PERPETUAL HELP MEDICAL CENTER-BIÑAN
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
FAMILY PLANNING
 LNG-IUS (Levonorgestrel Intrauterine System/Mirena)-
CONTRACEPTION AND FAMILY PLANNING
Contraception- the intentional prevention of pregnancy
by artificial or natural means.
Family Planning- allows individuals and couples to
anticipate and attain their desired number of children
and the spacing and timing of their births. It is achieved
through use of contraceptive methods and the
treatment of involuntary infertility.
 Recommended Timing and Spacing:
o At least 2 years after live birth
o At least 6 months from a miscarriage
 Contraceptive Effectiveness
o Typical use- actual use, including
occasional inconsistent or incorrect use.
o Perfect use- correct and consistent use
with every intercourse
TIER METHODS (CONTRCEPTIVE METHODS)
1. Tier 1: Highly Effective : Intrauterine Devices
(IUDs), Implants, Male and Female Sterilization
- Fewer than 1 pregnancy per 100 women in 1
year
2. Tier 2: Very Effective: Injectables, Pills, Patch,
Ring
- 6 to 12 pregnancies per 100 women in 1 year
3. Tier 3: Effective: Barrier methods, Lactational
Amenorrhea, Periodic Abstinence, Coitus-
related methods
- 18 or more pregnancies per 100 women in
1 year
TIER 1: HIGHLY EFFECTIVE
Long Acting Reversible Contraceptives (LARC)
 A single-rod Etonogestrel subdermal implant
(Nexplanon), the Copper T380A intrauterine
device, and several Levonogestrel intrauterine
systems (LNG-IUS)
 Highly effective with rapid return to fertility
after removal. (after removal: approx.. 1 week
women can get pregnant)
 Reduces risk of rapid repeat pregnancy of even
postpartum/post abortal period.
o Rapid Repeat Pregnancy- not getting
pregnant within the year after delivery
 ACOG recommends this method as a first-line
contraception to most women (ACOG, 2009).
1. Intrauterine Devices
 Most commonly used reversible method of
contraception worldwide.
 Small, flexible T shaped plastic frame with either
copper or releases small amounts of levonorgestrel
(progestin only contraceptive) per day
 Have one or two strings tied to them which hang
through the cervix into the vagina.
Types of IUD:
 Copper T 380A IUD (Paragard)- effective for at
least 12 years
Trans by: Manimtim-Cariaga
effective for 5 years.
Mechanism of Action
 IUD- induces local inflammatory reaction to
endometrium hostile to sperm no ovulation
occurs
 Copper IUD-causes inflammation  affects function
and viability of gametes  prevents ovulation.
o Impede sperm transport and viability in the
cervical mucus
 LNG-IUS- Progestin thickens cervical mucus 
impede sperm transport and access to upper genital
tract.
o Decreases tubal mobility
o Thin, inactive endometrium
o Inhibits ovulation
o More effective than copper IUDS
Insertion and Timing
 Immediately after postabortion
 On any day of the cycle of non-pregnant woman
 Immediately postpartum following either vaginal or
cesarean delivery
Adverse Effects
 Abnormal uterine bleeding: increased for Cu-IUD,
reduced for LNG-IUS
 Perforation-rare (1 in 1000)
 Pregnancy complication
 Infection- Pelvic inflammatory disease incidence is 6x
higher in 1st 3 weeks post insertion due to aseptic
technique; IUD itself does not cause the infection.
Contraindication
 Suspicion of pregnancy
 Acute Pelvic Inflammatory Disease
 Postpartum endometritis or infected abortion
 Known/suspected uterine or cervical cancer
 Genital bleeding of unknown origin
 Previously inserted IUD
Overall Safety/Benefits
 IUD is useful method of contraception for women
who have completed their families and have
contraindications to sterilization.
 Reduction in risk of endometrial CA with the LNG-IUS
 Maybe used for early stage endometrial CA (LNG-
IUS)
 Reduction of menstrual cramps and endometriosis
(LNG-IUS)
2. Subdermal Implants
 Consist of one or more thin rods containing
progestin hormone (etonogestrel or levonorgestrel)
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  Inserted subdermally in the non-dominant arm using  Speculum is inserted to the cervix reaching the
a trocar fallopian tube
 Effective from 3-5 years, thus can be used for
spacing

Mechanism of Action MALE STERILIZATION

 Prevents ovulation  Vas deferens is isolated, cut  ends are closed

 Causes thickening of the cervical mucus, preventing (ligation or fulguration) replaced in scrotal sac
sperm penetration  Prohibits sperm from passing to ejaculate

