|Year : 2018 | Volume
| Issue : 4 | Page : 208-223
Chinese expert consensus on clinical application of female contraceptive methods
Li-Nan Cheng1, Wen Di2, Yan Ding3, Guang-Sheng Fan4, Xiang-Ying Gu5, Min Hao6, Jing He7, Li-Na Hu8, Ke-Qin Hua9, Wei Huang10, Li Jin4, Bei-Hua Kong11, Jing-He Lang4, Jin-Hua Leng4, Jian Li12, Cai-Xia Liu13, Guan-Yuan Liu14, Lei Song15, Xiao-Ye Wang16, Shang-Chun Wu17, Min Xue18, Hui-Xia Yang19, Qing Yang13, Shu-Zhong Yao20, Zhen-Yu Zhang14, Ying-Fang Zhou19, Lan Zhu4
1 Shanghai Institute of Planned Parenthood Research, Shanghai, China
2 Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
3 Department of Gynecology, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
4 Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
5 Department of Family Planning, Tianjin Medical University General Hospital, Tianjin, China
6 Department of Obstetrics and Gynecology, The Second Hospital of Shanxi Medical University, Taiyuan, China
7 Department of Obstetrics, Zhejiang University School of Medicine, Hangzhou, China
8 Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
9 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
10 Department of Obstetrics and Gynecology, The West China Second University Hospital, Sichuan University, Chengdu, China
11 Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
12 Department of Family Planning, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
13 Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
14 Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
15 Department of Obstetrics and Gynecology, PLA General Hospital, Beijing, China
16 Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
17 Research Institute of National Health Commission of the People's Republic of China, Beijing, China
18 Department of Gynecology, The Third Xiangya Hospital of Central South University, Changsha, China
19 Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
20 Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
|Date of Submission||13-Nov-2018|
|Date of Web Publication||11-Jan-2019|
Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730
Source of Support: None, Conflict of Interest: None
Unintended pregnancy is a global issue, with approximately 85,000,000 women around the world having unintended pregnancy annually. The contents of clinical application of women's contraceptive methods are very wide, involving multiple areas. This consensus deeply discusses the specific contraceptive needs at different statuses, combined with gynecological diseases, postabortion contraception, and postpartum family planning, ensuring the correct use of contraceptive methods under the corresponding status. The top priority of the consensus is the specific contraception consensus section for women combined with gynecological diseases because medical treatment effect as well as side effects should be weighed carefully. The consensus is to make high-efficiency and individual contraceptive strategy for different groups based on multidisciplinary (gynecology, obstetrics, and family planning) and multidimensional aspects, which can provide uniform guidance for medical and health organizations under the condition as relevant global guidance or consensus is still lacking.
Keywords: Contraceptive Methods; Gynecological Disease; Postabortion Contraception; Postpartum Family Planning; Unintended Pregnancy
|How to cite this article:|
Cheng LN, Di W, Ding Y, Fan GS, Gu XY, Hao M, He J, Hu LN, Hua KQ, Huang W, Jin L, Kong BH, Lang JH, Leng JH, Li J, Liu CX, Liu GY, Song L, Wang XY, Wu SC, Xue M, Yang HX, Yang Q, Yao SZ, Zhang ZY, Zhou YF, Zhu L. Chinese expert consensus on clinical application of female contraceptive methods. Reprod Dev Med 2018;2:208-23
|How to cite this URL:|
Cheng LN, Di W, Ding Y, Fan GS, Gu XY, Hao M, He J, Hu LN, Hua KQ, Huang W, Jin L, Kong BH, Lang JH, Leng JH, Li J, Liu CX, Liu GY, Song L, Wang XY, Wu SC, Xue M, Yang HX, Yang Q, Yao SZ, Zhang ZY, Zhou YF, Zhu L. Chinese expert consensus on clinical application of female contraceptive methods. Reprod Dev Med [serial online] 2018 [cited 2019 Jan 17];2:208-23. Available from: http://www.repdevmed.org/text.asp?2018/2/4/208/249891
| Introduction|| |
Unintended pregnancy is a global issue, with approximately 85,000,000 women around the world having unintended pregnancy annually. About 40% of the pregnancy is unintended and 50% of the unintended pregnancy ends with induced abortion, that is, there are 4,000–6,000 induced abortion cases every year. High-efficiency contraception rate of women is very low in China and high-efficiency contraceptive methods are not widely known, which leads to high induced abortion rate. According to the data from the Statistical Yearbook of National Health and Family Planning Commission, the number of induced abortions in 2014 was higher up to 9,620,000 cases. Both vacuum aspiration and medical abortion will destroy the natural protection barrier of women, damage the endometrium, and cause potential harm to the reproductive system and function. Thus, taking contraception seriously is the first step to protect women's reproductive health. The Medical Eligibility Criteria for Contraceptive Use issued by the World Health Organization (WHO) is the technical guideline for family planning, which has authoritative evaluation on the effective rate of the current contraceptive methods, including intrauterine device (IUD), hormonal contraception, and correct use of condoms. However, the selection on the contraceptive methods may differ for the women at different physiological statuses or with different diseases. Thus, the method selection should be made after evaluation on these conditions.
The contents of clinical application of women's contraceptive methods are very wide, involving multiple areas. Based on multidisciplinary cooperation, this consensus deeply discusses the specific contraceptive needs at different statuses, combined with gynecological diseases, postabortion contraception (PAC), and postpartum family planning (PPFP), ensuring the correct use of contraceptive methods under the corresponding status. The top priority of the consensus is the specific contraception consensus section for women combined with gynecological diseases. The consensus can provide uniform guidance for medical and health organizations under the condition as relevant global guidance or consensus is still lacking.
Women with common gynecological diseases and needs for contraception should take a full consideration on the interaction between the diseases and contraceptive methods as well as the contraindication. Besides, we should be paid attention to the influence of the contraceptive method on protection and treatment of the gynecological disease. Women with different gynecological diseases should choose appropriate contraceptive method. Moreover, postoperative gestational interval is a critical factor influencing pregnancy and its outcome. Meanwhile, major surgery within 4 weeks postoperatively is a risk factor of venous thromboembolism (VTE); therefore, more attention should be paid to appropriate contraceptive method.
Ovulation can be recovered after 2 weeks of abortion, so pregnancy may happen before the first menstruation. However, re-pregnancy within this short time will cause greater damage to women. To avoid repeated abortions, postabortal high-efficiency and long-term contraception measures should be taken immediately, insisted, and correctly used. Besides, all kinds of situations should be considered at the time of abortion (abortion in the first and second trimesters and infected abortion) to provide appropriate contraceptive method.
Timely postpartum and high-efficiency contraception can guarantee female reproductive health and avoid the risks of postpartum pregnancy or induced abortion within short time. The risk of VTE in women in puerperium is twenty times of that in nonpregnant women and five times of that in pregnant women. During this period, contraceptive methods with possible VTE risk should be avoided. Factors such as body mass index >30 kg/m2, hypertensive disorder complicating pregnancy, postpartum bleeding, cesarean section, blood transfusion during delivery, and prolonged labor (stage of labor >24 h), will aggravate hypercoagulability and increase VTE risk in pregnant women, which should be paid more attention to. Besides, combined hormonal contraception (CHC) used in lactation period may influence milk volume and its composition. Thus, women during this period should choose the contraceptive method cautiously. The contraception after cesarean section needs particular attention. The WHO suggests that the pregnancy interval should be at least 2 years to guarantee good outcome of mother and child during re-pregnancy. After 6 months of lactation period, the selection on contraceptive methods is same as that in nonpregnant women.
The aim of this consensus is to make high-efficiency and individual contraceptive strategy for different groups based on multidisciplinary (gynecology, obstetrics, and family planning) and multidimensional aspects. The selection for contraceptive method in different stages and statuses based on the Medical Eligibility Criteria for Contraceptive Use is listed in [Table 1]. Based on the clinical characteristics, women are grouped into those with gynecological diseases, postinduced abortion, and postpartum, who are described as follows in detail.
|Table 1: Use and categories for contraceptive method in different stages and statuses (Medical Eligibility Criteria for Contraceptive Use)|
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| Part I: Clinical Applications of Contraceptive Methods under Common Gynecological Diseases|| |
The aim of this part is to recommend contraceptive methods for women with common gynecological diseases, such as uterine fibroid, endometriosis, adenomyosis, endometrial hyperplasia, abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O), primary dysmenorrhea, pelvic inflammatory disease (PID), and those after surgical treatment. The incidences of these diseases are relatively high in women of childbearing age, who are a special group with contraceptive needs in clinic. Evidence-based medicine has proved that hormonal contraception may bring more noncontraceptive benefits., Therefore, for these patients, gynecologists should recommend individual contraceptive method, giving consideration of contraception and disease treatment and weighing benefits and risks.
