HORMONAL

CONTRACEPTIVES
HORMONAL CONTRACEPTIVES
• They contain synthetic hormones (i.e. a combination
of estrogen and progestin, or progestin only) which
work primarily by preventing ovulation and making
the cervical too thick for sperm penetration.
• NB. Methods containing estrogen are not advisable
for women who are breastfeeding because this
method can suppress lactation.
• Progestin- only pills are ideal for breastfeeding
mothers, they are provided to breastfeeding women
from four weeks postpartum.
Classification of hormonal contraceptives

• Hormonal contraceptives are classified into the following seven

categories;
I. Combined oral contraceptives (COCs)
II. Progestin-only contraceptive pills (POPs)
III. Progestin-only Injectable contraceptives
IV. Combined Injectable Contraceptives
V. Progestin-only contraceptive implants
VI. Hormone-releasing intrauterine device
VII. Contraceptive patch and vaginal rings
• The following hormonal methods are commonly
available in Kenya
• Combined oral contraceptive pills (COCs)
• Progestin-only injecatables contraceptive ( DMPA, NET-EN)
• Progestine- only contraceptive Implants (implanon,
nexplanon)
• Hormone realsing intrauterine systems (LNG20-IUS)
• Emergency contraceptives
• Progestine only pills (POPs)
• The following are les commonly available in Kenya.
• Combined injectable contraceptives
• Combined contraceptive (skin) patch (Evra)
• Combined vaginal contraceptive ring ( NuvaRing)
COCs (Combined oral contraceptives )
 COMBINED ORAL CONTRACEPTIVE
PILLS
• They contain synthetic oestrogen and progesterone, which are similar
to the natural hormones produced I the woman’s body.
• Apart from contraception, COCs also have other significant health
benefits

Mechanism of action
Prevent release of eggs from the ovaries.
• Over the years, the amount of oestrogen hormone
has reduced to lower and safer levels, which has
decreased occurrence of side effects.
• High dose contain 50 micrograms of oestrogen
• Low dose pills contain 30-35 micrograms of
oestrogen( most commonly used in Kenya)
• Ultra-low dose pills contain 20 micrograms ethinyl
oestadiol.
TYPES OF COCs
• The pill comes in packets of 21 or 28 tablet in the 28-
pill packet, only the first 21 pills are active i.e. they
containhormones. The remaining 7 pills are not active
and usually contain iron.
The low dose pill comes in three types:
i. monophasic: each pill contains the same amount
of oestrogen and progestin. E.g. microgynon, Lo-
femenal, Nordette, Marvelon and yasmin.
ii. Biphasic: the active pills contain two different
different dose combination of estrogen &
progestin . E.g. in a cycle of 21 active pills, 10 may
contain one combination, while 11 contain another.
E.g. biphasil, ovanon and normovlar.
 TYPES OF COCs

• Triphasic : the active pills contain three different dose

combinations of oestrogen and progestin. Out of a
cycle of 21 active pills, six may contain one
combination, five pills contain another combination,
while 10 pills contain other combinations of the same
two hormones. E.g. Logynon and Trinordial.

N.B. biphasic and triphasic pills are not in common use

in Kenya.
 How Combined Pill works

Suppresses hormones
responsible for
Ovulation (LH &FSH)

Thickens
cervical mucus to block sperm

10
ADVANTAGES OF COCs
A. Contraceptive benefits
a) They are highly effective. Are effective immediately
when started within the first five days of the
menstrual cycle.
b) They are safe for the majority of the women
c) They are easy to use
d) Can be provided by trained non-clinical service
providers.
e) A pelvic exam is not required to initiate use of
COC’s.
ADVANTAGES OF COCs
B. Non contraceptive benefits
a) Reduction of menstrual flow (lighter, shorter
periods)
b) Decrease in in dysmenorrhoea
c) Reduction of symptoms of endometriosis
d) Improvement & prevention of anemia
e) Protection against ovarian and endometrial cancer.
f) Possible protection from symptomatic pelvic
inflammatory disease
g) Treatment of acne & hirsutism.
Limitations and side effects of coc’s
• COCs must be taken daily to he effective, preferably at
the same time each day.
Minor side effects include
• Nausea (more common in the first 3 months)
• Spotting or bleeding in between menstrual periods,
especially if a woman forgets to take her pills or takes them
late (more common in the first three months)
• Mild headaches
• Breast tenderness
• Slight weight gain
• Mood change
• Amenorrhea ( some women see amenorrhea as an
advantage)
Major side effects (or complications are rare, but
possible)
• Myocardial infarction
• Stroke
• Venous thrombosis or embolism or both.
Management of common side effects
• Nausea and vomiting
• asses for pregnancy
• Reassure the client that its is a common side effect and
that it may diminish in a few months.
• Advice client to take pills with meals or at bedtime.
• Spotting
• Asses for pregnancy
• Reassure client its is harmless and common especially
during the first 3 months.
• Encourage client to take pills at the same time each day.
• If it persists and unacceptable for the client to consider
changing the method
How to use
• Take one pill every day for 21 days. Rest 7 days before starting a new
packet (21 day packet)

