The
Health Provider A PUBLICATION OF THE NATIONAL FAMILY PLANNING BOARD
ARE ALL
PILLS
THE SAME?
Misconceptions about ecp
VOLUME 3 NUMBER 4
EmErgEncy contracEptivE & your HEaltH
Missed pills: taking missed pills in the 21 and 28 day pack
Editorial The Contraceptive Pill is a traditional method of contraception used by women for decades to prevent pregnancies. In recent times, the pill has been used by female clients for other health benefits other than pregnancy prevention. This deviation from its conventional use as a contraceptive method has heralded the advent of the pill being prescribed for other reasons beneficial to the health of the female consumer based on the particular brand of pill, and its specific composition. This quarterly edition of our Health Provider newsletter will focus on a variety of contraceptives in order to address any misconceptions or lack of information, pertaining to the pill as a contraceptive method. The article titled “Are all pills the same” compares brands and the benefits of each to the female client. It also looks at a common phenomenon of females changing from the pill to other forms of contraceptive methods; and disseminates information from the 2008 Reproductive Health Survey, on the popularity of other methods when the woman decides to
Credits newsletter co-ordinator Harriett M. Clarke- Communications Officer (Writer) CONSULTING EDITORS Dr. Olivia McDonald Executive Director Dianne Thomas Director Outreach Prorgrammes Kevin Bell Director Policy Formulation, Monitoring & Evaluation
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switch from the pill. A contraceptive update comes in the form of the article titled “Missed Pills: Revised Regimen for Taking missed pills in the 21 and 28 day pack.” This article gives accurate information on how to instruct a client who has missed her pill. The information is also designed to impact first time users in case this occurs in order to dispel any anxieties which may occur if this happens. The article “Emergency Contraceptive and Your Health” examines the importance of the Emergency Contraceptive Pill within the contraceptive mix. It looks at who can use the method as against who should not, and identifies the medical conditions that militate against its use. It also highlights the use of the Intrauterine Device as an emergency contraceptive with the added benefit of an extended period of contraception for the user, to assist clients faced with similar situations which would normally require the use of an ECP. The common misconceptions about the Emergency Contraceptive Pill are addressed in the article “Misconceptions about ECP” which focuses on how the ECP works, and cautions against the abuse of the method. It also seeks to debunk the belief that the ECP could be used to abort a pregnancy. The articles in their simplest forms give a refreshing outlook on this specific method which has constantly evolved. It is our hope that the objectives of this newsletter to clarify and demystify misconceptions with regard to contraceptive information will be met in this edition.
The Importance of ECP in the Contraceptive mix Even though the ECP rated low in methods ever used -10.9 percent compared to condoms 76.6 percent; this method is a very important inclusion in the contraceptive mix for the following reasons: • To prevent pregnancy of women who have been victims of sexual assault • To prevent pregnancy in women who are condom users but whose condom may have burst during sex. This method can also be used intentionally with a condom Abstract: The Importance of ECP in the facilitating dual method protection. contraceptive mix; who should and should • To prevent pregnancy in women who had not use the method identifying the medical risky sexual intercourse.
EmErgEncy contracEPtIvE
&
your HEaLtH
conditions that mitigate against its use. Written by Communication Officer (Writer) Harriett M. Clarke
Introduction
The use of the method One of the concerns that individuals considering taking the emergency contraceptive pill have is about the safety to themselves and its effectiveness.
Most clients taking a contraceptive method or about to take a contraceptive method are usually concerned about the effects of the method on their health whether it may be short term effects as in the symptoms associated with the method or its long term effects if any.
The emergency contraceptive pill is considered a very safe and effective method of contraceptive when used for the purpose for which it was designed.
Generally, contraceptives are not harmful as long as they are administered according to the instructions. It is also imperative that both client and health care provider are aware of the contraindications, and if there are any precautions stated for the method. The Emergency Contraceptive (ECP) is one such method which clients usually express concerns about because of the short term use of the method.
