MODULE 4

HORMONAL CONTRACEPTIVE METHODS

OVERVIEW
This module discusses a group of artificial family planning methods that is known as hormonal methods. Hormonal methods contain one or both of the naturally occurring female hormones, estrogen and progesterone.

OVERVIEW
There are two types of hormonal contraceptives included in the Philippine Family Planning Program.  Combined contraceptives  Low dose COCs  Contraceptive Patch  Combined Injectable  Progestin only Contraceptives  Progestin-only Pills  Progestin-only injectable (POIs)

Module Objective
The module will make participants:
‡ Understand the features of hormonal contraceptives. ‡ Provide the hormonal contraceptives to appropriate clients.

Sessions
Session 1 Session 2 Session 3 Session 4
LowLow-dose Combined Oral Contraceptives (Low-dose COCs) (LowOther Combined Contraceptives ProgestinProgestin-only Pills

ProgestinProgestin-only Injectable Contraceptive (DMPA)

SESSION 1

LOWLOW-DOSE COMBINED ORAL CONTRACEPTIVES

Objectives
At the end of the session, the participants will be able to: ‡ Describe the low-dose COCs ‡ Relate the mechanism of action of the COC with the menstrual cycle. ‡ Explain the effectiveness of the COC. ‡ Enumerate the advantages and disadvantages of the COC. ‡ Discuss the possible side effects of the COCs and the management of these

Objectives
‡ Identify conditions suitable for COC use based on the WHO MEC and checklist ‡ Explain the guidelines in providing the COCs, including follow-up ‡ Enumerate the warning signs of complications of the COCs. ‡ Manage problems on using the COCs ‡ Correct myths and misconceptions on the COCs.

Description
‡ Known as pills or oral contraceptives ‡ Contains hormones similar to the woman·s natural hormones ²estrogen and progesterone.

Two Types
‡ 28 pills - has 21 "active" pills, which contain hormones, followed by 7 "inactive or reminder" pills of a different color. The reminder pills do not contain hormones 21 pills - contains only the 21 "active" pills.

‡

Mechanism of Action
‡ Prevents ovulation ‡ Thickens the cervical mucus, which makes it difficult for sperm to pass through.

Low-dose COCs do not disrupt an existing pregnancy

Effectiveness
‡ Correctly and consistently used = 99.7% ‡ As commonly used = 92%

Factors affecting effectiveness
‡ ‡ ‡ ‡ Correct and consistent use Proper storage, observance of shelf life and expiration date Vomiting or Diarrhea Drug Interaction

Possible Side Effects
‡ Nausea (first 3 months) ‡ Spotting or bleeding between menstrual periods ‡ Mild headaches ‡ Breast tenderness ‡ Amenorrhea

MEC WHEEL

Medical Eligibility Checklist for Combined Oral Contraceptives (COCs)

Guidelines on Initiating Use
‡ Advise the client to take one pill a day regularly, preferably at the same time, even if she is not having sex daily. ‡ A pack of 21 pills containing ´activeµ hormones requires a 7-day rest period before starting a new pack. ‡ A 28-day pack contains 21 ´activeµ pills and 7 ´nonhormoneµ tablets of a different color. The client takes a pill each day until she finishes the pack. No rest period required.

When to Start
‡ Start within the first 7 days of the menstrual period ‡ If started after the 7th day of her menses, abstain or use a back up contraceptive for the next 7 days. ‡ Low-dose COCs may be started anytime you can be reasonably sure that the client is not pregnant.

When to Start
POSTPARTUM: encourage feeding with breastmilk
‡ If fully or nearly fully breastfeeding more than 6 months, and no menses yet 
Start at any time for as long as reasonably certain that the woman is not pregnant.  Use back-up for the first 7 days of use

‡ If fully or nearly fully breastfeeding more than 6 months, and menses have returned = start within 7 days of menses ‡ If not breastfeeding = start at 3 weeks after delivery

When to Start
POSTABORTION
‡ May start immediately after an abortion. ‡ No back-up method needed if started within the first 7 days following the abortion.

Missed Pills
If a woman misses 1 or 2 active COC pill in any day of the first 3 weeks (first 3 rows) or starts a pack 1 day late
Take the missed pill as soon as she remembers

Take the scheduled pill at the usual time

Continue taking 1 pill at a time until pack is finished. No back-up is necessary

If a woman misses 3 or more active COC pills in the first 2 weeks (rows 1-2) or starts a pack 2 or more days late
Take the last missed pill as soon as she remembers Take the pill scheduled for the day at the regular time Abstain from sex or use back up method for the next 7 days Continue taking the pill until pack is finished.

