Long acting hormonal contraceptives
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Transcript of Long acting hormonal contraceptives
There are about 1.2 billion women of
reproductive age world wideAn estimated 1.5 million unplanned
pregnancies occur in Nigeria every year and about half of these result in elective abortion.
Bankole A , Oye-Adediran. International Family Planning PerspectivesVolume 32, Number 4, December 2006
Introduction
Unexpected or unplanned pregnancy poses a major public health challenge in women
of reproductive age, especially in developing countries.
It has been estimated that of the 210 million pregnancies that occur annually worldwide, about 80 million(38%) are unplanned, and 46 million (22%) end in abortion.
Abortions account for 20%–40% of maternal
deaths in Nigeria.
Many factors contribute to unwanted pregnancy
in Nigeria, and a very important factor is the low
level of contraceptive use
Contraception a key strategy for the prevention
of unwanted pregnancy.
Open Access Journal of Contraception 2010: 19–22
The current prevalence rate for contraceptive
use in Nigeria is approximately 11%–13%.
The Nigeria’s family planning commitments is
to achieve a contraceptive prevalence rate of
36% by 2018.
National Strategy and implementation plan (2013-
2015)
The low prevalence of contraceptive use in Nigeria and indeed in the Sub‑Saharan region is due to interplay of many factors:
Socio‑cultural, economic, political, religious, and demographic.
Contraceptive prevalence= Women of reproductive age (15-49) who are
married or in a union and who are currently using any method of contraception
x 100 Total number of women of reproductive age
(15-49) who are married or in a union
Family planning programs have yielded positive gains over the past decade
Like all aspects of medicine, contraception is also witnessing advances, changes, improvements.
LARC is defined as contraceptive methods that require administration less than once per cycle or month.
Included in the category of LARC are:copper intrauterine devicesprogestogen-only intrauterine systemsprogestogen-only injectable contraceptives
Nice clinical guideline 30. 2014
LONG ACTING REVERSIBLE CONTRACEPTIVES
progestogen-only subdermal implants
Progesterone Vaginal Ring (PVR)
The uptake of LARC is low in Great Britain, at around 12% of women aged 16–49 in 2008–09, compared with 25% for the oral contraceptive pill and 25% for male condoms
Are the most effective reversible methods available Have high rates of user satisfaction as indicated
by high continuation rates Are set and forget methods that do not require
daily adherence Require fewer visits to health services than many
other methods Are cheaper than using the pill over 12 months Are easily reversible Are suitable for women of all ages Do not affect fertility after removal
BENEFIT OF LARC
A lack of familiarity with, or misperceptions about, the
methods
High upfront costs
Lack of access to insertion services
Health care providers’ concerns about the safety of IUD
use, especially in nulliparous ,younger women and
teenagers
Patient barriers, including a general lack of awareness of
LARC methods and information about their safety and
effectiveness
Barriers to LARC use
progestogen-only intrauterine systems
progestogen-only subdermal implants
progestogen-only injectable contraceptives
Progesterone Vaginal Ring (PVR)
Long acting hormonal contraceptives
Progestogens in Long acting ContraceptionSynthetic progesterone preps for
long acting contraception.Adminstered largely as depots,
implants, and as intra-uterine systems.
Contraceptive efficacy relies on daily slow release of progestogen
Mechanisms of action are largely:Centrally inhibiting ovulationThickening of vaginal and
cervical mucusThinning of endometrium
Is a levonorgestrel-releasing intrauterine device
Is T-shaped with reservoir on the vertical arm
Releases progestin levonorgetsrel 20ug daily Has 2 monfilament string attached to the
vertical arm.Life span is 5years
PROGESTOGEN INTRAUTERINE SYSTEM(MIRENA)
Thickening of cervical mucus impeding sperm acsent.
Alteration in uterotubal fluid that interferes with sperm migration
Anovulation in 10-15% of cycles.Thinning of endometrium to reduce likelihood
of implantation.FR: 0.1-0.7 preg/100 WYr
Mechanism of action
Risks50% of pregnancy as a result of failure are ectopic
preg.Irregular bleeding common in the initial 3-4
months of use.About 25% of users become amenorrhoeic after
the 2nd year of useBenefitsImprovement in dysmenorrhoea.Used for Rx of Menorrhagia Reduced incidence of PID.Reduces risk of endomitral carcinoma
Progesterone diffuses at a continuous flow of 10mg per day through the siliconeProlongs lactation amenorrhoeaUsed for Postpartum contraceptionAfter 6 weeks of delivery and for 3 months
Progesterone Vaginal Ring
A vaginal ring is inserted at postnatal visit (6 weeks)
Once inserted, the Ring is worn for 3 months At end of 3 months, it is removed and another
replacedFor now, use is stopped when menstruation
returns, or for a maximum of 1 yearMeant for breastfeeding women only
How the Ring is Used
Types: Progestin-OnlyDepo Medroxy Progesterone Acetate (DMPA)
150 mgMicrocrystalline suspension3 monthly
Norethisterone Enanthate (Net-En) 200 mgIn oil2 monthly
progestogen-only injectable contraceptives
Inhibition of ovulation by suppressing gonadotropinns.
