WHO MEC: Special situations MAR-2011-AP-(IN)-3627-SS 30-Aug-2012.

WHO MEC: Special situations

WHO MEC: Special situations

MAR-2011-AP-(IN)-3627-SS 30-Aug-2012 MAR-2011-AP-(IN)-3627-SS 30-Aug-2012

Efficacy of methods

Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year. United States of America.Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year. United States of America.

Contraceptive revolution – reversible methods

WHO medical eligibility criteriafor contraceptive use: classification

Condition: Category

For which there is no restriction on use of the method 1

Where the advantages generally outweigh the theoretical or proven risks

2

Where the theoretical or proven risks usually outweigh the advantages of using the method

3

Represents an unacceptable health risk of the contraceptive method if used

4


WHO medical eligibility criteriafor contraceptive use: classification

Category With clinical judgement With limited clinical

judgement

1 use method in any circumstances Yes

(use the method)2 generally use the method

3 use of method not usually recommended unless other more

appropriate methods are not available or not acceptable

No

(do not use the method)

4 method not to be used


Contraceptive Methods Available in India.Contraceptive Methods Available in India.Abbreviations mentioned in WHO MECAbbreviations mentioned in WHO MECContraceptive Methods Available in India.Contraceptive Methods Available in India.Abbreviations mentioned in WHO MECAbbreviations mentioned in WHO MEC

Low-dose combined oral contraceptives: COCs

Progestogen-only Pills: POPs

Intrauterine devices IUDs

Depot medroxyprogesterone acetate : DMPANorethisterone enantate : NET-NE

Copper-bearing IUD: Cu-IUDs

Levonorgestrel-releasing IUD (20 g/24hours): LNG-IUD

Combined contraceptive Vaginal Ring: R

Implant IMP


Case 1

A 18 year old unmarried woman, seeking contraception advice

She also c/o; constant pelvic pain worsening during menses

Medical History: None

Family History: No reports of bleeding disorder Obstetrical History: G0P0A0

Investigations: USG-NAD

WHO Guidelines

Condition Category

COC

Dysmenorrhea 1

Evidence: There was no increased risk of side-effects with COC use among women with dysmenorrhoea compared with women notusing COCs. Some COC users had a reduction in pain and bleeding1

1. Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009

Case-2

A 24 year old married woman, seeking contraception advice

She also C/O: constant pelvic pain worsening during menses

Medical History: None

Family History: No reports of bleeding disorder

Obstetrical History: G0P0A0

Investigations: USG- free fluid in the cul-de-sac

WHO Guidelines

Condition Category

COC

Endometriosis 1Evidence: A Cochrane Collaboration Review identified one randomized controlled trial evaluating the effectiveness of COC use compared with a GnRH analogue in treating the symptoms of endometriosis. Women with endometriosis did not report worsening of the condition or any adverse events related to COC use1.

1. Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009 2. Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotrophin-releasing hormone agonist versus a low-dose oral contraceptive for

pelvic pain associated with endometriosis. Fertility and Sterility 1993;60(1):75–9.

Case 3

A 35 year old female patient seeking advice on contraception

C/O: heavy menses

Family history: Mother underwent surgery for hysterectomy at the age of 45 due to uterine fibroids

Obs/Gyn History: G1P1A0

Investigations: USG- 4 heterogeneous structures, in the muscular layer without distortion of uterine cavity suggestive of leiomayomata.

WHO Guidelines

Condition Category

COC

Uterine Fibroids(With or without distortion of uterine cavity)

1

Comments: COCs do not appear to cause growth of uterine fibroids


Case 3

A 30 year old female patient complaining about irregular bleeding pattern seeks advice on contraception

Family history: unknown

Physical examinations: mild acne lesions on face and hirsutism on face and limbs

Obs/Gyn History: G1P0A1

WHO Guidelines

Condition Category

COCIrregular pattern without

heavy bleeding Heavy or prolonged bleeding

(includes regular and irregular patterns)

1


MEC use in women with different patterns of vaginal bleeding (WHO MEC 2009)

