Professional Documents
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Benefits WHO Tools COC
Benefits WHO Tools COC
Session I, Slide 1
Defining Contraception and Family
Planning
What is the definition of contraception?
Contraception is the intentional prevention of
pregnancy by artificial or natural means.
What is the definition of family planning?
Family planning allows individuals and couples to
anticipate and attain their desired number of children
and the spacing and timing of their births. It is
achieved through use of contraceptive methods and
the treatment of involuntary infertility.
– World Health Organization,
Department of Reproductive Health and Research
Session I, Slide 2
Family Planning Saves Lives
Region/ Number of Lifetime risk of
country maternal deaths maternal death 1 in:
Sub-Saharan Africa 162,000 39
Southern Asia 83,000 160
These 2 regions account for 85% of maternal deaths worldwide
Developed regions 1,700 4,300
Improves well-being
of families and
Helps achieve the communities
healthiest outcomes
Allow women and for women and their
couples to delay, children
space, and limit
pregnancies
Session I, Slide 6
Medical Eligibility Criteria for
Contraceptive Use
• Evidence-based
recommendations
• Use by policy-makers and
program managers to improve
access to, and quality of,
family planning services
• 19 contraceptive methods
• Variety of medical conditions
and client characteristics
• Periodic reviews and updates
Session I, Slide 7
Selected Practice Recommendations
for Contraceptive Use
• Evidence-based recommendations
on safe and effective use
• 33 questions related to
contraceptive methods
• Range of issues including initiation,
continuation, incorrect use,
treatment of side effects, and
some programmatic issues
• Use by policy-makers and program
managers
• Periodic reviews and updates;
latest update 2008 Session I, Slide 8
Family Planning:
A Global Handbook for Providers
• Essentials needed to provide
family planning clients with
good-quality care
• Latest guidance for delivering
19 contraceptive methods
appropriately and effectively
• Use by clinical providers
• Periodic reviews and updates;
latest update 2011
Session I, Slide 9
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
When clinical
Category Description judgment is
available
No restriction for Use the method under
1
use any circumstances
Session I, Slide 11
Combined Oral Contraceptives
Objectives
Participants will be able to:
• Describe the characteristics of COCs in a manner that clients
can understand
• Demonstrate how to screen clients for eligibility for COC use
• Describe when to initiate COCs
• Explain how to use COCs, what to do when pills are missed,
and when to return
• Address common concerns, misconceptions, and myths
• Explain how to manage side effects
• Identify conditions that require switching to another method
• Identify clients in need of referral for COC-related complications
Session I, Slide 12
COCs Key Points for
Providers and Clients
• Contains both estrogen and progestogen hormones.
Take a pill every day. • Works mainly by stopping ovulation.
• “Would you remember to take a pill each day?”
Effectiveness depends • No need to do anything at time of sexual intercourse.
• Very effective if taken every day. But if woman forgets pills,
on the user. Can be she may become pregnant.
very effective. • Easy to stop: A woman who stops pills can soon become
pregnant.
• Pills are not harmful for most women’s health and studies
show very low risk for cancer due to pills for almost all women.
Very safe. The pill can even protect against some types of cancer.
• Serious complications are rare. They include heart attack,
stroke, blood clots in deep veins of the legs or lungs.
Some women have
side-effects at first–
• Side-effects often go away after first 3 months.
not harmful and often
go away after first 3
months.
No protection against • For STI/HIV/AIDS protection, also use condoms.
STIs or HIV/AIDS. Session I, Slide 13
What Are COCs? Traits and Types
Session I, Slide 14
Effectiveness of COCs
In this progression of effectiveness, where would
you place combined oral contraceptives (COCs)?
Implants
More
effective Male Sterilization
Female Sterilization
Intrauterine Devices
Progestin-Only Injectables COCs
Male Condoms
Standard Days Method
Session I, Slide 16
COCs: Mechanism of Action
Suppresses
hormones
responsible for
ovulation
Thickens
cervical mucus
to block sperm
Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011 . Session I, Slide 18
COCs: Menstrual-Related Health
Benefits
• Decreased amount of flow and fewer days of
bleeding; no bleeding (less common)
Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis, 2007.
Session I, Slide 20
No Overall Increase in Breast Cancer
Risk for COC Users
Analysis of a large number of studies:
•No overall increase in breast cancer risk among women
who had ever used COCs
•Current use and use within past 10 years: very slight
increase in risk
– May be due to early diagnosis or accelerated growth
of pre-existing tumors
More recent study:
•No increase in breast cancer risk regardless of age,
estrogen dose, ethnicity, or family history of breast cancer
Source: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.
