Contraception where have we been and where are we going.pptx
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The document outlines the extensive achievements and roles of Dr. Laxmi Shrikhande in women's health, including her involvement in various medical organizations and awards received for contributions to maternal health and family planning. It highlights the critical need for improved contraception in India, presenting data on family planning methods, unmet needs, and the effectiveness of various contraceptive options. Additionally, it discusses developments in contraceptive methods, emphasizing the importance of addressing the rising population challenges and promoting reproductive health education.
Contraception where have we been and where are we going.pptx
- 1. • Chairperson Elect ICOG –Indian College of OB/GY • National Corresponding Editor-Journal of OB/GY of India JOGI • National Corresponding Secretary Association of Medical Women, India • Founder Patron & President –ISOPARB Vidarbha Chapter • Chairperson-IMS Education Committee 2021-23 • President-Association of Medical Women, Nagpur AMWN 2021-24 • Nagpur Ratan Award @ hands of Union Minister Shri Nitinji Gadkari • Received Bharat excellence Award for women’s health • Received Mehroo Dara Hansotia Best Committee Award for her work as Chairperson HIV/AIDS Committee, FOGSI 2007-2009 • Received appreciation letter from Maharashtra Government for her work in the field of SAVE THE GIRL CHILD • Senior Vice President FOGSI 2012 • President Menopause Society, Nagpur 2016-18 • President Nagpur OB/GY Society 2005-06 • Delivered 11 orations and 450 guest lectures • Publications-Thirty National & Eleven International • Sensitized 2 lakh boys and girls on adolescent health issues Dr. Laxmi Shrikhande MBBS; MD(OB/GY); FICOG; FICMU; FICMCH Medical Director- Shrikhande Fertility Clinic Nagpur, Maharashtra
- 2. Contraception- Where have we been and where are we going? Dr Laxmi Shrikhande Consultant –Shrikhande Hospital & Research Centre Pvt Ltd Nagpur
- 3. Population Projection – India & Global India accounts for 17% of world’s population By 2050 : expected population : India : 1.63 Billion World’s population 9.3 billion (16% in 2050 will be over 65 – more would be over 85 yrs) • Population increase due to lack of contraception Decline in infant mortality Increase in life expectancy.
- 4. The policy for the world population to survive, thrive and prosper was defined by the world leaders in 2015 as the 17 sustainable development goals. Heads of Governments undertook the responsibility of helping to achieve these goals in their own countries, the region and the world by 2030.
- 5. SDGs and the World Population • The goals are laudable but cannot be achieved with an ever increasing population. • To survive and thrive; the denominator i.e. the population need to be stable. Contraception is the need of the hour Global : Unmet need 225 million women in the reproductive age group who want contraception. 80 million unwanted pregnancies
- 6. 15.6 Million Abortions Occur Annually in India The Lancet Global Health—was conducted jointly by researchers at the International Institute for Population Sciences (IIPS), Mumbai; the Population Council, New Delhi; and the New York–based Guttmacher Institute. 2017
- 7. Maternal deaths could be prevented by 3 Baskets of Care- Contraception, Safe abortion care & Emergency Obstetrics 2 Medical interventions have been prioritised and chosen on the basis of their link with key causes of death and high impact potential to save lives, and have been validated through literature review and expert opinion. 3 HIV data is estimated. Various sources state the total burden to be 3-17%. The 7% estimate is based on Spectrum modelling data. 4 Examples of treatment include uterotonics, uterine massage, balloon tamponade, uterine compression sutures, hysterectomy. Text
- 8. Importance of FP and MCH Linkages Unmet need for FP Unintended pregnancy Childbirth Maternal mortality and morbidity Abortion Unsafe abortion Family planning plays a critical role in reducing maternal and infant mortality rates.
- 10. Current use of family planning methods (among married women of reproductive age) India (%) Total unmet need 9.4 Any modern method use 56.5 Female sterilization 37.9 Male sterilisation 0.3 IUD/PPIUCD 2.1 Pill 5.1 Condom 9.5 Injectables 0.6 Source: National Family Health Survey (NFHS-5) 2019-20. Ministry of Health & Family Welfare, Government of India • Unmet need : 9.4 %, indicating that 1 in 10 women want to space or limit births, are not able to do so • Undue burden of family planning on women, the focus continues to be on female sterilization. • Adoption of spacing methods and male participation remain low.
