Obstetrics & Gynecology: Contraception Nozer Sheriar, Mala Arora, Paul D Blumenthal, Ritu Joshi
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fm1World Clinics Obstetrics and Gynecology Contraceptionfm2
fm3World Clinics Obstetrics and Gynecology Contraception
Editor-in-Chief Mala Arora FRCOG (UK) FICOG FICMCH Guest Editors Paul D Blumenthal MD MPH Nozer Sherlar MD DNB FICOG FCPS DGO Ritu Joshi MS June 2013 Volume 3 Number 1
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Cover images: (Left) The levonorgestrel-releasing intrauterine system: A polyethylene T-shaped contraceptive device. Courtesy: Seetha R Pal, Bhaskar Pal. (Middle) Three to eight coils showing outside the ostia. Courtesy: Vinod Kumar, Janesh K Gupta. (Right) The vaginal ring: Each ring contains 2.7 mg ethinylestradiol (EE) and 11.7 mg etonogestrel (ENG) uniformly dispersed within the ethylene-vinyl acetate (EVA) core. Ring releases 15 μg/day EE and 120 μg/day ENG. One ring per cycle regime includes 3 week of ring use and one ring-free week. Courtesy: Suchitra N Pandit, Gorakh G Mandrupkar, Rakhee R Sahu.
World Clinics Obstetrics and Gynecology: Contraception
June 2013, Volume 3, Number 1
ISSN: 2248-9517
9789351523611
Printed in India
fm5Contributors
Editor-in-Chief
Guest Editors
Contributing Authors
fm13Editorial
Mala Arora FRCOG (UK) FICOG FICMCH
Editor-in-chief
‘I am a woman. My person is my own.
I must decide alone, when my body I share. With children I may bear.
I am a woman. I urge you not to see. My femininity, as my fecundity!’
Loella Lobo Prabhu
The burden of unintended pregnancies is borne not only by the woman but also by the family and by society at large. This influences the maternal mortality rate directly and indirectly related to induced abortions; it influences the infant mortality rate due to maternal neglect and robs the family unit of its harmony. Hence, unintended pregnancies pose a serious public health issue. Moreover, from the rights perspective, a woman is entitled to use contraception till such time that she is mentally and physically ready to endure a pregnancy.
The couple protection rate is the lowest in the developing world due to illiteracy, ill-founded myths in society, lack of resources as well as shortage of trained personnel. The burden of teenage pregnancies is high due to lack of awareness of contraceptive services at that age. Hence, we need to pool in our current resources to increase awareness as well as to make available a choice of contraceptives. Women are most receptive to counseling during the postabortion and postpartum phase. This should be followed up by the easy availability of affordable contraceptives at their doorstep.
We have long realized that a cafeteria approach is the most suitable and availability of an empathetic counselor will improve acceptability. Information needs to be dispensed in the local language, whether verbal or written. Various public health models have proved that the decision to choose a contraceptive method is private and requires its acceptance by the partner, although this is not a legal binding.
Broadly, contraceptives may be classified as permanent or reversible, which may further be short-or long-acting. Permanent methods of standard/no scalpel vasectomy for the male and hysteroscopic/laparoscopic sterilization for the female are minimally invasive surgical techniques.fm14
Reversible methods include hormonal contraception (both oral as well as non-oral) intrauterine devices and barrier methods. These are suitable for couples in a stable relationship. Natural methods of identifying the fertile period and practicing abstinence are suitable for women with regular menstrual cycles with infrequent coital contact. Breastfeeding should be promoted, as not only is it beneficial for the baby, lactational amenorrhea also provides contraception. Progestin-only pill is advised in breastfeeding mothers. Emergency contraception is useful for women with unexpected sexual encounters, especially rape and one-night stands.
Hormonal contraceptives may be administered as oral pills, vaginal rings, skin patches, or subdermal implants. They are safe and efficacious. In women with co-existing medical disorders, the WHO medical eligibility criteria should be consulted. Hormonal contraceptives also provide a wide range of noncontraceptive benefits in women with heavy menstrual bleeding, dysmenorrhea, adenomyosis, endometriosis, benign ovarian cysts, and endometrial hyperplasia. They are widely employed for regulating ovarian stimulation protocols in assisted reproductive techniques. They lower the incidence of ovarian, endometrial, and colorectal cancers.
The intrauterine devices, both copper-containing and medicated are excellent long-acting reversible methods of contraception and can be safely used in nulliparous women, as well as teenagers who are likely to default with daily pills.
Barrier methods, both male and female condoms, are essential to prevent sexually transmitted infections (STIs) and according to current recommendations, should be combined with all other methods of contraception to reduce the incidence of STI's, especially HIV/AIDS. The current version of the female condom is being redesigned to provide comfort and protection from STIs to sex workers.
The rising burden of teenage pregnancies and induced abortions can be significantly reduced by easy availability and increasing awareness about contraceptives. The National Health Service in UK runs family planning courses for medical personnel. There is need to certify both medical and paramedical personnel in family planning counseling. School health programs need to integrate and dispense contraceptives to reduce the teenage pregnancy rates. The health workers in rural areas need to be trained to counsel and dispense contraceptives. Media plays an important role in sensitization of the society. Acceptance is improved, if key opinion leaders act as mentors and express their opinion publicly.
