Reproductive health

2024/07/29
BY L.K.MOTSWASELE-SIKWANE
LEARNING OUTCOMES
• Client assessment and screening
• Follow-up visits
• Initiating contraceptive methods in non-menstrating women
• Management of side effects
• Emergency contraception
• Combination prevention
• Counselling in the context of contraceptive service provision
• processes for method provision
Introduction

• Reproductive health is defined as a state of physical, mental, and

social well-being in all matters relating to the reproductive
system, at all stages of life.
• Good reproductive health implies that people can have a
satisfying and safe sex life, the capability to reproduce, and the
freedom to decide if, when, and how often to do so.
• Men and women should be informed about and have access to
safe, effective, affordable, and acceptable methods of family
planning of their choice.
• Women should have the right to appropriate healthcare services
that enable women to safely go through pregnancy and childbirth.
Client assessment and screening

History taking
• It is important to take a comprehensive personal medical history particularly before clients select
hormonal contraception, Cu IUD (copper intrauterine device), or sterilisation

HIV testing
• HIV counselling and testing, and discussions relating to risk and prevention, should be provided as a
routine part of the consultation. The frequency of an HIV test should be guided by possible
exposure to HIV, for both the client and their sexual partners. Clients who test HIV-positive should
be initiated onto antiretroviral treatment, as per national Test and Treat guidelines.
Sexually transmitted infection (STI) screening and management
• Should be done as an integrated part of contraception service provision, as per national DOH
guidelines.
Client assessment and screening CONT
Tuberculosis (TB)
• Due to the high incidence of HIV and TB co-infection, the consultation is an opportunity to screen,
provide information, treat, or refer, as per national DOH TB guidelines.
Blood pressure
• The measurement of blood pressure is essential for sterilisation. It is recommended that blood
pressure is measured before and during the use of hormonal contraception. However, where this is
not possible, hormonal methods should not be denied, providing there is no history of high blood
pressure. Where feasible, provision must be made to check blood pressure on a subsequent visit.
Pelvic examination
• This is only essential before fitting an intrauterine contraceptive device/system or before female
sterilisation, unless the need for a pelvic examination is indicated in the history taking. This needs to
be performed with sensitivity and with a focus on privacy and dignity.
Client assessment and screening CONT
Breast and cervical screening
• Where possible, the consultation should serve as an opportunity to educate clients about breast
self-examination and the purpose and value of cervical screening. Information should be provided
concerning the frequency of cervical screening, as per national guidelines. The actual screening,
where appropriate, can be done on the initiation of a contraceptive method or at a mutually agreed
appointment.
For HIV-positive women
• Provide a cervical screening on HIV diagnosis, and then every three years. If there is an abnormal
smear, manage according to national guidelines with annual checks recommended until resolved and
thereafter every three years.
For HIV-negative women
• Free cervical screenings from the age of thirty at ten-year intervals are recommended.
Screening for pregnancy
• Ensuring a client is not pregnant is important when screening for contraception. It is especially
recommended before starting hormonal contraceptives and before IUD insertion.
Follow-up visits

• Follow-up visits should be scheduled according to sound medical reasoning.

