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Contraceptive Methods - Combined Hormonal Contraceptives PowerPoint Presentation

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Description : Check out this medical presentation on sexual health by Raqibat Idris, MBBS, DO, MPH, Geneva Foundation for Medical Education and Research. This medical PPT titled "Contraceptive methods - Combined hormonal contraceptives" is about combined hormonal contraceptives.

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Contraceptive methods Part 1 - Combined hormonal contraceptives Raqibat Idris, MBBS, DO, MPH Geneva Foundation for Medical Education and Research "Family Planning”: An Online Evidence-based Course 2021
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Outline and objectives Description of the method Mechanism of action Effectiveness Benefits and side effects Eligibility criteria Interventions for associated effects 2
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Methods Combined hormonal contraceptives Combined oral contraceptives (COCs) Combined injectable contraceptives (CICs) Combined contraceptive patch Combined contraceptive vaginal ring (CVR) 3
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Comparing Effectiveness of Family Planning Methods How to make your method more effective Implants, IUD, female sterilization: After procedure, little or nothing to do or remember Vasectomy: Use another method for first 3 months Injectables: Get repeat injections on time Lactational Amenorrhea Method (for 6 months): Breastfeed often, day and night Pills: Take a pill each day Patch, ring: Keep in place, change on time Male condoms, diaphragm: Use correctly every time you have sex Fertility awareness methods: Abstain or use condoms on fertile days. Standard Days Method and Two-Day Method may be easier to use. More effective Less than 1 pregnancy per 100 women in one year Less effective About 30 pregnancies per 100 women in one year Female condoms, withdrawal, spermicides: Use correctly every time you have sex 4 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined oral contraceptive pills (COCS) 5
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What are COCs? Traits and types COCs are pills that contain low doses of 2 hormones, a progestin and an estrogen like the natural hormones progesterone and estrogen in a woman’s body. They are also called “the Pill,” low-dose combined pills, OCPs, and OCs. Traits and types 6 Table adapted from Training Resource Package for Family Planning: https://www.fptraining.org/ Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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COCs: Mechanism of action Thickens cervical mucus to block sperm Suppresses hormones responsible for ovulation COCs have no effect on an existing pregnancy. 7 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Combined oral contraceptives (COCs):Effectiveness Spermicides Vasectomy Tubal Ligation LNG-IUD Copper-IUD LAM (6 months) Progestin-only Injectables COCs Progestin-only Pills Male Condoms Standard Days Method Female Condoms Implants First-Year Pregnancy Rate per 100 Women 8 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COCs: Characteristics Less effective when not used correctly (91%) Require taking a pill every day Do not provide protection from STIs/HIV Have side effects Have some health risks (rare) Most women can safely use the pill Safe and more than 99% effective if used correctly Can be stopped at any time No delay in return to fertility Are controlled by the woman Do not interfere with sex Have health benefits 9 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COCs: Health benefits Menstrual Decreased amount of flow and fewer days of bleeding; no bleeding (less common) Regular, predictable menstrual cycles Reduced pain and cramps during menses Reduced pain at time of ovulation Others Protection from Risks of pregnancy, ovarian cancer and endometrial cancer and symptomatic PID Reduced risk of ovarian cysts and iron-deficiency anemia Decreased symptoms of endometriosis (pelvic pain, irregular bleeding) Decreased symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body) 10 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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No overall increase in breast cancer risk for COC users Analysis of a large number of studies: No overall increase in breast cancer risk among women who had ever used COCs Current use and use within past 10 years: very slight increase in risk May be due to early diagnosis or accelerated growth of pre-existing tumors More recent study: No increase in breast cancer risk regardless of age, estrogen dose, ethnicity, or family history of breast cancer 11 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Relative risk for breast cancer among COC users and non-users Increased Risk No Effect Protective Effect 0.1 1 10 Non-users 1–4 yrs after stopping Relative Risk Log Scale 1.0 Current COC users 5–9 yrs after stopping 10+ yrs after stopping 1.24 [1.15–1.33] 1.16 [1.08–1.23] 1.07 [1.02–1.13] 1.01 [0.96–1.05] [95% Confidence Interval] 12 