1. Evidence based Family planning
Presented by:
Dr/ Heba Nour

2. Introduction
In 2008 Egypt Demographic Health Survey Overall, 60.3 % of currently married women in Egypt are using contraception
The national goal is to reach contraception prevalence rate (CPR) 70% by 2017

3. 36%
12%
The pill-oral contraceptive pills contain two hormones similar in a woman’s body-estrogen and progestin/progesterone.
Discussion points:
Method Oral contraceptive pil lHow it worksThe pill inhibits ovulation (release of the mature egg from the ovary)Thickens the cervical mu8cus, making it difficult for the sperm to pass through.Dees not disrupt pregnancy.How effectiveVery safe and effective especially when taken everyday.Who should use itSafe for almost all women of any ageAdvantagesVery convenient; no need to do anything at time of sexual intercourseRegulates menstruation and helps prevent menstrual crampsCan be used for as long as a woman does not want to get pregnant; but can be stopped anytime a woman is ready to get pregnant; fertility returns soon after stoppingCan help prevent certain cancers, anemia (low iron) and menstrual cramps and irregular bleeding and other medical conditionsDisadvantagesWomen who smoke or who are 35 years old or older and hypertensive, diabetic, are not advised to take the pill unless they are under the care of a doctor.Does not protect against Sexually Transmitted Disease (STD’s).Side effectsEspecially in the first few months, some women experience nausea or vomiting, bleeding between periods or “spotting”, weight gain, mild headache or moodiness. None of these side effects are dangerous and generally become less or disappear in a few months. 7%

4. Grades of Recommendation are based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the Expert Group

5. Evidence based Family planning
Contraceptive choices for breastfeeding women

6. What should a clinician assess when considering contraception for
a breastfeeding woman?

7. Major Recommendations
Given information about
all hormonal and
non-hormonal contraceptive methods
Give information about
chosen method
Assess needs
personal choice
sexual activity
breastfeeding pattern
menstruation, and
medical and social factors

8. What are the effects of breastfeeding on ovulation and fertility?

9. Major Recommendations
Breastfeeding delays the return of ovulation (Grade B).
Because BF delays ovulation, all contraceptives have low failure rates when used consistently and correctly (Grade C).
Awaiting the onset of menstruation before starting contraception is not advised (Grade B).

10. What do women need to know about their contraceptive choices:
effect on breast milk or infant growth?

11. Lactational Amenorrhoea Method (LAM)
If< 6 months postpartum, amenorrhoeic, and fully breastfeeding, (LAM) is over 98% effective in preventing pregnancy (Grade B).
Women using the LAM should be advised that the risk of pregnancy is increased
if breastfeeding decreases (particularly stopping night feeds),
when menstruation recurs, or
>6 months postpartum (Grade C).

12. Hormonal Contraception
The level of hormone in breast milk when using a hormonal contraception is comparable to levels observed when they have an ovulatory cycle (Grade C).
The available evidence is unable to prove if hormonal contraception has any effect on breast milk volume (Grade C).
The available evidence indicates that hormonal contraception has no adverse effect on infant growth (Grade A).

13. Combined Hormonal Contraception (COC)
The use of (COC) in the first 6 weeks postpartum may have an adverse effect on breast milk volume (Grade B).
Avoid COC in the first 6 weeks postpartum (Grade B).
COC can be used without restriction from 6 months postpartum (Grade C).
COC is not recommended between 6 weeks & 6 months postpartum. But, if breastfeeding is established, COC may be considered if other contraceptive methods are unacceptable (Good Practice Point).

14. Progestogen-Only Contraception (POC)
The use of POC in the first 6 weeks postpartum have no adverse effect on breast milk volume (Grade B).
The POC when breastfeeding provides over 99% efficacy (Grade B).
The problematic bleeding associated with POC appears to be more acceptable than that experienced by not breastfeeding (Grade B).
The use a POC of contraception <6 weeks postpartum if other contraceptive methods are unacceptable (Good Practice Point).

15. Intrauterine Device (IUD)
Unless an IUD can be inserted within the first 48 hrs postpartum insertion should be delayed until 4 weeks postpartum (Grade C).

16. Barrier Methods, Spermicides, and Fertility Awareness
The use of diaphragms and cervical caps should be delayed until uterine involution is complete (from 6 weeks postpartum) (Grade C).

21. What follow-up is required for
breastfeeding women using contraceptive methods ?

22. Follow up recommendations
Return at any time to discuss
side effects or other problems, or
if they want to change their contraceptive method (Grade C).

