Background Information
Although they are less common birth control than COCs (combined oral contraceptives), progestogen-only pills (POPs) have a strong safety profile and might be a very useful option for women for whom COCs (oestrogen-containing pills) are either not tolerated or contraindicative. Some call them the “mini-pill.” Progestogen only pills are taken at the same time each day; there are no pill-free intervals.
The working mechanism of progesterone
Sperm entrance is inhibited by the cervical mucus changes brought about by all POPs. Furthermore weakened, the endometrium is unfit for implantation. ‘Conventional’ POPs prevent ovulation in up to 60% of cycles; nevertheless, the main mechanism of action of POPs containing the next generation progestogen “Desogestrel” prevents ovulation in up to 97% of cycles. Within 48 hours after the treatment begins, the cervical mucus changes become fully effective.
Effectiveness
POPs prevent pregnancy to a minimum of 99% when used correctly. The failure rate will go up as with any short-acting, user-dependent methods. As people become older and have additional children, traditional POPs seem to work better. Women who weigh more over 70 kg are treated with the same regimen because there is no evidence that their POP effectiveness is reduced.
Advantages
For most women, the POP is a safe method with far fewer contraindications than estrogen-based methods. It’s safe for women over 35 who smoke, have known thrombogenic mutations, or get aura migraines. If oestrogen is contraindicated, the desogestrel-containing POP is a great alternative in younger women because it works just as well as the COC. Use of it is safe for nursing mums up to the age of fifty-five. It is taken as one tablet every day without any pill-free intervals, and this simple schedule may lead to better compliance and fewer pill-taking mistakes.
Disadvantages
Compliance
Typical user failure rate is higher than in ideal circumstances, as with all non-LARC procedures. Since POPs have to be taken every day at or within three hours of the same time, this user-dependent approach requires excellent compliance. POPs containing desogestrel have a ’12-hour window’ during which to take them.
Side effects
No causal link between variations in weight, depression, migraines, CVS disease, or breast cancer.
Bleeding patterns
When using progestogen alone, bleeding patterns can change often, and this is acknowledged as the main reason why POP is stopped. Women should be informed that their bleeding pattern may change before starting the procedure. 20% of women will be amenorrheic, which might be desirable; 40% will bleed regularly; and 40% will flow sporadically. More unpredictable is the bleeding than with a combined contraceptive method.
Interactions with Drugs
Drugs that increase liver enzymes, such phenytoin, quicken the breakdown of the effectiveness of POP contraception may be reduced by progestogens. Condoms should be worn in addition to the POP approach and for at least four weeks after stopping these medications by women taking them for a brief period of time. Long-term users of medications that stimulate the liver enzymes should switch to another method of contraception.
Other
Condoms should be used in addition if required as this method does not protect against STIs.
Formation of regiments
The POP works best when started on days 1 through 5 of the menstrual cycle.
right now. ” It can start at any time during the menstrual cycle as long as the woman is fairly positive she is not pregnant, and the pregnancy risk has been evaluated. If the process starts beyond day five, more precautions need to be followed for 48 hours.
A miscarriage or an induced abortion should be followed by the POP starting right away or within five days. In mums who are nursing their babies, postpartum might start right away. If begun beyond day 21 postpartum, additional precautions must be used for 48 hours.
Late or missed POPs
The following missed pill rules apply if a regular POP is taken more than three hours late (more than 27 hours after the last tablet) or a desogestrel-containing POP is taken more than twelve hours late (more than 36 hours after the last pill):
- When you recall, take the missed pill
- Take the next dose at the regular time; this could mean taking two tablets in one day
- After taking the POP, take extra precautions for 48 hours
- Emergency contraception may be needed if UPSI happens within 48 hours of skipping a pill
Vomiting
Should a woman throw up two hours after taking a POP? she should take another tablet immediately. The missing pill rules would kick in if she keeps vomiting or has really bad diarrhoea.
Follow-up
- Overcoming bleeding problems might be difficult.
- Woman can receive a 12-month supply of POP and be instructed to come back for an evaluation sooner if there are any problems with the method or changes in her health.
- Other reasons of: Atypical PVB (such as STIs and pregnancy) must be ruled out.
- While modifying the kind or dosage of progestogen could help, another course of action could be needed if the unsatisfactory bleeding pattern continues.
Progestogen-only injectable contraception
Background
Injectable contraceptives containing solely progestogens are available in the UK in three forms:
1. Provera® depo
2.Sayana Publishing®
3. Nordisterat® In America, women frequently utilize the injectable form of DMPA as a reversible method of birth control. The injection is also referred to as the “shot,” but its brand name Depo Provera (depot-medroxyprogesterone acetate, or DMPA) is more widely used.
Mode of action:
The mode of action of injectable contraception that just contains progestogen prevents ovulation. The endometrium changes to become unsuitable for implant and the cervical mucus thickens as side effects. Since progestogen-only injectable contraceptives are LARC techniques, they are more successful than short-acting ones. Within the advised dose interval, the first-year failure rate is roughly 0.2%. Typical usage has a failure rate of about 6%.
