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Selected practice recommendations for contraceptive use, 3r d edition (SPR)

M a r y Ly n G a f f ie ld

Scientist, H u m an Rep ro d u ctio n Team

Budapest, May 2018

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C onflic t o f in terest sta tem ent

I, Mary E Gaffield, declare no significant relationship or affiliation with any corporate organization or the sponsors of the ESC2018 Congress. I have no conflicts of interest to declare.

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Background

q High quality contraceptive services depend upon numerous practices, including :– m a x im iz in g th e e ffe c t iv e n e s s o f c o n tra c e p t iv e m e th o d s

– m a n a g in g s id e e ffe c ts

– a d d re s s in g p ro b le m s a s s o c ia te d w ith in c o rre c t m e th o d u s e

– p ro v id in g a p p ro p r ia te fo llo w -u p

– d e te rm in in g w h e n e xa m s a n d te sts s h o u ld b e d o n e

q The World Health Organization’s (WHO) Selected practice recommendations for contraceptive use (SPR) guideline provides evidence-based guidance on how to safety and effective use contraceptive methods.

Se lected p ractice reco m m en d atio n s fo r co ntraceptive u se

2 0 0 1

2 0 0 4

2 0 0 8

1 4 D e c e m b e r 2 0 1 6

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Methods

q Two consultations to: (1) prioritize topics, (2) develop PICO questions, (3) formulate final recommendations

– 19 topics reviewed

q Adhered to WHO requirements for guideline development

– 13 systematic reviews of epidemiological and clinical evidence– GRADE approach to evidence assessment– Consensus-driven process

q GRC and ADG approved in early Fall 2016

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Se lected p rac+ ce reco m m en d a+ o n s fo r

co ntracep+ ve u se , 3rd ed i+ o n

Recom m endations for health care providers on the following topics:

q Initiation/continuation of m ethods

– For specific situations (regular menstrual cycles, postpartum, post abortion, switching from another method, breastfeeding)

q Incorrect use of m ethods (e.g. m issing pills, delayed re-injection)

q Problem s during use (such as vom itting and/or diarrhea from em ergency contraceptive pill use, m enstrual

irregularities associated with horm onal m ethods)

q Program m atic issues (such as required exam s and tests, appropriate follow-up, advanced provision of supplies)

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Method-specific recommendations

Comprehensive recommendations are available for the following topics: q COCs, ECPs, POPs

– in i t ia t io n / c o n t in u a t io n , in c o r r e c t u s e , p r o b le m s d u r in g u s e , b le e d in g i r r e g u la r i t ie s , p r o g r a m m a t ic i s s u e s ( e x a m s & t e s t s , n u m b e r o f p i l l p a c k s , fo l lo w - u p )

q Injectables– in i t ia t io n / c o n t in u a t io n , b le e d in g i r r e g u la r i t ie s , p r o g r a m m a t ic i s s u e s

( e x a m s & t e s t s , fo l lo w - u p )

q Implants– in i t ia t io n / c o n t in u a t io n , b le e d in g i r r e g u la r i t ie s , p r o g r a m m a t ic i s s u e s

( e x a m s & t e s t s , fo l lo w - u p )

q IUDs– in i t ia t io n / c o n t in u a t io n , b le e d in g i r r e g u la r i t ie s , P ID , p r e g n a n c y d ia g n o s is

d u r in g u s e , p r o g r a m m a t ic i s s u e s ( e x a m s & t e s t s , fo l lo w - u p )

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C lassificatio n fo r d ifferentiatin g ap p licab ility o f vario u s exam s an d tests

q Class A : essen'al and mandatory

q Class B : contributes substan'ally to safe and effec've use, risk of not performing exam or text should be balanced against the benefits of making the method available

q Class C : does not contribute to safe and effec've use

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Exams and testsS it u a t io n C O C C IC P O P P O I Im p la n t s IU D

B re a s t e x a m c c c c c c

P e lv ic / g e n ita l e x a m c c c c c a

C e r v ic a l c a n c e r

s c re e n

c c c c c c

R o u t in e la b te s t s c c c c c c

H a e m o g lo b in c c c c c b

S T I r is k a s s e s s m e n t c c c c c a

H IV / S T I s c re e n in g c c c c c b

B lo o d p re s s u re † † † † † c

In general, most exams and tests do not contribute to the safe and effective use of a contraceptive method. Blood pressure measurements are desirable (†) prior to initiation of most methods; however, lack of a measurement should not be used to deny access to any method.

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R u lin g o u t p regn an cy: in stru ctio n s fo r gu id in g m eth o d in itiatio n an d co ntin u atio n

The provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets the following criteria:

has not had intercourse since last normal menseshas been correctly and consistently using a reliable

method of contraceptinis within the first 7 days after normal mensesis within 4 weeks postpartum for non-lactating womenis within the first 7 days postabortion or miscarriageis fully or nearly fully breastfeeding, amenorrhoeic, and

less than 6 months postpartum.