• If the packet has 28 pills e.g. femiplan, 21 pills have hormone while 7
are plain.
–In such a case take the pill daily till the last day and
continue the next packet the following day.
 Who can use COC
• Sexually active women of reproductive age
• Women of any parity, including nulliparous with established menses
• Women who want highly effective protection against pregnancy
• Breastfeeding mothers after 6 months postpartum
• Women who can follow a daily routine of pill taking
• Post-abortion clients
 Who should not use COC.
• Breastfeeding mothers before 6 months postpartum
• Women who are pregnant or suspected of being pregnant
• Women with unexplained or suspicious abnormal vaginal bleeding
• Women with a history of blood clotting disorders
• Women with a history of heart disease
• Women with active liver disease
• Women with hypertension
• Women with complicated diabetes mellitus
WHEN TO START
• A woman can start using COCs at any time if its
reasonably certain she is not pregnant.
❖If she begins using COCs within 5 days after start of
her monthly bleeding, she will not need a back up
contraceptive method.
❖If she begins using COCOs more than 5 days after the
start of her monthly bleeding, during the 7 days when
she takes COCs she should use a back up method i.e.
condoms.
• What to do in the case of missed pill(s)
Pills missed Action and consequences

One or two days missed or started Take a pill as soon as possible.

new pack one or two late Little or no risk
of pregnancy.

3 or more days in a row missed in the Take a pill as soon as possible.

1st or 2nd week or started a new pack 3 Use a back up method for the
or more days late next 7 days, she can consider
ECPs
Pills missed Action and consequence
3 or more days in a row in the third week Take a pill as soon as possible, finish all
hormonal pills in the pack ( if 28 pill
pack are used, throw away the 7 non
hormonal pills) and start a new pack the
next day. Use back up method for the
next . Also if client had sex in the past 5
days, she can consider use of ECPs

Sever e vomiting or diarrhoea If she vomits within 2 hours after taking a

pill, she should take another pill from her
pack as soon as possible, then keep taking
pills usual.

If she has vomiting or diarrhoea for more

than 2 days, follow instructions for one or
two missed pills, above.
Correcting Myths and Misconceptions

• Combined oral contraceptives:

• Do not build up in a woman’s body. Women do not need a “rest” from taking
COCs.
• Do not make women infertile or change women’s sexual behavior.
• Do not cause birth defects or multiple births.
• Do not disrupt an existing pregnancy.
Progesterone Only Pills
(POPS)
Definition
• The Progestin Only Pills (POPs) are oral hormonal contraceptives that
contain progesterone only in a smaller dose (typically 10 – 50%) less
than that used in the combined pill. They do not contain Estrogen
hence clients do not experience the side effects associated with
estrogen
PROGESTINE ONLY PILLS(POPs)

• The contain only one hormone- progestin. They do

not suppress production of breast milk.
Types of POPs
• Microlut
• Micronor
• Microval
• Ovrette
• Noriday
Progesterone Only Pills (POPs)

Micronor
MECHANISM OF ACTION

• They thicken cervical mucus hence blocking sperms

from meeting an egg.
• Disrupt the menstrual cycle, including preventing the
release of eggs from ovaries ( Ovulation)
Advantages of POPs

• They are effective

• They are safe(no known health risk)
• Women return to fertility immediately upon
discontinuation.
• A pelvic examination is not required to initiate use.
• They don’t affect milk production, safe for
breastfeeding women and their babies.
• Taking POPs doesn’t increase blood clotting.
Limitations
• They provide a slightly lower level of contraceptive
protection than COCs.
• They require strict daily pill taking, preferably at the
same time each day.
• They don’t protect against STI’s, including hepatitis B
and HIV/AIDS. Therefore at risk individuals should use
a barrier method to ensure protection against STI’s
and HIV/AIDS.
• They may lower effectiveness when certain drugs are
taken concurrently(e.g. certain antiTBs, ARVs and
anti-epileptic drugs.
Side effects