Uterine fibroid is the most common benign tumor in female reproductive organs. The clinical manifestations depend on the site, size, growth rate, and complication of the tumor. Myomectomy is a common surgery for preserving women's reproductive function. In patients with a desire for pregnancy who undergo myomectomy, to reduce the risk of scarred uterus disruption during gestational period, contraception should be taken within 3 months after subserosal myomectomy and within 6–12 months for other kinds of myomectomy.
According to uterine fibroids and postoperative disease conditions, contraceptive methods, such as combined oral contraceptive (COC), levonorgestrel-releasing intrauterine system (LNG-IUS), etonogestrel (ETG) implants, depot medroxyprogesterone acetate (DMPA), are recommended. Among them, COC and LNG-IUS can alleviate symptoms, such as menorrhagia and dysmenorrheal, at the same time of contraception. Thus, they are the preferred contraceptive methods.
- COC: Uterine fibroid is not a contraindication of COC. No evidence has proved that low-dose COC causes tumor growth. Contrarily, it can inhibit the growth and reduce menstrual volume and bleeding time. Therefore, COC contraception is recommended for patients with uterine fibroids., Given the evidences of its wide applications, our expert group recommends COC as one of the preferred contraceptive methods for patients with uterine fibroids.
- IUD or LNG-IUS: LNG-IUS can inhibit the proliferation and apoptosis of uterine fibroid cells, which significantly improves menorrhagia of patients with uterine fibroids, increases hemoglobin content, and reduces uterine volume.,, A multicentric randomized controlled study has proved that the probability of uterine fibroids in patients implanted with LNG-IUS is lower than those with copper (Cu)-IUD. The WHO recommends that, for uterine fibroid patients without distortion of uterine cavity, LNG-IUS is one of the preferred contraceptive methods. For patients with submucosal myoma, transcervical resection of submucous myoma is suggested at first, followed by LNG-IUS placement, which can effectively reduce expulsion rate.
Endometriosis and adenomyosis
Endometriosis and adenomyosis are the major reasons causing dysmenorrhea and chronic pelvic pain. For women suffering from these diseases and undergoing surgical treatment, hormonal contraception can alleviate pain, reduce menstrual volume, and protect from postoperative recurrence simultaneously. Therefore, COC, LNG-IUS, DMPA, or ETG implant is recommended for these patients, especially COC or LNG-IUS.
- COC: COC is a first-line treatment drug for endometriosis-relevant pain and primary dysmenorrhea. It is also effective for treating adenomyosis-relevant pain and menorrhagia, as well as postoperative pain and recurrence protection of endometriosis and adenomyosis. Through inhibiting ovulation and endometrium growth, it reduces the secretion of prostaglandin, relieves pain, and decreases menstrual volume.
For women with requests for reproduction, to reduce the risk of gestational disruption of scarred uterus after adenomyosis surgery, the suggested contraception interval is 0.5–1 year. The use of COC also reduces the recurrence rate after endometriosis surgery. For women with endometriosis and adenomyosis without requests for reproduction, COC is recommended postoperatively.
COC possesses significant advantages in the aspects of safety and compliance and can be administrated for a long time in a continuous or cyclic way. Cyclic administration is recommended at first. If the pain is not significantly relieved, the patient can turn to continuous use to improve the pain relief rate.
- LNG-IUS: LNG-IUS is recommended by the European Society of Human Reproduction and Embryology to apply in the treatment of endometriosis-related pain. It can improve the quality of life of patients. Meanwhile, LNG-IUS has been widely applied in the treatment of adenomyosis in clinic to reduce endometrial thickness and uterine volume. It is more effective than COC in pain relief and reduction of menstrual volume. The placement of LNG-IUS after endometriosis surgery can reduce the postoperative recurrence.
For endometriosis patients without requests for reproduction, LNG-IUS or COC is recommended until they desire to get pregnant. Similar to the case of patients with uterine fibroid, the LNG-IUS in patients with adenomyosis may move down or expulse. The possible reason is that the increased uterine volume leads to significant increase in uterine cavity and menstrual volume. Thus, LNG-IUS is suggested to place avoiding the period of large menstrual volume. Alternatively, gonadotropin-releasing hormone agonist is administered for 3–6 months at first, and then LNG-IUS is placed when the uterine volume is shrunken. The patients are followed up after the placement.
- Other progestogen contraceptives: DMPA can inhibit ovulation and alleviate metrorrhagia and menstruation-related symptoms. A randomized controlled study has indicated that DMPA is effective as leuprorelin and danazol. Given that long-term use of DMPA can reduce bone mineral density, it is suggested to be a candidate contraceptive method.
ETG implant is a long-term acting reversible contraception (LARC) with 3 years of contraceptive period. There are few evidences on the benefits of the implant except for contraception. A randomized controlled study has proved that ETG effectively relieves endometriosis-related pain, such as dyspareunia, dysmenorrhea, and nonmenstrual pelvic pain, and the efficacy and side effects are similar to that of DMPA.
The occurrence of endometrial hyperplasia is related with oversecretion of estrogen in the ovary and lack of progestogen, commonly seen in menstrual status without ovulation. Endometrial hyperplasia is divided into hyperplasia with atypia and hyperplasia without atypia. The risk of endometrial hyperplasia without atypia progressing to endometrial cancer is <5% over 20 years.
LNG-IUS is preferred for hyperplasia patients without atypia, which can effectively reverse endometrium, and can be used as the secondary protection to reduce postoperative recurrence.
- COC: According to the guidelines on the Clinical Management of Endometrial Hyperplasia (Hong Kong), COC is not a conventionally recommended contraceptive method.
- LNG-IUS: For patients with endometrial hyperplasia without atypia, LNG-IUS and continuous high-dose oral progestogen can effectively reverse endometrium. A long-term follow-up study has proved that the complete regression rate of endometrial hyperplasia at 12 months after LNG-IUS placement is 94.7%. The therapeutic effect on the endometrial hyperplasia is better than that on oral progestogen, and the bleeding pattern of ING-IUS users is better with fewer adverse reactions. Therefore, the Management of Endometrial Hyperplasia, Green-top Guideline, proposed by the Royal College of Obstetricians and Gynaecologists/British Society for Gynaecological Endoscopy (RCOG/BSGE) in 2016, recommends LNG-IUS as a first-line option for hyperplasia patients without atypia. Patients should be followed up once every 6 months after placement, until the results are negative in successive two endometrial biopsies.
For hyperplasia patients with atypia, surgical treatment is preferred. For those refusing surgery but wishing to keep reproductive function, the potential malignancy of atypical endometrial hyperplasia and the risk of development into endometrial carcinoma should be sufficiently informed and comprehensively evaluated. LNG-IUS or oral progestogen is the preferred recommendation.
The occurrence of endometrial polyp is related with an abnormal expression of local estrogen receptor. The American Association of Gynecological Laparoscopists Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps suggest that conservative treatment can be selected for asymptomatic polyp (Level A) because 20% of the polyps have been proved to naturally regress. The recurrence rate after hysteroscopic endometrial polypectomy is relatively high. Thus, for patients without needs for reproduction, LNG-IUS or COC is recommended for contraception to reduce the recurrence rate of postoperative polyps.
- COC: COC can take dual effects in endometrial atrophy and endometrial growth. Postoperative oral COC can repair impaired endometrium, resist high level of estrogen in endometrium, avoid endometrial hyperplasia, and reduce recurrence of polyps. A study following up endometrial polyp patients undergoing hysteroscopic endometrial polypectomy and taking oral COC has indicated that the recurrence rate of endometrial polyp is significantly lower than those who do not take COC. COC can control menstrual cycle and reduce menstrual volume and duration. The protective effect for postoperative recurrence is superior to the progestogen-only treatment.
- LNG-IUS: LNG-IUS placement after hysteroscopic endometrial polypectomy can reduce menstrual volume and prevent the recurrence of endometrial polyps. The possible mechanism is that levonorgestrel directly acts on endometrium and greatly inhibits endometrial hyperplasia. Besides, LNG-IUS reduces the risk of endometrial polyps of patients administrated with tamoxifen. Thus, the expert group of this consensus suggests LNG-IUS as one of the preferred contraceptive methods for patients without needs for reproduction temporarily.
Abnormal uterine bleeding associated with ovulatory dysfunction
Ovulatory dysfunction, including oligo-ovulation, anovulation, and corpus luteum insufficiency, is mainly caused by hypothalamic–pituitary–ovarian axis dysfunction, which is commonly seen in adolescence, child-bearing period, and menopausal transition. It can be also arisen from polycystic ovarian syndrome (PCOS), obesity, hyperprolactinemia, and thyroid diseases. For AUB-O patients completing reproduction or without needs for reproduction temporarily, COC or LNG-IUS is recommended to achieve contraception, regulate menstrual cycle, and protect endometrium. Especially for AUB-O patients in menopausal transition, LNG-IUS is the optimal contraceptive method.
