1. Progesterone Vaginal Ring Session 3: Providing the PVR
Photo credits: © 2006 David Alexander/CCP, Courtesy of Photoshare
In this session, learners will be able to demonstrate how to counsel a woman about using the PVR as her contraceptive method
Respond correctly to patient questions about the PVR
Address patient concerns and misconceptions about the PVR
Instruct her about how to insert it and remove it
Advise her about how long she can use the same ring, what to do with it when she removes it, and how soon she must re-insert it for effectiveness to be continuous

2. Learning Objectives
Demonstrate how to counsel a woman about using the PVR as her contraceptive method.
Respond correctly to client questions about the PVR.
Address client concerns and misconceptions about the PVR.
Instruct her about how and when to insert and remove it.
In the previous session, we learnt how to screen women and determine if the PVR was a good option for them. In this session, you will learn how to counsel a woman after you have screened her and determined that the PVR would be a good option.
You will learn about how to counsel the woman, answer her questions and address any concerns she may have. You will also learn about how to dispel misconceptions if they arise. Finally, you will learn about how to provide instructions to the client on how to insert and remove the PVR so that it is used safely and effectively.

3. When to Start the PVR (A Review)
Don’t include the “Client situation” list on the slide.
Now, we will do group work to review together what we learnt in the earlier session about which type of client can use the PVR, when she can start using it.
Each group will work through a case which describes a particular potential PVR user. The cases are the following:
The mother has just given birth and is about to be discharged.
Correct answer: She is not eligible to begin using PVR until she is 4 weeks postpartum AND if she is breastfeeding the baby at least 4 times per day.
2) The mother is 12 weeks postpartum, she has been breastfeeding the baby more than 4 times per day, and her menses have not returned.
Correct answer: She is eligible to begin using PVR so long as she continues to breastfeed the baby at least 4 times per day.
3) The mother is 2½ weeks postpartum, not breastfeeding.
Correct answer: She is not eligible to use PVR because she is not breastfeeding the baby. She can initiate breastfeeding and return when the baby is a month old.
4) The mother is 2½ weeks postpartum, currently breastfeeding and wishes to continue.
Correct answer: She is not eligible to use PVR until she is at least 4 weeks postpartum and is breastfeeding the baby at least 4 times per day.
5) The mother is 6 weeks postpartum, an injectable user, amenorrheic, and within the reinjection window; she breastfeeds the baby before and after work, and during the day the baby gets formula.
Correct answer: She is not eligible to use PVR because she is not breastfeeding the baby at least 4 times per day.
What if this client wants to initiate PVR?

4. Key Counseling Topics for PVR Users
Safety and efficacy
How PVR works
Health benefits
Possible side effects
No protection from STIs/HIV
Inform provider she uses PVR in case of serious new health problem
Reasons to return: questions, concerns or experiencing any warning signs
These are the key points to cover while counseling the client on the PVR.
Safety and efficacy: The PVR is safe and protects against pregnancy as long the user is breastfeeding at least four times/day. About 1.5 women out of every 100 women will get pregnant on the PVR; compare this with 2 women out 100 who will get pregnant while using the male condom or 85 women out of 100 who are not using any method.
How PVR works in 3 ways: 1) the PVR works by preventing ovulation. 2) it works by extending the protection that women get when they breastfeed by postponing their menstruation and 3) it thickens the cervical mucus so that the man’s sperm cannot meet the woman’s egg.
Health Benefits: The PVR helps a woman to space her pregnancies well so that she has time to recover from a pregnancy and delivery before becoming pregnant again. Since it works as long as the user is breastfeeding, the baby gets all the natural nutrients it needs from the mother’s milk. Thus, baby and mother benefit.
Side-effects: The side-effects are minor and include some changes in bleeding patterns (spotting or irregular bleeding or no menstrual bleeding). Some women may have mild cramping and others breast tenderness. But all these side-effects resolve by themselves.
No STI/HIV protection: if a user thinks she is at risk of an STI/HIV, she needs to use a condom in addition to the PVR. The PVR will not protect against STIS of HIV.
Serious new health problem: These will be rare but if the user experiences anything different, she should mention to the provider that she is using the PVR.
Return: The user should return to the clinic if she experiences severe pain or bad smelling discharge, or if she has questions or concerns.