Effectiveness Side Effects

BTL
 99.95% for BOTH typical and perfect use:
because once inserted the patient does not have to  Pain/swelling on incision site
do anything for at least 3 years.  Superficial bleeding
 Etonogestrel subdermal implant (Implanon
NXT): a single rod implant that is good up to 3 years; Vasectomy
only one available in the Philippines
 Discomfort for 2-3days
Insertion and Timing
 Pain in the scrotum, swelling, and bruising which
decreases for about 2-3 days
 Any day of the cycle provided she is not  Brief feeling of faintness after the procedure
pregnant
 Immediately postpartum or postabortal
When to Start

Side Effects
 BTL: Within 2-7 days postpartum, >6 weeks
postpartum
• Altered bleeding pattern – amenorrhea, infrequent  Vasectomy: anytime  semen analysis to confirm
or prolonged bleeding; patient is not to worry about
blood pooling in the uterus or develop into a myoma
TIER 2: VERY EFFECTIVE
as there is no thickened endometrium to be
sloughed off (MOA of Implants)
1. Injectable Suspension
 Depo-medoxyprogesterone acetate: 150mg IM or
o Headache
104 mg SC every 3 months
o Bloating
o Acne
Mechanism of Action
o Breast tenderness
o Nausea, dizziness
o Changes in appetite with subsequent weight  Inhibits ovulation: suppressing FSH and LH levels 
gain/loss prevent LH surge  thickening of the cervical mucus
o Hair growth/loss  Altering the endometrium

3. Permanent Contraception: Sterilization Side Effects

 Male and Female sterilization
 Altered bleeding pattern
Female Sterilization  Weight changes
 Blocks fertilization by cutting or occluding the  Mood changes
fallopian tubes  Headache
 Highly effective  Decrease bone mineral density
 Reduced risk for ovarian CA by bilateral
salpingectomy Non-Contraceptive Use Benefits
 Most prevalent after 30 years old
 Advised to patients with more than 3-4 cesarean  Reduces risk for iron deficiency anemia and PID
sections  Reduces risk for endometrial cancer
Different approaches:  Reduce incidence of primary dysmenorrhea,
o Transabdominal endometriosis, ovulation pain, functional ovarian
 During cesarean section, infraumbilical (postpartum cysts
NSD), minilaparotomy (interval), Modified Pomeroy
 Interval ligation – after delivery of the baby; fallopian When to Start
tube is easily seen.
o Laparoscopic  6 weeks postpartum (fully breastfeeding), 3
 Bipolar cautery, Filshie clip, Silastic band (Falope weeks postpartum (non or partial
ring) breastfeeding)
o Transcervical  Immediately post abortion
 Essure device – occludes the fallopian tube; need to  Anytime during menstrual cycle as long as not
be checked for 3 months pregnant

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 2. Oral Contraceptives  Condoms - Thin sheath of latex rubber made to fit
 Contains hormones similar to the woman’s natural a man’s erect penis or woman’s vagina
hormones- combination of estrogen and  Often times lubricated and some have spermicidal
progesterone (COC) or progesterone only (POP) components.
 2 types: 21 or 28 pills

Mechanism of Action

 Inhibits ovulation Mechanism of Action

o Estrogen (FSH suppression), progestin (LH  Acts as barrier that prevents the sperm from
surge) getting into the vagina and/or uterine cavity
 Thickens cervical mucus  Helps prevent both pregnancy and STIs (double
 Thinning of endometrium protection)

Side Effects Effectiveness

 Perfect use: 98% (M); 95% (F)
 Typical use: 85% (M); 79% (F)
 Nausea
 Breast tenderness
 Headache
 Acne
 Weight gain 2. Lactational Amenorrhea Method
 Altered bleeding patterns- for POP
Woman practicing LAM met the following conditions:
Non-Contraceptive Use Benefits
 Fully or nearly fully breastfeeding (on demand, not
 Reduces risk for iron deficiency anemia and PID greater than 4 hours interval during the day and 6
 Reduces risk for ovarian, endometrial, colon and hours at night time, use both breasts)
rectal cancer  Amenorrhea (menses not returned after 8 weeks
postpartum)
 Reduce incidence of excess hair in body and acne
 Infant is less than 6 months old
 Reduce symptoms of PCOS and endometriosis

Mechanism of Action
Risk

 Prevents the release of eggs from the ovaries

 Risk is not increased even in high risk patients (family
(ovulation)
history, BRCA1 and 2 mutations)
 Temporarily prevents the release of the hormones
 Cervical CA – increased in OC users →increases with
that cause maturation and release of the ovum
duration of use

