Hormonal Contraception Management

Pharmacological therapy

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• Monophasic: Each tablet contains a fixed amount of estrogen and progestin
• Biphasic: Each tablet contains a fixed amount of estrogen, while the amount of progestin increases in the second half of the cycle
• Triphasic: The amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases
• Quadriphasic: A higher dose of estrogen is delivered at the beginning of the cycle and ends with the lowest dose; progestin dose is varied also during the cycle

Current evidence does not support the fact that other phasic formulations offer superior efficacy or improved bleeding patterns compared to monophasic formulations.  

Uses  

Usual cycle involves hormonal pills being taken for 3 weeks followed by a hormone-free week. In extended use, hormonal pills are taken for 12 weeks followed by a hormone-free week. This has only four scheduled withdrawal bleeds per year and reduced hormone withdrawal symptoms. In continuous use, there is uninterrupted intake of hormonal pills without a hormone-free interval.  

Indications  

Combination oral contraceptives are considered for any woman seeking a highly effective, reversible and coitally-independent method of contraception. They may be considered in women in whom estrogen is not contraindicated and who wish to take advantage of combination oral contraceptives’ non-contraceptive benefits. Ethinyl estradiol and Norgestimate may be used in women ≥15 years old for treatment of moderate acne unresponsive to topical anti-acne medications. Ethinyl estradiol and Drospirenone may also be used for the treatment of premenstrual dysphoric disorder symptoms in women taking oral contraceptives.  

Actions  

The main mechanism of action is suppression of midcycle gonadotropin secretion that in turn inhibits ovulation. They induce endometrial atrophy, stimulate production of viscous cervical mucus that impedes sperm transport, and affect secretion & peristalsis within the fallopian tube, interfering with ovum and sperm transport.  

Effects  

Combined oral contraceptive is a highly effective method of contraception. The failure rates in the first year of use are 0.3% in perfect users (correct and consistent use according to directions) and 7% in typical users (actual use which includes either incorrect or inconsistent use).  

Non-Contraceptive Benefits  

Combination oral contraceptives may decrease menstrual flow, dysmenorrhea, perimenopausal symptoms, and may improve acne, hirsutism and other signs of polycystic ovarian syndrome (PCOS). They may decrease risk of colorectal cancer, endometrial cancer, ovarian cancer, fibroids, ectopic pregnancy, ovarian cyst, benign breast disease, and premenstrual dysphoric disorder or premenstrual syndrome (PMS). They also regulate menstrual cycle and reduce risk of iron-deficiency anemia. Lastly, combination oral contraceptives increase bone density.  

Disadvantages  

Disadvantages of combination oral contraceptives include:

• Spotting during the first few cycles and with inconsistent use
• May suppress lactation and may cause decreased libido or anorgasmia
• Daily pill intake may be stressful
• Increased risk of cervical adenocarcinoma, but not squamous cell cervical cancer
• No protection against STI
• May cause hypertension in 1% of combination oral contraceptives users but this is reversible in 1 to 3 months after discontinuation
• Concomitant use of certain drugs (eg anticonvulsants, antiretroviral drugs, Rifampicin, Rifabutin) may lower its effectiveness

Absolute Contraindications  

Absolute contraindications to combination oral contraceptives include:

• Less than 6 weeks postpartum if breastfeeding
  • Use of a combination oral contraceptive during breastfeeding may affect growth and development of the infant because of diminished quantity of breast milk, decreased duration of lactation, and the infant’s exposure to steroids
• Less than 21 days postpartum not breastfeeding with VTE risk factors
• Smoker ≥35 years old (≥15 cigarettes per day)
  • Increased risk of CV events
• Obesity (BMI ≥40 kg/m²)
• CV disease (CVD)
  • Cerebrovascular accident or stroke, ischemic heart disease, multiple risk factors for arterial disease
• Hypertension (systolic BP [SBP] ≥160 mmHg or diastolic BP [DBP] ≥100 mmHg)
  • May have an increased risk of stroke or MI
• Current or past history of VTE
  • Less than 21 days postpartum not breastfeeding with other added VTE risk factors
• Vascular and congenital disease (complicated by pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
  • Combination oral contraceptive use may further increase the risk of arterial thrombosis
• Major surgery with prolonged immobilization
• Known thrombogenic mutations (eg Factor V Leiden)
• Migraine headache with focal neurological symptoms and aura at any age
• Gestational trophoblastic neoplasia (when hCG is abnormal)
• Current breast cancer
  • Breast cancer is a hormonally sensitive tumor, the prognosis may be worsened with combination oral contraceptive use
• DM with retinopathy nephropathy, neuropathy or DM >20 years in duration
• Severe decompensated liver cirrhosis
  • Combination oral contraceptive use may adversely affect women whose liver function is decreased
• Liver tumor (adenoma or hepatoma)
• Active viral hepatitis
• Reynaud’s disease
• Predisposed hyperkalemia (renal insufficiency, hepatic dysfunction, adrenal insufficiency) especially combination oral contraceptives containing Drospirenone
• Systemic lupus erythematosus (SLE) diagnosis with positive antiphospholipid antibodies