- 11. Female Sterilisation , 37.9% Male Sterilisation , 0.3% IUD/PPIUD, 2.1% Pills , 5.1% Condom, 9.5% Injectables , 0.6% India Source: National Family Health Survey (NFHS-5) 2019-20. Ministry of Health & Family Welfare, Government of India
- 18. Promoting quality sterilization services 1. Enhanced Compensation Scheme (for HFS) 2. National Family Planning Indemnity Scheme 3. Mobile teams dedicated for FP services in hard to reach areas 4. Scheme for ensuring pick up and drop back services to sterilization clients 5. Technical Manual Update for ensuring quality in services
- 20. Injectable Contraceptive MPA (Antara Program) Long-acting reversible contraceptive (LARC) • 4th most prevalent contraceptive • Currently 42 million women worldwide use MPA as a method of choice • Developed in 1954 by the Upjohn Company for treatment of endometriosis and habitual or threatened abortions • Since 1960, licensed to be used as Contraceptive • USFDA in Feb 1992 approved DMPA as a contraceptive • Currently approved for use in more than 130 countries (WHO: Family Planning: A Global Handbook for Providers)
- 21. Global Evidence (OCPs) • Oral Contraceptive Use: • Worldwide, 8% of all married women- 100 million women. • Number one contraceptive method in Africa, Europe, America and Oceania (Australia, New Zealand and the South Pacific islands).
- 22. During the last 50 years, improvement of the oral pill has been concentrated on continuously lowering the Estrogen dosage, and developing newer generations of Progestogens to make “safer” and “made to order” pills Gregory Pincus The first research on the Oral Contraceptive pill 50 Years
- 23. Development of Hormonal Contraception 150 μg mestranol 50 μg EE 35 μg EE 30 μg EE 25 μg EE 20 μg EE (10-15 μg EE) lowering the Estrogen dosage Newer generations of Progestogens Estrogen component is : Ethanyl estradiol Modifications to neutralize the androgenic activity Norethisterone Levonorgestrel Gestodene Desogestrel Drospirenone Cyproterone acetate Reducing Androgenicity
- 24. Global Evidence : ECPs Use of ECPs is increasing worldwide. • Most women who had ever used emergency contraception had done so once (59%) or twice (24%)* • From 2009 to 2014-India’s market for emergency contraceptives jumped by 88%, ranking the country third in the world after the US and China. • **One in four (23%) Young adult women aged 20–24 were most likely to have ever used emergency contraception *(Euro monitor International’s report) ** (Source: CDC, NCHS Data Brief No. 112, February 2013).
- 25. Is there a need for a newer contraceptive in India ? Study shows that addition of one method available to at least half the population correlates with an increase of 4–8 percentage points in total use of all modern methods
- 26. Two New Progestin-only contraceptives introduced in India DMPA –SC (Sayana Press) Subcutaneous injectables Subdermal Progesterone Implants
- 27. Both are injectable Medroxy Progesterone Acetate for 3 monthly use
- 28. Action of DMPA Prevents ovulation Endometrium thinner Cervical mucous thicker
- 29. Uniject Gap
- 30. Activate the Uniject 9.5 mm needle length •The injection site should NOT be massaged by the provider or the client as this may make the body use the DMPA faster and act for a shorter time.