Effectiveness
Contraindications

 Perfect use: 99.5%

o Smokers > 35 y/o
 Typical use: 98%
o Uncontrolled HTN
o History of breast, endometrial or liver cancer
3. Periodic Abstinence
o History of vascular disease (thromboembolism,
 Safe days: 7 days before
thrombophlebitis, atherosclerosis & stroke)
and after the first day of menses
o Active SLE
o Undiagnosed uterine bleeding
Methods
 On medications: rifampicin, phenytoin,
Calendar method
phenobarbital, carbamazepine

 6 cycles: subtract 18 days from shortest cycle

How to Take It
and 11 days from longest cycle
 Recompute every month
 For Combined oral pills
o Cyclic: daily for 28 days (21 active & 7 days
Standard Days method
inert) or daily
 For 21 days then pill free for 7 days
o Extended/Continuous: 84 active pills then  For patients with 26-32 days cycle, unsafe period is
pill free for 7 days D8-19 of menses
 For Progestin only pills
o On tablet daily for 28 days Basal Body Temperature
o Ideally same time every day (not more than Billing’s Ovulation
3 hours late)
 Consistency of discharged is checked
TIER 3: EFFECTIVE  If “pasty”, then it is safe

1. Barrier Methods Symptothermal (combined calendar, temperature, cervical

mucus)

