Family Planning Training Resource Package Summary of Updates in the WHO Medical eligibility criteria for contraceptive use, Fifth edition, 2015

Medical Eligibility Criteria for Contraceptive Use Offers evidence-based recommendations on contraceptive eligibility in the presence of medical conditions and client characteristics Covers 20 contraceptive methods Fifth edition included review of fourteen topics (encompassing over 575 recommendations) In many instances, either no new evidence was identified, or emerging evidence confirmed previous findings. Therefore, relevant recommendations in 4th edition were reviewed and upheld.

MEC 2015 Executive Summary Presents the summaries of key recommendations about the updates. May be downloaded at: http://www.who.int/reproductivehealth/publications/family_planning/Ex-Summ-MEC-5/en/

MEC wheel 2015 update Based on the MEC, provides quick information on who can use methods Includes COCs, POPs, DMPA, NET-EN (IM&SQ), implants, and copper IUDs, LNG-IUD, combined injectable contraceptives, patch, vaginal ring Available in print version, may also be downloaded: http://www.who.int/reproductivehealth/publications/family_planning/mec-wheel-5th/en/

Other WHO FP Cornerstones Selected Practices Recommendations for contraceptive use Range of issues including initiation, continuation, incorrect use, treatment of side effects, and some programmatic issues Being updated, will be available in late 2015 Family Planning: A Global Handbook for Providers Essentials needed by clinical providers to provide quality care Present guidance for delivering contraceptive methods appropriately and effectively Update underway Suggested script: Selected Practices Recommendation for Contraceptive Use Similar to the process used to develop the medical eligibility criteria, WHO assembled a team of experts to review existing evidence and make recommendations about how to use contraceptive methods safely and effectively when clients are determined to be medically eligible. The recommendations are conveyed in the answers to thirty-three questions included in the Selected Practice Recommendations for Contraceptive Use. The questions were selected based on 1) important controversies or inconsistencies in existing guidance, 2) the likelihood that relevant evidence was available, and 3) proposals from expert working group participants and family planning organizations or agencies. The SPR provides guidance on the use of hormonal contraceptives, IUDs, emergency contraception, fertility awareness-based methods, and sterilization on a range of issues including: initiation and continuation, adjustments for incorrect use such as missed pills or other problems during use such as vomiting or diarrhea, treatment of menstrual abnormalities, and what to do if an IUD user is diagnosed with pelvic inflammatory disease or becomes pregnant. The document also includes recommendations on several programmatic issues such as, which examinations or tests should be done routinely before providing a method of contraception, advice on how many packs of oral contraceptive pills should be given at initial and return visits, what type of follow-up is appropriate for combined oral contraceptive (COC), progestin-only pill (POP), implant and IUD users; and guidance that providers can use to be reasonably sure that a woman is not pregnant. The SPR guidance is intended to be used by policy-makers, program managers, and the scientific community to provide guidance to national family planning and reproductive health programs in the preparation of guidelines for service delivery of contraceptives. Much like the MEC, many countries have incorporated the guidance in this document into their national service delivery guidelines. The team of experts meets every four to five years to review new research findings and update their recommendations. WHO introduced updates to the SPR in April of 2008. At that time, very few changes were made, so instead of reprinting the whole document, a short  document just giving the updates was developed as an insert to the book. The new edition of the SPR is due to come out in late 2015 with new updates from the last Guidelines . These updates are will be reflected in the technical information in this training resource package. Global Handbook As the title suggests, Family Planning: A Global Handbook for Providers, translates scientific evidence on family planning into practical guidance for health providers. The handbook reflects the consensus of experts from leading health organizations and is based on the guidance from the Medical Eligibility Criteria for Contraceptive Use and the Selected Practice Recommendations for Contraceptive Use. The Global Handbook provides guidance on the provision of 19 contraceptive methods and other key reproductive health issues. Each of the method chapters describe the characteristics of the method, explain who can and cannot use the method, give instructions on providing the method, provide information on how to assist continuing users, and include a collection of frequently asked questions and answers. The handbook also includes recommendations on other programmatic and reproductive health issues, such as guidance on serving diverse client groups and an overview of sexually transmitted infections. There are also several useful job aids and tools such as instructions for using condoms and a description of the menstrual cycle that can be used when counseling clients. The Global Handbook is intended to be used by facility-based clinicians although the guidance can be used by any cadre of provider authorized to provide the services described. Similar to WHO’s MEC and SPR guidelines, the Global Handbook is periodically reviewed and updated to ensure that it reflects the most current practice recommendations. WHO introduced an updated version of the Global Handbook in 2011based on the latest recommendations from the MEC and SPR. This is due to be updated after the MEC and SPR revisions are completed in 2015. These updates are reflected in the technical information included in this training resource package. The Global Handbook is an excellent reference manual and job aid for providers. It is available in multiple languages in both print and electronic form. Available from: http://www.globalhandbook.org/index.shtml

MEC Categories Where warranted, recommendations will differ if a woman is starting a method (I = initiation) or continuing a method (C = continuation)