Relative Contraindications

• Breastfeeding between 6 weeks to <6 months postpartum
• Less than 21 days postpartum not breastfeeding without VTE risk factors
• Between 3 and 6 weeks postpartum not breastfeeding with VTE risk factors
• Smoker ≥35 years old (<15 cigarettes per day or stopped smoking <1 year ago)
• Obesity (BMI 35-39 kg/m²)
• Hypertension (SBP 140-159 mmHg, DBP 90-99 mmHg)
• VTE in a first degree relative <45 years old
• Immobility (unrelated to surgery)
• Migraine headache without focal symptoms and aura in patients ≥35 years of age
• Past history of breast cancer with no evidence of disease for 5 years and no known gene mutations associated with breast cancer
• Currently symptomatic gallbladder disease medically treated
• Mildly compensated cirrhosis
• History of combination oral contraceptive-related cholestasis
• Users of medications that may interfere with combination oral contraceptive metabolism (eg anticonvulsants, Lamotrigine [for combination oral contraceptives only], Rifampicin, Rifabutin, Fosamprenavir)
• Known hyperlipidemias
• Bariatric surgery – malabsorptive type (for combination oral contraceptives only)

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• Getational trophoblastic neoplasia
• History of breast cancer and no evidence of disease for 5 years
• Severe decompensated cirrhosis
• Acute viral hepatitis
• Liver tumor (adenoma or hepatoma)
• Use of medications that may interfere with progestin-only pill metabolism (eg anticonvulsants, Rifampicin, Rifabutin) (for progestin-only pills)
• SLE diagnosis with positive antiphospholipid antibodies
• Acute blood clot in lungs or deep veins of the legs
• Bariatric surgery – malabsorptive type (for progestin-only pills)

Progestin-only Contraceptive Implants  

Progestin-only contraceptive implants are long-acting reversible contraceptives (LARC) that contain Etonogestrel or Levonorgestrel. An implant containing Etonogestrel is effective for 3 years, while Levonorgestrel implants provide contraception for 3-5 years. Other available implant includes the subcutaneously-administered depot Medroxyprogesterone acetate (DMPA) which appears to be therapeutically similar to injectable DMPA.  

Indications  

Progestogen implants may be considered in any woman seeking a highly effective, reversible and coitally-independent method of contraception. These do not require daily attention and are suitable for poorly-compliant women. They may also be considered in women who are breastfeeding and in women in whom estrogen is contraindicated.  

Actions  

Progestin-only contraceptive implants suppress ovulation, thicken cervical mucus, and alter the endometrium.  

Effects  

Efficacy can be nearly 100%, thus a highly effective, reversible method of contraception. The efficacy of Levonorgestrel may be reduced near the end of the duration of use stated on the product’s label in patients who are overweight and obese and thus may need implant replacement sooner.  

Non-Contraceptive Benefits  

Non-contraceptive benefits of progestin-only contraceptive implants include decreased menstrual blood loss per cycle, thus less risk for anemia, decreased dysmenorrhea and risk of ectopic pregnancy, decreased pain with endometriosis, lactation is not affected, and lastly, help reduce the risk of endometrial cancer.    

Disadvantages  

The disadvantages of progestin-only contraceptive implants include frequent irregular menstrual bleeding and hormonal side effects, insertion and removal of the rods require a minor surgical procedure with local anesthesia, and the risk of implant migration into systemic vasculature.  

Absolute Contraindications  

The absolute contraindications of progestin-only contraceptive implants are same as progestin-only pills.  

Relative Contraindications  

The relative contraindications of progestin-only contraceptive implants are same as progestin-only pills; another is unexplained vaginal bleeding.