• Unnecessary, frequent follow-up visits should be discouraged.
• Recommendations for the timing of follow-up visits for each method are given in the method-
specific sections of the Handbook for Contraceptive Method Provision (2019), which are based on
WHO Selected Practice Recommendations for Contraceptive Use 2016.
• Clients are encouraged to return for any queries or are anxious or need support with the method,
particularly with regards to the management of side effects.
Types of Birth Control/Family planning
methods
Types of birth control
Hormonal Methods
• Oral Contraceptives
(Birth Control Pill)
• Injections (Depo-Provera)
• Implants (Norplant I & II)
Contraceptive pill
• Developed by American biologist Dr Gregory
Pincus, the pill works by suppressing
ovulation.
• It was tested in the 1950s on Puerto Rican and
Haitian women and launched in the USA in
1960.
• In the USA, around 1.2 million women used
the pill within two years of its launch. Now the
number of users is around 11 million.
• Worldwide, around 100 million women take the
pill.
 Birth Control Pills
Pills can be taken to prevent pregnancy
Pills are safe and effective when taken properly
Pills are over 99% effective
 Advantages od oral contraceptives
• Oral contraceptives not only prevent pregnancy, but they also reduce
the risk of endometrial and ovarian cancer
• It protects against acute pelvic inflammatory disease and ectopic
pregnancies.
• The birth control pill is a safe, simple, and convenient way to prevent
pregnancy.
• It reduces acne, making your periods lighter and more regular, and
easing menstrual cramps.
• Reduce your chance of getting cancer of the uterus (womb), ovaries,
and bowel.
• Help with symptoms of polycystic ovary syndrome (PCOS) and
endometriosis.
Disadvantages of oral contraceptives
The most common adverse effect of combined OCPs is breakthrough
bleeding.
Women will also complain of nausea, headaches, abdominal cramping,
breast tenderness, and increased vaginal discharge or decreased
libido.
Therefore, Nausea can be avoided by taking the medication at night
before sleep.
However, oral contraceptives increase the risk of cardiovascular
disease.
The recommended protocol for a missed pill
• If a client is more than 3 hours late in taking a pill, she should take it as soon as possible, then keep taking
one pill each day
• as usual use condoms or avoid sex for the next 48 hours.
• The instructions apply if more than one pill is missed. Women who have monthly bleeding regardless of
their
• Breastfeeding status should consider using emergency contraception if they have seen in the past days.
INJECTABLES
• Progestogen-only injectables are a highly effective method of reversible contraception suitable for most
women.
• They contain synthetic progestogens administered by deep intramuscular injection.
• There are two available and widely used progestogen-only injectables in South Africa: depot
• medroxyprogesterone acetate (DMPA}, and norethisterone enanthate (NET-EN}.
INJECTABLES
• The injection contains a hormone called depot medroxyprogesterone
acetate (DMPA), which is like the hormone progesterone.
• The DMPA is slowly released into your bloodstream over 3 months.
• The contraceptive injection contains the hormone progestin. Depo-
Provera is a well-known brand name for medroxyprogesterone
acetate, a contraceptive injection that contains the hormone
progestin.
• Depo-Provera is given as an injection every three months
 DEPO
PROVERA
How the injection works
• The injection prevents pregnancy by releasing progestogen which:
• prevents you from releasing an egg (ovulating)
• makes it difficult for sperm to get to an egg
• thins the womb lining, so there’s less chance an egg will attach to it
DEPO PROVERA ADVANTAGES
• Depo-Provera® is 96% effective in preventing pregnancy,
• Most users have no vaginal bleeding at all or very light bleeding.
• Periods may be less painful.
• it lasts for 12 to 14 weeks.
• it can be used while breastfeeding.
The side effects of contraceptive injections?

• Injection include:
changes to your periods, such as periods stopping, being irregular, or
lasting longer – the longer you use it the more likely it is that your
periods will stop completely.
Weight gain?
Pain, a small lump, or a scar where the injection is done
Noristerat/Nuristerate(Norethisterone
enantate)
• This lasts for 8 weeks, administered in your bum. Sometimes you may
have it in your upper arm.
• It’s usually used for short periods – for example, if your partner is
waiting for a vasectomy.
• A doctor or nurse does this type of injection.
When it starts to work
• Can have the injection at any time during your menstrual cycle, as
long as you’re not pregnant.
• If you have it during the first 5 days of your cycle, you’ll be
immediately protected against pregnancy.
• If you have it on any other day of your cycle, you should use
additional contraception such as condoms for 7 days.
Side effects of injectables
• Weight gain
• Description
• Weight gain is an increase in body weight. This can involve an
increase in muscle mass, fat deposits, excess fluids such as
water or other factors. Weight gain can be a symptom of a
serious medical condition
• Weight gain is a side effect of Depo-Provera. Also, women with
obesity are at higher risk of side effects of birth control,
Side effects of injectables
• Headaches
• Description
• Headache, also known as cephalalgia, is the symptom of pain
in the face, head, or neck. It can occur as a migraine, tension-
type headache, or cluster headache. There is an increased risk
of depression in those with severe headaches. Headaches can
occur as a result of many conditions
Su-ide effects of injectables
• Breast pain
• Description
• Breast pain is the symptom of discomfort in either one or both
breasts. Pain in both breasts is often described as breast
tenderness, is usually associated with the menstrual period and
is not serious.
• Spotting between periods
• Bleeding more days than usual. Spotting (light bleeding or
brown discharge between periods). Not getting your period at
all.
Side effects of injectables
• Periods may become irregular, heavier, lighter, longer, or
shorter. It may make acne worse.
Irregular bleeding
Irregular menstruation is a menstrual disorder whose
manifestations include irregular cycle lengths as well as
metrorrhagia.
The possible causes of irregular menstruation may vary.
The common factors are related to lifestyle, such as stress, body
weight, and smoking status
Types of implants:

• Jadelle: 2 rods containing levonorgestrel (LNG), highly effective for 5

years.
• Implanon NXT (also known as Nexplanon; replaces Implanon): 1 rod
containing etonogestrel (ETG), labeled for up to 3 years of use (a
recent study shows it may be highly effective for 5 years).
 IMPLANT
The advantages of contraceptive implants
• High effectiveness of up to 99
percent within seven days of
implant insertion
• Very inexpensive method of
long-term contraception,
comparable to intrauterine
devices
• Safe in the majority of women
• Efficacy for three years without
further intervention
The advantages of contraceptive implants
CONT
• Easily removed to allow pregnancy to occur naturally
• Independent of user memory or schedule and sexual intercourse, as it
provides continuous contraception
• Relieves menorrhagia and dysmenorrhea in many cases
• Amenorrhea in one of every five women on the implant, which is
often perceived to be a
• Safe for use during lactation
The advantages of contraceptive implants
CONT
• Reduces the risk of pelvic inflammatory disease due to the thick
cervical mucus, which prevents microbes from ascending from the
vagina into the uterus
• Suitable in conditions that prevent the use of combined hormonal
contraception
• Quick return of fertility within 21 days of implant removal
• Some women experience improvement in acne following the use of
implant
• Offers some protection against endometrial cancers
The disadvantages of contraceptive implants
• It offers no protection against sexually transmitted infections (STIs)
• Interaction with anticonvulsants, certain antibiotics, or St. John's wort
may occur
• Immediate protection may not be available in all situations, and
another mode of effective contraception must then be used for at
least seven days following insertion
Minor side effects

1. Disruption of normal menstruation

alterations in the regular menstrual pattern.
women who receive the implant should be warned about what to
expect and advised to come in for evaluation if abnormal bleeding
patterns develop to rule out ectopic gestation, pregnancy, or disease
conditions including:
• Amenorrhea
• Light or irregular bleeding
• Frequent bleeding episodes (more than five in 90 days)
• Continuous bleeding for weeks (more than 14 days)
• Occasionally menorrhagia
conditions including:
• Acne in over 13 percent
• Breast pain as well as enlargement of the breast, nipple discharge,
and pruritus vulvae
• Abdominal pain
• Pharyngitis
• Leukorrhea (mechanism for the vagina to clear the body of any
infections and continues to create a protective barrier of the mucosa
of the vaginal wall.” Leukorrhea should not smell)
Major complications of contraceptive
implants
• Migration
Migration may occur in the blood vessels of the arm, and some reports
indicate migration into the pulmonary artery
• Hypertension
Hormonal contraception is contraindicated in women who have a
history of hypertension, with complications,
Progestin-only implants may be used if the hypertension is well-
controlled and under close monitoring, IT must be removed if BP is
uncontrollable
Major complications of contraceptive
implants cont
Non-palpable implants
• Early removal should be scheduled once the location is known -
exploration without knowing where the implant can be dangerous
and should never be attempted.
• Failure to remove a misplaced implant results in prolonged
subfertility, ectopic gestation, or adverse events related to progestin
administration.
• Anaphylactic reactions
• Known to occur, including angioedema of the skin and subcutaneous
tissue.
 Major complications of contraceptive
implants cont
Ectopic pregnancies
• Often occurs if women conceive while the implant is in situ (which is
extremely rare).
• Vascular events
including pulmonary, deep leg vein, myocardial, and cerebrovascular
arterial or venous thrombotic events.
• Ovarian cysts
The prolonged release of low-dose progestin normally suppresses
follicular development in the ovaries, if a follicle escapes this inhibition,
it may grow to be a normal mature follicle and form a follicular cyst.
OVARIAN CYST
Major complications of contraceptive
implants cont
Reproductive organ cancers
• Hormonal contraception is contraindicated in women with a history
of breast cancer because of the known sensitivity of these tumors to
sex hormones.
• Progestin-only implants are unlikely to produce the same kind of
cancerous change, women family history of breast growth or cancers
should be closely followed up.
• READ FURTHER ON REFERENCES REGARDING MORE COMPLICATIONS
Disadvantages of implant
• Periods may become irregular, heavier, lighter, longer, or shorter.
• It may make acne worse.
• It doesn't offer any protection against sexually transmitted infections
(STIs).
Emergency contraception
• Emergency contraception (EC) can prevent up to over 95% of
pregnancies when taken within 5 days after intercourse. EC can be
used in the following situations: unprotected intercourse, concerns
about possible contraceptive failure, incorrect use of contraceptives,
and sexual assault if without contraception coverage.
Emergency contraception
• What are the main benefits of the morning after pill?
• The morning-after pill is a type of emergency birth control, also called
emergency contraception.
• It can help prevent pregnancy after sex if your regular birth control
method didn't work or wasn't used.
• The morning-after pill isn't meant to be a couple's main method of
birth control. It's a backup option
Emergency contraception disadvantages
• What are the disadvantages of the morning after pill?
• Some symptoms of taking a morning-after pill (Plan B One-Step® or
Ella®) can include: Changes to your normal menstrual cycles (your
period might be earlier or later than normal). Spotting (light
bleeding). Nausea and vomiting.
• The morning-after pill is a type of emergency birth control, also
called emergency contraception. It can help prevent pregnancy after
sex if your regular birth control method didn't work or wasn't used.
• The morning-after pill isn't meant to be a couple's main method of
birth control. It's a backup option. Most morning-after pills contain
one of two types of medicine: levonorgestrel (Plan B One-Step,
Fallback Solo, others) or ulipristal acetate (ella, Logilia).
Side effects of the morning-after pill
• Side effects of the morning-after pill often last only a few days. They
can include:
• Upset stomach or vomiting.
• Dizziness.
• Fatigue.
• Headache.
• Tender breasts.
• Light bleeding between periods or heavier menstrual bleeding.
• Pain or cramps in the stomach area.
Emergency contraception