- COC: COC can be used to stop bleeding during AUB-O bleeding period. Afterward, it will regulate the cycle, prevent endometrial hyperplasia and AUB recurrence, and provide contraception. For AUB-O patients with persistent anovulation, COC improves PCOS-relevant symptoms, such as hirsutism and acne, by inhibiting ovary and adrenal gland activity. Continuous COC use for months is conducive to stopping acute bleeding and improving anemia symptoms. After the improvement, it can be administrated via cyclic use.
- LNG-IUS: The placement of LNG-IUS in AUB-O patients who have completed childbirth or those without family planning within 1 year can reduce the bleeding volume of the anovulation patients and prevent endometrial hyperplasia. Women in menopausal transition still have reproductive function, facing the risk of unintended pregnancy. Thus, contraception is necessary. Especially for AUB-O patients in menopausal transition, due to the long duration of the period and easy recurrence, long-term management is particularly needed to control the recurrence and improve the quality of life. LNG-IUS can be combined with estrogens in hormone replacement therapy that inhibits endometrial hyperplasia, protects endometrium, and reduces the risk of endometrial carcinoma. Besides, the systemic drug concentration of LNG-IUS is very low. Thus, the long-term use has small influences on the lipid metabolism and liver function in the perimenopausal women, without increase in the risk of cerebrovascular and cardiovascular diseases.
COC or LNG-IUS is recommended for primary dysmenorrhea patients as a contraceptive method to effectively alleviate dysmenorrhea symptoms and improve the quality of life.
- COC: COC is a first-line treatment drug for primary dysmenorrhea. It inhibits ovulation and endometrial growth, reduces prostaglandin and pitressin levels, and alleviates dysmenorrhea through hypothalamic–pituitary–ovarian axis.
- LNG-IUS: The WHO recommends LNG-IUS be applied in alleviating symptoms of patients with severe dysmenorrhea. In Japan, the approved indications of LNG-IUS include contraception, menorrhagia, and dysmenorrhea. Through slow release of levonorgestrel, LNG-IUS inhibits the growth of endometrium and implantation of fertilized ovum in endometrium and makes uterine smooth muscle rest to achieve effective contraception and dysmenorrheal treatment.
Pelvic inflammatory disease
During PID period, sexual life is suggested to avoid until the infection is healed. Because the occurrence of PID is closely related with sexually transmitted diseases (STDs), the contraceptive method should not only meet the requirements of contraception, but also prevent reproductive system from infection and STD. Thus, combination of condoms with COC or LNG-IUS is recommended for these patients.
- COC: The progestogen in COC is helpful for the formation of cervical mucus plug to reduce the ascending infection rate of bacteria. Persistent COC use can decrease menstrual volume, prevent abnormal uterine bleeding caused by ovulatory dysfunction and abnormal endometrium, and further reduce the incidences of endometritis and salpingitis. Correct COC use can achieve high contraception rate, reduce unwanted pregnancy and induced abortion rate, and is also attributed to reducing PID postabortion. During the COC use, if acute PID occurs, drug administration is suggested to be continued until the end of the antibiotic treatment. It avoids pelvic congestion caused by menstrual onset because of COC withdrawal, which contributes to PID treatment. Thus, for PID patients, the combination of condoms with COC is recommended as one of the optimal contraceptive methods.
- LNG-IUS: IUS is a safe, high-efficiency, long-term, reversible intrauterine contraceptive device. The PID incidence in adults or adolescents with IUS is relatively low (only 0.4%–0.6%).,, The termination rate of LNG-IUS because of PID is significantly lower than that of Cu-IUD. For women with PID symptoms, examination and treatment should be given firstly, and the LNG-IUS should be placed until remission. For LNG-IUS patients with PID, the treatment can be continued without LNG-IUS withdrawal because LNG-IUS will not influence the clinical therapeutic effect. However, LNG-IUS cannot prevent STDs and AIDS, and hence the combination of condoms and LNG-IUS is recommended for people with high risk as the optimal contraceptive method.
| Part II: Clinical Applications of Postabortion Contraceptive Methods|| |
PAC service is a series of standard process, aiming to prevent women undergoing induced abortion from unwanted pregnancy again and avoid repeated abortion. The Chinese Society of Family Planning of the Chinese Medical Association has incorporated the content, form, and service process of PAC into the Clinical Treatment Guidelines and Technical Operation Criteria: A Fascicule of Family Planning (2017). The Department of Maternal and Child Health, National Health Commission of the People's Republic of China, has been in charge of making postabortion family planning service standard, representing that the PAC service will be enrolled into the routine work of family planning technical services. This consensus takes the clinical applications of PAC in the special people as the priority and provides academic support for the PAC service.
Postinduced abortion contraceptive methods
Induced abortion is the termination of pregnancy at <28 months voluntarily required by the service object with unwanted pregnancy. The methods of induced abortion include vacuum suction before 10 weeks of gestation, forceps curettage at 10–14 weeks, induced abortion in the second trimester at 14–27 weeks by intra-amniotic or extra-amniotic injection with ethacridine (biparietal diameter ≤6.5 cm), and medical abortion by mifepristone combined with misoprostol within 16 weeks.
As a remedial measure of contraception failure, induced abortion is widely applied in China, solving the worries of unintended pregnancy to the women, spouse, and family. Generally, the current conventional induced abortion method is safe and effective. However, both surgical and medical abortions could generate potential damage in reproductive system and function due to the destruction of self-protective barrier and injury of endometrium. These harms will aggravate with times of induced abortion, so repeated abortion should be paid special attention to.
The most appropriate time for medical staffs to provide PAC is the time when women receive the process of induced abortion. The awareness of active contraception of women (spouses, partners, and friends) can be improved through collective propaganda and one-on-one counseling. Moreover, high-efficiency contraceptive method can be immediately implemented with help from the medical staffs after induced abortion.
High-efficiency contraception is a contraceptive method with pregnancy rate <1 (Bill index) used for 1 year among 100 women, including IUD, subcutaneous implant, LARC, male/female sterilization, and insisted and correctly used short-term COC.
- IUC: IUC is a most widely applied LARC method in China. It can be provided in any medical institution with induced abortion service. Currently, a multicenter clinical trial in China has proved that instant replacement of IUC postinduced abortion does not increase the risks of bleeding, perforation, and infection. The effective, expulsion, and extraction rates of the women after 1-year follow-up have no significant differences with those whose IUCs were placed during menstrual period. The long-term safety after 1 year needs more clinical evidence. After IUC is taken out, the reproductive function of women is recovered immediately. IUC has no bad influences on the mother and child regardless of its type.
- IUC type and contraceptive effect: Cu-IUD is the main type of IUC in China, as well as IUD containing Cu and drug. Another type is IUS containing progestogens
- Cu-IUD: Cu-IUD plays a contraceptive role by cupric ion killing sperm or fertilized egg, influencing the metabolism of endometrial cells and intervening implantation. The higher the superficial area of Cu contained in IUD is, the better the contraceptive effect will be. The pregnancy rate of Cu-IUD used for 1 year has been proved to be about 1% woman-year, suggesting the achievement of high-efficiency contraceptive effect. Besides, Cu-IUD with or without support from memory alloy as a scaffold can significantly reduce the expulsion rate of IUD
- IUD containing Cu and drug: Addition of indomethacin (prostaglandin synthetase inhibitor) in the IUD containing Cu has been proved to effectively control the menorrhagia caused by IUD placement and relieve pain
- IUS containing progestogens: Compared with other IUDs, the contraceptive effect of LNG-IUS that is commonly used in China is better. Bill index in the first-year use is 0.5% woman-year. LNG-IUS can reduce the occurrence risk of ectopic gestation and effectively reduce menstrual volume. Moreover, it can be used to treat idiopathic menorrhagia and alleviate dysmenorrhea.