World population is increasing by 1.14% per year and is currently 7 billion. If not checked, it will outstrip the natural resources of our planet. This book is an endeavor to integrate knowledge and current research in the field of contraception for the medical practitioners.
Mala Arora FRCOG (UK) FICOG FICMCH
Director, Noble IVF Centre, Faridabad, Haryana, India.
Consultant, Fortis La Femme, New Delhi, India
Email: narindermala@gmail.com
fm15Abbreviations ACOG
American College of Obstetricians and Gynecologists
AIDS
Acquired immunodeficiency syndrome
APS
Antiphospholipid syndrome
ART
Antiretroviral therapy
ARV
Antiretroviral
BBDs
Benign breast diseases
BBT
Basal body temperature
BET
Bromodomain and extraterminal
BMD
Bone mineral density
BP
Blood pressure
CASH
Cancer and steroid hormone
CCP
Center for Communication Program
CICs
Combined injectable contraceptives
CIN
Cervical intraepithelial neoplasia
COCs
Combined oral contraceptives
CPA
Cyproterone acetate
CSSM
Child survival and safe motherhood
CT
Computed tomography
CVA
Cerebrovascular accident
CVR
Combined vaginal ring
D&E
Dilation and evacuation
DALY
Disability-adjusted life years
DES
Diethyl stilbestrol development
DMPA
Depot medroxyprogesterone acetate
DNA
Deoxyribonucleic acid
DVT
Deep vein thrombosis
E2
Estradiol
E2C
Estradiol cypionate
E2V
Estradiol valerate
EC
Emergency contraception
EE
Ethinyl estradiol
EHFM
Electronic hormonal fertility monitor
ENG
Etonogestrel
EVA
Ethylene-vinyl acetate
FCs
Female condoms
FP
Family planning
FSH
Follicle-stimulating hormone
GDM
Gestational diabetes mellitus
GnRH
Gonadotropin-releasing hormone
HAART
Highly active antiretroviral therapy
HCA
Healthcare assistant
hCG
human chorionic gonadotropin
HCs
Hormonal contraceptives
HFI
Hormone-free interval
HIV
Human immunodeficiency virus
HLD
High-level disinfection
HPV
Human papillomavirus
HTN
Hypertension
ICSI
Intracytoplasmic sperm injection
ICTC
Integrated Counseling and Testing Centers
IEC
Information, education, and communication
IHD
Ischemic heart disease
IMR
Infant mortality rate inhibitors
IPPF
International Planned Parenthood Federation
IRH
Institute for Reproductive Health
IUCD
Intrauterine contraceptive device
IUS
Intrauterine systems
IVF
In vitro fertilization
JSSK
Janani Shishu Suraksha Karyakram
LAM
Lactational amenorrhea method
LARC
Long-acting reversible contraceptive
LH
Luteinizing hormone
LHRH
Luteinizing-hormone releasing hormone
LIF
Leukemia inhibitory factor
LNG
Levonorgestrel
fm16LNG-IUS
Levonorgestrel-releasing intrauterine system
MCH
Maternal and child health
MCHIP
Maternal and Child Health Integrated Program
MDG
Millennium development goals
MEC
Medical eligibility criteria
MI
Myocardial infarction
MPA
Medroxyprogesterone acetate
MRI
Magnetic resonance imaging
NES
Nestorone
NET-EN
Norethisterone enanthate
NFP
Natural family planning
NG
Norgestrel
NICE
National Institute for Health and Clinical Excellence
NICHD
National Institute of Child Health and Human Development
NNIs
Non-nucleoside inhibitors
NRHM
National Rural Health Mission
NRTIs
Nucleoside reverse-transcriptase inhibitors
NSV
No-scalpel vasectomy
OCPs
Oral contraceptive pills
OTC
Over-the-counter
P4-IUS
Progesterone intrauterine system
PAC
Postabortion Care
PC-6
Proprotein convertase 6
PET
Polyethylene terephthalate
PI
Pearl index
PID
Pelvic inflammatory disease
PMS
Premenstrual syndrome
POIs
Progestogen-only injectables
POP
Progestogen-only pill
PPFP
Postpartum family planning
PPH
Postpartum hemorrhage
PPIUCD
Postpartum intrauterine contraceptive device
PSA
Prostate-specific antigen
PSI
Population Services International
RA
Rheumatoid arthritis
RCH
Reproductive and child health
RISUG
Reversible inhibition of sperm under guidance
RMNCH+A
Reproductive, Maternal, Newborn, Child, and Adolescent Health
RTI
Reproductive tract infection
SCD
Sickle-cell disease
SDM
Standard day's method
SELENA
Safety of estrogens in lupus erythematosus national assessment
SHBG
Sex hormone-binding globulin
SLE
Systemic lupus erythematosus
SMA
Styrene maleic anhydride
SPRM
Selective progesterone receptor modulator
SRS
Sample registration survey
STDs
Sexually transmitted diseases
STI
Sexually-transmitted infection
TFR
Total fertility rate
UIP
Universal Immunization Program
UPA
Ulipristal acetate
UPT
Urine pregnancy test
VTE
Venous thromboembolism
WC
Woman's condom
WRAI
White Ribbon Alliance of India
ZDV
Zidovudine