• Emergency contraception (both emergency contraception pills and the Cu IUD) is effective within
120 hours (five days) after unprotected sex, the sooner it is used, the more effective.
Condoms

• Condoms protect against HIV, STIs, and pregnancy if used

correctly and consistently with all sexual partners during every
event of sexual intercourse.
• Therefore, men need to know, in detail, how to use condoms
correctly and consistently for each sexual act.
• Men who use condoms need to understand the importance of
emergency contraception in the case of breakage, slippage, or
incorrect use of the condom.
• They will also need to have an HIV test, and post-exposure
prophylaxis may be necessary if either partner is HIV-positive.
The main advantages are that condoms are:

• safe and simple to use.

• small and easy to carry.
• cheap and easily available — you don't need a prescription.
• able to protect against STIs and unwanted pregnancy.
The disadvantages of condoms?

• Some people are embarrassed to use condoms or feel they may

interrupt foreplay or intercourse.
• Both partners must be comfortable with using a condom and be
prepared to use one every time they have sex.
• Condoms may decrease sexual sensation.
• Some people are allergic to latex (rubber). ...
• Condoms may break or leak.
Why do condoms have flavour?

• This is where flavored condoms come in handy.

• Since the taste and smell of latex can be a big turn-off for your
partner,
• flavored condoms are designed to improve the quality of oral sex.
• The taste of these condoms can help in amplifying your lovemaking
experience.
Methods of family planning cont
Vasectomy
• Vasectomy is a permanent choice of contraception and, as such, requires serious consideration.
• It has fewer side effects and complications than most contraceptive choices for women.
• It is, therefore, suitable for men who do not want to have any more (biological) children.
 Essential information about methods for
informed choice
• The aim of counseling for informed decision-making is to assist the client in choosing a method appropriate to their needs and tolerance of side effects.
• Well-informed clients are more likely to be satisfied with their method.
Clients need to understand:

• how the method works (mechanism of action)

• effectiveness

• how to use the method and maximize its effectiveness

• possible side effects

• ensure clients know how to ameliorate symptoms and reassure them about the safety of their chosen method

• return to fertility, including when to return for additional supplies, next dosage, removal, and reinsertion

• rights related to contraception use in terms of choice,

• continuation, and when to stop

Essential information about methods
for informed choice
• PERSONAL DETAILS • How old are you?
• Do you have children?

• Are you planning to get pregnant?

• REPRODUCTIVE GOALS • IF YES: When?
• IF NO: Are you using a contraceptive method?

• Have you used contraception before?

CONTRACEPTIVE HISTORY
• IF YES: Which method(s) have you used?
• Did you have any side effects?
• How long did you use it/them for?
• Why did you stop using it/them?
Essential information about methods
for informed choice
• HIV • Have you been tested for HIV?
• IF YES, AND HIV-NEGATIVE:
When were you last tested? Would
you consider re-testing?
• IF YES, AND HIV-POSITIVE:
• Ask ART-related questions as per
national HIV management guidelines
• Do you know your partner's HIV
status?
• HIV prevention? Condom use?
PrEP?
References:

• Reproductive Health | HHS Office of Population Affairs (2022).

Available at: https://opa.hhs.gov/reproductive-health?pregnancy-
prevention/hormonal-methods/implant/index.html (Accessed: 16
August 2022).
• Women's sexual and reproductive health - Better Health
Channel (2022). Available at:
https://www.betterhealth.vic.gov.au/campaigns/womens-sexual-and-
reproductive-health (Accessed: 16 August 2022).
1.Turok D. Emergency contraception.
https://www.uptodate.com/contents/search. Accessed Jan. 29, 2024.
2.American College of Obstetricians and Gynecologists. Practice
Bulletin #152: Emergency contraception. Obstetrics & Gynecology.
2015;126:e1. Reaffirmed 2022.
3.FAQs: Emergency contraception. American College of Obstetricians
and Gynecologists. https://www.acog.org/womens-
health/faqs/emergency-contraception. Accessed Jan. 29, 2024.
4.Emergency contraception. Office on Women's Health.
https://www.womenshealth.gov/a-z-topics/emergency-
contraception. Accessed Jan. 29, 2024