- 31. DMPA -SC Initiate within 7 days of menses Rule out pregnancy Reinjection in 3 months Safe during lactation , after 6 weeks postpartum Grace period : works for 3 months + 4 weeks Return of fertility delayed 7 to 10 months Contra-indications: migraine headaches, h/o heart attack, stroke,serious liver condition,high blood pressure, CA breast
- 32. DMPA SC–Side effects Temporary mild skin irritation Irregular menses initial months Amenorrhoea : 55% at one year 70% at 2 years Bone Mineral Density (BMD) Use is associated with loss of BMD After stopping, recovery of BMD is seen , return to baseline in 1-4 years No increase in fracture risk Berenson et al. Obstet Gynecol 2004;103, Scholes et al. Arch Pediatr Adolesc Med 2005;159:139, Harel et al. Contraception 2010;81:281
- 33. Contraceptive efficacy : 99% Highly effective contraception with a similar tolerability profile to DMPA-IM DMPA-SC is an effective and well-tolerated contraceptive option, providing comparable efficacy and BMD safety to DMPA-IM. -Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive efficacy and bone mineral density Andrew M Kaunitz 1, Philip D Darney, Douglas Ross, Kevin D Wolter, Leon Speroff ORIGINAL RESEARCH ARTICLE| VOLUME 80, ISSUE 1, P7-17, JULY 01, 2009
- 34. Acceptability studies for User Less invasive/ painful - prefer the smaller needle and SC route Uganda and Sengal : > 80 % preferred DMPA SC over DMPA IM
- 35. Providers and community health workers : 98 % preferred DMPA SC over DMPA IM
- 36. DMPA-SC Self injection Way forward … Client self- injection under supervision at PHC (two visits) Self-injection independently at home for two doses Client returns to healthcare facility after six months for check up and DMPA-SC re- supply DMPA-SC can be self –Administered- Improve autonomy Cost effectiveness : travel, service provision Improved continuation rates DMPA SC injection admistered by Healthcare provider
- 37. Why DMPA-SC ? The dose is lower (one-third) Equally effective and safe Prefilled with the correct dose, sterile More acceptable : Users Less invasive/ painful Health workers & frontline workers Can be self –Administered- Improve autonomy Cost effectiveness : travel, service provision Improved continuation rates Reduced plastic waste :Uniject generates 70 percent less
- 39. Implants - LARC Implanon NXT (Nexplanon): 1-rod effective for 3 years 68 mg of Etonorgestrel bio-equivalent to Implanon but has an addition of barium sulphate that makes it radio-opaque. Jadelle: 2-rod effective for 5 years Levonogestrel 75 mg Progestin-filled small flexible rod Inserted under the skin of the Inner upper arm
- 40. Who Can Start Implants blood pressure ≥160/100, postpartum and breast feeding < 6 weeks, cervical cancer, history of DVT/PE, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for CVD, heart disease, hypertension >160- >100, migraine with aura Category 2 adolescents, nulliparity, heavy smokers, breastfeeding 6 weeks to < 6 months, endometriosis, endometrial or ovarian cancer, thyroid disorders, uterine fibroids, hepatitis, hypertension 140-150/90-99,HIV, PID Category 1 Conditions WHO Category Source: WHO, 2015. Implants are safe for nearly all women. Many women who cannot use methods that contain estrogen can safely use • Based on WHO Medical eligibility criteria (MEC)
- 41. Clinical effectiveness: Highly effective. Best among long acting reversible More effective than permanent sterilization 0.05% typical (and perfect-use) failure Croxatto HB. Eur J Contracept Reprod Health Care. 2000;5(suppl 2):21 Funk et al. Contraception 2005;71:319 Trussell. Contraception 2011;83:397
- 42. Implant Insertion Outpatient procedure Pre-loaded device rule out pregnancy Back up method if not within the 1st 5 days of menses Funk et al. Contraception 2005;71:319. IMPLANON / Nexplanon should be inserted at the inner side of the non-dominant arm about 8 to 10 cm (3–4 inches) above the medial epicondyle of the humerus special applicator
- 43. Implant removal Minor surgical procedure Local anaesthesia Trained provider Average removal time 3.5 minutes Difficult removal- due to local fibrosis
- 44. Complications from Implants Are Uncommon or Rare Infection at insertion site If occurs, most likely within the first 2 months Difficult removal Rare if inserted properly and removed by a trained provider Expulsions Rare; most occur within the first 4 months Source: CCP and WHO, 2011.