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Protective effect of COC use on ovarian and endometrial cancer Reduces risk by more than 50% Protection develops after 12 months of use and is present for at least 15 years Source: Petitti and Porterfield, 1992; CASH Study 1987. Lifetime risk of acquiring ovarian or endometrial cancer after 8+ years of COC use Number per 100 women 100 1.7 0.6 0.6 0.7 0.2 0.2 3.1 0.7 0.4 1.2 0.3 0.1 0 2 4 6 8 10 United States Costa Rica China Non COC users COC users Ovarian Cancer Non COC users COC users Endometrial Cancer 13 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COCs and cervical cancer Cervical cancer is caused by certain types of human papillomavirus (HPV). Some increase in risk among women with HPV and others who use COCs more than 5 years. Risk of cervical cancer goes back to baseline after 10 years of non-use Cervical cancer rates in women of reproductive age are low. Risk of cervical cancer at this age group is low compared to mortality and morbidities associated with pregnancy. COC users should follow the same cervical cancer screening schedule as other women. 14 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COCs: Risk of blood clots is limited COCs may slightly increase risk of blood clots: Stroke Heart attack Risk is concentrated among women who have additional risk factors, such as: Hypertension Diabetes Smoking Stop COCs immediately if a blood clot develops. Deep vein thrombosis Pulmonary embolism 15 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COC users and risk of blood clots Pregnancy presents a higher risk of blood clots than do COCs. Estimates of venous thromboembolism per 100,000 woman-years 16 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COC users and risk of heart attack Estimated number of heart attacks per million woman-years 17 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COC side effects Nausea (upset stomach)- most common Changes in bleeding patterns (lighter, irregular, infrequent or no monthly bleeding) Mood changes or headaches Tender breasts Dizziness Slight weight gain or loss Many women do not have any side-effects. Side-effects often go away after a few months and are not harmful. 18 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Who can use COCS Category 1 and 2 examples: 19 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Who should generally not use COCs Category 3 Examples: 20 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Who should not use COCs Category 4 Examples: 21 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COC use by women with HIV Women with HIV or AIDS can use without restrictions Women on ARVs can use COCs safely Should not be used by women who take medications for seizures or rifampacin or rifabutin for tuberculosis (may reduce effectiveness of COCs) Using low-dose COCs is appropriate Condom use should be encouraged in addition to COCs 22 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COC use by postpartum women Non-breastfeeding women should not initiate COCs before 3 weeks postpartum (3-6 weeks postpartum with VTE risk factors) Breastfeeding women Should not use COCs before 6 weeks postpartum Should not use COCs from 6 weeks to 6 months postpartum unless no other method is available Can generally initiate COCs at 6 months postpartum 23 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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When to start COCs - 1 Anytime you are reasonably certain the woman is not pregnant Pregnancy can be ruled out if the woman meets one of the following criteria: Started monthly bleeding within the past 7 days Is breastfeeding fully, has no menses and baby is less than 6 months old Has abstained from intercourse since last menses or delivery Had a baby in the past 4 weeks Had a miscarriage or an abortion in the past 7 days Is using a reliable contraceptive method consistently and correctly If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or waiting until next menses 24 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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When to start COCs - 2 If starting during the first 5 days of the menstrual cycle, no backup method needed After day 5 of her cycle, rule out pregnancy and use backup method for the next 7 days Postpartum Not breastfeeding: May start 3 to 6 weeks after giving birth, depending on presence of risk factors for blood clots Breastfeeding: May start 6 months after giving birth 25 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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When to start COCs - 3 After miscarriage or abortion Immediately, if within 7 days after first- or second-trimester miscarriage or abortion, no backup method needed If more than 7 days after, rule out pregnancy, use backup method for 7 days Switching from hormonal method May start immediately, no backup method needed (with injectables, initiate within reinjection window) Switching from non-hormonal method If starting within 5 days of start of menstrual cycle, no backup method needed If starting after day 5 of cycle, use backup method for 7 days After