Progesterone Only Method of Contraception

Types Of Progesterone Only Method

Depo-Provera 

Progestogen only pill (POP)

Implants

Intrauterine system (Mirena)

We will only discuss POP and depo provera here.

Progestogen Only Pill (POP)

 

  • Types of POPs are available:

    • Traditional POPs

    • eg: Noriday (Norethisterone- NET), Microlut ( Levonorgestrel- LNG)

  • Contain small doses of synthetic progesterone with no estrogen.

  • Both contain 28 pills in a packet and are taken continuously with no pill free period.

  • Typical use Failure Rate is 9%.

  • No delay in fertility return following the discontinuation.

  • Safe in patients with migraine.

  • No association with headache, cardiovascular disease (MI, VTE or stroke) or breast cancer.

  • Change in the bleeding patterns is common:

    •  2 in 10 women have no bleeding.

    •  4 in 10 women have regular bleeding and

    •  4 in 10 woman have irregular bleeding.

  • Mood changes can occur.

Mechanism Of Action (POP)

  • Suppression of ovulation ( up to 60% of LNG users and 97% of DSG users)

  • Variable dampening effect on the mid cycle peaks of LH and FSH

  • An Increase in cervical mucous viscosity

  • Reduction in the number and size of endometrial gland

  • pop-diagram

Eligibility(POP)


INDICATION

  • Breast feeding

  • Women at high risk of estrogen based contraindication

  • Older age group women

  • Women with cardiovascular/ hypertension condition

 

CONTRAINDICATION

  • Breast cancer

  • Undiagnosed per vaginal bleeding

  • Suspected pregnancy

  • Liver tumours

  • Acute liver disease

 

 


Starting The POP

  • Take one POP at or around the same time everyday without a pill free period.

  • POP can be started day 1 to day 5 of the menstrual period without need of any other added contraceptive method for next 48 hours.

  • If started at anytime (pregnancy excluded) additional contraception is advised for the next 48 hours.

  • POP can be initiated immediately postpartum.

  • POP can be started immediately after a miscarriage.

Missed Pills Regime POPs

  • Traditional POPs ( 3 hrs Window)

  • If more than 3 hrs late, ie more than 27 hrs from the last pill OR

  • Desogestrel POPs ( 12 hrs window)

  • If more than 36 hrs late since the last pill:

    • A) The last pill should be taken as soon as remembered, if more than one pill has been missed, ONLY one pill should be taken.

    • B) The next pill should be taken at the usual time. This may mean that 2 pill are taken in one day.

    • C) Additional Contraceptive Precautions ( condoms or avoidance of sex) are advised for 2 days ( 48hrs) after restarting the POP.

    • D) Emergency contraception is indicated if unprotected sexual intercourse occurred after the missed pill and within 48 hrs of restarting the POP.

Progesterone Only Injectables

  • Intramuscular progestin are Depo medroxy progesterone acetate ,DMPA 150mg and norethisterone enanthate, NET-EN).

  • DMPA is an aqueous suspension and is in a prefilled syringe. It needs to be vigorously shaken to ensure complete suspension of the content.

  • NET-EN is a thick, oily fluid that needs to be drawn out to syringe. The ampule needs to be emerged in warm water to reduce the vicosity prior.

  • Both are administered intramuscularly into the upper outer quadrant of the buttock or in the deltoid as an alternative

  • Typical use Failure Rate is 6%

  • Use maybe continued till age 50 years.

  • Concurrent use of medication ie antibiotics or liver enzyme – inducing drug will not reduce its efficacy.

  • There is no association of DMPA use with mood swing, libido and headache.

  • It alters the bleeding pattern and may cause ammenorhoea amongst user after 1 year of usage. ( 70%)

  • There is a small association of weight gain amongst users after 6 months. However the weight gain is mostly due to water retention.

  • There maybe a small loss of BMD with will recover after discontinuation, however there is no increase in fracture risk.

  • There may a delay in fertility return after 1 year of usage.


Long Term Use of Progesterone Only Injectable

  • Women using DMPA who wish to continue use should be reviewed every 2 years to assess individual situations and to discuss the Benefits and Potential Risks

  • Women are Generally advised to switch to another method at Age 50.

  • THERE IS NO NEED TO STOP DMPA in Long Term Users AS LONG AS ITS USE IS WITHIN WHO MEC 1 or 2.

Eligibility (Progestogen Only Injectable)


INDICATION

  • Breast feeding

  • Women at high risk of estrogen based contraindication

  • Older age group women

  • Women with cardiovascular/ hypertension condition

  • Can be used in patients <18yrs after consideration of other methods


CONTRAINDICATION

  • Breast cancer

  • Undiagnosed per vaginal bleeding

  • Suspected pregnancy

  • Liver tumours

  • Acute liver disease

Mechanism Of Action Progesterone Only Injectable

 

 

 

 

 

 

 

 

 

 

 

 

Starting The Progesterone Only Injectables

  • Start up to day 21 postpartum for immediate protection.

  • If started after that additional method is required for the next 7 days.

  • May be given immediate after surgical or medical abortion but if after 5 days then an additional method is required.

  • Clients can return every 12 weeks for repeat injection of DMPA.

  • If necessary, the repeat injectable contraception can be given up to 2 weeks earlier or 2 weeks late without any need of an additional contraception.


References

  1. Progesterone -Only Pills, Clinical Effectiveness Unit, Faculty of Sexual and Reproductive Healthcare Clinical Guidance, March 2015, Updated January 2016

  2. Trussell James, Contraceptive Failure in the United States, Contraception 2011 May; 83 (5): 397-404

  3. Best practice in Postpartum family Planning,Best Practice Paper No 1, June 2015, RCOG

  4. OGSM basic contraception Course 2016

  5. WHO Medical elilgibilty criteria updates, volume 94, Issue 3, September 2016

  6. A prospective comparison of bone density in adolescent girls receiving depot medroxyprogesterone acetate (depo provera), levonogesterel (norplant) or oral contraceptive. Cromer BA et al, J Pediatr, 1996, Nov;129 (5): 671-6

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