It was never intended to be used as an ongoing contraceptive method such as regular methods as the pill or the injection. Based on this, clients should be advised to begin to take a regular contraceptive method after use of the emergency contraceptive pill if they are not already on a method, because it does not provide ongoing protection against pregnancy. These methods include condoms, oral contraceptive pills, the injection, Intra-Uterine Device, implants and tubal ligation.
The emergency contraceptive was designed for as its name indicates emergencies.
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EmErgEncy contracEPtIvE & your HEaLtH Method of Emergency Contraception Emergency contraception can be provided using one of two methods: 1. Emergency contraceptive pills (ECPs)
are no other medical conditions known in which ECPs should not be used. Experts believe that the precautions associated with continuous use of COCs and progestin only pills do not apply to ECPs.
The IUD is a highly effective method for emergency contraception when used within seven • Use within 72 hours days of unprotected sexual intercourse. Unlike ECPs, it must be inserted within 120 hours of 2. Intra-uterine devices (IUDs) unprotected sex and is most effective if the procedure is done within seven days of unprotected • Insert within 7 days and conintercourse. Once inserted, the IUD should retinue use as long term method. main in place until the client’s menstrual period begins, which would mean the absence of a The client should be informed that these pregnancy. The IUD can also remain in place to methods can be used immediately after ECP serve as a regular contraceptive for up to 5-10 use, for example, the next day after the second years. dose of ECP or within 1-7 days of her next menses. References Who can use the method? • Emergency Contraception for conflictAll potential contraceptive users and clients Affected settings - the Reproductive using temporary family planning methods can Health Response in Conflict consortium, use ECPs, specifically those persons who have Reproductive Health Response in Crises been advised not to use OCP as a regular (RHRC), 2004. method. Breastfeeding mothers can also use ECP. Women who do not know whether they are • Reproductive Health Survey-Final pregnant may use the ECP as there is no eviReport, National Family Planning Board, dence to suggest that harm can be done to the 2008. woman or to an existing pregnancy. This also goes for women with a history of previous • Contraceptive Technology 19th Revised ectopic pregnancy . One major contraindication Edition, Robert Hatcher etal, 2007. for the use of ECP is pregnancy or suspected pregnancy mainly because the method would be • Jamaica Family Planning Service rendered ineffective. Delivery Guidelines, National Family Planning Board, 2007. The pills are used for such a short time that there 3
aRE
aLL
PILLS
THE
saME?
Abstract: An exploration of the various brands and the benefits of each –a market survey. Should a woman change her type of oral contraceptive over time? Written by Communication Officer (Writer) Harriett M. Clarke Background bleeding. It also provides some protection against breast growth (that is not cancer), related Since the 1960s many contraceptive pills have ectopic pregnancy, vaginal dryness, and painful emerged on the market catering to various re- intercourse related to menopause. productive needs and lifestyles of women of all ages by introducing varying amounts or differ- The progestin hormone is also contained in the ent types of synthetic hormones. The mix con- progestin only pill/ “mini pill� which appears in sists of two essential categories; combined smaller doses than in the combined oral contracontraceptive pill and the progestin only contra- ceptive pill with the same compounds. Howceptive pill. ever, the effectiveness of the progestin only pill (POP) is highly dependent on compliance with Combined Contraceptive Pill the directions indicated for the POP and consistent use. The combined contraceptive pill has evolved since its initial introduction in the 1960s in In Jamaica, pills are one of the most used conterms of the doses of sex steroids found within traceptive methods after condoms. Knowledge each pill. These have decreased significantly of a contraceptive method affects its use; if there giving rise to the low dose contraceptive pill is not enough information on the method or the which is safer with fewer side effects. In addi- average person just does not know of it, the tion it was also discovered that with long term method will not be used. The Reproductive or short term use of the combined contraceptive Health Survey 2008 indicated that a little more pill there were several non-contraceptive bene- than half (53.8%) of women aged 15-49 years fits to be gained. The hormones in "the Pill" can indicated that they knew about the pill. be used to treat some medical conditions, such as endometriosis, anaemia related to menstrua- Most women who used the pill as their choice tion, and painful menstruation (dysmenorrhea). of contraceptive method used either Perle Oral contraceptives are often prescribed as med- (36.2%) which has a low dose component or ication for mild or moderate acne. The pill can Minigynon- (32.8%). also regulate the menstrual cycle for women suffering from irregular periods and certain dis- The less commonly used brands of pills include orders where there is dysfunctional uterine Lo-Femenal 8.1% and Tri-Regol 6%. The Yas4