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• Liver disease (severe decompensated cirrhosis) or tumors (adenoma or hepatoma)
• CVD risk factors
• BP ≥160/100 mmHg
• Vascular disease, history of ischemic heart disease, stroke
• Acute deep vein thrombosis (DVT) or pulmonary embolism (PE)
• Past history of breast cancer with no evidence of recurrence for 5 years
• SLE diagnosis with positive antiphospholipid antibodies
• Unexplained vaginal bleeding
• DM with retinopathy, nephropathy, neuropathy or DM >20 years in duration

Progestin-only Contraceptive Intrauterine System  

Progestin-only contraceptive intrauterine system is also a LARC that releases Levonorgestrel directly into the uterine cavity.  

Indications  

Progestin-only contraceptive intrauterine system can be used on women who smoke and especially suited for women who have excessively heavy and painful menstruation; decrease in blood loss protects against iron-deficiency anemia.  

Actions  

Progestin-only contraceptive intrauterine system prevents fertilization, thickens cervical mucus, and impairs sperm passage.  

Effects  

The effectivity of progestin-only contraceptive intrauterine system is >99% with perfect use. The intrauterine system itself may contribute slightly to the contraceptive effect.  

Non-Contraceptive Benefits

The non-contraceptive benefits of progestin-only contraceptive intrauterine system includes reduction of the risk of endometrial and cervical cancer and the risk of ectopic pregnancy, and aiding in the treatment of endometrial hyperplasia, endometriosis and menstrual disturbances during perimenopause. Additionally, higher-dose Levonorgestrel IUD may be used to treat heavy menstrual bleeding and may be an alternative to endometrial ablation and hysterectomy.  

Disadvantages  

The disadvantages of progestin-only contraceptive intrauterine system includes the need to be inserted by a trained healthcare provider and the risk of ectopic pregnancy with failure of treatment or uterine perforation.  

Contraindications  

Contraindications of progestin-only contraceptive intrauterine system include: Not to be used in women 48 hours to 4 weeks postpartum, women with unexplained vaginal bleeding, benign gestational trophoblastic disease, cervical, endometrial, ovarian or current breast cancer, fibroids, current PID, purulent cervicitis, distorted uterine cavity, chlamydial or gonorrheal infection, puerperal sepsis, advanced HIV disease, acute blood clot in lungs or deep veins of legs, severe liver cirrhosis or tumor, and SLE with positive antiphospholipid antibodies and not on immunosuppressive therapy.  

Progesterone-releasing Vaginal Ring  

A progesterone-releasing vaginal ring is a flexible silicone vaginal ring that does not contain estrogen. It does not protect against STIs.  

Indications  

Progesterone-releasing vaginal ring may be considered for any woman seeking a highly effective, reversible and coitally-independent method of contraception that does not demand daily attention. Breastfeeding women >4 weeks postpartum can use the progesterone-releasing vaginal ring without restrictions. To maintain efficacy, active breastfeeding should be done (eg at least 4 times a day).  

Action  

Progesterone-releasing vaginal rings prevent ovulation.  

Effect  

The effectiveness of progesterone-releasing vaginal rings is 98-99%.  

Disadvantages  

Health risks of progesterone-releasing vaginal rings may be similar with that of Progestin-only pills.

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• Failure to use contraceptive method or failure to use additional contraceptive precautions when starting hormonal methods of contraception
• Barrier failure (eg condom breaks or leaks, diaphragm or cervical cap is dislodged)
• Unprotected intercourse or barrier failure during or within 28 days after use of liver enzyme-inducing drugs
• One missed pill in the first week of combination oral contraceptive use or ≥3 missed pills in the second or third week of combination oral contraceptive use
• Missed or late Progestin-only pill use
• Late administration of progestin-only injectable
• Partial or complete removal of IUDs without immediate replacement
• Ejaculation on the external genitalia
• After sexual assault (if victim is not using any reliable contraception)

Methods  

Emergency contraception should be used as soon as possible or any time up to 5 days after an unprotected sexual intercourse. As return of fertility is immediate after taking ECPs, it would not prevent a pregnancy from unprotected sexual intercourse >24 hours after taking ECPs. Estimated number of pregnancies in 100 women who had unprotected sexual intercourse during the second or third week of the menstrual cycle is as follows combination oral contraceptives 2, POPs 1, Levonorgestrel 1, Ulipristal acetate <1.  

Hormonal Regimen  

Emergency contraceptions will be more effective if given earlier.  