Vaginal Bleeding patterns Hormonal

contraceptivesProgesterone

only PillsProgesterone only

injections

Irregular bleeding without heavy bleeding 1 2 2

Heavy or prolonged bleeding (includes

regular or irregular)1 2 2

Unexplained vaginal bleeding (suspicious

of serious pathology) before evaluation

2 2 3

Medical Eligibility criteria (MEC)

• 1: A condition for which there is no restriction for the use of the contraceptive method• 2: A condition for which the advantages of using the method generally outweigh the theoretical or proven risks• 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method• 4: A condition that represents an unacceptable health risk if the contraceptive method is used.

DSG+EE Vs LNG+EE: Which one has better affect on acne

hirsutism and weight change

Sanam and Ziba, Saudi Med J 32:23-26, 2011

Design and Method

Amir hospital &Family Planning

Clinic

Health Centers, Samnan, Iran

Women ranging from 18-35 years with no contraindication to OCs and have not used hormonal contraception in past 6 months

Baseline analysis: weight, acne, number of leisions, hirsutism evaluation, SHBG

levels and free testosterone

DSG+EE Grpn=50

LNG+EE Grpn=50

n=100

Outcome analysis: weight, acne, number of leisions, hirsutism evaluation,

SHBG levels and free testosterone

0 months

1months

2 months

3 months

4 months

5 months6 months

Randomization

The effect of the pill on weight, hirsutism and acne

Sanam and Ziba, Saudi Med J 32:23-26, 2011

0.0121.0±2.02.8±4.2Terminal hirsutism severity

0.000-1.7±2.90.3±1.8Hirsutism severity changes

0.8362.7±4.42.5±4.3Base hirsutism severity

Hirsutism

0.001-3.0±6.20.4±3.3Number of acne changes

0.0111.8±3.64.7±6.7Terminal number of acne

0.7584.8±8.24.3±7.0Base number of acne

Acne

0.0000.0±2.53.3±3.6Weight Changes (Kg)

0.90265.3±11.065.8±15.6Terminal Weight (Kg)

0.57665.3±10.663.2±15.6Base Weight (Kg)

Weight

P-ValueDSG+EELNG+EEParameters

Case 4

A 28 year old female patient seeking advice on contraception

C/O: constant lower abdominal pain and lower back pain

Obs/Gyn History: G0P0A1 . (Surgical abortion of an unplanned pregnancy at a local clinic, two months ago.)

Investigations: USG- Relevant findings in transvaginal sonogram shows normal ovary close to thickened fallopian tube in right adnexa

WHO Guidelines

Condition Category

COC

Pelvic Inflammatory Disease(PID-Current)

1

Comments: COCs may reduce the risk of PID.


A summary of a few more situations where COC are favorable…

Condition Category Additional Notes

(Evidence/Comments)COC

Gestational Trophoblastic Disease

(decreasing or undetectable levels of β-HCG/ persistently

elevated β-HCG levels or malignant disease)

1 Evidence found COC use did not increase the risk of postmolar trophoblastic disease and some COC users experienced a more rapid regression in hCG levels, compared with non-users.

Endometrial Cancer 1 COC use reduces the risk of developing endometrial cancer. While awaiting treatment, women may use COCs. In general, treatment of this condition renders a woman sterile.

Ovarian Cancer 1 COC use reduces the risk of developing ovarian cancer. While awaiting treatment, women may use COCs. In general, treatment of this condition renders a woman sterile.

Cervical Ectropion 1 Cervical ectropion is not a risk factor for cervical cancer, and there is no need for restriction of combined hormonal contraceptive use

Medical eligibility criteria for contraceptive use. (ed 4). A WHO Family planning cornerstone. 2009MAR-2011-AP-(IN)-3627-SS 30-Aug-2012 MAR-2011-AP-(IN)-3627-SS 30-Aug-2012

WHO MEC: Special situations MAR-2011-AP-(IN)-3627-SS 30-Aug-2012.

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