- 45. Etonogestrel implant bleeding patterns Funk et al. Contraception 2005;71:319. ~20% amenorrhea in 1st year Mansour et al. Eur J Contr Reprod Health Care 2008;13S1:13
- 46. Management of bleeding Mansour et al. Contraception 2011;83:202 1st Choice Daily COC for 21 days, followed by 7-day break. Use for up to 3 months. 2nd Choice High-dose progestin for 21 days with 7-day break (e.g. medroxyprogesterone acetate 10mg twice daily). Use for up to 3 months.
- 47. Other Side Effects Weight gain : Not a significant increase Overall increase in BMI 0.7kg/m2 12.7% of women reported weight gain Not contraindicated in obese women Acne : 17% reported acne No differences in BMD changes Return to fertility: Within one month of removal Funk et al. Contraception 2005;71:319. Beerthuizen et al. Human Reproduction 2000;15:118
- 48. Emergency contraception Method Dosing Formulation Efficacy Number of days after intercourse Side effects LNG 0.75mg 2 doses 12 hours apart LNG 750mcg 12 hours apart 75% 3 days Well tolerated LNG 1.5 mg One dose LNG 75% 3 days Well tolerated Ulipristal One dose SPRM 30mg 75% 5 days Nausea & vomiting Cu IUD 99% 5 days Combined pills 2 doses 12 hours apart EE 200mcg+LNG 1mg 12 hours apart 75% 3 days Frequent nausea & vomiting.
- 49. Emergency contraception Ulipristal acetate ( progesterone receptor modulator) Single dose 30mg within 120 hours The UPA EC regimen is slightly more effective than LNG as shown by a meta-analysis (n = 3242) of two randomised controlled comparative trials UPA may be more effective than LNG for women who are obese. Cu-IUD Inserted within 120 hours Large systematic review of 42 studies showed that Cu‐IUD is the most effective EC with failure rates of <0.1%. Levonorgestrel 1.5 mg single dose ? Although for use within 72 hours, there is evidence that efficacy may be maintained up to 96 hours post UPSI Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials. Contraception 2011;84:35–9 Cheng L, Che Y, Gulmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev 2012;8:CD001324
- 50. Other newer routes of administration of combined hormonal contraception Vaginal rings Contraceptive Patch Monthly combined Injectable
- 51. Nuvaring – vaginal ring A flexible transparent ring of ethylene vinyl acetate with an outer diameter of 54 mm and cross-sectional diameter of 4 mm One size for all! Combined hormonal contraceptive vaginal ring containing 2.7 mg ethinylestradiol and 11.7 mg etonorgestrel It has the lowest oestrogen content of any combined hormonal contraceptive
- 52. Ingredients - Nuvaring Every 24 hours the device releases: 15 mcg EE 120 mcg ENG The hormones are absorbed into the rich supply of blood vessels within the vagina and enter the general circulation, avoiding the first-pass metabolism by the liver Each Nuvaring is used for one monthly cycle It stay in the vagina for 3 weeks and is then removed for a 1 week ring-free interval The 7 days without Nuvaring allows for a withdrawal bleed No daily pill taking; low dose; avoids 1st pass effect; low incidence of BTB or adverse effects; latex free
- 53. Evra - contraceptive patch Daily dose 20mcg EE + 150 mcg Norelgestromin (similar to Cilest) Levels sufficient to inhibit ovulation for at least 7 days Efficacy similar to triphasic COC (overall PI 1.24) BTB more common in 1st 2 cycles than COC Suitable for women with absorption problems, who are forgetful or have difficulty swallowing pills
- 54. Combined injectable contraceptives (monthly injectables) 54 Compared to progestin-only injectables DMPA 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 DMPA is injected every 3 months.
- 55. Women are Dying Every Day… • Every 15 minute……., somewhere in India, a woman dies in pregnancy or childbirth -One – Third of these deaths could be avoided if women who wanted effective contraception had access to it
- 56. Questions
- 57. My World of sharing happiness! Shrikhande Fertility Clinic Ph- 91 8805577600 shrikhandedrlaxmi@gmail.com
- 58. The more you give, the more you will get. Then life will become a sheer dance of love. H. H. Sri. Sri. Ravishankar The Art of Living Thank you