Combination oral contraceptives (Yuzpe method):

• Combined Ethinyl estradiol and progestins Levonorgestrel, Norgestrel or Norethisterone given for 2 doses, 12 hours apart
• Number of pills to take may vary from 2 to 5 pills per dose in some preparations

Progestin-only pills (eg Levonorgestrel or Norgestrel):

• Due to the very small amounts of hormone in progestin-only pills, several pills are given per dose (eg 40 pills for 0.0375 mg Levonorgestrel or 0.075 mg Norgestrel; 50 pills for 0.03 mg Levonorgestrel) but are safe to take

Levonorgestrel (dedicated ECP formulation) may be given as 2 doses of 0.75 mg Levonorgestrel taken 12 hours apart, or 1 dose of 1.5 mg Levonorgestrel. It is considered to be a more effective method, with fewer side effects than the Yuzpe method. It has been shown to prevent pregnancy by preventing follicular rupture or causing luteal dysfunction. However, it is not effective once fertilization has occurred and does not affect embryo-endometrial attachment. Levonorgestrel IUD is non-inferior to the copper IUD and may be inserted up to 5 days after unprotected intercourse. Resumption or initiation of any regular contraceptive method may be done immediately (ie the day after the last ECP dose) after emergency contraception with hormonal methods; the use of a back-up method for the first 7 days is needed.  

Antiprogestins  

Mifepristone  

Mifepristone is available in some countries as an effective post-coital contraceptive. Aside from binding to progesterone receptors and blocking progesterone effects. It may also disrupt luteal phase events and endometrial development.  

Ulipristal acetate  

Ulipristal acetate has shown to inhibit or delay ovulation and suppress growth of lead follicles if taken immediately before ovulation. However, it is ineffective in delaying follicular rupture if administered at the time or after luteinizing hormone (LH) peak. It has been found to be more effective than Levonorgestrel when taken within 72-120 hours of unprotected sexual intercourse. Either combined hormonal or progestogen-only contraceptives may be resumed or initiated on the sixth day after emergency contraception with Ulipristal acetate; use of a back-up method for the first 7 days is needed.  

Copper-bearing IUD  

Copper-bearing IUD should be offered to all eligible women who present within 120 hours after the first episode of unprotected sexual intercourse or within 5 days of the earliest date of ovulation. Notably, back-up contraception is not needed. Women generally continue to have regular menstrual periods. These IUDs release copper ions toxic to sperm cells while associated inflammation impairs ovum transport or implantation of the fertilized egg. These have been documented to have low failure rate and have shown to be more effective than hormonal emergency contraception, with an efficacy of >99%. They give long-term protection from pregnancy of up to 12 years; no delay in return of fertility after its removal. These also decrease the risk of ectopic pregnancy and may help protect against cervical and endometrial cancer. These can be given to breastfeeding women within 48 hours after childbirth. Otherwise, one must wait until 4 weeks. These should not be given to women 48 hours to 4 weeks postpartum, women with liver disease, unexplained vaginal bleeding, ovarian, uterine or cervical cancer, benign gestational trophoblastic disease, current PID, purulent cervicitis, distorted uterine cavity, chlamydial or gonorrheal infection, advanced HIV disease, or SLE with severe thrombocytopenia, or those at high risk for STIs at the time of IUD insertion. Routine antibiotic prophylaxis prior to insertion is not indicated. Women should undergo a pelvic examination and STI risk assessment before IUD insertion; it is not necessary to remove the IUD during treatment for a positive test result. If cervicitis is suspected, test for gonorrhea and chlamydia. Women should be advised of the risk of PID in the first 20 days following insertion if she has gonorrhea or chlamydia.

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Nonpharmacological

Determinants of Effective Contraceptive Method  

Information Provided by Healthcare Providers  

Information that is provided by healthcare providers include:

• Birth control options and their effectiveness
• Specific characteristics of the contraceptive method
• Common adverse effects
• Balance between risks and benefits of the method
• Instructions on the correct use of the chosen method
• Actions to be taken in case problems arise
• Strategies to help with consistent use of a specific method over time
• Information to avoid STIs

Woman’s Attitude Towards Specific Method  

It is important that there is openness in discussing contraception with the physician and partner on personal perception or matters concerning sexuality. The woman’s perception on what method is accepted or rejected by partner, relatives, or society as a whole, greatly influences her choice and compliance.  

Specific Behavioral Skills  

Formulation of the contraceptive health agenda is also important to consider.  