5. Additional Key Topics: Instructions for Use
Explain how to insert and remove.
Explain the length of protection and when to change it out.
Describe reasons to return for follow-up.
Ask participants: What are some other key counseling topics related to PVRs? <participants brainstorm; accept responses from several participants>
Let us compare your responses with the slide. <click the mouse to reveal the list>
In addition to the topics we have already discussed, it is imperative that during counseling about PVRs providers also:
Explain the procedure used to insert and remove the PVRs. Use illustrations if possible. Include the length of time it takes to complete the procedure, who will perform it, and that it may be somewhat uncomfortable but not painful.
Provide post-insertion instructions so that a client knows how to care for the incision and when to return to the clinic if something does not seem right. We will also review these instructions in more detail.
Explain how long the PVRs protect against pregnancy. Help women remember when they should come back to have the PVRs removed or replaced. All clients should be provided with the following information:
Type of PVR
Date of insertion
Month and year when PVRs will need to be removed
Where to go in case of questions or problems
A reminder card like the one shown on the slide can be useful for this purpose. Reminder cards are optional if your program has the feasibility for using them.
Finally, the provider should advise a client about circumstances that require her to return, which are described in more detail on the next slide.

6. Common Rumors and Misunderstandings about the PVR
Correct
The PVR keeps working after it is removed, and so the woman will have trouble getting pregnant.
The PVR stops working once it is removed. Its hormone do not remain in a woman’s body.
PVR stops monthly bleeding, and blood is building up inside the woman.
The PVR prevents monthly bleeding, but this is not harmful. It is similar to not having monthly bleeding during pregnancy. Blood is not building up inside the woman.
PVR makes a woman infertile.
The PVR does not make women infertile once she stops using it.
PVR moves to other parts of the body.
The PVR does not move to other parts of the body. It will remain in the vagina.
Explain: that rumors are unconfirmed stories that are transferred from one person to another by word of mouth.
Explain: that a misunderstanding is a mistaken interpretation of ideas or information. A misunderstanding can become a rumor if it is not corrected.
Ask: How can you correct rumors and misunderstandings?
Listen: to their answers.
Ensure: that the following ideas emerge:
When a client mentions with a rumor, always listen politely. Don’t laugh.
Define what a rumor or misconception is.
Use strong scientific facts about FP methods to correct misinformation.
Always tell the truth. Never try to hide side effects or problems that might occur with various methods.
Describe some potential rumors listed on the table in the slide in the first column and the correct answers on the second column.

7. Counseling About Side Effects
Common side effects:
Changes in bleeding patterns (spotting, irregular bleeding)
Mild cramping
Breast tenderness
Explain that side effects:
Are mild and do not usually require
medical treatment
Are not signs of illness
Often go away with time
Reassure the client and encourage her to come back if she has questions or concerns
Ask: providers to name the common side effects that a woman using the PVR might experience.
Ensure: that the following common side effects are mentioned:
Changes in bleeding patterns (Spotting, Irregular bleeding, No menstrual bleeding)
Mild cramping
Breast tenderness
Ask: What should a woman who experiences any of these side effects do?
Ensure: that they respond that she does not need to do anything. These mild side effects are not a sign of illness and should go away with time.
Add: that the provider should reassure the woman and tell her that if she has questions or concerns, she can come back to the clinic.
Ask: Why is it important to counsel a woman about common possible side effects before she begins to use the PVR?
Ensure: that their responses include the following points:
If she experienced one of the common side effects, but did not know that they were normal and not harmful, she might be frightened.
She might remove the PVR without having another contraceptive available, and thus not be protected from becoming pregnant.
If she experienced one of the rare, dangerous side effects, she might not return to see the provider and ask for help.

8. Management of PVR Side Effects
Counseling and reassurance are key.
Problem
Action/Management
Spotting or Irregular Bleeding
Reassure the client that this is common and not harmful.
Amenorrhea
Reassure client that this is common and not harmful.
Mild Cramping
Suggest pain medication.
Breast Tenderness
Recommend a supportive bra or compresses.
Read: the sentence in red letters: “Counseling and reassurance are key.”
Ask: providers why this is true.
Ensure: that they respond (in their own words):
The side effects of the PVR are generally very mild, but a woman may be nervous about them if she thinks they may be harmful.
Counseling will help her continue to use the method, unless there is a valid reason why she should stop.
Review: the problems listed on the screen, along with the action(s) the provider may take to counsel and reassure the client.
Source: CCP and WHO, 2011.

9. Supporting Method Continuation
Tell her:
No routine visit is required, except to pick up another PVR.
She may return any time for any reason.
She can switch to another method at anytime
If she returns, ask:
Is she satisfied with the method?
Does she have questions?
Does she remember the key points about using the PVR?
Ask participants: Ask: what “supporting method continuation” means.
<Participants brainstorm; accept responses from several participants>
Ensure: that they respond (in their own words) that it means helping a client continue to use the contraceptive method she has chosen, either by answering questions or addressing concerns that she may have about the method.
Ask: providers to share any steps that they have taken to support method continuation among their clients—even if they are not about the PVR specifically.
Listen: to their suggestions.
Ensure: that the following suggestions emerge:
Assure clients that they are welcome to come back any time for any reason.
When a client does return, even if it is for another reason, ask her whether she is satisfied with the method and does she have any questions about it. If she is satisfied with the PVR, then there is nothing to do. If she is not satisfied with the PVR, find out what bothers her. If it is regarding side-effects, reassure her that they are minor and will reduce over time. You can also counsel her about switching to another method if she prefers.
Check to make sure that she remembers the key points about using the PVR: She needs to breastfeed her baby 4 times a day; each ring can be worn for 3 months; if she removes the ring, she needs to reinsert it within 2 hours for the PVR to be effective; and she can use the PVR until the baby is 1 year old.
3. Ask her if she has any questions?