23. Evidence based Family planning
Contraception for women aged over 40 years.

24. INTERVENTIONS AND PRACTICES CONSIDERED
1. Assessment of patient's medical eligibility for contraceptive use
2. Counseling and educating women about the risks and benefits of contraceptive use
Combined hormonal contraception
Progesteron-only contraception
Barrier contraception
Copper intrauterine contraception
Sterilization
3. Yearly follow-up visits for women using contraception

25. Do sexually active women aged over 40 years
still require contraception ?

26. Major recommendations
Although a natural decline in fertility occurs from the age of 37 years, effective contraception is required (Grade B).
There are risks of congenital and chromosomal abnormalities, spontaneous abortion, pregnancy complications, and of maternal morbidity and mortality increase >40 years (Grade B).

27. How can a clinician assess medical eligibility for
contraceptive use by a woman aged 40 years ?

28. Clinical history including:
sexual history
CVD and cerebrovascular disease
neoplasia
(Good Practice Point).

29. Which contraceptive methods can be used by
a woman aged 40 years ?

30. No contraceptive method is contraindicated by age alone (Grade C).
Advise about the risks and non-contraceptive benefits of all contraceptive methods (Grade C).

31. Combined Hormonal Contraception
Combined hormonal contraception can be used unless there are co-existing diseases or risk factors (Grade B).

32. Clinicians prescribing COC to women aged over 40 years should consider a monophasic pill with <30 microgram ethinylestradiol with a low dose of norethisterone or levonorgestrel as a suitable first-line option (Good Practice Point).

33. Potential risks with Hormonal contraception
Smoking women aged ≥ 35 years may be at increased risk for CVD and cerebrovascular disease.
Risk of VTE can increase up to five-fold
There is a very small increase in the absolute risk of ischemic stroke.
Women aged over 40 years with CVD, stroke, or migraine (even without aura) should be advised against the use of combined hormonal contraception.
small increase in risk of breast cancer and increased risk of cervical cancer and cervical intraepithelial neoplasia after 5 years' use.

34. Non-Contraceptive Benefits Associated with Combined Hormonal Contraceptive Use
An increase in bone mineral density (Grade B).
A reduction in risk of ovarian and endometrial cancer and the risk of colorectal cancer (Grade B).
menstrual bleeding and pain may be reduced (Grade B).
COC may reduce hot flushes (Grade C).

35. Progestogen-Only Contraception (POC)
Potential Risks
Current VTE.
History of IHD or stroke.
Long-term use of injectables is associated with a reduction in (BMD) but this returns to normal after cessation.
Irregular bleeding

36. Non-Contraceptive Benefits of Progesteron-Only Contraception (POC):
POC may reduce the risk of endometrial and ovarian cancer.

37. Stopping Hormonal Contraception
Advise that amenorrhoea is not a reliable indicator of ovarian failure (Good Practice Point).

38. Stopping Combined Contraception
Advise to switch to another suitable contraceptive method at the age of 50 years (Good Practice Point).
FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free or oestrogen-free interval (Good Practice Point).

39. Stopping POPs and Implants
Women can be advised that a POP or implant can be continued until the age of 55 years when natural loss of fertility can be assumed.
Alternatively, the woman can continue with the POP or implant and have FSH levels checked on two occasions 1 or 2 months apart, and if both levels are > 30 IU/L this is suggestive of ovarian failure.
In this case the woman may continue with the POP, implant or barrier contraception for another year (or 2 years if aged less than 50 years) (Good Practice Point).

40. Stopping Progestogen-Only Injectables
Counseling about the risks and benefits of continuing with the progestogen-only injectable at the age of 50 years and
Advice to switch to a suitable alternative) (Good Practice Point).

41. Removing the LNG-IUS
Women who have the LNG-IUS inserted at age 45 years or older for contraception or for the management of menorrhagia
can be counseled about retaining the device for up to 7 years (Good Practice Point).

42. Follow up If they develop any problems with contraception or
develop any new medical history or
when they reach the age of 50 years (Grade C).

43. Evidence based Family planning
Intrauterine contraception

44. Counseling/Insertion
2. Insertion of device
Timing of insertion
Safe insertion
Training
Informed consent
Pain relief
Emergencies ttt
Documentation
Information for follow-up
Duration of use & removal
Checking threads and device
Reducing the risk of (STIs)
1. Counseling on risks and benefits of IUD
Mode of action of (Cu-IUD) and levonorgestrel-releasing intrauterine system (LNG-IUS)
Efficacy and failure rates
Duration of use
Risks
Return to fertility
Non-contraceptive benefits
Choice of device

45. What Should Clinicians Assess When a Woman Is Considering
Intrauterine contraception?

46. A clinical history (including sexual history) or if their regular partner has other partners (Grade C).
Swab for Chlamydia trachomatis and Neisseria gonorrhoeae (GPP)
High risk of STIs, if results are unavailable before insertion prophylactic antibiotics (at least to cover C. trachomatis
In asymptomatic women - no indication to test or treat other lower genital tract organisms or delay insertion until the results of tests are available (Good Practice Point).