using emergency contraceptive pills Initiate immediately after taking progestin-only ECPs, use backup method for 7 days After taking ulipristal acetate (UPA) ECPs she can start or restart COCs on the 6th day after taking UPA EPs 26 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/ Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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How to take COCs 28-pill pack 21-pill pack If you use the 28-pill pack: No waiting between packs. Once you have finished all the pills in the pack, start new pack on the next day. If you use the 21-pill pack: 7 days of no pills Once you have finished all the pills in the pack, wait 7 days before starting new pack. For example: If you finish the old pack on Saturday, take the first pill of the new pack on the following Sunday. Take one pill each day, by mouth. 21-pill pack Waiting too long between packs greatly increases risk of pregnancy. Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COCs: Missed pills instructions Miss 1 or 2 active pills in a row or start a pack 1 or 2 days late: Always take a pill as soon as possible. Continue to take one pill every day. No need for additional protection. Miss 3 or more active pills in a row or start a pack 3 or more days late: Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or avoid sex for next 7 days. If she had sex in the past 5 days, she can consider ECPs. OR AND If these pills missed in week 3, ALSO skip the inactive pills in a 28-pill pack and start a new pack If the inactive pills are missed, throw away the missed pills and continue taking pills 1 each day week 3 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/ Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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COCs: Correcting rumors and misconceptions COCs: Do not build up in a woman’s body. Women do not need a “rest” from taking COCs. Must be taken every day, whether or not a woman has sex that day. Do not make women infertile. Do not cause birth defects or multiple births. Do not change women’s sexual behavior. Do not collect in the stomach. Instead, the pill dissolves each day. Do not disrupt an existing pregnancy. 29 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Management of COC side effects Counseling and reassurance are key. Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Management of COC side effects:Bleeding changes Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Advise to stop taking COCs, use a backup method, and see a health care provider. Severe, constant pain in belly, chest, or legs Very bad headaches A bright spot in your vision before bad headaches Yellow skin or eyes When to return: Warning signs of rare COC complications 32 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Problems that may require stopping COCs or switching to another method - 1 33 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Problems that may require stopping COCS or switching to another method - 2 34 Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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COCs: Summary Safe for almost all women Effective if used consistently and correctly Fertility returns without a delay Screening and counseling are essential Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
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Combined injectable contraceptives (monthly injectables) 36
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What are monthly injectables? Monthly injectables or combined injectable contraceptives contain 2 hormones, a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman’s body. (Combined oral contraceptives also contain these 2 types of hormones.) They are also called combined injectable contraceptives, CICs, the injection. They are available as: Medroxyprogesterone acetate (MPA) 25mg + estradiol cypionate Cyclofem, Ciclofemina, Ciclofem, Cyclo-Provera, Lunella, Lunelle, Novafem, Feminena Norethisterone enanthate (NET-EN) 50 mg + estradiol valerate Mesigyna, Norigynon 37 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Mechanism of action and effectiveness Mechanism of action Like COCs, monthly injectables work primarily by preventing the release of eggs from the ovaries (ovulation). Effectiveness As commonly used, about 3 pregnancies per 100 women using monthly injectables over the first year. This means that 97 of every 100 women using injectables will not become pregnant. Less than 1 pregnancy per 100 women using monthly injectables over the first year (5 per 10,000 women), when women receive their injections on time. 38 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Characteristics of monthly injectables COCs: Do not require daily action by the user Can be used privately Injections can be stopped at any time Good for spacing births Slightly delayed return to fertility (An average of about 5 months, one month longer than with most other methods) No protection against sexually transmitted infections or HIV 39 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Differences from progestin-only injectables Compared to progestin-only injectables DMPA or NET-EN, monthly injectables: Contain estrogen as well progestins, that is, combined methods. Contain less progestin More regular bleeding, fewer bleeding disturbances. Require a monthly injection, whereas NET-EN is injected every 2 months and DMPA, every 3 months.. 