Missed Pills
If a woman misses 3 or more active pills on the third week (row 3)
Discard inactive pills. Immediately start a new pack and continue taking the pill until the pack is finished.

Take the last missed pill as soon as she remembers

Continue taking the remaining active pills until consumed.

Abstain from sex or use back up method for 7 days

If a woman misses any non-hormonal pill (last row of pills in a 28-pill pack)
Start a new pack as usual and keep taking COCs one each day

Discard the missed nonhormonal pill(s)

Warning Signs
J-A-C-H-E-S J A C H E S Jaundice Abdominal pain, severe Chest pain, shortness of breath Headache, severe Eye problems, blurring of vision Severe leg pains

SEEK IMMEDIATE CONSULTATION

Follow-Up
‡ Return to the clinic:
² For re-supply ² At any time when any of the µwarning signsµ occur.

‡ For any concerns related to the use of the COC:
î Verify complaint by asking about the character, duration, accompanying symptoms î Refer to physician if further examinations are needed

CORRECTING RUMORS and MISCONCEPTIONS

Key Learning Points 
Compliance is increased in low-dose COCs users when proper counseling is performed.  Low-dose COCs are safe, effective, and reversible. They are some of the most extensively studied medications ever used by human beings. Serious side effects are very rare.  Low-dose COCs have many non-contraceptive health benefit

Key Learning Points 
Low-dose COCs may be used by healthy, nonsmoking women throughout their reproductive lives.  Clients should be provided with enough pills for more than three cycles, provided they have a safe place to store them and the program has enough stocks. Give more than three cycles when they have completed a three-month trial period on the lowdose COCs.

Key Learning Points 
Low-dose COCs appear to have no apparent overall effect on risk of breast cancer.  Low-dose COCs do not protect against STIs and HIV. Women at risk of infection must also be offered condoms.  Low-dose COCs are not recommended for breastfeeding women because they can reduce the milk supply

Session 2

Other Combined Contraceptives

Objectives
‡ ‡ ‡ ‡ ‡ Describe the contraceptive patch. Enumerate the advantages and disadvantages of the contraceptive patch. Discuss the possible side effects of the patch. Identify conditions suitable for use of the patch. Explain the guidelines in providing the COCs, including how to start and what to do for missed patch changes.

Objectives
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Describe the combined injectable contraceptive (CIC). Explain the mechanism of action of the CIC. Enumerate the advantages and disadvantages of the CIC. State the effectiveness of the CIC. Discuss the possible side effects of the CIC. Determine conditions suitable or unsuitable for CIC use. Explain how to use the CIC. Enumerate the ³warning signs´ for CIC use.

Description

Form of combined (estrogen + progestin) contraceptive applied to the skin that contains estrogen and progestin

Mechanism of Action

Hormones are slowly absorbed and released in the bloodstream causing inhibition of ovulation.

Advantages
‡ Effective (99%) ‡ No daily pill intake ‡ Regulates menstrual flow ‡ Can be stopped at any time by the client ‡ Does not interrupt sex ‡ Increased sexual enjoyment ‡ Convenient and simple to use ‡ Safe

Disadvantages
‡May be less effective in women with body weight greater than 90 kg. ‡Affects quantity and quality of breastmilk ‡Has to replace the patch every 7 days ‡Does not protect against STIs

Possible Side Effects
‡Skin irritation or rashes at the site of the patch ‡ Headache ‡ Menstrual bleeding irregularities ‡ Nausea ‡ Breast tenderness

Who Cannot Use
‡ Pregnancy ‡ Smoking and are 35 years old or over ‡ 35 years old or over and stopped smoking less than a year ago ‡ Breastfeeding ‡ Overweight ‡ History of current thrombosis ‡ History or current heart disease

How To Start
Having menses or switching from nonhormonal methods or POP
o Any day within the first 5 days of the menstrual cycle o Any time it is reasonably certain that she is not pregnant. If more than 5 days since menses started, she can start using the patch but should avoid unprotected sex for the next 7 days. Condom use is advisable.