• Irregular spotting or bleeding, frequent or infrequent

bleeding, amenorrhea (less common). Bleeding
changes are common but not harmful.
• Headaches, dizziness, nausea.
• Mood changes.
• Breast tenderness (although also common with
COCs).
 Who can use POPs
Women of any reproductive age or parity who:
• Want to use this method of contraception
• Cannot or should not take pills containing estrogen
• Are breastfeeding (POPs do not suppress breast milk production)
 Who should not use POPs
• Suspected pregnancy
• Current breast cancer
• Liver disease
• Women suffering from deep venous thrombosis (DVT)
Method prescription and use
• POPs can be given to a woman at any time to start
later. If pregnancy can not be ruled out, a provider
can give her pills to take later, when her menses
begin.
• Client should take one pill everyday at the same time
+/- 2 hours to avoid pregnancy and minimize side
effects.
• When ne pack is finished, client should begin the next
pack with no break in between packs.
• An estimated 48 hours of POP use is usually required
to achieve the contraceptive effect on cervical
mucous.
• All clients can initiate use of POPs under the following
circumstances.
• If she is breast feeding and has not resumed her menses,
initiate any time between 4 weeks and 6 months after child
birth.
• After child birth and she is not breast feeding, initiate
within the first four weeks (no back up method needed) or
any other time it is reasonably certain that the client is not
pregnant.
• If initiated after 4 weeks post partum, non menstruating
women and women whose menses started >5 days should
use backup method( condom)or abstain for 2days.
• After miscarriage or abortion, initiate within the first 5 days
after an abortion, POPs can be initiated without the need
for backup protection. After 5 days, a condom should be
used as a backup for 2 days.
• If client is having menstrual cycles, initiate any time if it is
reasonably certain that she is not pregnant.
• if method is initiated within 5 days, a condom should be
used for the next 2 days.
PROBLEMS THAT MIGHT REQUIRE SWITCHING
METHODS
a) Unexplained vaginal bleeding
This condition requires evaluation, diagnosis, and
treatment as appropriate
b) Starting treatment with anti convulasnts, rifapicin,
rifabutin or ritonavir.
If these medications involve long term treatment, a
client may need help to chose a different method. If
treatment is short-term, the client can use a backup
method along with POPs.
• Migrane headaches
• For migrane headaches without aura, a client can
continue using POPs if she so wishes. If auras are
present she should stop taking POPs
 d) Certain serious health conditions
• These include DVT, liver disease, ischemic heart
disease, breast cancer, or SLE with positive
antiphospholipid antibodies.
• If the condition worsens after client starts using POPs,
she should stop immediately. The provider should
help her choose a method without hormones. Give
her back method till condition is evaluated. Refer her
for diagnosis and care if she is not already under care.
 e) Suspected pregnancy
• Assess the client for pregnancy, including ectopic
pregnancy. Inform the
Management of common side effects
of POPs
Spotting
• Reassure client its common with POP use.
• If bleeding starts after several months of normal or no
monthly bleeding, or there other reasons to suspect
pregnancy ( if client missed a pill) , asses for
pregnancy or other underlying conditions. Manage
condition or refer client to level.
Heavy or prolonged bleeding( twice as much as usual
or longer than eight days)
• Reassure client that some POP user experience this
type of bleeding, but it is generally not harmful.
• For the modest relief prescribe 800mg ibuprofen TDS
5/7.
• If no relief, suggest another type of POP if available or
help choose another method.
Amenorrhoea
• If client is BF, reassure her that it is normal not to
have menses while BF.
• If client is not BF, reassure her that some women stop
having monthly periods while taking POPs.
• If there are reasons to suspect pregnancy (e.g client
has missed pills), assess for pregnancy. If client is
pregnant, advice her to stop using POPs and refer for
antenatal care. If not pregnant reassure her to
continue POPs.
Headache or dizziness
• Determine cause. If no cause is found, counsel client
and recommend common pain killers.
• If headaches worsen while using POPs (e.g. she
develops migraines with aura), help client select
alternative method. Refer if need be.
Abnormal suspicious vaginal bleeding
• Evaluate client by history and pelvic examination
(refer as necessary) including VIA/VILI and pap smear.
Treat or refer for treatment as necessary.
Mood changes or nervousness
• Counsel client. If condition worsens, help client select
alternative methods.
Severe pain in lower abdomen
• R/O ectopic pregnancy, if it’s the case refer.
• What to do in the case of Missed pill(s)
Missed POP Suggested action
Client’s menses have returned and she Take one pill as soon as possible
misses one or more pills by more than 3 and continue taking the pills as
hours (or 12 hours in the case of 75g usual, one each day.
desogestral containing pill), regardless of
whether or not she is breast feeding Abstain from sex or use a back up
method e.g. condom for the next 2
days.

