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OVERVIEW
This module discusses a group of artificial family planning methods that is known as hormonal methods. Hormonal methods contain one or both of the naturally occurring female hormones, estrogen and progesterone.
OVERVIEW
There are two types of hormonal contraceptives included in the Philippine Family Planning Program. Combined contraceptives Low dose COCs Contraceptive Patch Combined Injectable Progestin only Contraceptives Progestin-only Pills Progestin-only injectable (POIs)
Module Objective
The module will make participants:
Understand the features of hormonal contraceptives. Provide the hormonal contraceptives to appropriate clients.
Sessions
Session 1 Session 2 Session 3 Session 4
LowLow-dose Combined Oral Contraceptives (Low-dose COCs) (LowOther Combined Contraceptives ProgestinProgestin-only Pills
SESSION 1
Objectives
At the end of the session, the participants will be able to: Describe the low-dose COCs Relate the mechanism of action of the COC with the menstrual cycle. Explain the effectiveness of the COC. Enumerate the advantages and disadvantages of the COC. Discuss the possible side effects of the COCs and the management of these
Objectives
Identify conditions suitable for COC use based on the WHO MEC and checklist Explain the guidelines in providing the COCs, including follow-up Enumerate the warning signs of complications of the COCs. Manage problems on using the COCs Correct myths and misconceptions on the COCs.
Description
Known as pills or oral contraceptives Contains hormones similar to the womans natural hormones estrogen and progesterone.
Two Types
28 pills - has 21 "active" pills, which contain hormones, followed by 7 "inactive or reminder" pills of a different color. The reminder pills do not contain hormones 21 pills - contains only the 21 "active" pills.
Mechanism of Action
Prevents ovulation Thickens the cervical mucus, which makes it difficult for sperm to pass through.
Effectiveness
Correctly and consistently used = 99.7% As commonly used = 92%
MEC WHEEL
When to Start
Start within the first 7 days of the menstrual period If started after the 7th day of her menses, abstain or use a back up contraceptive for the next 7 days. Low-dose COCs may be started anytime you can be reasonably sure that the client is not pregnant.
When to Start
POSTPARTUM: encourage feeding with breastmilk
If fully or nearly fully breastfeeding more than 6 months, and no menses yet
Start at any time for as long as reasonably certain that the woman is not pregnant. Use back-up for the first 7 days of use
If fully or nearly fully breastfeeding more than 6 months, and menses have returned = start within 7 days of menses If not breastfeeding = start at 3 weeks after delivery
When to Start
POSTABORTION
May start immediately after an abortion. No back-up method needed if started within the first 7 days following the abortion.
Missed Pills
If a woman misses 1 or 2 active COC pill in any day of the first 3 weeks (first 3 rows) or starts a pack 1 day late
Take the missed pill as soon as she remembers
If a woman misses 3 or more active COC pills in the first 2 weeks (rows 1-2) or starts a pack 2 or more days late
Take the last missed pill as soon as she remembers Take the pill scheduled for the day at the regular time Abstain from sex or use back up method for the next 7 days Continue taking the pill until pack is finished.
Missed Pills
If a woman misses 3 or more active pills on the third week (row 3)
Discard inactive pills. Immediately start a new pack and continue taking the pill until the pack is finished.
If a woman misses any non-hormonal pill (last row of pills in a 28-pill pack)
Start a new pack as usual and keep taking COCs one each day
Warning Signs
J-A-C-H-E-S J A C H E S Jaundice Abdominal pain, severe Chest pain, shortness of breath Headache, severe Eye problems, blurring of vision Severe leg pains
Follow-Up
Return to the clinic:
For re-supply At any time when any of the warning signs occur.
Session 2
Objectives
Describe the contraceptive patch. Enumerate the advantages and disadvantages of the contraceptive patch. Discuss the possible side effects of the patch. Identify conditions suitable for use of the patch. Explain the guidelines in providing the COCs, including how to start and what to do for missed patch changes.
Objectives
Describe the combined injectable contraceptive (CIC). Explain the mechanism of action of the CIC. Enumerate the advantages and disadvantages of the CIC. State the effectiveness of the CIC. Discuss the possible side effects of the CIC. Determine conditions suitable or unsuitable for CIC use. Explain how to use the CIC. Enumerate the warning signs for CIC use.
Description
Form of combined (estrogen + progestin) contraceptive applied to the skin that contains estrogen and progestin
Mechanism of Action
Hormones are slowly absorbed and released in the bloodstream causing inhibition of ovulation.
Advantages
Effective (99%) No daily pill intake Regulates menstrual flow Can be stopped at any time by the client Does not interrupt sex Increased sexual enjoyment Convenient and simple to use Safe
Disadvantages
May be less effective in women with body weight greater than 90 kg. Affects quantity and quality of breastmilk Has to replace the patch every 7 days Does not protect against STIs
How To Start
Having menses or switching from nonhormonal methods or POP
o Any day within the first 5 days of the menstrual cycle o Any time it is reasonably certain that she is not pregnant. If more than 5 days since menses started, she can start using the patch but should avoid unprotected sex for the next 7 days. Condom use is advisable.
