Special contraceptive needs

The adolescent requiring contraception

Adolescence, defined as 10-19 years of age, is a time of physical, sexual, and emotional development and experiences. Adolescents may face pressure to participate in high-risk behaviour, including sexual activity, and have the right to request and receive unbiased contraceptive counselling. They have the right of choice concerning which contraceptive they wish to use. It should be noted that the pre­scriber should know the legal guidelines of the particular statutory body or bodies where they practise (70).

Most contraceptive methods may be offered to adolescents ex­cept permanent methods which are seldom appropriate because of their irreversibility. The adolescent should be advised about the use of a LARC method whenever possible but her choice

Table 53.6 WHO recommendations for use of hormonal contraception for women at high risk of HIV infection and women living with HIV (11,68)

CIC, combined injectable contraceptives; COC, combined oral contraceptive pills; DPMA, depot medroxyprogesterone acetate; ETG, etonogestrel; LNG, levonorgestrel; LNG-IUD, levonorgestrel-releasing intrauterine device; NET-EN, norethisterone enanthate; POI, progestogen-only injectable; POP progestogen-only pill.

Source data from World Health Organization. Hormonal contraceptive eligibility for women at high risk of HIV Guidance - Recommendations concerning the use of hormonal contraceptive methods by women at high risk of HIV (2017). https://www.who.int/reproductivehealth/publications/family_planning/HC-and-HIV-2017/en/.

of a contraceptive option will determine what method she is given (71, 72).

Sufficient time for consultation should be provided and these cli­ents must be encouraged to return at any time if they experience problems with their contraceptive choice. Young women have been found to be less tolerant of side effects and abandoning contracep­tion will place them at risk of unintended pregnancy. Correct and consistent condom use must be promoted to prevent STIs and dual protection with another effective method of contraception to pre­vent pregnancy must be encouraged. Adolescents may have specific health concerns or risks which need to be addressed at the first con­sultation. They should have easy access to emergency contraception.

Sexually active young people are more likely to have short-term sexual relationships with more partners and may have a greater risk of STIs, including HIV acquisition. In the counselling and other medical advice concerning infection prevention, all victims of non- consensual coitus should be offered postcoital contraception as well as postexposure prophylaxis for HIV acquisition.

Table 53.7 Women living with HIV using antiretroviral therapy (11)

CIC, combined injectable contraceptives; COC, combined oral contraceptive pills; DPMA, depot medroxyprogesterone acetate; ETG, etonogestrel; LNG, levonorgestrel; LNG-IUD, levonorgestrel-releasing intrauterine device; NET-EN, norethisterone enanthate; POI, progestogen-only injectable; POP, progestogen-only pill.

Source data from World Health Organization.

Contraception at the end of reproductive life

The contraceptive needs of the perimenopausal woman often do not receive adequate attention. These women are still vulnerable in terms of unintentional conception, are usually still sexually active, and pos­sibly may have a new partner which put them at risk of STIs. Ideally, the contraception they are offered should provide them with health benefits as well as contraceptive protection. A pregnancy which oc­curs at the end of reproductive life is often unintended and can cause considerable distress and concern. Many women find the choice of termination of pregnancy unacceptable although at the same time they have not planned a pregnancy in their 40s and 50s (45, 73, 74).

When reviewing the contraceptive options for older women, age alone is not a contraindication for most of the contraceptive methods. The current advice, however, is that the combined contraceptive pill and the injectable progestogen options should be stopped at 50 years of age unless there have been earlier contraindications. Factors such as body mass index, medical problems, and risk factors for cardio­vascular and hypertensive disease will impact contraceptive options (75). The use of hormonal contraception is also protective in terms of certain cancers (76-78).

The COC can usually be utilized after the age of 50 years in a woman with no additional risk factors and consideration should be given to utilize lower-dose pills (79). Unfortunately these are not universally available and are not supplied in many public health sys­tems in developing countries. Similarly, the other delivery methods such as transdermal patches are not available in low-resource settings (80).

The advantages of the combined contraceptive pill are that this impacts positively on bone metabolism and reduces ovarian and endometrial cancer.

Progestogen-only contraception has many routes of administra­tion including oral, subdermal, and intramuscular. Many women have unscheduled bleeding which causes concern and the implica­tions of this therapy need to be carefully discussed with potential users (73, 82).

The copper intrauterine contraceptive device has no systemic impact and in addition has the advantage of offering long-term contraception for the perimenopausal woman. Unfortunately many consumers chose not to use this method, despite the very acceptable efficacy record.

Barrier contraception in the older women may be important as often they are involved in new relationships and protection against human papillomavirus and HIV is needed. Condom difficulty has been reported with older partners who may have erectile dysfunc­tion and the use of the female condom has received variable accept­ance. In many countries the diaphragm and the cervical cap are not available and there is considerable concern about the use of spermi­cides which may increase HIV transmission. Natural contraception is always problematic and while sterilization is appropriate in the older woman, she may find this unacceptable.

Advice on when to stop contraception is important in this age group. At present, it is generally accepted that 1 year after the last menstrual bleed if a woman is 50 years or older is a reasonable time to discontinue contraception. In the younger woman, it is recom­mended she should continue contraceptive measures for at least 2 years. When a woman reaches 55 years regardless of her men­strual pattern, it is suggested that no contraceptive method needs to be utilized. There may, however, be indications for further inves­tigations of ongoing bleeding. It must be stressed that hormone re­placement therapy is not a contraceptive option for older women and the healthcare professional should be aware of the patient's particular needs.

Contraception in women with medical disorders

In the past, medical conditions were often regarded as a contra­indication to both contraception and pregnancy. As treatment has improved and management of many medical disorders has been optimized, women who previously would not have considered pregnancy are now requesting contraception and pregnancy man­agement. This involves interdisciplinary consultation and an under­standing of the impact of pregnancy on the underlying condition and of the condition on pregnancy.

Pregnancy may trigger cardiovascular disease or escalate under­lying problems such as autoimmune disorders (83, 84). It is essential that all healthcare providers are aware of the needs of the woman with medical disorders. In some situations pregnancy is totally contraindicated and the client and her partner need to be appro­priately counselled. In many instances, improved medical care will result in stabilization of the patient and the possibility of pregnancy may be considered. It is essential that no pregnancy is unintended, that women are offered appropriate contraception until they de­sire pregnancy and that this contraceptive advice embraces the particular problems of their condition. In women with significant medical conditions it is essential that postpartum contraception is discussed and adequately implemented (85, 86).

The WHO MEC for contraceptive use offer a valuable resource to healthcare providers who are dealing with patients with med­ical problems. It is important that we recognize when pregnancy should be best postponed to optimize the medical condition, and when pregnancy is contraindicated as it will impact the mother's survival. Once women with medical disorders have completed their family, permanent or long-acting contraception should be considered (11).

Maternal death through an unintended pregnancy is a tragedy. It impacts not only the mother and her partner but also all the sur­viving children and results in higher infant and child mortality rates. Ensuring adequate and safe contraceptive provision to women with major medical disorders and ongoing medical input is a cornerstone of good reproductive healthcare.

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