Client is Bf and is amenorrhoeic, and she Take 1 pill as soon as possible and
misses one or more pills, by more than 3 continue taking the pills as usual,
hours ( or 12 hours in the case of 75mcg one each day.
desogestrel- containing pill ).
If she is <6 months post partum,
no back up method is needed.
NOTE:
• Inconsistent or incorrect use of pills is a major cause
of unintended pregnancy. It is important to ensure
POPs are taken at approximately the same time each
day. An estimated 48 hours of POP use is deemed
necessary to achieve the contraceptive effects on
cervical mucus.
Correcting Myths and Misconceptions

• Progestin-only pills:
• Do not cause a breastfeeding woman’s milk to dry up.
• Must be taken every day, whether or not a woman has sex that day.
• Do not make women infertile.
• Do not cause diarrhea in breastfeeding babies.
• Reduce the risk of ectopic pregnancy
EMERGENCY CONTRACEPTIVES
EMERGENCY HORMONAL CONTRACEPTIVES.
• Emergency contraception refers to the use of certain contraceptive
methods by women to prevent pregnancy after unprotected sexual
intercourse.
• They must be taken within 72-120 hours of intercourse, however, the
sooner they are taken the more effective they are.
• ECPs provide a second chance for preventing pregnancy after
unprotected sex, either accidental or coerced sex or rape.
• EC should not be used on a regular basis ( from
month to month) because it is less effective than
other methods.
Mechanism of action
• They prevent or delay ovulation
• Inhibit or slow down transportation of the egg and
sperm through the fallopian tubes which prevents
fertilization and implantation.
TYPES OF ECPS AND DOSAGE
a) Combine oral contraceptives
• Eugynon ( 50mcg)- 2 tablets to be taken as soon as possible
after unprotected sex within 120 hours, repeat the same
dose in 12 hours. A total of 4 pills are required.
• Microgynon (30 mcg)- 4 tablets to be taken as soon as
possible after unprotected sex within 120 hours and a
repeat dose in 12 hours. A total of 8 pills are required.
b) Progestin only oral contraceptives
These dedicated ECPs contain the same progestin hormone
(levonorgesteral) as POPs, although in higher doses. They
are more effective than COCs preventing up to 95% of
unexpected pregnancies. Available brands in Kenya are;
Postinor 2, smart lady, Ecee2, and Truston 2.
• The standard dose is as follows;
• One 750mcg levonorgestrel pill to be taken as soon as
possible after unprotected intercourse, but within 120
hours. Repeat the same dose in 12hours. A total of 2 pills
are required
• Two 750mcg levonorgestrol pills to be taken as a single
dose as soon as possible after unprotected intercourse.
This regimen is preferred because it is easier to comply
with the one- dose regimen compared to the two dose
regimen.
• Regular POPs may be used: 20 pills taken within 120 hours
after unprotected sex, repeat the same dose in 12 hours. A
total of 40 pills are required.
Advantages and benefits of ECPs
• They provide emergence protection for about 75-95%
of those at risk
• Can reduce unwanted pregnancies that lead to child
neglect, abandonment, and unsafe abortions.
• They are an important element in post-rape care.
• EC offers the following benefits
• It is safe, effective, and easy to use.
• No medical examination or pregnancy tests are necessary
or required.
• It can be used at any time during the menstrual cycle.
• They are readily available.
Limitations and side effects
• They are only effective if used within 72- 120 hours of
unprotected sex.
• They are not to be used as a regular method.
• They don’t protect against STIs, HIV, or AIDS
• They can cause nausea.
Method prescription and use
• EC pills should be started as soon as possible, but
within 72-120hours of unprotected sex.
• The sooner they are used after unprotected sex, the
more effective they are in preventing pregnancy.
MANAGEMENT OF COMMON SIDE EFFECTS.
Nausea and vomiting
• Women should be counseled (at the time of ECP
supply) about the possible occurrence of nausea.
• For women using POPs or COCs as emergence
contraceptives, an anti-emetic may be used before
the pills are taken.
• If vomiting occurs within 2 hours, the woman should
repeat the previous ECP dose orally as soon as
possible.
• If she vomits again, give the dose vaginally, placing
the needed dose high up in the vagina.
Slight irregular bleeding
• Reassure women that this is not a sign of pregnancy
or other condition .
• Irregular bleeding due to ECPs is common and will
stop without treatment.
Change in timing of the next monthly bleeding
• Explain that it is not unusual for the next monthly
bleeding to start a few days earlier or later than
expected.
• Asses for pregnancy if woman’s next monthly
bleeding is more than one week later than expected.
Starting FP methods after EC
• contraceptive methods and when to begin using
them after EC.