How To Use
Patch cycle: Apply a new patch once a week, every week, for 3 weeks (21 days). Stop for 7 days (patch-free days).
Warning Signs
J-A-C-H-E-S J A C H E S Jaundice Abdominal pain, severe Chest pain, shortness of breath Headache, severe Eye problems, blurring of vision Severe leg pains
Description
The combined injectable (CIC) is a contraceptive containing a combination of estrogen and progestin in an injectable form. Norifam
Norethisterone 50 mg Estradiol valerate 5 mg
Mechanism of Action
Inhibition of ovulation Thickening of the cervical mucus Contraceptive effect is similar to that achieved by daily intake of the COC.
Advantages
Similar to the COC with the following additional benefits: Does not require daily action No need to take a pill every day Private More regular monthly bleeding as compared to DMPA
Disadvantages
Requires injection every month Delayed return to fertility after the woman stops the method (average of 1 month longer than with the COCs) Does not protect against STIs, including HIV
Effectiveness
How To Provide
Schedule
First injection is given on the first day of the menstrual cycle. Succeeding injections are given every 30 +/- 3 days
Client Instructions
What to expect
Vaginal bleeding episode is expected within one or two weeks after the first injection. This is normal. With continued use, bleeding episodes will occur at 30 days interval. Visit the clinic if no bleeding occurs within 30 days after an injection to rule out pregnancy.
Client Instructions
Follow-Up
Return to the clinic every 30 days for the next injection. If injection has not been given after 30 days, abstain from sexual intercourse or use condom until the next injection. Come back to the clinic no matter how late you are for the next injection. You may still be able to use the injectable.
Client Instructions
Return to the clinic at any time if:
You develop any of the warning signs You have any questions or problems You think you are pregnant.
Warning Signs
J-A-C-H-E-S J A C H E S Jaundice Abdominal pain, severe Chest pain, shortness of breath Headache, severe Eye problems, blurring of vision Severe leg pains
Session 3
Objectives
At the end of the session, the participants will be able to:
Describe POPs and commonly available preparations. Relate the mechanism of action of the POP with the menstrual cycle. Enumerate the advantages and disadvantages of the POP. Enumerate the possible side effects of the POP. Explain the management of the possible side effects of the POP.
Objectives
At the end of the session, the participants will be able to:
Identify conditions suitable for POPs based on the WHO MEC and checklist. Explain the guidelines in providing the POPs including follow-ups. Correct myths and misconceptions.
Description
Contains a small amount of only one kind of hormone. progestin Does not contain estrogen
Mechanism of Action
Causes thickening of the cervical mucus, which makes it more difficult for sperm to pass through Prevents ovulation in about half of menstrual cycles
Effectiveness
For breastfeeding women, POPs are very effective: 99% when typically used, 99.5% when perfectly used. POPs are less effective for women not breastfeeding.
Less common
Amenorrhea for several months Prolonged or heavy menstrual periods Breast tenderness Headache
4. Nausea or dizziness
Suggest taking POPs at bedtime or with food.
MEC WHEEL
Take one pill each day at the same time until the packet is finished. Start a new packet the day after she finishes the previous packet without break. No pill-free days.
Missed Pills
If missed taking the pills by more than 3 hours, abstain from sexual intercourse or use a back-up method during the next 48 hours after re-starting the pills. If breastfeeding and amenorrheic and missed pills more than 3 hours, take one pill as soon as possible and continue taking pills as usual. If still covered by LAM, no back-up is needed.
FollowFollow-Up
Reasons for follow-up follow For questions or problems For warning signs of possible complications
Extremely heavy bleeding (twice as much and/or twice as long previous menses) Abdominal pain Headaches that start or become worse after she started POP Skin or eyes becoming yellow Symptoms of pregnancy
POPs are pills that contain very low doses of progestin like the natural hormone progesterone in a womans body. POPs do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen.
Session 4
Description
Available preparations:
DMPA(depot-medroxyprogesterone acetate) 150 mg. given every 3 months Noristerat (norethisterone enanthate) 200 mg. given every 2 months
Mechanism of Action
Inhibits Ovulation
After a 150-mg-injection of DMPA , ovulation does not occur for at least 14 weeks. Levels of the follicle stimulating hormone (FSH) and luteinizing hormone (LH) are lowered and an LH surge does not occur.
Effectiveness
Highly effective
Perfect use: 99.7% Common/typical use: 97.0%
MEC WHEEL
Amenorrhea: Reassure the client that amenorrhea is an expected side effect, and that she can expect menstrual cycles to return to normal within 6 months of discontinuing the POI. Menstrual irregularity: Reassure the client that breakthrough bleeding and spotting are common.
Special Considerations
Administering DMPA requires a sterile syringe and a 21-23 gauge needle. Ample supplies of both must be available Syringes and needles are manufactured for single use only and must be safely disposed of (in a sharps container, for example) following DMPA administration Storage conditions are critical to product stability. Follow manufacturer's storage recommendations.