Administration
Usually supplied in a sterile aqueous solution, DMPA a prefilled syringe. Just before taking, both SC (sub-cutaneous) and IM(Intera-muscular) formulations should be well shaken to make sure the contents are totally suspended. It has to be given by deep intramuscular injection, ideally into the gluteus maximus muscle. Another position is the deltoid. Before use, the vial should be immersed in warm water because NET-EN is an oily solution with a high viscosity at low temperatures. The upper anterior thigh or abdomen receives a subcutaneous Sayana Press® injection.
Advantages
Most women find that DMPA is a safe method of contraception; the only absolute contraindication is active breast cancer. It can be used by ladies who are not advised to take medications containing oestrogen. It is a long-acting method, hence everyday use is not necessary for its effectiveness. By reducing ovulation, it may help with dysmenorrhea and symptoms of endometriosis and PMS( Premenstrual syndrome).
Drug interactions
DMPA is not impacted by drugs that stimulate liver enzymes or antibiotics.
Effects on health
Insufficient information exists to either support or refute a relationship between stroke and MI. Use of a PO-injectable now may be weakly associated with a (probably low) risk of breast cancer. This will probably go down with time after stopping.
Side Effects
Weight rise
Using DMPA has been associated with weight increase. Averagely speaking.
After two years, women will gain three kilograms (range 2-6.1 kg). DMPA users who are teenage women (age <18) and have a higher BMI at start (≥30 kg/m2) are more likely to acquire weight than those with a lower BMI (<25 kg/m2).
Changes to bleeding pattern
Changed bleeding patterns are known to result from DMPA use. Around half of women will be faced with amenorrhea after a year of use, and by the second year, 70%. This can be seen favourably by women. It is possible that other bleeding patterns, such spotting, prolonged, or irregular bleeding, will be less tolerated than amenorrhoea, and the technique will be discontinued.
Other side effects
There is inadequate data to link DMPA to other negative effects, including alopecia, headaches, vaginitis, reduced libido, and mood swings.
BMD (bone mineral density)
Density has caused controversy in a number of nations, chief among them the US, where in 2004 the FDA included a “black box warning” on the package of Depo-Provera. The idea that DMPA reduces estradiol levels (by limiting follicular development) and hence lowers BMD is the basis for concerns. Currently available data points to a modest decrease in BMD that is often recovered after stopping DMPA therapy. Whether this suggests a higher chance of a fracture is unknown. Teenage BMD is a topic of some worry because DMPA lowers BMD at a time when it is typically rising and before they have attained their peak bone mass. These problems mean that DMPA should only be used in women under the age of eighteen after other options have been investigated.
Every two years, women on DMPA should have their risk factors for osteoporosis evaluated.
Return to fertility
Although stopping the progestogen-only injection can cause ovulation to be delayed for up to a year, there is no long-term evidence of reduced fertility.
Opening regiments
No additional safety measures are required if DMPA is begun on days 1 through 5 of a normal menstrual cycle. Starting it at any time during the menstrual cycle is possible as long as the woman is relatively sure she is not pregnant, and the pregnancy risk has been evaluated. If the process is started after day five, further precautions have to be taken for seven days.
DMPA should be taken as soon as possible—ideally within five days—after an induced abortion or miscarriage. Starts after day five need further precautions for seven days.
When a woman is bottle-feeding, postpartum start can happen right away, and the method can be applied freely. Should care be initiated after day 21 postpartum, it must be continued for seven days (for both nursing and non-breastfeeding women).
Missed or late injections
An injection can be repeated at any time because there is little chance of ovulation (up to 14 weeks after the last injection for IM and SC DMPA).
Follow-up
Check the medical history before each injection and record any changes or adverse effects that occur. Every two years the procedure’s continuation should be evaluated.
Bleeding issues
If additional sources of bleeding, e.g. Reassurance may be helpful if sexually transmitted infections are ruled out because several injections typically clear up the bleeding pattern. There is some suggestion that mefenamic acid or EE (as a COC) can help control the excessive bleeding linked to this method.
Progestogen-only implants
Background
Nexplanon® (USA and UK) is a single subdermal rod that is authorized for three years of use. It goes by Implanon NXT® in Australia. That simply varies from Implanon and its precursor are radio-opaque, but they also use distinct application devices and insertion techniques. Two more brands of subdermal contraceptive implants that are accessible globally are Norplant® and Jadelle®. The six-rod LNG implant known as Norplant® is still extensively used in underdeveloped nations even though it is no longer accessible in the US, the UK, or other Western countries. In countries such as New Zealand, Norplant has been replaced by the two-rod LNG implant Jadelle. Both Jadelle and Norplant have licenses for continuous usage for five years.