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  Can only be used by women with regular menses
4. Emergency Contraception
 Prevents pregnancy after unprotected intercourse
a.k.a. “morning after pill”
 Can be used up to 120 hours after intercourse
Mechanism of Action
 Inhibits or delays ovulation
Methods
 Yuzpe method: using combined oral contraceptive
(EE +LNG) 2 doses for 4 tablets every 12 hours
o Trust contraceptive is the one that is readily
available in the Philippines
 Intrauterine device
CPG GENERAL GUIDELINES IN FAMILY PLANNING
Level of Evidence
Grading of Evidence of support
Fertility Awareness-Based (FAB)Methods
Recommendations:
FAB methods may be used by regularly Level III
menstruating women and highly motivated Grade C
couples.
Couples should be trained and counseled well
regarding the proper use of FAB methods.
Family planning service providers should be well
versed with the different methods of FAB and
should always offer them as contraceptive
choices.
The couple should refrain from vaginal intercourse
during the woman’s fertile period which is
computed as:
• Shortest recorded cycle minus 18 (start of
the fertile period)
• Longest recorded cycle minus 11 (end of
the fertile period)
The couple should abstain from vaginal Level III
intercourse from menstrual days 8-19 among Grade C
women with cycles of 26-32 days.
BBT is recommended for any reproductive age Level III
woman who is willing to take and chart her BBT Grade C
daily and practice abstinence during her fertile
days. The couple should refrain from vaginal
intercourse from the first day of the menses until
3 days after the temperature rise of 0.2 to 0.5°C.
The Cervical Mucus Method is recommended for Level III
any reproductive age woman without evidence of Grade C
vaginal infections or abnormal vaginal discharge.
The couple should refrain from vaginal intercourse
once the presence of a clear, wet, and slippery
mucus secretion is observed until the 4th day after
her peak day of wetness.
The STM is recommended for any reproductive Level III
age woman who is willing to take and chart her Grade C
BBT daily, has the patience and diligence to chart
her daily observations of her cervical mucus,
make a daily record of all these, and willing to
practice abstinence during the fertile period.
he couple should refrain from vaginal intercourse
when the woman senses cervical secretions, until
both the 4th day after peak cervical secretions and
the 3rd full day after the rise in BBT.
Like the cervical mucus method, the Two-Day Level III
Method is recommended for any reproductive age Grade C
woman without evidence of vaginal infections or
abnormal vaginal discharge. Once the woman
notices any secretions of any type, color and
consistency, the couple should refrain from
vaginal intercourse on that day and the day after.
Monitoring of ovulation using the saliva should be Level II-3
started at the end of the menses. Grade B
The couple should refrain from vaginal
intercourse on the days that a ferning pattern is
observed.
Advise the client that the discontinuation rates Level III
with FAB methods are high. These are mainly due Grade C
to trouble learning a particular method, difficulty
using it, challenge of sexual abstinence, lack of
confidence, dissatisfaction and shifting to another
family planning (FP) method.
Advise the client to use barrier methods in GPP
situations when vaginal intercourse cannot be
avoided during the fertile period.
Advise the client that FAB methods have no GPP
physical side effects.
All breastfeeding women should be counseled Level III
that LAM can safely be used provided all three Grade C
requirements are met:
1. The mother’s monthly menstrual cycle
has not returned.
GPP 2. The mother is fully or nearly fully
breastfeeding her baby.
GPP 3. The baby is less than six months old.
If any of the above is not met, the client should be
advised to use another family planning method.
Advise the client who is HIV positive to avoid Level II-2
Level III breastfeeding. Grade A
Grade C Advise the client not to breastfeed if she has Level II-2
active/untreated tuberculosis. She may resume Grade B
breastfeeding if she is on TB medications for at
least 2 weeks and is verified non-infectious.
Advise the client not to breastfeed if she has Level II-2
active Herpes Simplex Virus (HSV) lesions on the Grade B
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breast.
Barrier Methods
Male Condom
Recommendations:
Client should be advised to check the
packaging, instructions for use and valid
expiry date before using the condom.
Condoms should be stored in a cool, dry
place with temperatures not exceeding 37.7
C (100 F) and not below 0 C (32 F)
The client should be advised on the use of
non-oil based lubricants when using latex
condoms
Spermicidal lubricants (specially containing
nonoxynol-9) should not be used with
condoms because they do not provide
additional protection against pregnancy or
STIs.
Condoms must be used correctly with every
act of vaginal intercourse as follows:
 Remove the condom from the
packet, taking care not to damage
it with any sharp object (e.g.
fingernails, teeth)
 Put the condom on by holding the
closed end with the forefinger and
thumb to expel any air
 Unroll the condom all the way to
the base of the erect penis before
the penis makes any genital
contact
 Immediately after ejaculation, hold
the rim of the condom and
withdraw the penis while it is still
erect to avoid spilling semen.
 Use a new condom for every
vaginal intercourse
Client should be advised that condoms are
effective in preventing the transmission of
HIV and reducing the risks of other STIs
The client should be informed that the only
contraindication to the use of latex condom
is allergy to latex
Barrier Methods
Female Condom
Recommendations:
The client should be advised that if additional
lubrication is needed, she can use clean water,
saliva, oil, lotion or any oil-based lubricant
with a female condom
Female condoms must be used correctly and
consistently in every act of vaginal Grade C
intercourse.
The client should be advised to:
• Insert just prior to or up to 8 hours
before vaginal intercourse.
• Use a new one for each act of vaginal
intercourse.
• Remove the condom immediately
after vaginal intercourse. To remove
the female condom after intercourse:
• Squeeze and twist the outer ring to
keep the semen inside the pouch.
• Remove it gently before you stand up.
Wrap it in a tissue and throw it away
in the garbage. Do not flush it down
the toilet.
The client should be advised that with correct Level II-2
and consistent use of the female condom, the Grade B
risk of HIV transmission and other STIs may be
reduced.
The client should be properly advised on the GPP
GFP need to practice insertion prior to actual use,
on possible discomfort and slippage, and
noise during intercourse.
Combined Hormonal Contraceptives
Combined Oral Contraceptives
Level II-2 Recommendations:
Grade B The client should be advised that third and Level I
second generation COC s are better tolerated Grade A
Level II-3 than the first generation COCs. 2
Grade B
Monophasic pills should be the first choice for Level III
women starting oral contraceptive use. Grade C
The client should be advised that COC s GPP
available in themarket can be used as
Levell III
extended cycle by taking the active pills
Grade C
straight for 12 weeks followed by a one week
pill-free period.
The health provider should be guided by the GPP
World Health Organizaion (WHO) Medical
Eligibility Criteria (MEC) when
prescribing/dispensing COCs. Please see
Appendix D.
Client should be advised that: Level III
 She should take a missed hormonal Grade C
pill as soon as possible then keep
taking pills as usual, one each day.
(She may take 2 pills at the same time
or on the same day.)
 When 1 pill is missed or a new pack is
started 1 day late
o She should take a hormonal
pill as soon as possible
Level II-2 o No back up is required
Grade B
• When 2 pills are missed or a new pack Level III
Level II-3 is started 2 days late Grade C
Grade B o She should take 1 hormonal
pill as soon as possible
o No back up is required
• When 3 pills are missed in a row in
the first or second week or started a
new pack 3 days late
Level II-2 o She should take a hormonal
Grade B pill as soon as possible
o Use a back up method for the
next 7 days
Level III o Also, if she had vaginal
intercourse in the past 5
days, she can consider
emergency contraception
• When 3 pills are missed in the third Level III
week Grade C
• Discard the current pack and start a
new pack right away
• Use a back up method for the next 7
days
• Also, if she had vaginal intercourse in
the past 5 days, she can consider
emergency contraception
• When a nonhormonal pill is missed
(last 7 pills in 28- pill pack)
• Discard the missed nonhormonal pill/s
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 • Start the new pack as scheduled; keep factors.
taking the COCs as usual Among women with diabetes mellitus, use of Level II-2
COCs should be limited to healthy, nonsmoking Grade B
• When there is severe vomiting or Level III clients who are younger than 35 years and
diarrhea Grade C with no evidence of hypertension,
• If she vomits within 2 hours after nephropathy, retinopathy or other vascular
taking a pill, she should take another disease.
pill as soon as possible, then keep
The client should be advised that: Level I
taking the pills as usual
• a personal history of benign disease or Grade A
• If she has vomiting or diarrhea for
family history of breast cancer is not
more than 2 days, follow instructions
a contraindication to COCs
for 3 missed pills, above
• COCs reduces the risk for both
• For pills with 20 mcg of estrogen or
endometrial and ovarian cancer
less, women missing one pill should
follow the same guidance as for COCs are not recommended for women with Level I
missing one or two 20-35 mcg pills. documented history of VTE. Grade A
Women missing 2 or more pills
should follow the same guidance as COCs can be considered for women with Level II-2
for missing 3 or more 30-35 mcg pills. migraine headache without aura provided they Grade B
are healthy, nonsmoking and younger than 35
The client should be advised that: Level II-3 years.
• COCs do not disrupt an existing Grade B The client should be advised to return to the GPP
pregnancy clinic 3 months after initiation then annually
• COCs do not cause birth defects and thereafter. However, the client should return
will not harm the fetus even if the to the clinic anytime for any problem or
woman becomes pregnant while questions that may arise.
taking the pills or accidentally starts
the pill when she is already pregnant Combined Hormonal Contraceptives
Combined Injectable Contraception
The client should be advised that most women Level I Recommendations:
do not gain or lose weight due to COCs. Grade A If pregnancy occurs with CIC, it should be GPP
The client should be advised that COCs have no Level II-2 discontinued
effect on the mood or sex drive of a woman. Grade B
CIC is not recommended for breastfeeding GPP
The client should be advised that the Level II-1 mothers.
effectiveness of COCs are reduced with Grade B
rifampicin, phenytoin, phenobarbital,
Combined Hormonal Contraceptives
carbamazapine, primidone, and ethosoximide
Combined Vaginal Ring Contraception
COC should not be used for women who are Level I Recommendations:
older than 35 years and who smoke 15 sticks Grade A
If pregnancy occurs with CVR in situ, the ring GPP
or more per day.
should be removed.
Healthy, nonsmoking women doing well on Level II-2
CVR is not recommended for breastfeeding GPP
COCs can continue their method until Grade B
mother during the first 6 months.
menopause after weighing the risks and
benefits.
COCs are started anytime after 3 weeks Level II-2 Progestin Only Pills
postpartum if client is not breastfeeding and Grade B Recommendations:
do not have any other risk for venous POPs are recommended for breastfeeding Level I
thrombosis. women, forthose with cardiovascular Grade A
COCs are not recommended as the first choice Level II-2 problems, and women who are smokers.
for breastfeeding women. Grade B POPs should be taken on a continuous daily Level I
For clients who are fully or nearly fully GPP basis with no pill-free interval, at the same Grade A
breastfeeding for 6 months, COCs are started time every day.
anytime if still amenorrheic but should be The client should be advised that POPs can be Level II
started within the first 5 days of menses if started at any time during the menstrual cycle. Grade B
menstruation has resumed. However, if not started during the first day of
COCs can be started immediately after an Level II-3 menses, a back up contraceptive is required
abortion. No back up contraceptive is needed if Grade B for 2 days.
begun within th first 7 days following abortion. POPs should be taken on the same hour of Level III
every day. Grade C
COCs should be used with caution in obese Level II-2
In case of missed pills, the client should be Level III
women older than 35 years old because of the Grade B
advised to take it as soon as possible and use a Grade C
increased risk of VTE.
back up method for the next 2 days.
COCs may be appropriate for healthy, Level II-1 The client should be advised that POP should Level III
nonsmoking clients who are 35 years old or Grade B not be taken concurrently with medications Grade C
younger with well controlled and monitored known to decrease its effectiveness.
hypertension and with no signs of end-organ The client should be advised that the most Level III
vascular disease. common side effect is altered bleeding pattern Grade C
COCs may be appropriate for healthy, non- Level II-1 and is the most common reason for
smoking women with known dyslipidemia Grade B discontinuation.
without other known cardiovascular risk