40 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Side effects Changes in bleeding patterns Lighter bleeding, fewer days of bleeding Irregular bleeding Infrequent bleeding Prolonged bleeding Amenorrhea (no monthly bleed) Weight gain Headaches Dizziness Breast tenderness Bleeding changes are normal and not harmful. 41 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Health risks and benefits Safe and suitable for nearly all women Long-term studies are limited Benefits and risks similar to those of COCs Less effect on blood pressure, blood clotting, lipid metabolism, and liver function 42 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Who can and cannot use monthly injectables Have or have not had children Are married or are not married Are of any age, including adolescents and women over 40 years old Have just had an abortion or miscarriage Smoke any number of cigarettes daily and are under 35 years old 43 Smoke fewer than 15 cigarettes daily and are over 35 years old Have anemia now or had anemia in the past Have varicose veins Are living with HIV, whether or not on antiretroviral therapy Nearly all women can use monthly injectables safely and effectively, including women who: Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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When to start monthly injectables - 1 Having monthly bleeding: Within 7 days after the start of monthly bleeding, it can be assumed she is not pregnant. Start injection and no need for a backup method. If after 7 days after the start of her monthly bleeding, rule out pregnancy before giving injection, use a backup method for 7 days. A woman can start injectables any time she wants if it is reasonably certain she is not pregnant (use the Pregnancy Checklist). There is no need for pregnancy test, any blood tests, other routine laboratory tests, pelvic examination, cervical screening or breast examination. 44 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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When to start monthly injectables - 2 Postpartum: If breastfeeding fully or nearly fully: wait 6 months If breastfeeding partially: wait 6 weeks If not breastfeeding: anytime within 4 weeks after delivery on days 21- 28 (if additional risk for VTE, wait until 6 weeks), no need for backup (after 4 weeks, rule out pregnancy and use backup methods for 7 days). After miscarriage or abortion: anytime within 7 days (after day 7 rule out pregnancy and use a backup method for 7 days). When switching from another method: start immediately if reasonably certain she is not pregnant. No need for a backup method. If switching from another injectable, give the new injectable when the repeat injection would have been given. 45 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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When to start monthly injectables - 3 After taking emergency contraceptive pills (ECPs): Progestin-only or combined ECPs: Start or restart injectables on same day as taking the ECPs or anytime after ruling out pregnancy. Use a backup method for 7 days after the injection. After taking ulipristal acetate (UPA) ECPs: Start or restart injectables on the 6th day after taking UPA-ECPs or anytime after the 6th day after ruling out pregnancy. Use a back up method from the day of taking UPA-ECPs until 7 days after the injection. 46 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Managing late injections Less than 7 days late for a repeat injection: Give next injection. No need for tests, evaluation, or a backup method. More than 7 days: Give next injection if she has not had sex 7 days after the injection was due or she has used a backup method or taken ECPs if she had. Use a backup method for 7 days after the injection. If not, rule out pregnancy before giving the next injection. 47 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Correcting misconceptions Monthly injectables: Can stop monthly bleeding, but this is not harmful; blood does not build up inside the woman Do not make women infertile Do not cause early menopause Do not cause birth defects or multiple births Do not cause itching Do not change women's sexual behaviour 48 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Management of side effects Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: Management of side effects Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: New problems that may require switching methods Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: New problems that may require switching methods Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Monthly injectables: summary Safe for almost all women Effective if used consistently and correctly - Coming back every 4 weeks is important for greatest effectiveness. Injection can be as much as 7 days early or late. Screening and counseling are essential Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch
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What is the combined patch? A small, thin, square of flexible plastic worn on the body. Continuously releases 2 hormones, a progestin and an estrogen which are like the natural hormones progesterone and estrogen in a woman’s body, directly through the skin into the bloodstream. Also called Ortho Evra and Evra. 55 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Mechanism of action Works primarily by preventing the release of eggs from the ovaries (ovulation). The woman puts on a new patch every week for 3 weeks, then no patch for the fourth week. During this fourth week the woman will have monthly bleeding. No delay in return of fertility after patch use is stopped. Does not provide protection against sexually transmitted infections. 56 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Effectiveness As commonly used, about 7 pregnancies per 100 women using the combined patch over the first year. That is, 93 of every 100 women using the combined patch will not become pregnant. When no mistakes are made with use of the patch, less than 1 pregnancy per 100 women using a patch over the first year (3 per 1,000 women). Pregnancy rates may be slightly higher among women weighing 90 kg or more. 57 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Side effects Skin irritation or rash where the patch is applied Changes in bleeding patterns: – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Prolonged bleeding – No monthly bleeding Headaches Nausea 58 Vomiting Breast tenderness and pain Abdominal pain Flu symptoms/upper respiratory infection Irritation, redness, or inflammation of the vagina (vaginitis) Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Known health benefits and health risks Long-term studies of the patch are limited, but researchers expect that its health benefits and risks are like those of combined oral contraceptives. 59 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Who can start and when to start Medical eligibility criteria guidelines for when to start and helping continuing users for the combined patch are the same as for combined oral contraceptives and the combined vaginal ring. 60 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Late replacement or removal, or patch comes off - 1 Forgot to apply a new patch after the 7-day patch-free interval or late changing patch at the end of week 1 or 2: Apply a new patch as soon as possible and keep the same patch-change day. If late by only 1 or 2 days (48 hours or less), there is no need for a backup method. If more than 2 days late (more than 48 hours), use a backup method for the first 7 days of patch use. The new patch will begin a new 4-week patch cycle, and this day of the week will become the new patch-change day. If more than 2 days late and unprotected sex occurred in the past 5 days, consider taking emergency contraceptive pills. 61 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Late replacement or removal, or patch comes off - 2 Late taking off the patch at the end of week 3: Remove the patch. Start the next cycle on the usual patch-change day. No need for a backup method.. The patch came off and was off for less than 2 days (48 hours or less): Apply a new patch as soon as possible. (The same patch can be re-used if it was off less than 24 hours.) No need for a backup method. Keep the same patch change day. 62 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: Late replacement or removal, or patch comes off - 3 The patch came off and was off for more than 2 days (more than 48 hours): Apply a new patch as soon as possible, use a backup method for the next 7 days and keep the same patch-change day. If during week 3, skip the patch-free week and start a new patch immediately after week 3. If a new patch cannot be started immediately, use a backup method and keep using it through the first 7 days of patch use. If during week one and unprotected sex occurred in the past 5 days, consider taking emergency contraceptive pills. 63 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined patch: summary Health benefits and risks are like those of combined oral contraceptives. Replace each patch on time for greatest effectiveness. No delay in return of fertility after patch use is stopped. Screening and counseling are essential Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combinedvaginal ring
