11.5 Contraception


Contraceptive method should be chosen based on medical indications or contra-indications1 and the preference of the woman, who is in the best position to know which method fits her lifestyle.

The following clinical examinations are essential:
For hormonal contraception: blood pressure. Combined oestrogen-progestogen contraceptives are contra-indicated in women with hypertension but progestogen only oral contraceptives and implants can be used.
For an intrauterine device: speculum and digital vaginal examination. Placement of an intrauterine device is contra-indicated in case of pelvic infection. In this situation, the device is inserted after the infection has resolved.

For both methods, exclude pregnancy (if in doubt, perform pregnancy test).

No other laboratory testing is required for prescribing contraceptives.

11.5.1 Contraceptive methods

Breastfeeding

Breastfeeding is a temporary and effective (> 98%) method of contraception, but only if all of the following conditions are met:
– exclusive breastfeeding of an infant less than 6 months old;
– less than 6 hour-intervals between feedings;
– continued amenorrhoea.

Hormonal contraception

There are several products that differ in terms of route of administration, composition or duration of action (Table 11.1).

Table 11.1 - Hormonal contraception

Type

Examples

Combined oestrogen-progestogen oral contraceptives

Ethinyloestradiol/levonorgestrel (Microgynon®, Minidril®, etc.)

Progestogen-only contraceptives


  • Oral progestogens (“minipill”)
Levonorgestrel (Microlut®, Microval®, Norgeston®, etc.) or desogestrel
  • Progestogen injectables
Medroxyprogesterone (Depo-Provera®, etc.)
  • Progestogen implants (long-acting contraception)
Levonorgestrel (Jadelle®), etonogestrel (Nexplanon®), etc.

Intrauterine device

This copper device inserted in the uterus provides long-term contraception.

Condoms

Male and female condoms, in addition to their contraceptive effect, are the only method of protection against HIV and other sexually transmitted infections.
They should always be offered in addition to the other methods, as protection against sexually transmitted infections.

Sterilisation

Sterilisation (bilateral tubal ligation for women and vasectomy for men) is irreversible.
If the provision of sterilisation is being considered, inquire about the national regulations (eligibility criteria, etc.).
Patients should be clearly informed about the permanent nature of sterilisation and about possible alternatives (effective, long-acting methods like intrauterine device or contraceptive implants). Written consent is always required to perform the intervention.

Female sterilisation can be performed during caesarean section or by minilaparotomy after delivery.

11.5.2 For women who are breastfeeding

If any of the requirements that make breastfeeding an effective contraceptive method are not met, offer one of these methods.

Hormonal contraception

– Oral progestogens should be initiated at 6 weeks postpartum. If, however, they are the only available or acceptable contraceptive method, they may be started 21 days postpartum.

– Progestogen implants and injections can be used from the sixth week postpartum. However, if a woman cannot be seen again after 6 weeks (e.g. nomadic populations), or if they are the only available or acceptable contraceptive method, implants or injections may be used as soon as the opportunity presents itself, including immediately after delivery.

– Combined oestrogen-progestogen oral contraceptives should be avoided during the first 6 months postpartum. If, however, they are the only available or acceptable contraceptive method, they can be introduced sooner, but only after 6 weeks postpartum.

Intrauterine device

Intrauterine devices can be inserted either in the first 48 hours after delivery (after the third stage of labour), or from the fourth week postpartum.

11.5.3 For women who are not breastfeeding

Hormonal contraception

Hormonal contraception is started on or after Day 21. If a woman cannot be seen again after 21 days (e.g., nomadic populations), progestogen implants or injectables may be used as soon as the opportunity presents itself, including immediately after delivery.

Intrauterine device

As for women who are breastfeeding (Section 11.5.2).

11.5.4 Special situations

HIV infection

Condom use helps prevent HIV transmission to a partner, reinfection by other strains of the HIV virus if the partner himself is HIV-positive, and transmission of other sexually transmitted infections. HIV-positive patients should systematically use condoms.

Since condom use is not always optimal, however, using another effective contraceptive method in addition to condoms to prevent pregnancy is recommended. Different contraceptive methods can be used.

See also Treatment with liver enzyme inducers, next section.

Treatment with liver enzyme inducers

For women taking rifampicin and rifabutin, some antiretrovirals (e.g. efavirenz, nevirapine) and certain anti-epileptics (carbamazepine, phenytoin, phenobarbital): use an intrauterine device or an injectable progestogen as liver enzyme inducers reduce the efficacy of implants and oral contraceptives3.

Post-abortum

Contraception may be started immediately after abortion, with either a hormonal contraceptive or intrauterine device if there is no pelvic infection.

Emergency contraception

Every woman should be informed about—and, if needed, have access to—emergency contraception:

levonorgestrel PO (1.5 mg as a single dose), as soon as possible after unprotected or poorly-protected sex (preferably within 72 hours, and up to 120 hours or 5 days after4).
There are no contra-indications to emergency contraceptive; it can be used whether a woman is breastfeeding or not.
The dose of levonorgestrel should be doubled (3 mg) in patient taking a liver enzyme inducer5.
or
– Intrauterine device, to be inserted within 5 days after the unprotected or poorly-protected sex.



Footnotes
Ref Notes
1 For more information on contraception: World Health Organization. Medical eligibility criteria for contraceptive use, Fourth edition, 2010.
http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/