- Advantages and cautions of instant IUS placement postinduced abortion
- Advantages: The above types of IUC can be instantly placed after vacuum suction, which achieves high-efficiency long-term contraception and less pain. Meanwhile, it can avoid burden on the body, spirit, time, and economy caused by replacement. The delayed placement rate postinduced abortion has been indicated to be only 28%, much lower than the instant placement rate postinduced abortion (72%). The instant placement of LNG-IUS after vacuum suction thickens cervical mucus and reduces infection in the pelvic cavity
- Cautions of instant IUC placement and selection of IUC type: Women choosing instant IUC placement after vacuum suction should meet the following requirements: no infection signs preoperatively and intraoperatively; no surgical complications; and fully consulting and signing the informed consent. Generally, young women or those with a device history can choose IUD with high Cu surface area or LNG-IUS. For those with IUC expulsion history, uterine cavity depth >10 cm, or flabby cervical orifice, fixed IUD can be selected. Uterotonics, beneficial to uterine contraction, are suggested to be given before placement. Instant placement of the fixed IUD after vacuum suction has been proved to be safe and will not increase the risks of perforation, ectopia, and infection. Women with multiple induced abortion history, menorrhagia, moderate anemia (hemoglobin <90 g/L), dysmenorrhea, and allergy to Cu can choose LNG-IUS. When possible, it is suggested to place IUC under ultrasonic surveillance, or ultrasonography is performed after the placement to ensure the IUC in place
- Postoperative follow-up: Women with instant IUC placement postinduced abortion should be informed and educated by publicity materials. Besides, according to the requirements of induced abortion and IUC, women with significantly more menstrual volume, persistent pain in the lower abdomen, fever, bleeding time over 7 days, and abnormal vaginal secretion should visit hospital in time.
- Concerns of instant IUC placement after vacuum suction: Currently, whether the instant placement will increase incarceration or difficulty in removal still needs evidence. More evidence is relevant to the safety of instant IUC placement after vacuum suction, which can be used as a selection basis for the selection of IUC type. Another concern is the occurrence of incomplete abortion after vacuum suction, leading to irregular bleeding confusion caused by postoperative bleeding and IUC placement. Thus, it is suggested to perform the surgery under the guidance of ultrasound to reduce the occurrence of incomplete abortion and confirm the placement of IUC in place.
- Progestogen contraceptive method: Usage of implant and LNG-IUD is the obtainable progestogen contraceptive method in China. Except for these, progestogen contraceptive injection and oral progestogen contraceptives are widely used out of China. The progestogen contraceptive method is characterized by high safety, especially implant and LNG-IUS with extremely low release rate. Therefore, according to the Medical Eligibility Criteria for Contraceptive Use, the absolute contraindication is only the current breast cancer. Moreover, women in breastfeeding period can also take this method at 6 weeks postpartum. The main deficiency of the method is the high rate of irregular bleeding during use due to the lack of repair effect of estrogen on endometrium, or amenorrhea caused by the inhibitory effect to endometrium.
- Implant: Currently, the implant products in China include 6-rod and 2-rod implants containing levonorgestrel and 1-rod implant containing ETG, with effective contraception periods of 5, 4, and 3 years, respectively. After vacuum suction, medical abortion, and second-trimester induction of labor, the implant can be placed before discharge. The implant has a Bill index of only 0.05% woman-year, which is applicable for women with multiple induced abortion history. For those with uterine distortion, implant is the optimal contraceptive method. After implant withdrawal, the reproductive function is recovered at once. Thus, implant is a good option for the women never giving birth
- Levonorgestrel-releasing IUD (as detailed above)
- Progestogen-only contraceptive injection: The DMPA used in China is intramuscular injection at 150 mg, and the dose of subcutaneous injection is only 104 mg. Once-injection DMPA every 3 months has a good contraceptive effect, which can be injected for women in lactation period. However, it has deficiencies such as increased body weight and high incidence of amenorrhea and the recovery of reproductive function will be delayed for about half a year after withdrawal. Because of relatively long interval and good privacy, DMPA is a preferred contraceptive method in adolescent population out of China
- CHC: CHC includes COC, combined injectable contraceptive (CIC), combined vaginal ring, and combined patch. However, the latter two have not been marketed in China. Except CIC, other CHCs can be used by users themselves, so the failure rate may be relatively high. If they insist and correctly use it, a good contraceptive effect may be achieved. Estrogen in CHC can promote the repair of endometrium, reduce bleeding time and volume postinduced abortion, and control the cycle well. Progestogen contained in CHC can thicken cervical mucus and prevent the occurrence of pelvic infection. The co-effect on the repair of endometrium and reduction of infection risk can prevent intrauterine adhesion. Given the above advantages, women not receiving LARC could consider CHC as the preferred contraceptive method.
- Short-term COC: COC is a postinduced abortion contraceptive method recommended by the WHO because it is not limited by induced abortion method (medical abortion and surgical abortion) or complications of induced abortion (suspicious infection, bleeding, and injury do not influence the use). On the day of confirmation of complete abortion, COC can be administrated. Besides, there is no difference in the contraceptive effect and advantages of instant administration postinduced abortion among different COC products. However, the medical staffs can choose different products based on the health requirements of the abortion women, such as menstruation-related problems, or acne.
- CIC: In China, the provided CIC product for free is compound norethisterone enanthate injection (norethisterone enantate 50 mg, estradiol valerate 5 mg) intramuscularly injected once monthly. Women who cannot take COC daily can choose CIC that does not increase the burden of liver with high safety. After confirmation of complete abortion in clinic, they can get the first injection and should be informed the time of the second one.
- Combined vaginal ring: NuvaRing is widely used worldwide, containing ETG 11.7 mg and ethinyloestradiol 2.7 mg. It is placed within the 5th day of menstruation, continuously used for 3 weeks, and replaced with a new one with interval of 7 days. The vaginal ring avoids the contraception failure caused by missing pills and reduces the incidences of headache, nausea, and breast pain. The hormone is absorbed through vaginal mucosa, which avoids the gastrointestinal absorption and first-pass effect of liver. It not only increases the bioavailability, but also possesses higher safety. On the day of induced abortion or after confirmation of complete medical abortion, the vaginal ring can be used instantly.
- Sterilization: The operation of male or female sterilization is simple with fewer side effects. It is a safe and effective permanent contraceptive method and also a wise choice for the couples that have complete family planning to receive the sterilization postinduced abortion and before discharge. As a permanent contraceptive method, it is very important to make such decision when the couples are fully informed.
Women without sterilization contraindications can receive sterilization postinduced abortion. If the abortion contraindications exist, such as bleeding, cervical or vaginal laceration, fever, or other infectious signs, surgery should be delayed. During the induced abortion, if perforation happens, the sterilization surgery should be determined based on the specific circumstances, experience of physician, and anesthesia condition.
- Condom: Male or female condom possesses dual protective effects from unwanted pregnancy and sexually transmitted infection. The failure rate is relatively high (18–21% woman-year) because the correct use of condom cannot be insisted, leading to inefficient contraception postinduced abortion, which is not the optimal option. For couples (one or both) that have the risk of sexually transmitted infection, the combination of condom with other high-efficiency contraceptive method should be used. Condoms should be provided for free to meet the requirements of different people and their use should be ensured at any time after induced abortion.
- Other contraceptive methods: External contraceptives, safe period, and coitus interruptus are the major methods for women who had undergone abortion before induced abortion. Due to high failure rates (22%–28% woman-years), these methods are no longer advised. If they choose these methods due to some reasons, their use should be specially guided before leaving the medical institutions. Meanwhile, they should be informed with the indications to use and effectiveness of emergency contraception. Once they need the emergency contraception, they should come back to place the Cu-IUD that achieves long-term and high-efficiency contraception.
Selection of contraceptive method postinduced abortion in different population
- Women with twice or more times of induced abortion: The more the times of abortion, the higher the incidence of early and long-term complications. It suggests that special attention should be given to women whose contraception needs are not satisfied. For women without family planning within 2 years, IUC and implant are the preferred contraceptive methods that are implemented postinduced abortion. For those with family planning in the near future, it is suggested to use COC correctly to avoid re-pregnancy within 6 months. Unless the above contraceptive methods are not appropriate for the service objects, the methods depending on users themselves are not recommended, such as condoms or other contraceptive methods. If such method is the only option, the guidance of correct use should be emphasized and practiced when necessary.
- Women with multiple cesarean section history: The cesarean section rate in China is very high. The full implementation of the two-child policy makes multiple cesarean section history a common issue in clinic. Regardless of scarred uterine pregnancy, the prevention of unwanted pregnancy postinduced abortion should be discussed with the service subjects as an important problem. If vacuum suction is performed under ultrasound surveillance, and the surgery is successful, postoperative residual is unlikely to happen. IUC is suggested to place intraoperatively, and IUD with high Cu surface area or LNG-IUS is recommended. Implants have a good contraceptive effect and can be instantly placed after complete abortion, regardless of surgical or medical abortion. Similarly, in principle, the contraceptive methods depending on users themselves are not preferred.
- Women with complications during induced abortion: When the complication is confirmed or suspicious complications (bleeding and injury) occur, IUC should not be placed simultaneously. However, for those without family planning within 2 years, implant may be an optimal option. Generally, COC is not limited by the abortion complications and can be used immediately postinduced abortion. Women without family planning temporarily or giving birth should be informed. After the abortion complications are well treated, LARC method or sterilization should be implemented as soon as possible.