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What is the combined vaginal ring? A flexible ring that a woman places in her vagina. Continuously releases 2 hormones, a progestin and an estrogen which are like the natural hormones progesterone and estrogen in a woman’s body, from inside the ring. Hormones are absorbed through the wall of the vagina directly into the bloodstream. 66 Also called NuvaRing Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: Mechanism of action Works primarily by preventing the release of eggs from the ovaries (ovulation). The woman leaves the ring in her vagina for 3 weeks, then removes it for the fourth week. During this fourth week the woman will have monthly bleeding. No delay in the return of fertility after ring use is stopped. No protection against sexually transmitted infections. 67 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: Effectiveness Depends on the user. Risk of pregnancy is greatest when a woman is late to start a new ring. As commonly used, about 7 pregnancies per 100 women using the combined vaginal ring over the first year. That is, 93 of every 100 women using the combined vaginal ring will not become pregnant. When no mistakes are made with use of the combined vaginal ring, less than 1 pregnancy per 100 women using the combined vaginal ring over the first year (3 per 1,000 women). 68 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: Side effects Changes in bleeding patterns, including: – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Infrequent bleeding – Prolonged bleeding – No monthly bleeding Headaches Irritation, redness, or inflammation of the vagina (vaginitis) White vaginal discharge 69 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: Known health benefits and health risks Long-term studies of the vaginal ring are limited. Researchers expect that its health benefits and risks are like those of combined oral contraceptives. Evidence to date has not shown adverse effects. 70 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: Who can start and when to start Medical eligibility criteria, guidelines for when to start, and helping continuing users for the combined ring are the same as for combined oral contraceptives and the combined patch. 71 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: Late replacement or removal - 1 Left ring out for 48 hours or less during weeks 1 through 3: Put the ring back in as soon as possible, no need for a backup method. Left ring out for more than 48 hours during weeks 1 or 2: Put the ring back in as soon as possible and use a backup method for the next 7 days. If the ring was left out for more than 48 hours in the first week and unprotected sex occurred in the previous 5 days, consider taking emergency contraceptive pills. Left ring out for more than 48 hours during week 3: Put the ring back in as soon as possible and use a backup method for the next 7 days. Start a new ring at the end of the third week and skip the ring-free week. If unable to start the new ring at the end of the third week, use a backup method and keep using it through the first 7 days after starting a new ring. 72 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Forgot to insert a new ring at beginning of the cycle: Insert a new ring as soon as possible. If late by only 1 or 2 days (48 hours or less), that is, the ring is left out no longer than 9 days in a row, no need for a backup method. Keep the same ring removal day. If the new ring is inserted more than 2 days (more than 48 hours) late, that is, the ring is left out 10 days or more in a row, use a backup method for the first 7 days of ring use. If unprotected sex occurred in the past 5 days, consider taking emergency contraceptive pills. Kept ring in longer than 3 weeks: If the same ring is used for up to 28 days (4 weeks), no backup method is needed. She can take a ring-free week or start a new ring immediately. If the same ring is used for 28 to 35 days (more than 4 weeks but less than 5 weeks), insert a new ring and skip the ring-free week. No backup method is needed. 73 Combined vaginal ring: Late replacement or removal - 2 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Combined vaginal ring: summary Health benefits and risks are like those of combined oral contraceptives. Start each new ring on time for greatest effectiveness. No delay in return of fertility after patch use is stopped. Screening and counseling are essential Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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75 Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
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Acknowledgement This training presentation was adapted from the following resources: Training Resource Package for Family Planninghttps://www.fptraining.org/ World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project. Family Planning: A Global Handbook for Providers (2018 update). Baltimore and Geneva: CCP and WHO; 2018. Available from: https://www.fphandbook.org/ 76
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Additional resources WHO Medical Eligibility Criteria (MEC) for Contraceptive Use, Fifth edition. WHO, 2015. Available from: http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/ 77 WHO Selected Practice Recommendations for Contraceptive Use (3rd edition 2016). WHO, 2016. Available from: http://www.who.int/reproductivehealth/publications/family_planning/SPR-3/en/ For all the latest publications on family planning visit: https://www.who.int/reproductivehealth/publications/family_planning/en/ Implementation Guide for the Medical Eligibility Criteria and Selected Practice Recommendations for Contraceptive Use Guidelines. WHO, 2018. Available from: http://apps.who.int/iris/bitstream/handle/10665/272758/9789241513579-eng.pdf?ua=1