47. What Information Should Be Given to Women?
When Counselling Them about IUD

48. Mode of Action (Grade B)
Contraceptive Efficacy (Grade C)
The TCu380S and the LNG-IUS are the most effective IUDs (Grade A).
Duration of Use (Grade C)
Perforation is up to 2 /1000 insertions (Grade B).
Expulsion 1 in 20 - most common within 3 months of insertion (Grade B).
No differences in the rates of expulsion between different Cu-IUDs and between Cu-IUDs and the LNG-IUS (Grade A).

49. Risk of Ectopic Pregnancy
overall risk of ectopic pregnancy is reduced with use of IUDs when compared to using no contraception (Grade A).
Return to Fertility
No delay in return to fertility after removal of IUDs (Grade B).
Pelvic Infection
may be an increased risk of PID in the 20 days following insertion of IUD but the risk is the same as the non-IUD-using population thereafter (Grade B).
Bleeding Patterns and Pain
first 3 to 6 months of Cu-IUD use (Grade C).
first 6 months after insertion of the LNG-IUS but by 1 year amenorrhoea or light bleeding is usual (Grade B).

50. When Can IUD Be Safely Inserted?

51. A Cu-IUD can be inserted at any time in the menstrual cycle if it is reasonably certain the woman is not pregnant (Grade C).
It may be inserted by an experienced clinician any time after abortion if there is no suspicion that the pregnancy is ongoing (Good Practice Point).

52. Switching from another method of contraception
can be inserted at any time if another method of contraception has been used consistently and correctly.

53. Not pregnant?
if she has no symptoms or signs of pregnancy and meets any of the following criteria:
Has not had intercourse since last normal menses
Correctly and consistently using a reliable method of contraception
Is within the first 7 days after normal menses
Is within the first 7 days post-abortion or miscarriage
Is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.

54. Pain Relief
Discussion administration (GPP)
Routine Follow-Up
A routine follow-up visit should be advised after the first menses following insertion of IUD or 3 to 6 weeks later to exclude infection, perforation or expulsion. (Grade C).

55. Timing the Removal of Intrauterine Contraception
For a planned pregnancy
Remove at any time in the menstrual cycle (offer pre-pregnancy advice regarding folic acid, rubella immunity)
When removal and replacement is at the end of the licensed duration of use
Remove at any time in the menstrual cycle.
If pregnancy is to be avoided remove in the first few days after the onset of menstruation or
advise condoms or abstinence from sexual intercourse for at least 7 days before the procedure in case re-insertion is not possible

56. Risks outweigh benefits: Between 48 hours and <4 weeks postpartum
CONTRAINDICATIONS
Risks outweigh benefits:
Between 48 hours and <4 weeks postpartum
Current venous thromboembolism (on anticoagulants)
Initiation of method in women with ovarian cancer
Continuation of intrauterine methods in women with known pelvic tuberculosis
Unacceptable risks:
Pregnancy, puerperal sepsis, septic abortion
Initiation of the method in women with unexplained vaginal bleeding
Gestational trophoblastic neoplasia when serum hCG concentrations are abnormal
Initiation of the method in women with cervical cancer awaiting treatment or with endometrial cancer
Uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity
Initiation of intrauterine methods in women with current pelvic inflammatory disease or purulent cervicitis
Initiation of intrauterine methods in women with known pelvic tuberculosis

57. Family planning
DMPA

58. D(GPP) - Women attending up to 2 weeks late for repeat injection of DMPA may be given the injection without the need for additional contraceptives.
D(GPP) - Healthcare professionals should be aware that if pregnancy occurs during DMPA use there is no evidence of congenital malformation to the fetus.

59. Efficacy
C - The pregnancy rate associated with injectable contraceptives, when given at the recommended intervals, is very low (fewer than 4 in 1000 over 2 years) and the pregnancy rate with (DMPA) is lower than that with norethisterone enantate (NET-EN).

60. References contraceptive choices during lactation
Contraception for women aged over 40 years.
Intrauterine device
Recommended readings
Practice%20Guidelines%20For%20Family%20Physicians%20Volume%202.pdf
Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications:

61. Thanks