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The client should be advised that fertility Level III
returns immediately upon discontinuation of Grade C Emergency Contraception
the POP. Levonorgestrel Emergency Contraception
The client should be advised that POPs are the Level II-2 Recommendations:
preferred contraceptive method for lactating Grade B LNG is not an abortifacient and can be used at Level II-2
mothers, as it has no known adverse effect on any time during the menstrual cycle after Grade B
the infant or on lactation. unprotected vaginal intercourse.
The client should be advised that non- Level III LNG is most effective if given within 72 hours Level I
breastfeeding women may be started on POP Grade C but it can be given up to 5 days of unprotected Grade A
within 21 days postpartum vaginal intercourse.
POPs can be started in breastfeeding women Level III The client should be advised to refrain from Level III
less than 6 weeks to 6 months postpartum as Grade C unprotected vaginal intercourse after using Grade C
long as menstruation has not yet returned and LNG ECP until the onset of menses.
as long as reasonably sure that the patient is A repeat dose of LNG may be given when a Level III
not pregnant. client experiences vomiting within 2 hours of Grade C
The client should be advised to follow up 1 GPP drug intake.
month after the initial visit, or earlier if with Anti-emetics, although not given routinely, Level I
problems. may be given to women who vomit within 2 Grade A
Before breastfeeding is discontinued, shifting GPP hours of LNG intake.
to another form of contraception should be The client should be counseled that side Level II-1
discussed with the patient. effects of LNG ECP are usually minimal and Grade B
The client should be advised that injectable Level III resolve within 24 hours.
progestins are suitable for women who have Grade C The client should be assured that LNG ECP is Level II-2
hypertension, diabetes mellitus, not associated with any adverse pregnancy Grade B
cardiovascular disease, kidney disease, outcome or congenital anomaly.
migraine headaches without aura, varicose
veins or thrombophlebitis. It is also given to Emergency Contraception
postpartum and post-abortal patients. The Yuzpe Regimen
Recommendations:
Progestin Injectable The Yuzpe regimen can be used for emergency Level III
Recommendations: contraception. Grade C
The client should be advised that the most Level II-2 The initial dose of the Yuzpe regimen is started Level I
common side effect is altered bleeding Grade B as soon as possible and at most within 72 Grade A
pattern. This is also the most common reason hours of unprotected vaginal intercourse, and
for discontinuation. repeated 12 hours after.
The client should be adequately counseled Level II-2 The Yuzpe regimen can be used at any time Level II-1
that the most common side effect of DMPA is Grade B during the menstrual cycle after unprotected Grade B
unscheduled bleeding, which can have a vaginal intercourse.
variable pattern in the first 6-9 months of use. The client should be advised that the Yuzpe Level I
Other common side effects of DMPA include Level II-2 regimen has a weaker efficacy compared to Grade A
nausea, dizziness, changes in appetite with Grade B the LNG method of emergency contraception.
subsequent weight gain or loss, hair growth or The client should be advised that the side Level II-1
loss, oiliness of the skin, acne and headache.2 effects of the Yuzpe regimen are usually mild. Grade B
Among clients younger than 18 years or older Level II-2 These most commonly include nausea,
than 45 years, DMPA can be used but risks and Grade B vomiting and change in bleeding pattern.
benefits over time should be re-evaluated. Clients who vomit within 2 hours of intake
We recommend daily supplementation with GPP should be given anti-emetic 1-2 hours before
Calcium and Vitamin D for skeletal health of repeating the dose.
women on DMPA. The client should be advised that side effects Level II-1
Subsequent injection should be given every 3 Level II-2 are more prominent with the Yuzpe regimen Grade B
months for DMPA and every 2 months for NET- Grade B than with LNG ECP.
EN. The client should be assured that the Yuzpe Level I
regimen is not associated with any adverse Grade A
Progestin Subdermal Implants (PSI) pregnancy outcome or congenital anomaly.
Recommendations:
Progestin implants (PSI) can be inserted within GPP INTRAUTERINE METHODS
7 days after the start of her menstrual Recommendations:
bleeding. A medical and sexual history should be carried Level III
PSI must be inserted by trained individuals. GPP out as part of the routine assessment for IUC Grade C
PSI may be removed anytime, with fertility Level II-2 to assess suitability for use of the method
returning as early as 42 hours after removal. Grade B needed for STI testing.
PSI are suitable for adolescents. Level III Risk assessment for sexually transmitted Level III
Grade C infection (STIs) should be done for all Grade C
The client should be adequately counseled prospective IUD/IUS users but there is no
that it is common to have spotting or light need for routine STI screening tests prior to
bleeding during implant use, particularly in the insertion of IUD/IUS.
first year. Tests for Chlamydia trachomatis and Neisseria Level III
gonorrhea should be done before IUD/IUS Grade C

