - patch free week
 Pre-menstrual Syndrome

PROGESTIN-ONLY ORAL CONTRACEPTIVES

 Exluton
 Cezarette
 Daphne

PROGESTIN-ONLY INJECTABLES
 DMPA: given every 3 months
 Water-soluble
o Depo-Trust
o Depo Provera
o Lyndavel

OB 1 | 3 of 6 FERIA, BASTIAN, IMPERIAL

VAGINAL RING D. SURGERY
 Releases Etonogestrel and Ethinyl estradiol FEMALE STERILIZATION
 Inserted into the vagina and left in place for  May be reversible with recanalization
3 weeks
 Withdrawal bleeding occurs on the fourth
ring free week

NOTE
The morning afterpill (before) is essentialy an extremely high
dose of pure estrogen. It is part of the rape or incest protocol
in the United States. Must be given 72 hours after sex.
However, it is not used anymore because it may cause
vaginosis
MALE STERILIZATION
B. BARRIER METHODS  Issues to address: Irreversibility
 Male Condom (Spray condoms!)  Not very popular among Filipinos and Christian institutions
 Female Condom
 Spermicides
 Cervical Cap
 Diaphragm
 Contraceptive sponge

C. NATURAL METHODS
STANDARD DAYS METHOD
 Makes use of color- E. THE EVOLUTION OF INTRAUTERINE DEVICE
coded string of beads  1960’s: Plastic IUDs
 Helps woman identify o Lippes loop
fertile days of cycle o Marguilies spiral
 Woman moves a rubber o Saf T coil
ring over one bead  Early 1970s : Copper
everyday to visibly track bearing IUDs
where she is in the o T Cu 7
menstrual cycle o T Cu 200
 Can be used by women with 26 to 32 days cycle o Nova T
 Can also be used with a standard calendar o Copper inhibits
sperm survival and
transport
o Copper interfere the
capacity of surviving
sperm to fertilize
egg
Menstrual cycle-whitebead  Second Generation Copper IUDs

TWO DAYS METHOD (SYMPTOTHERMAL METHOD)

 Helps women determine whether they are fertile in any given
day
 Based on the presence or absence of cervical secretions
(Spinnbarkeit)
 If the woman notices secretions either today or yesterday, a. TCu 380 A b.TCu 220 C c. Multiload Cu 375
she would consider herself fertile
 Monitoring mucus secretion as well as basal temperature (an o TCu 380A
increase with 1 deg C indicates ovulation)  Widely used IUD
 Plastic T frame
LACTATIONAL AMENORRHEA (BREASTFEEDING)  Contains 380 mm2 of copper
 Requirements:  Pregnancy rate of 0.6-0.8 effective for 10 years
o Mother is fully or nearly fully breastfeeding
o Mother is amenorrheic
o Mother is within the first 6 months after delivery

OB 1 | 4 of 6 FERIA, BASTIAN, IMPERIAL

 Medicated IUD= Levonorgestrel Intrauterine  No longer used for contraception
System: Mirena  Femenal
o Levonorgestrel releasing system 2. Low dose pills
o Effective for 5 years  Contain 30-35 mcg estrogen
o w/ progestin effects on endometrium  Widely used
o Thickens cervical mucus  Marvelon, Nordette, Trust, Logentrol
o Causes less bleeding 3. Ultra-low dose pills
o and dysmenorrhea than other IUDs  Contain 20-25 mcg estrogen
o Amenorrhea common  Mercilon, Meliane
 Used by women with side effects on higher
estrogen doses (Nausea, breast tenderness,
bloating)
 Lower doses were created to avoid the sideffects of
acne and stroke
 According to Doc, this is the Best family planning
for him because suppression of ovulation has its
non-contraceptive benefits such as supression of
o May be used for treatment of heavy prolonged bleeding breast and ovarian however they are not protected
and painful menstrual cramps from having STI.
o Useful alternative to endometrial ablation or  Monophasic or Multiphasic Pills?
hysterectomy o No significant differences in efficacy and bleeding
patterns
 Frameless IUD: Gynefix o Monophasic preferred over multiphasic
o No plastic T frame  Monophasic: a single amount of dosage
o Consists of several copper cylinders tied together on a  Multiphasic: alternating or varying dosage
string anchored on the fundus of the uterus - Biphasic/triphasic
o IUD is best preffered for patient with mental illness.  Which progestin to choose?
o Second Generation:
F. MALE HORMONAL CONTRACEPTIVES: IS IT  Levonorgestrel
FORTHCOMING?  Norgestrel
 Suppresses testosterone  Norethindrone
 Clinical trials in phase III stage of development  Ethynodiol Diacetate
 Consists of testosterone alone or in combination with  Examples: Lady Pill, Nordette, Micropil
progestin or GnRH o Third Generation
 Combination with progestin or GnRH produces more  Desogetsrel
suppression of sperm production and reduces testosterone  Gestodene
side effects  Norgestimate
 Not ready for clinical use  Examples: Marvelon, Gynera
o Other Progestins
V. CONCEPTS AND CONSIDERATION IN OCPS  Cyproterone Acetate
 Considerations in pills to be used  Examples: Diane, Althea
o Safety  Drospirenone
o Efficacy  Example: Yasmin
o Health needs  Pills containing third generation progestins
o Personal considerations o As effective as pills containing third generation
 28 or 21 pill? progestins
o Advantages of 28 pill preparation: o Less effect on CHO and lipid metabolism
 Increases compliance o Effective in reducing acne and hirsutism
 Avoids lengthening of pill free intervals o Linked to reports of increased risk of venous thrombosis
 Progestin only pill or combined pill?  Levonorgestrel or norethindrone containing pill?
1. Progestin only pill o Levonorgestrel provides good cycle control and
 Indicated for breastfeeding women and for women decreased breakthrough bleeding
whom estrogen is contraindicated or not desirable o Norethindrone reduces moodiness, acne, greasy hair
(however, some studies say that it is a risk factor and skin, and hirsutism
for ectopic pregnancy because it disrupts the  Use of cyproterone acetate containing pills
normal peristaltic movement of the fallopian tube) o Higher risk of venous thrombosis
2. Combined pill o Reserved for women with severe acne, hirsutism, PCOS,
 More effective and produces regular menstrual and androgenic alopoecia
cycles o Suitable alternatives: pills containing desogestrel and
 High dose, low dose, or ultra-low dose pills? norethindrone
1. High dose pills
 Contain 50 mcg or > estrogen
 Less safe

OB 1 | 5 of 6 FERIA, BASTIAN, IMPERIAL

 Drospirenone containing pills
o With anti-mineralocorticoid and anti-androgenic
properties
o Supress acne, seborrhea, hirsutism and bloating
o Does not cause bloating, no sodium and water retention,
which is why women like it
 Cost considerations
o Pills which cost 22 to 70 pesos
 Trust
 Lady Pill
 Seif
 Marvelon
 Micropill

CHECKPOINT
True or False
1. The perfect use rate for condom is 85 %.
2. Those under WHO categories 2 and 3 for temporary use
should not use contraception with limited clinical
judgement.
3. Estrogen-containing OCPs are good for lactating mothers
and will decrease milk production.
4. IUDs are permanent type of contraceptives
5. Spinnbarkeit mucus means fertilization already occurred
ANSWERS: (1) FALSE, (2) FALSE, (3) FALSE, (4) FALSE, (5) FALSE

END

OB 1 | 6 of 6 FERIA, BASTIAN, IMPERIAL