- Women with unwanted pregnancy caused by LARC failure: Although the failure rate of IUC or implant is low (<1% woman-year), the induced abortion caused by the failure is still inevitable. These women should be encouraged to continue to choose this kind of contraceptive method. The failure rate of implant is 0.05% woman-year, significantly lower than IUD (0.8% woman-year) and LNG-IUS (0.2% woman-year). Thus, implants can be used as a preferred alternative contraceptive method for women with IUD failure. If they want to continue to use IUC, LNG-IUS or IUD with higher Cu surface area is suggested.
- Teenage girls aged ≤19 years: The statistical data of the WHO indicate that pregnancy and childbirth complications rank only second to suicide in the cause of death among girls aged 15–19 years. Therefore, teenagers should get good awareness and education on the contraception to prevent unintended pregnancy and avoid induced abortion. Meanwhile, those with unintended pregnancy should do the contraception work to avoid repeated abortion.
Currently, the use of LARC among teenagers is still concerned by the medical staffs in China, but the use of IUC or implant after unwanted pregnancy is acceptable. Therefore, after complete consulting and excluding contraindications, IUC and implant can be taken as the first-line contraceptive methods for the teenagers postinduced abortion. For those who are not appropriate to use LARC temporarily, COC is an alternative, which is more beneficial to the teenagers with abortion complications (bleeding, infection, and injury). Most teenagers do not have regular sex partners. Except for the above contraceptive methods, condoms (for boys or girls) should be provided for free to prevent STD. The physiological and psychological statuses of teenagers are still not stable and perfect, so safe period and coitus interruptus methods should be informed not to use. The failure rate of spermicide is high up to 28% woman-year and has no protection from STD. Thus, it is inappropriate for them to use.
- Women with intellectual disability: Unwanted pregnancy in women with intellectual disability may be caused by unwanted sexual life or even sexual assault. For those without needs or conditions for reproduction, after excluding complications and fully communicating with their guardians, postinduced abortion instant sterilization is optimal. IUC or implant can also be immediately placed. These women cannot take care of themselves during menstrual period, so LNG-IUS and implant could guarantee the effectiveness of contraception, reduce menstrual volume, or even cause amenorrhea. These women cannot use the contraceptive methods depending on users.
- Women with past ectopic pregnancy after induced abortion or ectopic pregnancy surgery: Ectopic pregnancy means the fertilized egg implants outside uterine cavity. Tubal pregnancy is the most common ectopic pregnancy that also includes ovarian pregnancy, abdominal pregnancy, broad ligament pregnancy, and cervical pregnancy. Cesarean scar pregnancy (CSP) and cornual pregnancy after cesarean section are in the uterine cavity. However, due to implantation site and specificity of clinical manifestations, they are often considered as ectopic pregnancy.
The probability of re-ectopic pregnancy after ectopic pregnancy surgery is relatively high. Thus, women without needs for reproduction within short time should implement high-efficiency contraceptive method as well as methods with strong ovulation inhibitory effect. For example, COC or CIC could be the preferred method, but insistence and correct use should be emphasized. Although LNG-IUS does not have a significant ovulation inhibitory effect, the data indicate that the ectopic pregnancy rate is very low, compared with that of IUD. Thus, it can be used as the optimal option for women without recent needs for reproduction postoperatively and can be placed before discharge. All the contraceptive methods have been proved to have protective effects on the occurrence of ectopic pregnancy. Compared with women without contraception, the absolute number of ectopic pregnancy is significantly decreased. However, for the contraceptive methods without ovulation inhibitory effect (IUC, female sterilization, and implants that cannot completely inhibit ovulation), once contraception is failed, the occurrence of ectopic pregnancy must be alerted. Above all, women who have given birth or have no family planning can still choose IUC, implants, and sterilization after ectopic pregnancy surgery. For those choosing IUC, such as cervical pregnancy, cornual pregnancy, and CSP, pregnancy tissue destroys the morphology of uterine cavity, so the placement and timing of IUC are determined according to the surgical condition.
- Women with distortion of uterus postinduced abortion: The American Fertility Society classifies uterine distortion into seven types, and septate uterus and arcuate uterus have the highest incidences. Women with distortion of uterus postinduced abortion have relatively high risk of pregnancy tissue residue due to abnormal uterine cavity. COC and CIC can be taken as the preferred contraceptive methods within 3 months postoperatively. Then, long-term reversible or permanent contraceptive method can be chosen according to uterine distortion and surgery outcomes. Implants and sterilization have nothing to do with the morphology of uterus, which are more appropriate for these women.
- Women with scarred uterus postinduced abortion: Scarred uterus is formed through tissue repair process in women with uterine surgery (such as intermural muscle myomectomy, adenomyoma excision, cesarean section, and malformed uterus orthopedics) or past uterine injury (uterine perforation and hysterorrhexis). These women have various problems, such as high surgical difficulty, high complication occurrence risk, and easy residual pregnancy tissues, during induced abortion. The high-efficiency contraception measure postinduced abortion should also be paid more attention to. For women without needs for preproduction within a short time, if the induced abortion surgery is successful, IUC can be placed instantly postinduced abortion. If the surgery is not successful or uterine cavity is not ideal, implant or sterilization can be selected. Those with current needs for reproduction or having unsuccessful surgery may choose COC or CIC.
- After medical abortion: COC can be administrated at the day of misoprostol use and confirmation of complete abortion. The Clinical Treatment Guidelines and Technical Operation Criteria: A Fascicule of Family Planning (2017) points out that, at the 3rd day of medical abortion, when the observation using misoprostol is finished, IUC can be placed after curettage. Generally, during the curettage due to bleeding or incomplete abortion after more than 1 week of medical abortion, IUC is not appropriately placed given infection risk. Implant is an optional LARC method worth recommending after medical abortion.
- Postinducing abortion in the second trimester: After forceps curettage in the second trimester and intra-amniotic injection of ethacridine, if no complication occurs, IUC can be placed immediately. Because the expulsion rate in this period is higher than that after induced abortion in the menstrual period and early pregnancy, the applicable level recommended by the WHO is 2. In women having completed family planning, implant can be placed postinduced abortion in the second trimester. They can also receive sterilization taking the opportunity of induced labor. Those who do not have LARC or permanent contraceptive methods can use COC or CIC at the night after complete abortion, especially for those with complications (bleeding, infection, and injury).
The guidelines or technical regulations,,, can provide reference for the medical staffs when studying PAC, especially Medical Eligibility Criteria for Contraceptive Use and Safe Abortion: Technical and Policy Guidance for Health Systems. All the guidelines,,, mainly focus on the general service objects with good health condition. This consensus pays special attention to the people with high risk of induced abortion or repeated abortion and reduces the risk of repeated abortion by implementing high-efficiency contraceptive method in these people, which is very important for improving the effectiveness of PAC service.
| Part III: Clinical Application of Postpartum Contraceptive Methods|| |
Postpartum is defined as the first 6 weeks after childbirth (vaginal delivery or cesarean section) in clinic. PPFP guides the family planning within 1 year after childbirth, aiming to prevent pregnancy with short interval and unwanted pregnancy. This part is the expert consensus on clinical application of postpartum contraceptive methods for implementing contraception consulting and high-efficiency long-term contraceptive measures after childbirth as soon as possible.
The incidence of postpartum unwanted pregnancy within 1 year in China is higher than those in the European and American countries. It has been reported that the incidence in Shanghai was 12.8/woman-year in 2012. In the early postpartum period, due to large change of female reproductive endocrine hormone, involution of uterus, wound healing, and lactation, if unwanted pregnancy happens, the complication risk will be significantly increased regardless of induced abortion or natural childbirth. Besides, it will have great influences on mother's and child's health, including mother's mental health. Thus, postpartum, especially 1 year postpartum, timely high-efficiency contraception has an effective protective effect on the reproductive health of women.
Postpartum contraception is an important issue for women, and it is also a challenging issue worldwide. Correct contraception method is critical to ensure the health of women. Simply following the service mode of PPFP is very difficult, even if there is successful experience under other conditions. Effective application of PPFP, especially service timing, depends on the health-care system, service pattern, and personnel structure. This part comes into consensus on the contraception education, consulting guidance, postpartum contraceptive method, and implementing procedures and provides standardized guidance for feasible and effective contraception service.
Necessity and importance of postpartum contraception
- Ovulation recovery: Regardless of childbirth or lactation, 40%–57% of postpartum women could have sexual life at 6 weeks after childbirth. If the women do not lactate, ovulation will come at about 4 weeks postpartum. In most cases, ovulation recovers before the 1st menstruation. Although the frequency of ovulation in the breastfeeding women is lower than that of nonbreastfeeding women, even in the amenorrhea of lactation period, the risk of pregnancy still exists. Because the first menses and ovulation are not synchronous, they cannot be taken as the markers for ovulation recovery, or even the basis for taking contraception measure. Appropriate postpartum contraception is necessary, and at least 70% of the pregnancy is unwanted at the first year postpartum.