aRE aLL PILLS THE saME min brand at 4.8%, had not been one of the popular brands although it had quite a number of non-contraceptive benefits such as reduced water retention, and premenstrual weight gain, fewer pre-menstrual symptoms, the prevention of acne, and was more tolerable than other oral contraceptives; Nordette was 2.8 % and offered non-contraceptive benefits to women such as more regular menstrual cycles, fewer menstrual symptoms and fewer blemishes from acne. Two percent (2.7 %) of females used Ovral. Orval consists of both estrogen and progestin hormones and is sometimes prescribed for the treatment of painful or irregular menstrual periods, acne, and Premenstrual Dysphoric Disorder (PMDD). Gynera ( 2%), considered a low dose contraceptive pill had non-contraceptive benefits such as regulating the menstrual cycle, treating painful cramps, and lightening menstrual flows and Diane-35, a combined contraceptive, is popularly prescribed for acne more so than as a contraceptive method, said Althea Tulloch, a pharmacist working at the York Pharmacy. Ms. Tulloch also indicated that most women requesting Diane 35 (3-6%) were directed by a dermatologist to get the product. A woman who expresses concern about changing her oral contraceptive as she gets older should be made aware of the fact that oral contraceptives are very safe for the healthy user who does not smoke, and has no previous predispositions to clots, or other contraindications. Oral contraceptives are generally well tolerated by women ages 35 and over who are in good physical condition and who do not smoke. However, the Reproductive Health Survey 2008 found that pill users sometimes preferred to switch to injectables (28.6%), implants (Norplant 23.1%), or female sterilisation (20.7%). 5
Conclusion Contraceptive pills come in a wide variety of packages, however, the pills themselves may consist of the same or similar ingredients with varying consistencies, and some depending on whether it is a combined or progestin only pill, may have different ingredients. None-the-less most of them are beneficial to the female user. The emergence of the contraceptive pill has indeed set the trend for the liberation and empowerment of women worldwide who are now able to manipulate their biological functions to delay pregnancy. It may be safe to say that oral contraceptives are even safer to take than it is to deliver a baby especially for women over the age of 35 years. Without a doubt the contraceptive pill continues to enable women, independent of their partners to successfully plan, space and limit their families to manageable sizes. References • WHO Medical Eligibility Criteria for Contraceptive Use, National Family Planning Board, December 2008. • Reproductive Health Survey-Final Report, National Family Planning Board, 2008. • Contraceptive Technology 19th Revised Edition, Robert Hatcher etal, 2007. • Jamaica Family Planning Service Delivery Guidelines, National Family Planning Board, 2007.
Mis
sed Pills :
revised regimen for
taking missed pills in the 21 and 28 day pack
Written by Communication Officer (Writer) Harriett M. Clarke The effectiveness of an oral contraceptive is Regimen for taking missed pills in a 21 day dependent on its timely and consistent use. In pack. the reproductive years of every woman who uses the contraceptive pill to prevent pregnancy, This regime should apply for women who: it is not unusual for her to, occasionally miss • Forgot to take the pill. taking a pill for a day or more. Therefore, it is • Started a pill pack late. important for women to know the regimen for • Vomited within 2 hours of taking it. taking both the 21 day pack and the 28 day • Experienced having diarrhoea for more pack. than two days after taking it. The Reproductive Health Survey, RHS 2008 indicated that the failure rate for oral contraceptives ranged from 5.7% at one year to 19.9% at 3 years. The reasons for failure are usually attributed to women missing their pills. Researchers have identified that a disruption in a woman’s daily routine, which involves her taking her pill, can cause interruptions in pill taking. Also levels of knowledge about the pill and their side effects generally affect consistent and effective use of the oral contraceptive method.