Environmental Factors  

Healthcare workers should consider factors that may lessen the ability of the woman to use method effectively, such as women in abusive or disempowered relationships, cost of contraception, those who are chemically dependent, etc.    

Patient Education  

Combination Oral Contraceptives  

It must be noted that combination oral contraceptives may be used from menarche to menopause. One may start combination oral contraceptive use ≥6 months postpartum if breastfeeding, >42 days postpartum if not breastfeeding. If combination oral contraceptive is started initially between 1 to 5 days of the menstrual cycle, there is no need for additional contraception. If started beyond this period, pregnancy should be excluded, and additional contraception for 7 days is advised. Ovulation is effectively inhibited after combination oral contraceptive for 7 consecutive days. Combination oral contraceptives should be taken every day, at around the same time, for 21 to 24 consecutive days followed by hormone-free days. Women using a 21-day preparation should be cautioned not to exceed the 7-day hormone-free interval due to potential ovulation. If combination oral contraceptive pill is taken >24 hours after the scheduled time, it is considered missed. For missed doses, the pill should be taken as soon as it is remembered and subsequent pills taken at the usual time. Delaying the start of combination oral contraceptives by >24 hours or missing one or more doses of combination oral contraceptives during the first week may decrease contraception. Use back-up contraception (eg abstinence condom use) with missed doses in the second or third week of hormone use until the combination oral contraceptive has been used for 7 consecutive days. Hormone-free intervals are eliminated when ≥1 days of combination oral contraceptives are missed in the third week to maintain contraception then start taking pills from the next pack. Contraception is not needed in the first 3 weeks after childbirth and is not recommended because there is increased risk of VTE. Non-breastfeeding women may start combination oral contraceptives 21 to 24 days postpartum. If it started beyond this, additional contraception is needed for 7 days. Women should be informed on symptoms which would prompt immediate medical consultation (eg warning signs of VTE, headache, eye problems, jaundice, abdominal pain). Follow-up visit 3 months after the first prescription of combination oral contraceptive is important to assess BP, medical problems, and give further instructions. It is important to note that fertility is restored within 1 to 2 weeks after stopping combination oral contraceptives. Post-pill amenorrhea is more common in women with history of very irregular menstruation but rarely persists up to 6 months.  

Combination Injectable Contraception  

Estradiol cypionate 5 to 10 mg and Medroxyprogesterone acetate 25 to 50 mg is administered with no more than 33 days between injections, though can be given 7 days early or late from scheduled date. If started within 7 days after the start of monthly bleeding, there is no need for a back-up contraception, but if started beyond this period, pregnancy should be excluded and back-up contraception is advised for the first 7 days after the injection. Lastly, return to fertility is rapid & may be as soon as 6 weeks after the last injection.  

Combination Transdermal Patch  

Combination transdermal patch is applied to clean, dry, hair-free skin on the buttock, lower abdomen, upper outer arm, or upper torso on the same day each week. One must avoid placing the patch on exactly the same site for two consecutive weeks. One must also avoid irritated or broken skin, breasts or skin in contact with tight clothing or cosmetics. One must smooth edges down upon application. Women should check the patch every day, making sure all edges remain closely attached to the skin. The location of patch should not be changed in mid-week. If started on first day of the menstrual cycle, no back-up contraception is needed, and after ruling out pregnancy, patch can be applied anytime with back-up contraception for 7 days. A new patch is applied every week for 3 weeks, followed by 1 patch-free week. Only 1 patch should be used at a time and the patch-free interval should not exceed 7 days. If the patch change is delayed by up to 48 hours in the middle of the cycle, there is no need for additional contraception, but if the patch-free interval is >9 days, a new patch should be applied and back-up contraception for 7 days should be used. Early detachment of the patch and delayed removal or application are considered missed or incorrect use of contraception. Avoid adhesive bandages, tattoos or decals on top of the patch which may affect absorption of hormones. Lastly, the same return of fertility as combination oral contraceptive occurs after discontinuing the method.  

Combination Vaginal Ring  

Combination vaginal ring is inserted into the upper two-thirds of vagina within the first 5 days of menstruation and left in place for 3 weeks (1 cycle). A cycle of continuous ring use should be followed by a 1-week ring-free interval to allow withdrawal bleeding. If the ring is used >3 weeks, the patient can take a ring-free week amd then insert ring to continue 21/7 schedule. If the ring-free interval is prolonged, use back-up contraception up to the first 7 days of ring use. When a vaginal ring falls out or is removed for any reason, it may be placed back in within 2 hours for Segesterone acetate/ethinyl estradiol, and 3 hours for Etonogestrel/ethinyl estradiol after cleaning the ring; no back-up contraception is needed. Fertility after discontinuation is immediate and excellent. The average return to ovulation is 11 days.  