- Birth interval: Too short birth interval will increase adverse outcomes of mother and child. Birth interval within 6 months will increase the incidences of low birth weight, premature delivery, spontaneous abortion, and stillbirth by 30%–90%. The risks of death, prenatal bleeding, premature rupture of fetal membrane, and anemia will be also increased. Near-term re-pregnancy after cesarean section aggravates the occurrence of CSP and difficulty of treatment and surgery, severely influencing the physical and psychological health of women.
The WHO indicates that, to reduce the adverse outcomes of mother, fetus, and newborn, at least 2-year birth interval is suggested.
- The risk from nontimely high-efficiency contraception: There are two outcomes of unintended pregnancy: artificial termination of pregnancy and continuous pregnancy to childbirth.
Artificial termination of pregnancy within 1 year postpartum will increase the probability of bleeding, poor uterine contraction, infection, and intrauterine adhesion in uterine cavity. The risk of uterine injury during surgery will be increased or even lead to severe adverse outcomes. Postpartum unintended pregnancy within short time continuing to childbirth will lead to bad pregnancy outcome for mother and child, such as abortion, premature delivery, and intrauterine growth retardation. The incidences of placental complications will be increased, such as adherent placenta, placental implantation, and placenta previa. The probability of full-term pregnancy rupture of uterus will be increased and will threaten mother's and child's health when severe. Thus, to reduce postpartum unintended pregnancy, postpartum contraception should be strengthened to reduce the unintended pregnancy rate and improve female reproductive health.
However, due to the specificity of postpartum lactation period, women often do not have the knowledge of health care and contraception. Some of them believe that postpartum lactation, menopause in lactation period, small menstrual volume, and irregular or infrequent sexual intercourse will not lead to pregnancy. Thus, many women and their partners will not take any contraceptive measures postpartum or ineffective contraceptive method, leading to unintended pregnancy. Cesarean section rate in women of childbearing age in China is very high, and the postpartum unwanted pregnancy rate and induced abortion rate also maintain relatively high levels.
Postpartum contraceptive methods
- LARC: LARC is a high-efficiency contraceptive method that does not depend on the compliance of users, which is appropriate postpartum. The Medical Eligibility Criteria for Contraceptive Use and Programming Strategies for Postpartum Family Planning consider LARC or permanent contraceptive method as the main recommendation of postpartum contraceptive method. The National Institute for Health and Care Excellence and American College of Obstetricians and Gynecologists also recommend LARC as the postpartum contraception method for women.,
- IUC includes Cu-IUD and LNG-IUS
- Currently, Cu-IUD is the main IUD widely applied in clinic in China. Because of the difference in Cu area, its period of use could be more than 10 years. Due to the existence of high-risk factors (such as large uterine cavity, thin uterine wall, and soft uterus), the expulsion rate of instant IUD placement is higher than that of postpartum IUD placement. The postpartum instant IUD placement needs comprehensive assessment on the postpartum women. Meanwhile, because surgical risk and operation difficulty are increased, high skill and rich experience are required on the staffs with strict training to reduce and avoid the occurrence of complications.
- IUD containing LNG-IUS: The materials and shape are more proper for the receptivity of uterus. Progestogen can be released in a constant rate, extending the contraception period to 5 years. Except for further improvement on contraceptive effects, it also possesses significant therapeutic effects on dysmenorrhea and menorrhagia. About 0.1% of levonorgestrel can be secreted by milk, but no adverse influences on the growth and development on the infants 6 weeks postpartum are observed.
Placement timing recommended by the WHO: For women not in the lactation period, IUC can be placed immediately within 48 h or more than 4 weeks postpartum. Women in lactation period: IUD and LNG-IUS are recommended to be placed within 48 h or after 4 weeks postpartum. If women have puerperal infection, the placement is forbidden.
A large sample size, prospective, noninterventional cohort study has indicated that the incidence of uterine perforation in the women with IUC is 0.13%. The placement at lactation period or 36 weeks after childbirth is related with the occurrence, and all these risk factors have no correlations with IUC type. In the new Clinical Treatment Guidelines and Technical Operation Criteria: A Fascicule of Family Planning (2017), the recommended placement timing for IUD and LNG-IUS is 4 weeks postpartum, including cesarean section postoperatively. Based on the guidance, evidence-based medicine data, and practical experience, the placement timing can be determined after balancing the clinical benefits (high-efficiency contraception avoiding unintended pregnancy) and risks (perforation of uterus and expulsion).
2. Subcutaneous implant: Subcutaneous implant is a progestogen-only contraceptive. Progestogen, silicone rubber, and materials with slow release function are prepared into rods or capsules and implanted subcutaneously into the upper arm to constantly release hormone to achieve contraception. The contraceptive time limit depends on the dosage form. Currently, there are 2- or 6-rod implants containing levonorgestrel made in China and imported single-rod implant containing ETG. The contraception period of the former is 4 or 5 years and that of the latter is 3 years. Compared with multiple doses, the placement and withdrawal of single-rod implant are more easier to operate and master.
3. Progesterone-only contraceptive injection: DMPA is the recommended product nowadays. The injection can effectively inhibit ovulation and continuously take effect for 3 months with high contraception rate, without influences on the quality of milk, newborns, and infants.
Recommended timing by the WHO: Non-breastfeeding women can use it immediately and breastfeeding women can use it at 42 days postpartum. The application is very limited in China.
Recommended timing by the WHO: Non-breastfeeding women can use the implants immediately and breastfeeding women can use implants at 42 days postpartum. Current clinical research indicates that the implant has no influence on the amount of milk and contents of protein, lactose, and fat. Implantation at 6 weeks postpartum has no influence on the height, body weight, head circumference, and development of infants.
Other contraceptive methods
- Short-term contraception: The actual contraceptive effectiveness is influenced by the compliance of users. Therefore, it is not the preferred method for postpartum contraception
- CHC: Includes short-term COC and contraceptive vaginal ring
- COC: The estrogen can decrease milk secretion and influence the components. Besides, women at 3 weeks postpartum are still in the high-incidence period of VTE. The use of COC can increase the risk of thrombus
Recommended timing by the WHO: Nonbreastfeeding women can use it at 21 days postpartum and breastfeeding women can use it at 6 months postpartum
- Vaginal contraceptive ring: Vaginal contraceptive ring is a steroid hormone-controlled release contraception tool in vagina, containing progesterone or estrogen and progesterone, placed in posterior vaginal vault, and taking effect after be absorbed by vaginal mucosa. The ring is placed into the body for 3 weeks monthly and taken out for 1 week. It can avoid the direct stimulation of oral contraceptive on gastrointestinal tract and reduce the influence on liver
Use timing recommended by the WHO: Same as COC.
- Barrier contraception method: The method includes condoms, contraceptive diaphragm, and cervical cap, which can be used immediately postpartum. However, due to the compliance, especially the influence of insistence and correct use, it is a low efficiency contraceptive method, not recommended as the preferred one.
- Permanent contraceptive method: Oviduct sterilization surgery has been widely applied in clinic with high contraceptive effectiveness. However, it is irreversible, so it is appropriate for women who do not have needs for pregnancy permanently or have extremely high risk at the time of re-pregnancy.
Use timing recommended by the WHO: Sterilization surgery can be implemented instantly to 7 days postpartum or 42 days postpartum. When accompanied with puerperal infection, puerperium bleeding, or other severe complications, the implementation should be delayed. When soft birth canal injury needs laparotomy, oviduct sterilization surgery can be conducted simultaneously. Male vasectomy can be performed at any time postpartum.
- Other: Lactational amenorrhea method (LAM) is a postpartum contraceptive method based on physiological amenorrhea in postpartum lactation period. However, the following three conditions should be met, and contraception can be achieved reaching a certain lactation frequency and duration: (1) within 6 months postpartum; (2) exclusive breastfeeding as required without complementary food; and (3) unrecovered menstruation in amenorrhea status.
The survey of the WHO indicates that, if women using LAM postpartum do not meet the above criteria, the effective rate of LAM contraception will be decreased. Thus, to avoid unintended pregnancy, this is not recommended as a conventional contraceptive measure for postpartum women, but other effective contraceptive one is suggested for them in time.