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insertion in individuals with very high Referral to a specialist in contraceptive care Level III
likelihood of exposure to these infections or in should be made if the client is currently Grade C
women who request for it. undergoing treatment for venous
Prophylactic antibiotics are not routinely Grade C thromboembolism (VTE) and there is a need
required for the insertion or removal of IUDs for hormonal contraception.
even in women at risk for infective In an intrauterine pregnancy with an IUD/IUS Level II-3
endocarditis. in situ, removal should be done provided the Grade B
The client should be advised that insertion of GPP string is visible, after thorough counseling
an IUD may cause pain and discomfort for a about the risk of miscarriage, preterm delivery
few hours and light bleeding for a few days, and infection. If the string is not
and they should be informed about visible/accessible, further evaluation is
appropriate pain relief. warranted.
IUS can be inserted: Level I The client should be advised that there is no Level II-3
• At any time during the menstrual Grade A evidence of a delay in the return of fertility Grade B
bleeding (day 1-7) following removal or expulsion of IUD/IUS.
• At anytime during the menstrual cycle The client should be informed that IUD use is Level III
provided that it is reasonably certain not contraindicated in nulliparous women of Grade C
that the woman is not pregnant reproductive age.
(Please see Appendix C) Intrauterine devices are safe and appropriate Level I
• Immediately after a non-septic methods for adolescents. Grade A
abortion The client should be advised that women in Level II-3
• At any time within 48 hours after child any reproductive age may use IUD/IUS Grade B
birth
• During cesarean section prior to The client should be advised that IUD/IUS can Level II-1
closure of the uterus be safely used during breastfeeding. Grade B
• From 4 weeks postpartum The client should be advised that copper IUDs Level III
• Immediately when shifting to another and LNG-IUS may be used by women with Grade C
method which was used correctly body mass index (BMI) over 30.
and accurately Follow-up is recommended after the first Level III
menses, or 3- 6 weeks after insertion. Grade C
Advise the client that IUD/IUS can be removed GPP Transvaginal ultrasound for visualization of IUD
anytime. The most common reasons for string is not recommended unless there is no
discontinuation for the IUD are desire for visualization of the string on inspection and
pregnancy, unacceptable vaginal bleeding, there is a suspicion of displacement of the
pain and infection. string. Instruct patients on how to routinely
The main reason for discontinuation of the palpate for the IUD strings.
LNG-IUS is amenorrhea. LNG-IUS is effective for patients with heavy Level I
The client should be advised that heavy Level I menstrual bleeding and dysmenorrhea Grade A
menstrual bleeding and/or dysmenorrhea are Grade A associated with endometriosis
likely with IUD use. Correct placement of an IUD during the Level I
During the first 6 months following LNG-IUS Level I postpartum period (immediate, delayed or Grade A
insertion, irregular bleeding and spotting are Grade A intra-cesarean) is a safe and effective
common while oligomenorrhea or contraceptive method.
amenorrhea is likely by the end of the first
year of its use. Sterilization
The client should be advised that heavy Level I Recommendations:
menstrual bleeding associated with IUD use Grade A BTL should be performed only by trained GPP
can be treated with antifibrinolytic agents and service providers.
nonsteroidal anti- inflammatory drugs
Before performing BTL, clients should be GPP
(NSAIDs).
counseled and advised regarding other forms
The client should be advised that if heavy Level I
of long term contraception.
bleeding associated with IUD use is Grade A
The client and the spouse must have GPP
unacceptable, she may consider shifting to a
understood and signed an informed consent
LNG-IUS or more appropriate method.
form after preoperative counseling and advice
The client should be advised that there is no Level I
Additional counseling and advice should be Level II-2
significant weight gain. Grade A
given to clients who are younger than 30 years Grade B
The client should be advised of the possible Level III of age, who do not have children or with low
development of acne. Grade C parity because of the high rate of regret
The client should be advised that the LNG-IUS Level III postoperatively.
may be used by women who have migraine Grade C The client should be informed that sterilization Level II-2
with or without aura. is not associated with a decrease in sexual Grade B
The client should be advised that the risk of Level II-2 interest and pleasure.
ectopic pregnancy when using IUD/IUS is lower Grade B In cases where the client cannot make an GPP
than when using no contraception. informed consent (i.e. mentally incapacitated
The client should be informed about Level III patients), the decision to perform a BTL
symptoms of uterine perforation or infection Grade C should be referred to an authorizing body.
that would warrant an immediate Although the procedure can be done any time Level II-2
consultation. as long as it is reasonably certain that the Grade B