A female who misses 1 or 2 pills from Rows 1 or 2 (including starting new pack 1 or 2 days late, vomited or had diarrhoea) should be advised to take the missed pill(s) immediately. They can take 2 pills at the same time or on the same day, however, they should continue the pack as usual, one (1) each day.
Two other reasons cited for women missing their pills were absence of husbands, and the presence of bleeding. It is very important that female clients do not confuse spotting with a menstrual period and stop taking the pills when there is bleeding.
The active pills contain the contraceptive ingredient which prevents the female from becoming impregnated whilst the inactive pills called placebos or regular iron tablets contain no contraceptive ingredient and are only to maintain Health Providers can alleviate the anxiety asso- the habit of taking a pill each day, creating a ciated with a client forgetting to take her pill by habit rather than providing any form of contragiving clear guidelines and instructions for ception. using either the 21 or 28 day pack. If the female client misses 3 or more pills from row 1 or 2 she should be advised to: 6
Missed Pills: revised regimen for taking missed pills in the 21 and 28 day pack • Take one (1) pill as soon as possible. • Throw away the others that were missed. • Use a back up method such as the male or the female condom or • Abstain from sexual intercourse for the next seven (7) days.
If the female client misses one (1) or two (2) pills from rows 1 or 2 (including starting new pack 1 or 2 days late, vomited or had diarrhoea) she is to: • Take the missed pill(s) immediately. • Take two (2) pills at the same time or on the same day and It is also important for them to know the use of • Continue the pack as usual, one (1) each emergency contraceptives within this regime. day. They should be aware that if they had sex within the last five (5) days of missing their pills, an If she misses three (3) or more pills from rows emergency contraceptive pill which is available 1 or 2 she is to: from most pharmacies can also be taken to prevent pregnancy. • Administer one (1) pill as soon as possible. If the female client misses three (3) or more pills • Throw away the others that were missed. from row 3 (including starting new pack 3 or Use a back up method, either the male or more days late) she is to: the female condom or avoid sex for the • Take one (1) missed pill as soon as next seven (7) days. possible. • However, if she had sex within the last • Take the rest of the pills in the pack, one five (5) days she is to use the emergency (1) per day. contraceptive pill, which is available over • Start a new pack of pills as soon as she the counter at most pharmacies. has finished all of the hormonal pills. • Use a back up method or avoid sex for the If the female client misses three (3) or more pills next seven (7) days. from row 3 (including starting new pack 3 or more days late) she must : Regimen for taking missed pills in a 28 day • Take one (1) pill as soon as possible. pack. • Take the rest of the white coloured (hormonal) pills in the pack, one (1) per day. • Throw away the brown (nonPersons who miss pills in the 28 day pack fall hormonal/iron) pills in the pack within the category of those who: • Start a new pack of pills as soon as the • Forgot to take the pill. white ones are finished. • Started a pill pack late. • Use a back up method or avoid sex for the • Vomited within two (2) hours of taking it. next seven (7) days. • Experienced diarrhoea for more than two days after taking it. 7
If she misses any from row 4 she is to: • Throw away these brown missed pills. • Start a new pack, taking one whitecoloured pill each day. A female taking oral contraceptives should be made aware that she should return to the health care provider upon realizing that she is always missing her pills as this is an indication that this contraceptive method may not be the most suitable one for her. She is to engage the health provider in discussions about other contraceptive choices which would better suit her life style or if there are side effects of the pill that may be bothering her. She should also be advised to always have another pack of pills to start as soon as the other one runs out. To adequately address the issue of Missed pills, Health Care providers may create educational
materials focusing on the importance of consistent Oral Contraceptive use even when there is the absence of the husband and even when there is the potential for the woman’s schedule to go haywire. References • Reproductive Health Survey-Final Report, National Family Planning Board, 2008. • Contraceptive Technology 19th Revised Edition, Robert Hatcher et al, 2007. • Jamaica Family Planning Service Delivery Guidelines, National Family Planning Board, 2007.