Progestin-only Pills  

The initial pill may be taken within day 1 to 5 of the menstrual cycle and then taken once daily continuously with no hormone-free days except for Drospirenone which is taken for 24 days with 4 hormone-free days; no additional contraception needed. The initial pill may also be taken at any other time, provided that pregnancy has already been ruled out, but additional contraception should be used for the first 48 hours. In postpartum women, the pill can be started from day 21 with no additional contraception, however if started after day 21, additional contraception is needed for the first 48 hours. Pills must be taken at the same time each day (at least within 3 hours after the 24-hour lapse) for traditional progestin-only pills. The efficacy is reduced if dose is delayed by >3 hours when using traditional progestin-only pills, so back-up contraceptive method is recommended for 48 hours if a woman is >3 hours late taking the dose. A back-up method may also be recommended each month at mid-cycle. Desogestrel, a novel POP, has a 12-hour pill intake window. Delay in intake of Desogestrel 75-mcg tablet of >12 hours could reduce contraceptive efficacy. Fertility returns rapidly to baseline after discontinuation. If the patient develops new symptoms of migraine, stroke or heart disease while on progestin-only pills, discontinue use, noting, however, that no causal association has been linked between progestin-only pill use and CVD (eg stroke or MI).  

Progestin-only Contraceptive Implants  

Depending on the formulation, progestin-only contraceptive implants may consist of 1-6 matchstick-sized rods containing the hormone and is then inserted into the inner aspect of the upper arm. Notably, the 6-rod implant is no longer in production. The implant is inserted during the first 5 to 7 days of the cycle (depending on the product used). If inserted after this, additional contraception is required for the first 7 days. They may be inserted immediately postpartum regardless of the breastfeeding status. Fertility is restored rapidly and completely after 3 to 6 weeks of removal.  

Progestin-only Injectable Contraceptives  

The injectable is given within the first 5 to 7 days of menstrual cycle every 8 to 12 weeks (depending on product used) to provide contraception for up to 2 to 3 months. Importantly, do not massage area where the shot was given for a few hours as it may reduce efficacy. DMPA can be given 2 weeks before or 4 weeks after the scheduled injection date while Norethisterone enanthate can be given 2 weeks before or after the scheduled injection date. Women should be counseled about the likelihood of menstrual disturbance and the potential for a delay in return to full fertility; it may take up to 10 months for DMPA and 5 months for Norethisterone enanthate.  

Progestin-only Contraceptive Intrauterine System  

Progestin-only contraceptive intrauterine system is inserted in the uterus during the first 7 days of menstrual cycle (can be inserted at any time if not pregnant) and the 52-mg IUD is effective for up to 5 years. Patients can retain the 52-mg IUD for up to 8 years. Nulliparous women can use a smaller IUD: 13.5 mg IUD for 3 years of use or 19.5 mg IUD for 5 years of use. It may also be inserted within 48 hours after delivery, >6 months after postpartum and immediately post abortion except for septic abortion. A higher continuation rate and risk of expulsion are associated with immediate insertion postpartum or postcesarean section. It can be given to breastfeeding women within 48 hours after childbirth, otherwise one must wait until 4 weeks. It must be noted that irregular bleeding is common in the first 4 to 6 months of use then amenorrhea develops. Routine antibiotic prophylaxis prior to insertion is not indicated. Women should undergo a pelvic examination and STI risk assessment before IUD insertion; it is not necessary to remove the IUD during treatment for a positive test result. If cervicitis is suspected, one must test for gonorrhea and chlamydia, and women should be advised of the risk of PID in the first 20 days following insertion if she has gonorrhea or chlamydia. Lastly, the return of fertility is rapid & complete after removal.  

Progesterone-releasing Vaginal Ring  

The vaginal ring is inserted into the vagina 4 to 9 weeks after childbirth and left in place for 90 days. The patient can use 4 rings, one after another, for 1 year after childbirth. Vaginal ring is not recommended to be removed during intercourse. Women who want to remove it may do so as long as the ring is put back in place within 2 hours. When the ring falls out, it may be placed back immediately after washing the ring with water. Lastly, there is no delay in the return of patient’s fertility after stopping its use.

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