Session I, Slide 21
COCs and Cervical Cancer
• Cervical cancer is caused by certain types of human
papillomavirus (HPV)
• Some increase in risk among women with HPV and others
who use COCs more than 5 years
– Risk of cervical cancer goes back to baseline after 10
years of non-use
• Cervical cancer rates in women of reproductive age are low.
Risk of cervical cancer at this age group is low compared to
mortality and morbidities associated with pregnancy.
Most common:
Session I, Slide 25
COCs Are Safe for Nearly All Women
Session I, Slide 26
Who Can and Cannot Use COCs
Session I, Slide 27
Who Should Not Use COCs (part 1)
My period
is late… Breast
Breast
feeding a
babyaless
feeding
Are Think they than
baby less6
Are may be thanmonths
6
pregnant pregnant
pregnant Think they old
months
may be old
pregnant
vision problems
(fits), or HIV baby less
than 6
Think they months
may be old
pregnant
I cannot
eat Have serious
sweets.
liver disease or
gall bladder
disease
Session I, Slide 30
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Session I, Slide 31
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
1
Use the method
2
3
Do not use the method
4
Session I, Slide 32
Category 1 and 2 Examples (not inclusive):
Who Can Use COCs
Session I, Slide 33
Category 3 Examples (not inclusive):
Who Should Generally Not Use COCs
Session I, Slide 38
Combined Oral
Contraceptive Pills
(COCs)
Session III: Providing COCs
Session I, Slide 39
When to Start COCs (part 1)
Session I, Slide 41
When to Start COCs (part 3)
• After miscarriage or abortion
– If within 5 days after miscarriage or abortion, no backup method needed
– If more than 5 days after, rule out pregnancy, use backup method for
7 days
• Discuss:
– Easy to remember to take pills?
– “What would help you to remember? What else do you do
regularly every day?”
– Easiest time to take the pills? At a meal? At bedtime?
– Where to keep pills.
– What to do if pill supply runs out.
Session I, Slide 43
The Pill
Session I, Slide 45
The Pill
Missed Pills Instructions,
continued
Miss 3 or more active pills in a row or start a
pack 3 or more days late:
• Take a pill as soon as possible, continue taking 1 pill
each day, and use condoms or avoid sex for next 7 days
AND OR
• If inactive pills are missed, throw away the missed pills and
continue taking pills, 1 each day
Source: WHO, 2004; updated 2008; CCP and WHO, 2011.
Session I, Slide 46
Key Counseling Topics for COC Users
COCs:
• Do not build up in a woman’s body. Women do not need
a “rest” from taking COCs.
• Must be taken every day, whether or not a woman has
sex that day.
• Do not make women infertile.
• Do not cause birth defects or multiple births.
• Do not change women’s sexual behavior.
• Do not collect in the stomach. Instead, the pill dissolves
each day.
• Do not disrupt an existing pregnancy.
Session I, Slide 48
What to Remember
• Take one pill each day See a nurse or doctor if:
• If you miss pills, you can
• Severe, constant • Very bad
get pregnant pain in belly, chest, headaches
or legs
• Side-effects are common
but rarely harmful. Come
back if they bother you.
• Come back for more pills
before you run out or if
• A bright
you have problems. spot in your
vision
before bad
• Yellow skin
Anything else I can headaches
or eyes
repeat or explain?
Any other questions?
Session I, Slide 49
Follow-up for COCs
Session I, Slide 50
The Pill Return Visit
Let’s check:
•For any new health conditions
•When do you take your pills?
•What do you do if you forget a pill?
•Need condoms too?
Session I, Slide 51
Management of COC Side Effects
Session I, Slide 52
Management of COC Side Effects:
Bleeding Changes
Problem Action/Management
Irregular Reassure client: If side effects persist
bleeding reinforce correct pill and are unacceptable
taking and review to client:
missed pill instructions; if possible, switch pill
ask about other drugs
formulations or offer
that may interact with
COCs; administer short
another method.
course of non-steroidal
anti-inflammatory drugs
Amenorrhea Reassure client: no
medical treatment
necessary.
Session I, Slide 53
When to Return: Warning Signs of Rare
COC Complications
• Severe, constant pain in belly, • Very bad headaches
chest, or legs
Session I, Slide 54
Problems That May Require Stopping COCs or
Switching to Another Method
Problem Action
Unexplained vaginal • Refer or evaluate by history and pelvic exam
bleeding • Diagnose and treat as appropriate
• If an STI or PID is diagnosed, the client may
continue using COCs during treatment
• If the client develops migraines with or without
aura, or her migraine headaches worsen, stop
Migraines COC use
• Help the client choose a method without
estrogen
Problem Action
Starting treatment with • These drugs make COCs less effective; COCs
anti- convulsants or may make lamotrigine less effective.
rifampicin, rifabutin, or • Advise the client to consider other contraceptive
ritonavir methods (except progestin-only pills).
Session I, Slide 57