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misconceptions about EcP Content: How ECP works; how many emergencies you are allowed to have; clarifying the belief that the ECP is an abortificient. Written by Communication Officer (Writer) Harriett M. Clarke Introduction
• Miscalculation of the infertile (safe) period • Failed coitus interruptus- the withdrawal method
Emergency contraception (EC) refers to contraceptive methods that can be used by women in the first few days following unprotected intercourse to prevent an unwanted pregnancy How the Emergency Contraceptive Pills work (WHO 1998). Unplanned & unwanted pregnancies carry a higher risk of morbidity and mortality as the women may undergo unsafe abortions. These types of pregnancies can be avoided by using the emergency contraceptive which provides a short term but safe and effective method for preventing pregnancy with the option of beginning a regular hormonal method thereafter, or continuing with the use of condoms, or abstaining.
The ECPs prevent or delay ovulation. The precise mechanism of action may depend on the time during the menstrual cycle when the woman had unprotected sex and when the ECP was taken. Pregnancy may be prevented by stopping the movement of sperm through the cervical mucus or by altering transportation of sperm, or ovum. However, it functions mainly by preventing fertilisation and inhibiting implantation.
The introduction of the Emergency Contraceptive should occur: Misconceptions and how they arise. • Where the client has had voluntary sexual intercourse where no contraceptive was used. • Where involuntary sex such as sexual assault has occurred • When a contraceptive method has failed or was used incorrectly, such as: • Condom leakage • Failure to take the Oral Contraceptive Pill for three (3) consecutive days • Delaying contraceptive injection more than two (2) weeks 9
Of all the contraceptives ever used, compared to the condom at 76.6 percent the emergency contraceptive is ranked low at 10.9 percent according to the Reproductive Health Survey 2008. Like most contraceptives the Emergency Contraceptive pill has several misconceptions which limit the use of the method. Inappropriate for regular use this method is also surrounded with misconceptions which every
misconceptions about EcP health care provider should be aware of and prepared to clarify. Because the ECP is for one-time use, there is usually the misconception that one dose provides protection for extended periods or that the ECP can be used indiscriminately every time they have unprotected sex which can be several times within one month. It is recommended that the ECP is not used more than once per month to ensure continued effectiveness. When administering the Emergency Contraceptive to clients it is important to address these perceptions and advise the client that it is crucial to begin use of a regular contraceptive method whether the pill, the injection, or the IUD after taking the full dosage of the ECP if pregnancy is to be prevented. The impression that the pills must be taken on the morning after sex is another common misconception. It should be pointed out to clients that the Emergency Contraceptive Pill should be taken as soon as possible after unprotected sex for it to be most effective, but can also be taken to prevent pregnancy three (3) days (72 hours) after sexual intercourse. The ECP as an abortificient The two ECP regimens, that is, the progestinonly and estrogen regimens act as regular COC and progestin only contraceptive pills and will not disrupt an established pregnancy. Therefore, it is beneficial to advise clients that the ECPs is not an abortion pill and will not cause an abortion.
ECPs are considered very safe. The Emergency Contraceptive pill has been around for almost 20 years and to date there has never been a reported case of death or serious medical complications caused by the method. The dose of hormones in ECPs is relatively small; the short exposure to estrogen and/or progestin does not appear to alter blood-clotting mechanisms, as sometimes occur with longer use of combined oral contraceptives (COCs). The COCs used as ECPs have never been associated with foetal malformations or congenital defects. T o date the ECP has never caused and does not increase the possibility that a pregnancy will become ectopic after its use.
References • Emergency Contraception for conflictAffected settings, The Reproductive Health Response in Conflict consortium, 2004. • Reproductive Health Survey-Final Report, National Family Planning Board, 2008. • Contraceptive Technology 19th Revised Edition, Robert Hatcher et al, 2007. • Jamaica Family Planning Service Delivery Guidelines, National Family Planning Board,2007.
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