10. Serious Complications from PVRs Are Uncommon or Rare
If she experiences any of these symptoms:
Severe pain
Unusual, bad smelling discharge
Genital lesions
… she should return to the clinic for examination.
Review: the serious symptoms listed on the slide, emphasizing that although they are very rare, a woman who experiences any of them must return to the clinic as quickly as possible.
Source: CCP and WHO, 2011.

11. Problems That May Require Switching from PVR to Another Method (Part 1)
Action/Management
Unexplained vaginal bleeding
Remove the PVR
Refer or evaluate by history and pelvic exam
If an STI is diagnosed, treat with PVRs in place
If no cause can be found, consider removing PVRs to make diagnosis easier
Migraines
If the client develops migraines with aura after PVRs are inserted, the PVRs should be removed
Help client choose a method without hormones
Blood clots, liver or heart disease, stroke, or breast cancer
Remove PVRs
Treat or refer to a specialist for treatment
As a review, brainstorm side effects and their management. Then discuss problems that may require switching to another method.
Explain that there are some serious health conditions that may require a client to stop using a PVR. These include:
If a client experiences unexplained vaginal bleeding or heavy or prolonged bleeding that is suggestive of a medical condition not related to the method, she might need to discontinue use of the PVR.
Refer the client or evaluate by taking her medical history and doing a pelvic examination. Diagnose and treat as appropriate.
If no cause of bleeding can be found, consider stopping the PVR to make the diagnosis easier. Provide the client with another contraceptive method of her choice until the condition is evaluated and treated. The alternative method should be something other than progestin-only injectables or a copper-bearing or hormonal IUD.
If the bleeding is caused by an STI or PID, the client can continue using the PVR during treatment.
Although women who have migraine headaches with an aura can initiate the PVR, the PVR should be removed if a woman develops migraines with aura after the PVR was inserted. The provider should help her choose a non-hormonal method.
If a woman develops health conditions such as blood clots in the deep veins of the legs or lungs, heart disease due to blocked or narrowed arteries, severe liver disease, or breast cancer, the PVR must be removed.
Although women with ischemic heart disease and women who have had a stroke can initiate use of the PVR, use of the PVR should be discontinued if these conditions develop or get worse while using the PVR.
Remove the PVR and give the woman a backup method to use until her condition is evaluated. Refer her for diagnosis and care if she is not already receiving treatment.
Finally, if a woman is pregnant, the PVR should be removed. However, there are no known risks to a fetus conceived while a woman has the PVR in place.
Source: WHO and CCP, 2018.

12. Problems That May Require Switching from PVRs to Another Method (Part 2)
Action/Management
Heart disease due to blocked or narrowed arteries (ischemic heart disease)
A woman who has one of these conditions can safely start PVRs. If, however the condition develops
while she is using PVRs:
Remove the PVRs or refer for removal
Help her choose a method without hormones
Refer for diagnosis and care if not already under care
Suspected pregnancy
Assess for pregnancy, including ectopic pregnancy
Remove the PVRs or refer for removal if she will carry the pregnancy to term
There are no known risks to a fetus conceived while a woman has PVRs in place
As a review, brainstorm side effects and their management. Then discuss problems that may require switching to another method.
Source: WHO and CCP, 2018.

13. Disposal of the PVR After Use
To dispose of a PVR (after she has used it for 3 months), the woman should:
Throw it in the garbage with other waste.
Do not flush down the toilet
Do not throw it into rivers, lakes, ponds or other water
Do not reuse as the PVR.
Do not share with others.
Review: Used PVRs should be disposed of in the garbage along with other trash.
There are some don’ts:
1.Do not flush it down the toilet.
2. Do not throw it into bodies of water such as rivers or ponds.
3. Do not reuse the PVR or
4. Share with others to use.

14. PVR: Summary
The PVR:
A new option that fulfills an unmet need for many women
Effective protection from unintended pregnancy when used correctly
Safe for baby and mother
Used by a new mother beginning 4 weeks after birth, if she is breastfeeding her baby at least 4 times per day and will continue to do so
Each ring effective for 3 months; replaced up to 3 times
Easy to use—inserted and removed by the woman
Very few side effects, generally mild
Summarize the important points about PVRs. Mention that at the end of this workshop they should have learnt about a new contraception option for breastfeeding women in the first year postpartum.
Review: the points listed on the slide, emphasizing the memory aide.
Ask: if the participants have any questions, thank them and end the session.