METHOD WHEN TO START

Condoms Start immediately after EC; use also
for dual protection.
Oral contraceptive pills Start the next day after second ECP
(COCs POPs) dose or 1-7 days after menses.
Injectables Start within the first 7 days after the
start of her next period ( 12 days for
IUCDs IUCD)
Implants
Voluntary sterilization
(VSC)
Fertility- awareness
methods (FAM)
Injectables
What it is

• Depo-Provera is the most

widely used injectable
contraceptive
• Injection given every 3 months

60
Mechanism of Action

Suppresses
hormones
responsible for
ovulation

Thickens
cervical mucus to
block sperm

61
INJECTABLE HORMONAL CONTRACEPTIVES
• They are injections containing long acting synthetic hormones.
Types of POI injectables
a) Depo Provera- it is a three month interval injection but it can be
given 1 month earlier or 2 weeks later. It contains Depot-
medroxyprogestrone acetate ( DMPA).
b) Noristerat – it is a 2 monthly injectable but can be given 2 weeks
earlier or 1 week later. It contains Norethisterone enanthate-(NET-
EN).
Mechanism of action
• It causes thickening of cervical mucus which
decreases sperm penetration.
• Makes the lining of the uterus less thick in blood,
making implantation impossible.
• May inhibit ovulation.
Indications
• Women of reproductive age.
• Women of any parity including Nulliparaity with
established menses.
• Breastfeeding mothers after 6 weeks post partum.
Contra-indications
• Pregnant women or those suspected to be pregnant.
• Breast cancer or unexplained breast lump.
• Unexplained uterine/ vaginal bleeding for the last
three months.
• Women with BP >140/100.
• Women with DM complicated with vascular diseases.
• Breastfeeding women <6 weeks post partum.
• Active liver disease
• Ischemic cardiovascular disease.
Who can use
• Women who need a highly effective long term
protection against pregnancy.
• Immediate post partum for non breast feeding
women.
• Women who will not remember to take oral pills daily.
• Post abortal clients.
Use with care with clients with the following
conditions
• Diabetes
• Hypertension
• Active liver tumor
• Impaired liver functions.
Non-contraceptive Health Benefits
• Amenorrhea, which might be beneficial for women
with (or at risk of) iron-deficiency anemia.
• Decrease in sickle cell crises
• Reduction of symptoms of endometriosis
• Protection against endometrial cancer
• Protection against uterine fi broids
• Possible protection from symptomatic pelvic
inflammatory disease
• Possible prevention of ectopic pregnancy
Client instructions
• Its very effective for preventing pregnancy.
• If they are using depo they should visit clinic 3
monthly, for NET-EN every 2 months.
• Note the following menstrual changes
• Less regular periods
• Spotting in between
• Amenorrhea
• When bleeding is of concern then she should report
to the client.
• Remind client to keep clinic appointment.
Limitations of Injectable Contraceptives

Return of fertility may be delayed for about four

months or longer after discontinuation.
• They offer no protection against STIs, including
hepatitis B and HIV; individuals at risk for these
should use condoms in addition to injectable
contraceptives.
• This method is provider-based, so a woman must go
to a health care facility regularly.
Side Effects of Injectable Contraceptives
Menstrual changes, such as:
• irregular bleeding
• heavy and prolonged bleeding
• light spotting or bleeding
• amenorrhea, especially after one year of use
• Weight gain
• Headache
• Dizziness
• Mood swings
• Abdominal bloating
• Decrease in sex drive
 MANAGEMENT OF SIDE EFFECTS