How To Start (cont·d)
Switching from injectables
o Immediately, if it is reasonably certain she is not pregnant. No need to wait for menses.

After childbirth, breastfeeding, and no menses yet
o After she stops breastfeeding or at 6 months (whichever comes first)

How To Start (cont·d)
After childbirth, not breastfeeding
o Within 3 weeks after childbirth. No need to wait for resumption of menses. o After 3 weeks, any time it is reasonably certain that she is not pregnant. She will need to abstain from sex or use an extra protection for 7 days. o If not reasonably sure she is not pregnant, wait for menses before using the patch.

How To Use
Patch cycle: Apply a new patch once a week, every week, for 3 weeks (21 days). Stop for 7 days (patch-free days).

Missed Patch Changes
Forgot to change at the beginning of a monthly cycle: ‡ Apply one as soon as remembered and record this as your first patch day. ‡ Use back-up method for the next 7 days Forgot to change 1 or 2 days in the middle of the cycle: ‡ Change patch as soon as remembered. ‡ Back-up method is not needed.

Missed Patch Changes (cont·d)
Forgot to change by more than 2 days in the middle of the cycle: ‡ Put on a new patch as soon as possible. Begin a new 4-week patch cycle. ‡ Record the day and use back-up method for the next 7 days Forgot to remove 3rd patch: ‡ Remove as soon as remembered. ‡ No need to change patch change day or use back-up contraception.

Warning Signs
J-A-C-H-E-S J A C H E S Jaundice Abdominal pain, severe Chest pain, shortness of breath Headache, severe Eye problems, blurring of vision Severe leg pains

SEEK IMMEDIATE CONSULTATION

Description
‡ The combined injectable (CIC) is a contraceptive containing a combination of estrogen and progestin in an injectable form. ‡ Norifam
Norethisterone 50 mg Estradiol valerate 5 mg

Mechanism of Action

‡ Inhibition of ovulation ‡ Thickening of the cervical mucus Contraceptive effect is similar to that achieved by daily intake of the COC.

Advantages
‡ Similar to the COC with the following additional benefits: ² Does not require daily action ² No need to take a pill every day ² Private ² More regular monthly bleeding as compared to DMPA

Disadvantages
‡ Requires injection every month ‡ Delayed return to fertility after the woman stops the method (average of 1 month longer than with the COCs) ‡ Does not protect against STIs, including HIV

Effectiveness

‡ Effectiveness in preventing pregnancy in the first year of use:
² Correct use (no missed or late injections): 99% ² Typical use (some missed or late injections): 97%

Possible Side Effects
‡ Changes in monthly bleeding:
² Lighter and fewer days of bleeding ² Irregular ² Infrequent or prolonged bleeding ² No monthly bleeding

‡ Headaches ‡ Dizziness ‡ Breast tenderness

Who Cannot Use
‡ Women with the following conditions are advised not to use the CIC:
² Pregnancy ² Breastfeeding an infant < 6 months old ² Smoke cigarettes and > 35 years old ² Hypertension ² Migraine headaches ² Breast cancer ² Undiagnosed abnormal vaginal bleeding

How To Provide
‡ Schedule
² First injection is given on the first day of the menstrual cycle. ² Succeeding injections are given every 30 +/- 3 days

‡ Administering the injection
² Follow infection prevention guidelines ² Slow deep intramuscular injection preferably intragluteal or alternatively on the upper arm ² Place plaster over the injection site after injection to prevent reflux of the solution

Client Instructions
‡ What to expect
² Vaginal bleeding episode is expected within one or two weeks after the first injection. This is normal. ² With continued use, bleeding episodes will occur at 30 days interval. ² Visit the clinic if no bleeding occurs within 30 days after an injection to rule out pregnancy.

Client Instructions
Follow-Up
² Return to the clinic every 30 days for the next injection. ² If injection has not been given after 30 days, abstain from sexual intercourse or use condom until the next injection. ² Come back to the clinic no matter how late you are for the next injection. You may still be able to use the injectable.

Client Instructions
Return to the clinic at any time if:
² You develop any of the ´warning signsµ ² You have any questions or problems ² You think you are pregnant.