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WHAT’S NEW IN THE 3RD EDITION? Selected prac,ce recommenda,ons for contracep,ve use, 3rd edi,on

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Contraceptive methods in the 3rd edition

q C o m b in e d o ra l c o n t ra c e p t iv e s ( C O C )

q C o m b in e d in je c ta b le c o n t ra c e p t iv e s ( C IC )

q la p i lu le s p ro g e s t iv e p u re ( P O P )q P a tc h – N E W

q C o m b in e d v a g in a l r in g - N E W

q P ro g e s to g e n - o n ly in je c ta b le s – D M PA & N E T- E N

q S u b c u ta n e o u s ly a d m in is te re d D M PA ( D M PA - S C ) - N E W

q Im p la n t s ( N o r p la n t , J a d e lle , Im p la n o n )q S in o - Im p la n t ( I I ) - N E W

q C o p p e r- b e a r in g IU D

q L N G - re le a s in g IU D

q E m e rg e n c y c o n t ra c e p t iv e p i l ls ( C O C a n d L N G b a s e d )

q U lip r is ta l a c e ta te ( a n E C P ) - N E W q S ta n d a rd D a y s M e t h o d

q V a s e c to m y

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2 - ro d , 1 5 0 m g L N G im p la n t

m a n u fa c t u re d in C h in a

C u r re n t ly u s e d b y m il l io n s o f w o m e n w o r ld w id e

( m o s t ly In d o n e s ia & C h in a )

C o n t ra c e p t iv e v a g in a l r in g

U lip r is ta l A c e ta te ( U PA )

S e le c G v e p ro g e s t e ro n e re c e p t o r

m o d u la t o r, d e la y s o v u la G o n

S in g le d o s e 3 0 m g e ff e c G v e u p t o 1 2 0 h o u rs

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New recommendations for 3rd edition

q The patch– e x is t in g r e c o m m e n d a t io n s fo r C O C s a p p ly– e x c e p t io n : In s t r u c t io n s fo r m is s e d o r d e la y e d p a t c h - t a k in g

q The combined vaginal ring– e x is t in g r e c o m m e n d a t io n s fo r C O C s a p p ly– e x c e p t io n : In s t r u c t io n s fo r m is s e d o r d e la y e d r in g u s e

q DMPA-SC– e x is t in g r e c o m m e n d a t io n s fo r D M P A in t r a m u s c u la r in je c t io n a p p ly

q Sino-Implant (II) – e x is t in g r e c o m m e n d a t io n s a s o t h e r L N G im p la n t s a p p ly

q ulipristal acetate (an ECP)– e x is t in g r e c o m m e n d a t io n s a s o t h e r E C P s ( e . g . , c o m b in e d a n d L N G ) a p p ly– e x c e p t io n : In s t r u c t io n s fo r in i t ia t in g r e g u la r c o n t r a c e p t io n a f t e r U P A u s e

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In itiatin g regu lar co ntraceptio n after EC P u se : N ew reco m m en d atio n s

q After ECPs containing LNG or combined estrogen-progestogen pills– A woman may resume a method immediately

• I f s h e d o e s n o t s t a r t im m e d ia t e ly , s h e c a n s t a r t C O C s , C IC s , P O I , P O P, p a t c h , r in g , im p la n t s a t a n y t im e i f i s r e a s o n a b ly c e r t a in s h e i s n o t p r e g n a n t .

• I f s h e d o e s n o t s t a r t im m e d ia t e ly , s h e c a n h a v e a n IU D ( e i t h e r L N G o r c o p p e r ) in s e r t e d , i f r e a s o n a b ly c e r t a in s h e i s n o t p r e g n a n t . I f s h e i s a m e n o r r h o e ic , s h e c a n h a v e t h e IU D ( e i t h e r L N G o r c o p p e r ) in s e r t e d i f i t c a n b e d e t e rm in e d t h a t s h e i s n o t p r e g n a n t .

q Need for additional contraception for LNG & COC ECP– The woman is advised to abstain from sexual intercourse or use barrier contraception for 2 days for POPs and 7 days for CHCs, as well as early pregnancy testing if warranted (e.g., no withdrawal bleed occurs within 3 weeks)

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In itiatin g regu lar co ntraceptio n after EC P u se : N ew reco m m en d atio n s

q A$er UPA EC– CHC or progestogen-containing methods can be started on the

6th day a<er taking UPA. A Cu-IUD can be inserted immediately. An LNG-IUD can be inserted immediately, if it can be determinedshe is not pregnant. – If not on the 6

thday, CHC (COCs, patch, CVR, or injectables) or

POCs (POPs, DMPA or NET-EN, implants or LNG-IUD) can be started at any Nme if reasonablycertain the woman is not pregnant. If Cu-IUD, can instert if reasonablycertain not pregnant. If woman is amenorrhoeic, determineshe is not pregnant prior to either LNG-IUD or Cu-IUD inserNon.

– Need for addiNonal contracepNon: conNnue to abstain from sexual intercourse or use barrier contracepNon for 2 days for POPs and 7 days for other hormonal methods.

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Conclusion

q Programmes and providers can now access the latest global standards for safe and effective contraceptive method provision of emergency, short-acting, long-acting and permanent methods in the SPR, 3r d

edition.

q WHO is committed to continually review the scientific evidence that provides the foundation for this standard setting.

q For further information: http:/www.who.int/topics/family_planning/spr

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Additional information

q F o r f u r t h e r in fo r m a t io n : w w w .w h o .in t / re p ro d u c t iv e h e a lth / to p ic s / fam ily _ p la n n in g / S P R -3 /e n /

q S e e C h e n M J , K im C R , W h ite h o u s e K C , B e r r y - B ib e e E , G a f f ie ld M E . D e v e lo p m e n t , u p d a t e s , a n d f u t u r e d ir e c t io n s o f t h e W o r ld H e a lt h O r g a n iz a t io n S e le c t e d P ra c t ic e R e c o m m e n d a t io n s fo r C o n t ra c e p t iv e U s e . In t J G y n e c o l O b s t e t 2 0 1 6 :1 - 7 ( o p e n a c c e s s )

q S e e C o n t r a c e p t io n S e p te m b e r 2 0 1 6 is s u e fo r s e le c te d s y s te m a t ic r e v ie w s a n d W e b A n n e x fo r f u l l l is t in g o f m a n u s c r ip t s

h t t p :/ / w w w .c o n t ra c e p t io n jo u r n a l.o r g / is s u e / S 0 0 1 0 - 7 8 2 4 ( 1 6 ) X 0 0 0 7 - 8