Spotting /light bleeding

• Reassure
• Assess for the other conditions/ infections.
Pregnancy-refer to ANC, gyaenacological
complications
• If STI continue with method while on treatment.
Counsel for abstinence/ condom use.
• If condition progress and client is bothered, stop/
change method or give COCs 1 tab for 7 days.
Correcting Myths and Misconceptions
• Progestin-only injectables:
• Can stop monthly bleeding, but this is not harmful. It is similar to not having
monthly bleeding during pregnancy. Blood is not building up inside the
woman.
• Do not disrupt an existing pregnancy.
• Do not make women infertile.
IMPLANTS
CONTRACEPTIVE IMPLANTS
• Contraceptive implants are small rods that are
inserted under the skin of a woman’s upper arm to
release the hormone progestine slowly and prevent
pregnancy.
Definition

• Progestogen-only implants are placed subdermally

• release progestogen at a controlled rate

thus

• providing very small daily doses to achieve the desired

contraceptive effect
.

Progestin-filled rods or capsules

that are inserted under the skin

Mechanism of action similar to

injectables
Examples

• 6-capsule Norplant
• 2-rod Jadelle
• 1-capsule Implanon

Second generation implants

Jadelle and Sinoplant (Zarin): 2-rod system,
effective for 5 years

Implanon (NXT): 1-rod system,

effective for 3 years
 Types of Implants
Implant Design Hormone Duration of
• . effectiveness
6 rods Levonorgestrel 7 Years
Norplant: 36mg

Jadelle 2 rods Levanorgestrel 5 years

75mg/rod

Implanon 1 rod Etonogestrel 3 years

(NXT) 68mg

Sino-implant 2 rods Levanorgestrel 4 years

Zarin 75mg/rod (possibly 5)
 Implants are . . .

• Inserted subdermally in upper arm or forearm by minor surgical

procedure under local anaesthesia

• After insertion, implants are palpable but rarely visible

• Protection against pregnancy starts within 24hrs after insertion

• Fertility is restored almost immediately after removal

 Mode of Action

➢Effect on cervical mucus in efficacy

• Mucous becomes viscous and scanty thus
• inhibiting sperm penetration
• Reducing sperm transportation
• Reducing ovum mobility
• Progestogen acts on the hypothalamus and pituitary and
suppresses the LH surge responsible for ovulation
• Suppressing ovulation in many cycles
• Thins the endometrium making it difficulty for implantation
Benefits of Implants- Contraceptive

• Safe
• Highly effective- 99.95% effectiveness
• Offer continuous long term protection
• Effective within a few days of insertion
• Immediate return to fertility
• Offer continuous long-term protection
• Do not require daily administration
 Pregnancy Rates by Method

Spermicides
Female condom
Standard Days Method
Male condom
Oral contraceptives
DMPA
IUD (TCu-380A) Rate during perfect use
Female sterilization
Rate during typical use
Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use

Source: CCP and WHO, 2007.

 Advantages and Benefits of Using
Contraceptive Implants
Contraceptive Benefits
• Implants are highly effective and safe.
• Contraception is immediate if inserted within the first
seven days of menstrual cycle, or within the first five
days for Implanon.
• There is no delay in return to fertility.
• They offer continuous, long-term protection
Non-contraceptive Health Benefits
Implants do not affect breastfeeding.
• They reduce menstrual flow.
• They help prevent ectopic pregnancy (but do not
eliminate the risk altogether).
• They protect against iron-deficiency anemia.
• They help protect from symptomatic PID.
• Protect against endometrial cancer
• Reduce frequency and pain in sickle cell crises
Limitations of Implants

• Must be inserted and removed by trained providers

• Require minor surgical procedure with appropriate IP for
insertion and removal
• Common side effects include menstrual changes e.g.
amenorrhea, spotting, intermenstrual bleeding
• Do not protect against STIs/HIV, HBV, HCV
Myths/rumours/misconceptions Facts
The one or two rod implants are less effective The implants are equally as effective i.e for the
than the six rod implants two rod the duration of use after insertion is
five years
Implants weaken women because of bleeding Although bleeding may be frequent, the amount
of blood loss is much lower. Several studies
have shown that haemoglobin content of blood
increases with continued use
The rods move around the body The rods are inserted under the skin and they
stay wherever they are placed until removal.
Each rod is surrounded by a small sheath of
fibrous tissue preventing it from moving
The procedure for inserting the rods is painful This is not the case because a local anaesthetic is
used therefore there is little or no pain at all.
Any pain after the anaesthetic has worn out can
be managed by simple pain killer.