Process guidance of postpartum contraception consulting and implementation
Currently, postpartum contraception education has been listed as a standard part of postpartum care. The main reason for the high postpartum unwanted pregnancy rate is that timely postpartum contraception knowledge and guidance are not given at prenatal registration, prenatal examination, and postpartum examination. The best timings for postpartum contraception service are prenatal periodic examination (last trimester), intrapartum hospitalization, and 42 days postpartum, when women return to hospital for postpartum visit and examination. The postpartum contraception service should include detailed postpartum contraception popularization education, consulting and guidance, informed choice, and contraceptive measures. The execution of postpartum contraception in China, especially LARC, has not met the requirements.
- Importance of informing septum contraception:First, too short birth interval will increase the adverse outcomes of mother and child, such as uterine injury, perforation, bleeding, disruption, and infection
Second, unintended pregnancy caused by not taking contraceptive measure postpartum increases the probabilities of medical abortion, induced abortion, or induced labor; significantly increases the risks of complications (bleeding infection, intrauterine adhesion, and organ injury), or leads to secondary infertility, and bad pregnant outcomes at the time of re-pregnancy; and increases the risks of long-term complications (placenta adherence, placenta previa, and placenta implantation).
After cesarean section, especially for women with termination of pregnancy undergoing cesarean section due to severe complications, if any contraceptive measure is not taken, the possibility of ectopic gestation (including CSP) and uterine rupture that may happen in the next pregnancy will be increased, or even the lives of the pregnant women will be threatened.
Above all, strengthening the education and knowledge training of medical staffs, pregnant women, and their spouses; improving the knowledge of postpartum contraception in medical staffs and pregnant women; strengthening the awareness of the servers to provide education and consulting; and promoting informed choice and implementing compliance of service object are critical steps to standardize postpartum contraception.
- Clarification of misunderstanding in contraception: In China, most postpartum women choose contraceptive methods with inefficiency and poor contraceptive effectiveness, including contraception in safe period, coitus interruptus, LAM, and condoms. The possible reason is that many women believe that these methods do not influence postpartum recovery and lactation. In fact, progestogen-only contraception does not influence the breastfeeding and development of infants, or the contents of protein, lactose, and fat in milk. The infants drinking milk with extremely low concentration of progestogen at 6 weeks postpartum are not influenced by the height, body weight, head circumference, and development.
The hormonal contraception has extra health benefits except for high-efficiency contraception, so it can be used as the preferred option for postpartum contraception.
- Individual recommended contraceptive methods: In different postpartum periods, women have significant change in different physiological statuses and they have lactation requirement. Therefore, the selection for contraceptive method is also different. The pregnant women and their spouses should know the contraception information including the type, characteristics, effectiveness, usage, period of validity, common adverse reactions, possible risks, reproductive recovery after discontinuity, health benefit except contraception, and how to initiate or terminate contraceptive method. All the information is recommended based on the requirements of the women.
People with high unintended pregnancy risk postpartum are screened. For these people, the risk of re-pregnancy postpartum is increased, and re-pregnancy will bring extremely severe consequences, so high-efficiency contraceptive method must be implemented. LARC is the first option. For postpartum women after cesarean section accompanied with puerperal infection, or other uterine cavity complications, implant is the preferred contraceptive method.
Contraceptive method is recommended according to cesarean section, breastfeeding way, and postpartum time. For women with willing to get re-pregnancy, at least 24-month interval between two times of pregnancy is recommended. Long-term or short-term high-efficiency contraceptive method is suggested. For women having the 2nd child, long-term contraceptive measure is recommended. For those with more than twice of cesarean section or combination with severe complications, permanent contraceptive method is recommended, such as male and female sterilization.
The options for postpartum contraceptive method recommended by PPFP strategy are illustrated in [Figure 1].
|Figure 1: Postpartum contraceptive options (timing of method initiation and breastfeeding considerations). IUC: Intrauterine device; LAM: Lactational amenorrhea method.|
Click here to view
- Treatment of adverse reactions: After implementing the contraceptive method, if adverse reactions happen, except for considering the side effects of contraceptives and tools, the combination of other diseases should be also considered. If associated with other diseases, corresponding treatment can be given according to the degree of adverse reactions and conditions when consulting a doctor. For nonbreastfeeding women, the treatment principle and method are same as those in the lactation period. For breastfeeding women, lactation should be considered at the time of treatment. Except for general treatment principle, the distribution of drug in the milk should be noticed. If the drug in the milk accounts for <1%–2% of the drug amount, it can be considered as harmlessness to the infants. The instruction should be read carefully when medicating.
Consulting process of postpartum contraception
The implementation of postpartum contraception begins from the prenatal education in the last trimester through the whole process of childbirth and postpartum. The education before discharge (including spouse education) should be strengthened, as well as each time of reexamination during 42 days postpartum. Pregnant women and their spouses should effectively communicate with medical staffs to understand the necessity of postpartum contraception and contraceptive methods to make informed choice. This process needs collaboration between different departments, such as departments of obstetrics and family planning.
[Figure 2] illustrates the suggestion of consulting process of postpartum contraception in each department and their corresponding work, providing reference for implementing efficient postpartum contraception in clinic.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann 2014;45:301-14. doi: 10.1111/j.1728-4465.2014.00393.x.
Wu SC, Qiu HY. Induced abortion in China: Problems and interventions. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2010;32:479-82. doi: 10.3881/j.issn.1000-503X.2010.05.001.
National Health and Family Planning Commission. China Health and Family Planning Statistical Yearbook. Beijing, China: China Union Medical University Press; 2015.
Wu SC, Wen Z, Gu XY. Adverse influences of induced abortion on reproductive health. Chin J Fam Plan 2016;24:7-10.
Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al.
Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997;350:1795-8. doi: 10.1016/S0140-6736(97)08140-3.
Chinese Society of Family Planning, Chinese Medical Association. Guidelines on family planning services after induced abortion. Chin J Obstet Gynecol 2011;46:319-20. doi: 10.3760/cma.j.issn.0529-567x.2011.04.024.
Marshall AL. Diagnosis, treatment, and prevention of venous thromboembolism in pregnancy. Postgrad Med 2014;126:25-34. doi: 10.3810/pgm.2014.11.2830.
Linnemann B, Bauersachs R, Rott H, Halimeh S, Zotz R, Gerhardt A, et al.
Diagnosis of pregnancy-associated venous thromboembolism – Position paper of the working group in women's health of the society of thrombosis and haemostasis (GTH). Vasa 2016;45:87-101. doi: 10.1024/0301-1526/a000503.
Lopez LM, Grey TW, Stuebe AM, Chen M, Truitt ST, Gallo MF, et al.
Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev 2015;20:CD003988. doi: 10.1002/14651858.CD003988.pub2.
Sabbioni L, Petraglia F, Luisi S. Non-contraceptive benefits of intrauterine levonorgestrel administration: Why not? Gynecol Endocrinol 2017;33:822-9. doi: 10.1080/09513590.2017.1334198.
Bahamondes L, Valeria Bahamondes M, Shulman LP. Non-contraceptive benefits of hormonal and intrauterine reversible contraceptive methods. Hum Reprod Update 2015;21:640-51. doi: 10.1093/humupd/dmv023.
Zhou YF. Emphasis on uterineminimally invasive surgery skills and protection of uterine rupture in gestation period. Chin J Obstet Gynecol 2016;51:832-4. doi: 10.3760/cma.j.issn.0529-567x.2016.11.006.
Chinese Expert Consensus Group on the Clinical Application of Combined Oral Contraceptives. Chinese expert consensus on the clinical application of combined oral contraceptives. Chin J Obstet Gynecol 2015;50:81-91. doi: 10.3760/cma.j.issn.0529-567x.2015.02.001.
Vilos GA, Allaire C, Laberge PY, Leyland N; SPECIAL CONTRIBUTORS. The management of uterine leiomyomas. J Obstet Gynaecol Can 2015;37:157-78. doi: 10.1016/S1701-2163(15)30338-8.
Xu Q, Qiu L, Zhu L, Luo L, Xu C. Levonorgestrel inhibits proliferation and induces apoptosis in uterine leiomyoma cells. Contraception 2010;82:301-8. doi: 10.1016/j.contraception.2010.03.002.
Magalhães J, Aldrighi JM, de Lima GR. Uterine volume and menstrual patterns in users of the levonorgestrel-releasing intrauterine system with idiopathic menorrhagia or menorrhagia due to leiomyomas. Contraception 2007;75:193-8. doi: 10.1016/j.contraception.2006.11.004.
Sivin I, Stern J. Health during prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: A multicenter study. International Committee for Contraception Research (ICCR). Fertil Steril 1994;61:70-7.
Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med 2015;372:1646-55. doi: 10.1056/NEJMcp1411029.
Li JW, Yang X. Clinical analysis of hysteroscopy combined with levonorgestrel intrauterine sustained-release system for the treatment of uterine fibroids with menorrhagia. Chin J Clin 2013;7:10354-6. doi: 10.3877/cma.j.issn.1674-0785.2013.22.126.