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client is not pregnant, it is best to have it ovarian tumors/cancers.
performed on the first 7 days of the menstrual Bilateral salpingectomy or fimbriectomy may GPP
cycle. be done for surgical sterilization for women on
The client should be counseled regarding the Level II-3 a postpartum or interval basis. However,
increased rate of regret when the decision to Grade B performance of a bilateral fimbriectomy may
undergo the sterilization procedure is done be easier to perform through a
postpartum. minilaparotomy incision than a bilateral
It is advisable to obtain an informed consent at Level III salpingectomy.
least 1 week prior if the tubal occlusion will be Grade C Women undergoing bilateral salpingectomy or GPP
done concurrent with an elective cesarean bilateral fimbriectomy, should be advised that
section. these methods are permanent with no
Postpartum sterilization is preferably done Level III prospects of reversal.
between 2 to 7 days post-delivery. Grade C Vasectomy should be performed only by GPP
Local practice recommends BTL within 48 GPP trained service providers.
hours after delivery due to economic Before performing vasectomy, clients should GPP
constraints and poor follow up. be counseled and advised regarding other
The choice of operative technique Level I forms of long term contraception.
(minilaparotomy versus laparoscopy) in Grade A The client and the spouse must have GPP
performing interval tubal occlusion should understood and signed an informed consent
depend on the skill and training of the form after preoperative counseling and
physician, and individual client characteristics advice.
and preferences since both procedures have Additional counseling and advice should be Level II-3
the same rate of major morbidity. given to clients who are younger than 30 years Grade B
Providers who have been trained in the Level II-2 of age, who do not have children or with low
hysteroscopic tubal sterilization (such as the Grade B parity because of the high rate of regret
Essure system) can offer it to clients desirous postoperatively.
of permanent forms of contraception. The client should be advised that vasectomy Level II-3
Effective techniques for tubal sterilization Level I has no negative effects on sexual performance Grade B
include cutting, tying, placement of clips or Grade A or frequency of sexual intercourse.
rings and electric current, but their The client should wait 3 months before relying Level II-2
comparative effectiveness is not clear. on his vasectomy for contraception, during Grade B
Any of the method of tubal occlusion (such as Level II-2 which he and his partner may use other forms
the modified Pomeroy, use of Filshie clips) can Grade B of contraception. Semen analysis, where
be used when a minilaparotomy approach is available, can confirm contraceptive
used. effectiveness after the 3-month waiting period.
It is advisable to perform a modified Pomeroy Level II-3 The client should be informed that even Level II-3
procedure for postpartum sterilization because Grade B though considered a permanent method, Grade B
of its lower failure rate. vasectomy has an associated failure rate and
When using the laparoscopic approach, Level I that pregnancies can occur several years later.
mechanical occlusive methods are preferable Grade A The client should be reassured that vasectomy Level II-2
over bipolar diathermy. is not associated with an increase in testicular Grade B
Specimens taken from BTL may not be Level III cancer or heart disease.
routinely submitted for histopathological Grade C The client should be informed about the Level II-1
examination, unless there is a question of possibility of chronic testicular pain after Grade B
their identity intraoperatively. vasectomy, and should be offered appropriate
The client should be informed that the risk of a Level II-2 pain relief.
subsequent ectopic pregnancy in failed BTL is Grade B The client should be informed of the success Level II-2
high. rates of reversal procedures, even though Grade B
The client should seek medical consult if they Level III vasectomy is considered a permanent method
experience abdominal pain or vaginal bleeding Grade C of contraception.
after sterilization, to rule out the possibility of
ectopic pregnancy.
The client should be reassured that tubal Level II-2
occlusion is not associated with an increased Grade B
risk of heavier and painful period. However,
they have an increased chance of irregular
menses.
If abnormal bleeding is encountered after GPP
tubal occlusion, further workup for the
etiology is warranted.
The client should be informed of the success Level II-3
rates of reversal procedures, even though Grade B
tubal occlusion is considered a permanent
method of contraception.
Bilateral salpingectomy or fimbriectomy may GPP
be done for surgical sterilization for women
undergoing cesarean section or conservative
gynecological surgery as prophylaxis against

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