Thickening of cervical mucus.Thinning of the endometrium.
Mechanism of action
During 1 year of use, the perfect use failure rate is 0.3 pregnancies per 100 woman-years, whereas the failure rate with typical use is 3 pregnancies per 100 woman-years.
The risk of ectopic pregnancy is significantly lower among users compared to women who do not use contraception.
The risk of endometrial cancer is reduced by as much as 80%, an effect that is long term and increases with duration of use.
Studies have shown as much as a 70% reduction in the frequency of sickle cell crises; the mechanism for this effect is not known.
Some women with endometriosis have improvement of symptoms with use of DMPA.
BENEFIT
Decrease in bone mineral density, hence, encourage calcium intake.
Irregular bleeding & prolonged menstrual flow
Amenorrhoea in prolonged usersMood swing & Depression.?Wt gain, about 5Ib(2.2kg) in 1 yr of use.Delayed return to fertility when discontinued,
≥10 months.
Disadvantages
Depo-subQ Provera (DMPA-SC)Contains 104 mg Depo-medroxy
progesterone acetateIn micro-crystalline suspension formNow Subcutaneous unlike Intramuscular in
DMPAAlso every 12 weeksShould not be used continuously for ˃2 years
Newly approved Depo-provera
Initially Six Rods, Norplant (now discarded)Two rod Jadelle (levonorgestrel) – 5 yearsOne rod Implanon (etonogestrel) – 3 yearsBio-degradable (Capronor) that does not
require removal (2 years) – Developed by Research Triangle Institute
Implants
[Levonorgestrel Implant]1st generation of implantsConsists of 6 rods, each measuring 34mm in
length & 2.4mm in diameter
NORPLANT
Each rod contains 36mg levonorgestrel.Approximately 80mcg of levonorgestrel is
released daily during the first 6-12 months after insertion.
Rate of release gradually declines to 30-35ug/day.
LH surge necessary for ovulation is suppressed in approximately 50% of cycles
Are mainly irregular bleeding pattern, which normalises over long term use.
HeadachesAcne, Weight gain/loss, mastalgia, mood
cahnge or depression.Hyperpigmentation over site of implantHirsuitism.Galactorrhoea.Symptomatic functional cyst occasionally
occur.
Side effects
Insertion is by special troca, subdermally on the inner surface of the left upper arm under local anaesthesia.
JADELLE [NORPLANT-2]Levonorgestrel preparationContains 2 non-biodegradeable silicone
elastomer capsule.Each capsule is 43mm in length & 2.5mm in
diameter.Each capsule contains 75mg Levonorgestrel.Insertion is effective for 5yrs.
Newer generation of Implants
Implanon: Non biodegradable
Single rod
Contain 68mg of etonogestrel active metabolite of desogestrel.
The hormone is released at an initial rate of 60mcg per day decreasing to 30mcg per day after 2years.
Duration of action is 3years
Nexplanon identical to Implanon except for containing 15mg Barium sulphate, added to the core to make it detectable by x-ray.
Rod is 4cm in length & 2mm in diameter.
Shld be removed after 3yrs, or earlier if
preg is desired .When the rod is removed, the return to
fertility is rapid, with the return of ovulation within 3 weeks
Apart form its effect on cervical mucus, it
also inhibits ovulation.
Compared with the Norplant system,
Implanon is associated with a higher
frequency of amenorrhea and
oligomenorrhea, a decrease in the prevalence
of frequent and prolonged bleeding, and a
decrease in the frequency of adverse effects
such as weight gain, headache, and acne.
Uniplant is a single implant contraceptive containing 38mg nomegestrel acetate in a 4cm silastic tube with a 100ug per day release rate
It provide contraception for 1year.
UNIPLANT
CAPRONOR, NORETHINDRONE PELLETSCAPRONOR: is a single capsule,
levonogestrel releasing subdermal implant2.4mm in diameter and 40mm in lengthIt provide contraception for 1year.Capsule remain intact for the first 12 months
allowing for easy removal then begins to disappear after 12months
Biodegradable implant
NORETHINDRONE PELLETS or anuelleIs injected subdermally and maintain
circulating contraceptive level of progestin for up to 3years.
This pellet is compose of 10% pure cholesterol and 90% norethindrone
This method is currently under development.
Expert clinical opinion is that LARC methods may have a wider role in contraception and their increased uptake could help to reduce unintended pregnancy
Enabling women to make an informed choice about LARC and addressing women's preferences is an important objective.
CONCLUSION
SH&FPA statement on LARCs: October 2013. Nice clinical guideline 30. 2014. Long acting reversible contraception (C-Gyn 34) New
statement july 2014. Increasing access to long acting reversible contraceptives in
nigeria: National strategy and implementation plan (2013-2015)
Open Access Journal of Contraception 2010:1 9–22 Kigbu J H, Daniyan A B C. UPDATES ON CONTRACEPTION.
Ibom Medical Journal.2008;3: 4-12 Current Concepts In Contraception. Text of Presentation at
the MDCAN, OOUTH Sagamu, CPD LECTURE SERIES. By Dr. Peter O. Adefuye.
Current Diagnosis & Treatment Obstetrics & Gynecology, Eleventh Edition.2013
Reference