Hauksson A, Ekström P, Juchnicka E, Laudański T, Akerlund M. The influence of a combined oral contraceptive on uterine activity and reactivity to agonists in primary dysmenorrhea. Acta Obstet Gynecol Scand 1989;68:31-4. doi: 10.3109/00016348909087685.
Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, et al.
ESHRE guideline: Management of women with endometriosis. Hum Reprod 2014;29:400-12. doi: 10.1093/humrep/det457.
Vercellini P, Frontino G, De Giorgi O, Pietropaolo G, Pasin R, Crosignani PG, et al
. Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril 2003;80:560-3.
Haberal A, Kayikcioglu F, Gunes M, Kaplan M, Ozdegirmenci O. The effect of the levonorgestrel intrauterine system on uterine artery blood flow 1 year after insertion. Ultrasound Obstet Gynecol 2006;27:316-9. doi: 10.1002/uog.2664.
Cho S, Jung JA, Lee Y, Kim HY, Seo SK, Choi YS, et al
. Postoperative levonorgestrel-releasing intrauterine system versus oral contraceptives after gonadotropin-releasing hormone agonist treatment for preventing endometrioma recurrence. Acta Obstet Gynecol Scand 2014;93:38-44.
Crosignani PG, Luciano A, Ray A, Bergqvist A. Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain. Hum Reprod 2006;21:248-56. doi: 10.1093/humrep/dei290.
Walch K, Unfried G, Huber J, Kurz C, van Trotsenburg M, Pernicka E, et al.
Implanon versus medroxyprogesterone acetate: Effects on pain scores in patients with symptomatic endometriosis – A pilot study. Contraception 2009;79:29-34. doi: 10.1016/j.contraception.2008.07.017.
Kim MK, Seong SJ, Kim JW, Jeon S, Choi HS, Lee IH, et al.
Management of endometrial hyperplasia with a levonorgestrel-releasing intrauterine system: A Korean gynecologic-oncology group study. Int J Gynecol Cancer 2016;26:711-5. doi: 10.1097/IGC.0000000000000669.
Peng X, Li T, Xia E, Xia C, Liu Y, Yu D, et al.
A comparison of oestrogen receptor and progesterone receptor expression in endometrial polyps and endometrium of premenopausal women. J Obstet Gynaecol 2009;29:340-6.
American Association of Gynecologic Laparoscopists. AAGL practice report: Practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol 2012;19:3-10. doi: 10.1016/j.jmig.2011.09.003.
Wang W, Wang XY. Efficacy of oral contraceptive or levonorgestrel-releasing intrauterine system after hysteroscopic endometrial polypectomy in preventing recurrence. Chin J Minim Invasive Surg 2013;13:249-51, 261. doi: 10.3969/j.issn.1009-6604.2013.03.018.
Wada-Hiraike O, Osuga Y, Hiroi H, Fujimoto A, Maruyama M, Yano T, et al.
Sessile polyps and pedunculated polyps respond differently to oral contraceptives. Gynecol Endocrinol 2011;27:351-5. doi: 10.3109/09513590.2010.492884.
Gu F. Effectiveness of hysteroscope combined with Diane-35 on endometrial polyps. Jiangsu Med J 2015;41:2771-2.
Wei H, Zou W, Liu DD. Effective observation on different kinds of drug for preventing recurrence after hysteroscopic resection of endometrial polyp. Mod Med Health 2013;29:672-4. doi: 10.3969/j.issn.1009-5519.2013.05.014.
Roman H, Loisel C, Puscasiu L, Sentilhes L, Marpeau L. Management of menometrorrhagia in women with and without pregnancy intention: Hierarchy of therapies. J Gynecol Obstet Biol Reprod (Paris) 2008;37 Suppl 8:S405-17. doi: 10.1016/S0368-2315(08)74781-1.
Cai HL, Ding XC, Qian RR, Yu RF, Sun LM, Li Q. Effect of the levonorgestrel intrauterine slow-releasing system on cytokines of uterine fluid after endometrial polyps resection by hysteroscopy. Chin J Hosp Pharm 2012;92:200-2. doi: 10.3760/cma.j.issn.0376-2491.2012.03.014.
Wong AW, Chan SS, Yeo W, Yu MY, Tam WH. Prophylactic use of levonorgestrel-releasing intrauterine system in women with breast cancer treated with tamoxifen: A randomized controlled trial. Obstet Gynecol 2013;121:943-50. doi: 10.1097/AOG.0b013e31828bf80c.
Chinese Society of Obstetrics and Gynecology, Chinese Medical Association. Guidelines for the diagnosis and treatment of abnormal uterine bleeding. Chin J Obstet Gynecol 2014;49:801-6. doi: 10.3760/cma.j.issn.0529-567x.2014.11.001.
Chinese Society of Obstetrics and Gynecology, Chinese Medical Association. Guidelines for clinical diagnosis and treatment of dysfunctional uterine bleeding. Chin J Obstet Gynecol 2009;44:234-6. doi: 10.3760/cma.j.issn.0529-567x.2009.03.020.
Committee on Practice Bulletins-Gynecology. Practice bulletin no 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013;122:176-85. doi: 10.1097/01.AOG.0000431815.52679.bb.
Wildemeersch D. Why perimenopausal women should consider to use a levonorgestrel intrauterine system. Gynecol Endocrinol 2016;32:659-61. doi: 10.3109/09513590.2016.1153056.
Burnett M, Lemyre M. No 345-primary dysmenorrhea consensus guideline. J Obstet Gynaecol Can 2017;39:585-95. doi: 10.1016/j.jogc.2016.12.023.
Ekström P, Akerlund M, Forsling M, Kindahl H, Laudanski T, Mrugacz G, et al
. Stimulation of vasopressin release in women with primary dysmenorrhoea and after oral contraceptive treatment – Effect on uterine contractility. Br J Obstet Gynaecol 1992;99:680-4.
Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol 2004;190:S5-22. doi: 10.1016/j.ajog.2004.01.061.
Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF. Positive testing for neisseria gonorrhoeae and chlamydia trachomatis and the risk of pelvic inflammatory disease in IUD users. J Womens Health (Larchmt) 2015;24:354-9. doi: 10.1089/jwh.2015.5190.
Turok DK, Eisenberg DL, Teal SB, Keder LM, Creinin MD. A prospective assessment of pelvic infection risk following same-day sexually transmitted infection testing and levonorgestrel intrauterine system placement. Am J Obstet Gynecol 2016;215:599.e1-599.e6. doi: 10.1016/j.ajog.2016.05.017.
Gemzell-Danielsson K, Apter D, Dermout S, Faustmann T, Rosen K, Schmelter T, et al.
Evaluation of a new, low-dose levonorgestrel intrauterine contraceptive system over 5 years of use. Eur J Obstet Gynecol Reprod Biol 2017;210:22-8. doi: 10.1016/j.ejogrb.2016.11.022.
Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: A randomized comparative trial. Contraception 1994;49:56-72.
National Commission of Family Planning and Department of Science and Technology Education. WHO family Planning Service Provider Handbook. Beijing, China: China Population Publishing House; 2009.
Chinese Society of Family Planning, Chinese Medical Association. Clinical Guidelines and Technical Specifications for Family Planning. Beijing, China: People's Medical Publishing House; 2017
Gaffield ME, Egan S, Temmerman M. It's about time: WHO and partners release programming strategies for postpartum family planning. Glob Health Sci Pract 2014;2:4-9. doi: 10.9745/GHSP-D-13-00156.
King JC. The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies. J Nutr 2003;133:1732S-6S. doi: 10.1093/jn/133.5.1732S.
American College of Obstetricians and Gynecologists. ACOG practice bulletin no 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011;118:184-96. doi: 10.1097/AOG.0b013e 318227f05e.
Barber JS, Axinn WG, Thornton A. Unwanted childbearing, health, and mother-child relationships. J Health Soc Behav 1999;40:231-57.
Committee opinion no 670 summary: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016;128:422-3. doi: 10.1097/AOG.0000000000001583.
Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European active surveillance study on intrauterine devices. Contraception 2015;91:274-9. doi: 10.1016/j.contraception.2015.01.007.
Hannon PR, Duggan AK, Serwint JR, Vogelhut JW, Witter F, DeAngelis C, et al.
The influence of medroxyprogesterone on the duration of breast-feeding in mothers in an urban community. Arch Pediatr Adolesc Med 1997;151:490-6.
Kennedy KI, Visness CM. Contraceptive efficacy of lactational amenorrhoea. Lancet 1992;339:227-30.
Speroff L, Mishell DR Jr. The postpartum visit: It's time for a change in order to optimally initiate contraception. Contraception 2008;78:90-8. doi: 10.1016/j.contraception.2008.04.005.
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