The rods are implanted permanently Once inserted the rods can be removed at any
time. In addition, they should be removed after
a period of 5 years for the two rods and 3 years
for the one rod implant
Obtaining Contraceptive Implants

• Can be provided at all KEPH levels (tier 1-4 )

• Level 1: outreach and mobile services
• Should be provided by specially trained health providers;
• Medical doctors
• Clinical officers
• Nurses
• Sites that offer insertion must provide removal facilities including
counseling and other alternative methods
Counselling clients for implants

• Informed decision key

To include:-
• Insertion
• Mechanism of action, failure rates, advantages and disadvantages,
limitations, common side effects, follow up issues and side effects
where to seek care in case has complications or side effects
• Dispel myths
• Does not protect against HIV
Assessment of clients

• History taking
• Past medical history
• Obstetric and gynaecological history
• Sexual history
• FP history
• Physical examination (dependant on findings from
history)
 Insertion of Implants (1)
• Insertion kit
• Position client’s arm
• Prepare site for procedure
• Clean and drape arm
• Infiltrate with local anaesthetic
• Incise skin
• Insertion of trochar
Insertion of Implants (2)

• Loading trochar with first implant (if it is the two rods)

• Insertion of the first implant
• Insertion of the second implant
• Removal of the trochar
• Confirming heamostasis
• Closing the wound
• Post operative instructions
Specific Instructions after insertion

• Keep insertion area dry for 4-5 days

• Can remove gauze bandage after 1-2 days but leave in
place the adhesive plaster for 5 days
• Return to the clinic if the rods come out or if soreness in
the arm lasts more than a few days
Warning Signs

• Severe arm pain

• Expulsion of capsules
• Severe headache
Indications for Removal

• Severe side effects or complications

• Desires to conceive
• Period of the use of implant has expired
• Switch to another method
• Approached menopause
• Others....
Removal procedure (1)

• Counselling critical
• Inform client on steps and what to expect
• Prepare removal kit
• Position arm
• Clean site
• Infiltrate lower end of the implants with local
anaesthetic
Removal procedure (2)

• Make small incision very close to the lower end of the

two or single rod
• Gently manipulate one end of the rod towards the
incision site.
• Once it can be sited grasp it with the forceps and gently
but firmly pull it out through the incision.
• Repeat for the second rod.
• Confirm haemostasis and dress wound
 Implants – Side Effects

• First several months:

light bleeding/spotting, prolonged irregular bleeding,
infrequent bleeding, amenorrhea
• After one year:
light bleeding for fewer days, irregular bleeding, infrequent
bleeding, amenorrhea
• Other side effects: nausea, headaches, breast tenderness,
weight change, abdominal pain
• less common than with progestin-only injectables
• diminish after the first few months

Source: Shoupe, 1991; CCP and WHO, 2007.

MANAGEMENT OF COMMON SIDE EFFECTS
SIDE EFFECT MANAGEMENT
Amenorrhoea Reassure
Rule out pregnancy

Irregular spotting or light bleeding • Reassure

• Non steroidal analgesics
• Persistent bleeding , unbearable remove Implants
Help her choose another method.

Heavy or prolonged bleeding (more • Reassure

than 8 days or twice as much as her • (NSAIDs other than aspirin) and hormonal
usual menstrual period) (COCs)
• Persistent bleeding , unbearable remove mplants
Help her choose another method.
Recurrent and persistent headaches Assess Reassure if mild. If severe, remove implants
especially with blurred vision and refer.
Implants expulsion Re-insert help the client to select alternative method.
 Indications for Removal
• User request: When client makes a firm request

• Pregnancy: As soon as pregnancy is confirmed

• Medical reasons: Heavy menstrual bleeding, repeated severe

headaches or migraines, symptoms of acute liver diseases, serious
infection of insertion site

• At the end of 7/5/3 years after insertion: If the woman wishes to

continue with method, insert a new set of implants after removing
the old set
Follow-up

• Within 1 month after insertion

• Thereafter, at least once a year

• Explain implant should be removed 7/5/3 years and give

specific month and year

• Explain importance of returning to same clinic for removal, and

if not possible visit another clinic with trained providers
Storage, shelf-life and supplies

• Store implants at room temperature away from excess heat and moisture

• Shelf-life is 5 years when stored as above

QUESTIONS???