Neptune
A soft, flexible rod called (Implanon NXT) has 68 mg of etonogestrel (ENG) incorporated in an ethylene vinyl acetate copolymer. It is non-biodegradable and 4 cm long by 2 mm in diameter. ENG’s release rate steadily declines from 60-70 μg/day in weeks 5-6 post-insertion to 35-45 μg/day by the end of the first year.
Action mechanism
Inhibiting ovulation is the main mode of activity. Furthermore, the progestogen-only implant (like other progestogen-only contraceptives) alters cervical mucus, limiting sperm access into the upper vaginal tract. The endometrium is also affected. This renders it inappropriate for implantation.
Efficacy
The progestogen-only implant is a LARC and thus exceedingly successful. The overall pregnancy rate after three years of use is less than one in 1,000. True failures of this operation are unusual, with reported pregnancies frequently due to medication interactions or poor timing of implantation. There is a negative connection between weight and serum etonogestrel levels. However, no greater pregnancy risk has been detected and demonstrated in women weighing up to 149 kg, but the manufacturer suggests that earlier replacement can be considered in ‘heavier’ women (without stating what BMI or weight this includes). There is no substantial evidence for prior replacement.
Advantages
This incredibly effective, estrogen-free technique is safe for most women.
Gynaecological
It may reduce dysmenorrhea and endometriosis symptoms in some women, and 20% of users will have amenorrhoea while using this technique, which some will find advantageous.
Fertility
There is no delay in returning to fertility following the end of this treatment.
Compliance
Because this procedure does not require daily or frequent administration, it is a wonderful option for women who are forgetful when using other methods.
Changes in weight, mood, or libido
There is no evidence that the progestogen-only implant causes weight change, mood change, or libido reduction.
Health effects
Progestogen-only implants are not associated with a higher risk of stroke or MI, and there is little or no risk of VTE. present is insufficient research to establish the influence of progestogen-only implants on breast cancer risk; still, any connected risk, if present at all, is predicted to be modest. This technique may induce a reduction in BMD; however, there is no evidence of a clinically meaningful effect.
Disadvantages of Progestogen
Side effects Contraindications
The lone absolute contraindication for utilizing a progestogen-only implant is current breast cancer
Changes in bleeding pattern
This operation is prone to bleeding pattern changes, which are the most prominent cause of early discontinuation. Approximately 20% of users will develop amenorrhoea, while up to 50% will experience sporadic, regular, or protracted bleeding. The poor bleeding patterns with this method are unlikely to improve with time.
Acne
Acne may develop, improve, or worsen while utilizing this technique.
Drug interactions: The efficacy of progestogen-only implants is decreased by the concomitant use of liver enzyme boosting drugs (e.g., anticonvulsants). This method’s efficacy is unaffected by antibiotics that do not generate enzymes. If taking a short course (<3 weeks) of an enzyme-inducing drug, utilize additional precautions, such as barrier approaches, and continue for 4 weeks after stopping the treatment. Women who are on long-term liver enzyme-inducing medicines should investigate an alternative contraceptive approach.
Starting regimens
The progestogen-only implant can be inserted on days 1–5 of the menstrual cycle without any further precautions. It can also be inserted at any other point in the menstrual cycle provided the practitioner has assessed the pregnancy risk and is reasonably sure that the lady is not pregnant. If the operation is beginning after day 5, further steps must be performed for seven days.
Following an induced abortion or miscarriage, the progestogen-only implant should be administered soon or within 5 days. If initiated beyond day 5, extra measures are required for 7 days.
Postpartum
The SPC for Nexplanon proposes commencing between days 21 and 28 postpartum; however, a progestogen-only implant can be implanted sooner and up to day 21 postpartum without further precautions (outside of the product licence). If a progestogen-only implant is implanted beyond day 21 postpartum, further precautions must be done for 7 days. The treatment has no influence on the composition or quantity of breast milk, and breast feeding mums can use it without restriction.
Insertion and removal techniques for ENG implants
The device should be inserted and removed by a skilled healthcare professional (HCP). Emergency equipment should be present in areas where insertion or removal procedures are done.
Management of Complications
Removal-related issues: Considering that Implanon was superseded by Nexplanon, possible issues like impalpable or damaged implants or implant migration are rare. The device applicator was developed to lessen the risk of deep and non-insertions, which at the time of removal left an implant impalpable. Although an X-ray or a computed tomography (CT) scan can detect Nexplanon, linear array ultrasound is still the major imaging method used to locate an impalpable device. A specialist should remove the device once imaging has been used to localize it. You could use ultrasound guidance for this.
Management of bleeding problems
Women who have a protracted shift in their bleeding pattern should be investigated for other possible causes, such as. STIs. There is inadequate evidence to support the efficacy of therapy for bleeding problems with ENG implants, and the majority of the evidence is extrapolated from LNG implants. If other pathology is excluded or treated and the condition remains, a COC can be awarded (if eligible) for three months, either cyclically or continuously (outside product licence). In the long run, if the bleeding pattern remains undesired, a different contraceptive method may be required.
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