Warning Signs
J-A-C-H-E-S J A C H E S Jaundice Abdominal pain, severe Chest pain, shortness of breath Headache, severe Eye problems, blurring of vision Severe leg pains

SEEK IMMEDIATE CONSULTATION

Session 3

Progestin Only Pills (POPS)

Objectives
At the end of the session, the participants will be able to:
‡ Describe POPs and commonly available preparations. ‡ Relate the mechanism of action of the POP with the menstrual cycle. ‡ Enumerate the advantages and disadvantages of the POP. ‡ Enumerate the possible side effects of the POP. ‡ Explain the management of the possible side effects of the POP.

Objectives
At the end of the session, the participants will be able to:
‡ Identify conditions suitable for POPs based on the WHO MEC and checklist. ‡ Explain the guidelines in providing the POPs including follow-ups. ‡ Correct myths and misconceptions.

Description
Contains a small amount of only one kind of hormone«. progestin Does not contain estrogen

Kinds of POPs Available:
.5 mg lynestrenol (Exluton) 75 ug desogestrel (Cerazette) Both are available in 28 tablet package.

Mechanism of Action

‡ Causes thickening of the cervical mucus, which makes it more difficult for sperm to pass through ‡ Prevents ovulation in about half of menstrual cycles

Effectiveness

‡ For breastfeeding women, POPs are very effective: 99% when typically used, 99.5% when perfectly used. ‡ POPs are less effective for women not breastfeeding.

(Source: Family Planning, A Global Handbook for providers 2007)

Possible Side Effects
‡ Common
² Changes in menstrual bleeding: irregular periods, inter-menstrual bleeding and spotting

‡ Less common
² Amenorrhea for several months ² Prolonged or heavy menstrual periods ² Breast tenderness ² Headache

Possible Side Effects
1. Amenorrhea (No monthly bleeding)
‡ Reassure that this is normal for breastfeeding women. It is not harmful. ‡ For non-breastfeeding women, reassure that some women using POPs stop having monthly bleeding and not harmful.

Possible Side Effects
2. Irregular bleeding (bleeding at unexpected times that bothers the client)
‡ Reassure that many women using POPs experience irregular bleeding, whether breastfeeding or not. ‡ To reduce bleeding, teach her to make up for missed pills properly. ‡ Consider other underlying conditions unrelated to method use and refer appropriately

Possible Side Effects
3. Ordinary headaches
‡ Suggest pain relievers (Paracetamol, Aspirin, Ibuprofen) ‡ If get worse or occur more often during POP use, warrants evaluation.

4. Nausea or dizziness
‡ Suggest taking POPs at bedtime or with food.

MEC WHEEL

Starting Use of the POP
Menstruating
‡ Start within the first 5 days of the menstrual cycle, preferably on the first day ‡ At any time during the menstrual cycle if reasonably sure that the woman is not pregnant
If not within the first 5 days of the menstrual cycle = abstain from sex or use a back-up for the next 2 days

Starting Use of the POP
Postpartum
‡ If breastfeeding, start after 6 weeks postpartum ‡ If not breastfeeding, can start immediately or at any time within the 6 weeks postpartum.

Taking the POP

‡ ‡

Take one pill each day at the same time until the packet is finished. Start a new packet the day after she finishes the previous packet without break. No pill-free days.

‡

Missed Pills
‡ If missed taking the pills by more than 3 hours, abstain from sexual intercourse or use a back-up method during the next 48 hours after re-starting the pills. ‡ If breastfeeding and amenorrheic and missed pills more than 3 hours, take one pill as soon as possible and continue taking pills as usual. ‡ If still covered by LAM, no back-up is needed.

FollowFollow-Up
Reasons for follow-up follow‡ For questions or problems ‡ For warning signs of possible complications
Extremely heavy bleeding (twice as much and/or twice as long previous menses) Abdominal pain Headaches that start or become worse after she started POP Skin or eyes becoming yellow Symptoms of pregnancy

Key Learning Points 

POPs are pills that contain very low doses of progestin like the natural hormone progesterone in a woman·s body. POPs do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen. 

Session 4

Progestin Only Injectables (POI)

Specific Learning Objectives
At the end of this session, the participants will be able to:
Describe the POIs and available preparations. Relate the mechanism of action of the POI with the menstrual cycle. Discuss the effectiveness of POIs. Enumerate the advantages and disadvantages of DMPA. Identify clients who can and cannot use the DMPA using the MEC wheel and checklist.