MEC 5th Edition New methods added Subcutaneously-administered depot medroxyprogesterone acetate (DMPA-SC) Generally follow recommendations for DMPA-IM Sino-Implant (II) ƒƒ Generally will follow recommendations for LNG implants Progesterone-releasing vaginal ring For use by women who are actively breastfeeding and are ≥ 4 weeks postpartum without restrictions (MEC Category 1) ƒƒUlipristal acetate (UPA) as emergency contraception With specific recommendations for breastfeeding women (MEC Category 2)

MEC 5th Edition Specific Topics Reviewed Combined hormonal contraceptive use (CHC) by age group, breastfeeding women, postpartum women, women with superficial venous disorders and with known dyslipidaemias. Progestogen-only contraceptive (POC) and levonorgestrel-releasing intrauterine device (LNG-IUD) use among breastfeeding women. IUD use for women with increased risk of sexually transmitted infections (STIs) Use of CYP3A4 inducers and obesity as new conditions for ECP use ƒƒƒƒHormonal contraception for women at high risk of HIV infection, women living with HIV, and women living with HIV using antiretroviral therapy (ART)

MEC 5th Edition Recommendations on specific topics Combined hormonal contraceptive use (CHC) Age group Without restriction from menarche to 40 years (MEC 1) 40 years and older can generally use (MEC 2) Breastfeeding women and post partum women Should not use CHCs if less than 6 weeks post partum (MEC 4) ≥ 6 weeks to < 6 months postpartum generally should not use CHCs (MEC 3). ≥ 6 months postpartum can generally use CHCs (MEC 2). Note some of the changes in the new edition of the MEC. More details will be found in the main document.

MEC 5th Edition Recommendations on specific topics Combined hormonal contraceptive use (CHC) Women with superficial venous disorders New terminology used (formerly superficial thrombophlebitis) Women with known dyslipidaemias New terminology used (formerly known hyperlipidaemia), and to include only women without other known cardiovascular risk factors Can generally use CHCs (note with clarifications in main document) . Note some of the changes in the new edition of the MEC. Changes are highlighted in bold font More details will be found in the main document.

MEC 5th Edition Recommendations on specific topics Progestogen-only contraceptive (POC) and levonorgestrel-releasing intrauterine device (LNG-IUD) use among breastfeeding women. Implants (LNG, ETG) and progestogen-only pills (POPs) can now be offered in the immediate postpartum period. LNG-IUD can be immediately inserted in first 48 hours. More details will be found in the main document. Changes are highlighted in bold font Some clarification notes: On the POCs and LNG-IUD use among breastfeeding women. Evidence is reassuring that progestogen-only contraceptives do not compromise a woman’s ability to breastfeed. Evidence is reassuring that progestogen-only contraceptives do not adversely affect infant health, growth, or development in the first year postpartum. Effects, or absence of effects, beyond the first year post-partum is not established.

MEC 5th Edition Recommendations on specific topics Copper-bearing IUD (Cu-IUD) or LNG-IUD use for women with increased risk of sexually transmitted infections (STIs) Initiation - Many women with increased risk of STIs can generally undergo IUD initiation (MEC Category 2); unless with a very high individual likelihood of STIs in which they generally should not have an IUD inserted until appropriate testing and treatment occur (MEC Category 3). Continuation - Women at increased risk of STIs can generally continue use of either Cu-IUD or LNG-IUD (MEC Category 2). Note some of the changes in the new edition of the MEC. Changes highlighted in bold font More details will be found in the main document.

MEC 5th Edition Recommendations on specific topics Use of CYP3A4 inducers and obesity as new conditions for ECP use For these conditions, ECP using COC, LNG or UPA are in Category 1. CYP3A4 inducers include rifampicin, phenytoin, phenobarbital, carbamazepine, efavirenz, fosphenytoin, nevirapine, oxcarbazepine, primidone, rifabutin, St John’s wort/ Hypericum perforatum Note some of the changes in the new edition of the MEC. New conditions highlighted in bold font More details will be found in the main document.

ƒƒƒƒHormonal contraception for women at high risk of HIV infection, and women living with HIV For women at high risk of HIV or living with HIV, WHO recommends no restrictions for: Combined hormonal contraceptives or progestogen-only contraceptives Women and couples at high risk of HIV infection & using POIs should be informed about (and have access to) HIV preventative measures, including male and female condoms. LNG –IUDs can generally be used; however, initiation should be generally avoided if advanced/severe disease Note some of the changes in the new edition of the MEC. Changes highlighted in bold font More details will be found in the main document. Filename

ƒƒƒƒHormonal contraception for women living with HIV using antiretroviral therapy (ART) For women taking ART, WHO recommends they are generally eligible to use hormonal contraception: Special consideration for efavirenz or neviripine & some protease inhibitors may be warranted. Consistent and correct use of condoms, male or female, is critical to protect against STIs/HIV and for prevention of HIV transmission Note some of the changes in the new edition of the MEC. Changes noted in bold font More details will be found in the main document. Filename

MEC 5th Edition Recommendations Details of the recommendations on the methods are available in the full MEC 5th edition document. http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/