Specific Learning Objectives
At the end of this session, the participants will be able to:
Enumerate the possible side effects of the DMPA. Explain the management of possible side effects of the Discuss the guidelines on DMPA provision. Correct myths and misconceptions on the POIs.

Description

‡ An injectable contraceptive containing a
synthetic progestin, which resembles the female hormone progesterone

‡ Available preparations:
DMPA(depot-medroxyprogesterone acetate) 150 mg. given every 3 months Noristerat (norethisterone enanthate) 200 mg. given every 2 months

Mechanism of Action
Inhibits Ovulation 

After a 150-mg-injection of DMPA , ovulation does not occur for at least 14 weeks. Levels of the follicle stimulating hormone (FSH) and luteinizing hormone (LH) are lowered and an LH surge does not occur. 

Thickens the Cervical Mucus 

The cervical mucus becomes thick, making sperm penetration difficult.

Effectiveness
Highly effective
‡ Perfect use: 99.7% ‡ Common/typical use: 97.0%

Effectiveness is dependent on having injections on time

DMPA is appropriate for«
Women who:
‡ Do not want others to know that she is using a contraceptive. ‡ Have problems of compliance with oral contraceptive intake. ‡ Cannot use an estrogen-containing contraceptive. ‡ Have completed her desired family size, but does not want sterilization.

DMPA is appropriate for«
Women who:
‡ Desire an effective long-acting, reversible contraceptive. ‡ Prefer a method that does not require any preparation before intercourse. ‡ Want a convenient method. ‡ Are breastfeeding and wants to use a hormonal method.

MEC WHEEL

Possible Side Effects
‡ Menstrual irregularities: breakthrough bleeding or spotting ‡ Amenorrhea ‡ Increased appetite

Management of Side Effects 

Amenorrhea: Reassure the client that amenorrhea is an expected side effect, and that she can expect menstrual cycles to return to normal within 6 months of discontinuing the POI. Menstrual irregularity: Reassure the client that breakthrough bleeding and spotting are common. 

Special Considerations 

Administering DMPA requires a sterile syringe and a 21-23 gauge needle. Ample supplies of both must be available Syringes and needles are manufactured for single use only and must be safely disposed of (in a sharps container, for example) following DMPA administration Storage conditions are critical to product stability. Follow manufacturer's storage recommendations.  

Timing of First Injection
For Interval Clients
‡ Preferably within 7 days of the menstrual cycle ‡ Any time it is reasonably certain that the woman is not pregnant. ‡ After 7 days of the menstrual cycle, advise the client to use a backup method or to exercise abstinence for the next 7 days.

Timing of First Injection

For Breastfeeding Clients
‡ As early as 6 weeks after delivery ‡ If menses have resumed, the woman can start injectables any time it is reasonably certain that the woman is not pregnant

Timing of First Injection
For Postpartum, Not Breastfeeding
‡ Immediately or at any time in the first 6 weeks after childbirth; no need to wait for menses ‡ After 6 weeks, any time it is reasonably certain that client is not pregnant ‡ If not reasonably certain that client is not pregnant, avoid sex or use condoms until her menses occur.

Timing of First Injection

For Postabortion Clients
‡ Immediately or within 7 days after an abortion. ‡ Any time it is reasonably certain that the client is not pregnant. ‡ If administered later than 7 days, avoid sex or use condoms for the next 7 days.

Return Visits and Follow-Up

‡ Clients return to the clinic for next
injection:
every three months for DMPA every two months for Noristerat for the next injection

‡ Advise every client during counseling and
during post-injection instructions about the importance of returning to the clinic on her scheduled date.

Return Visits and Follow-Up
‡ Come back no matter how late she is for the next injection. The injection may be administered 2 weeks early or 2 weeks late. ‡ Give her an appointment card or slip.

Return Visits and Follow-Up
WARNING SIGNS
‡ Severe headaches ‡ Heavy bleeding = twice as much and twice as long ‡ Severe lower abdominal pain ‡ Signs of pregnancy ‡ Swelling or prolonged bleeding at injection site

Key Learning Points
‡ Bleeding changes are common but not harmful. Typically, irregular bleeding for the first several months then no monthly bleeding ‡ Return for injections regularly. Every 3 months for DMPA ‡ Injections can be as much as 2 weeks early or late. Clients should come back even if later ‡ Return of fertility is often delayed. It takes several months longer on average to become pregnant after stopping POIs than after other methods.

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