Contraception Counselling & Care for Delayed Implanon Removal (PDF)

Case summary: A 22-year-old single mother received contraception counselling and preventive care while awaiting tertiary review for delayed Implanon removal and replacement. +-----------------------------------+-----------------------------------+ | Questions | Answer...

Case summary: A 22-year-old single mother received contraception counselling and preventive care while awaiting tertiary review for delayed Implanon removal and replacement. +-----------------------------------+-----------------------------------+ | Questions | Answer | +===================================+===================================+ | Contraception notes | CONTRACEPTION: EFFECTS & RISKS | | | Short-Acting Contraception SIDE | | | Combined Hormonal Contraception | | | (92- 99.7%) Migraines, nausea, | | | ?Weight gain VT E within the | | | first year (less than pregnancy), | | | breast/cervix cancer Progesterone | | | Only Pills (92-99.7%) Irregular | | | menses Mood swings, bloatedness, | | | weight gain acne Permanent | | | Contraception Tubal Ligation | | | (99.5%) & Vasectomy (99.9% | | | Operative risks Long-Acting | | | Contraception Intrauterine Copper | | | Intrauterine Device (99.4-99.6%) | | | Insertion risks: Infection, | | | perforation, expulsion Heavier | | | flow and dysmenorrhoea | | | Levonogestrel Intra-uterine | | | System (99.8%) Insertion risks: | | | Infection, perforation, expulsion | | | Lighter flow/amenorrhoea but | | | irregular Mood swings, | | | bloatedness, weight gain, acne | | | Implanon: Etonogestrel | | | subcutaneous implant (99.95%) | | | Insertion risks: Infection, | | | migration, breakage Irregular | | | menses Mood swings, bloatedness, | | | weight gain, acne Depot | | | medroxyprogesterone (94-99.8%) | | | Amenorrhoea, irregular menses | | | Mood swings, bloatedness, weight | | | gain, acne Osteoporosis/bone | | | weakening Delay return to | | | fertility | +-----------------------------------+-----------------------------------+ | Costs | KKH Implanon around 400-600 (with | | | removal) | | | | | | OCP in OPS around \$6/month | | | | | | IM DMPA in OPS around \$18 every | | | 3 months | +-----------------------------------+-----------------------------------+ | Implanon -- Source UTD | | +-----------------------------------+-----------------------------------+ | **General advice** | If the etonogestrel implant is | | | inserted more than 5 days after | | | the start of the last period, use | | | back-up contraception or abstain | | | for 7 days. Cervical mucus | | | changes quickly, within 36 hours | | | of insertion. Back-up options | | | include the previous | | | contraceptive method, condoms, or | | | other pericoital methods. | +-----------------------------------+-----------------------------------+ | **Risk of STI acquisition**  | The etonogestrel implant **does | | | not influence the risk of | | | acquiring STIs**. In contrast, | | | DMPA users may have a higher risk | | | of HIV acquisition and | | | transmission compared to | | | non-contraceptive users. | | | | | | Women at risk for STIs should be | | | counseled on using condoms for | | | protection. | +-----------------------------------+-----------------------------------+ | **Switching from an IUD**  | When switching from an IUD to an | | | implant, residual sperm may lead | | | to pregnancy if the IUD is | | | removed too soon. Options include | | | keeping the IUD for 7 days after | | | implant insertion, abstaining or | | | using barrier methods for 7 days | | | before IUD removal, or using | | | emergency contraception if recent | | | intercourse occurred. Back-up | | | contraception is recommended if | | | the implant is inserted more than | | | 5 days after the last period. | +-----------------------------------+-----------------------------------+ | **Non-contraceptive benefits**  | In addition to being extremely | | | effective, long-acting, and | | | private, the [etonogestrel | | | implant](https://www.uptodate.com | | | /contents/etonogestrel-implant-dr | | | ug-information?search=implanon&to | | | picRef=3266&source=see_link) gene | | | rally | | | lightens menstrual bleeding | | | (although women can have | | | irregular bleeding). The | | | etonogestrel implant has been | | | used to treat | | | endometriosis-related pain, | | | although data are limited | +-----------------------------------+-----------------------------------+ | **[Financial services for this | Check if son has preschool | | patient]** | subsidies/kindergarten financial | | | assistance scheme | +-----------------------------------+-----------------------------------+ | Community programs | AWARE Singapore provides | | | resources and advocacy for single | | | mothers, including sexual and | | | reproductive health education, | | | counseling, and assistance with | | | stable housing, which can | | | facilitate better health and | | | family well-being​ | | | | | | -has a sexual assault helpline | | | and care centre for more | | | vulnerable patients | | | | | | Family Service Centres (FSCs) and | | | healthcare institutions may offer | | | referrals for sexual health | | | services alongside psychosocial | | | support for single mothers, | | | helping to address health and | | | social challenges in a holistic | | | manner​ | +-----------------------------------+-----------------------------------+ | HPV Vaccinations | Advised for HPV Vaccination to | | | reduce risk of cervical, | | | vulvovaginal, anal cancer from | | | HPV infections -- Gardasil 9, | | | expensive \$400 | | | | | | -Gardasil 4 has already been | | | discontinued | | | | | | Depends on the age group: | | | | | | 14-26: it is a total of 3 doses | | | (at intervals of 0, 1-2 months | | | and 6 months | | | | | | 9-13, only 2 doses are | | | required, 6 mths apart | | | | | | Immunogenicity studies have | | | shown that two doses of HPV | | | vaccine given to 9--14-year-olds | | | at least 6 months | | | | | | apart provided as good or better | | | protection than three doses given | | | to older adolescents or young | | | adults. | +-----------------------------------+-----------------------------------+ | How would you counsel the patient | At this current age, patient will | | on HPV vaccination, given that | need 3 doses. Given that she is | | she's already sexually active? | already sexually active, the HPV | | | vaccine can protect from future | | | exposure to HPV but does not cure | | | any previous exposure, therefore | | | will be very important to | | | continue with cervical cancer | | | screening. | +-----------------------------------+-----------------------------------+ | What are the side effects of DMPA | Advantages | | | | | | Common side effects: Pain | | | associated with injections, mild | | | headache, breast tenderness, | | | water retention, AUB | | | | | | Rare side effects: Delayed | | | return of fertility, loss of bone | | | mass with prolonged use | | | | | | Bone mass side effect: The FDA | | | has issued a boxed warning | | | indicating that women using | | | Depo-Provera may experience | | | significant BMD loss, and it is | | | not recommended as a long-term | | | contraceptive method unless other | | | | | | options are inadequate | | | | | | Studies have shown that after | | | discontinuation, there is only | | | partial recovery of BMD, | | | especially in those who | | | | | | used it for more than two years | +-----------------------------------+-----------------------------------+ | What is the risk of breast cancer | We found that recent DMPA use | | amongst | for 12 months or longer was | | | associated with a 2.2-fold (95% | | DMPA users | CI: 1.2--4.2) | | | | | | increased risk of invasive breast | | | cancer. This risk did not vary | | | appreciably by tumor stage, size, | | | hormone | | | | | | receptor expression, or | | | histological subtype. Although | | | breast cancer is rare among young | | | women and the | | | | | | elevated risk of breast cancer | | | associated with DMPA appears to | | | dissipate after discontinuation | | | of use, our | | | | | | findings emphasize the importance | | | of identifying the potential | | | risks associated with specific | | | forms of | | | | | | contraceptives given the number | | | of available alternatives | | | | | | | | | https://www.ncbi.nlm.nih.gov/pmc/ | | | articles/PMC3328650/ | +-----------------------------------+-----------------------------------+ | Weaknesses | UPT should have been done | | | | | | Emergency contraception could | | | have been discussed | | | | | | STI screening should have been | | | performed | | | | | | Reliance on Patient-Reported | | | Contraception Expiry in Singapore | | | -- should cross check with EMR | | | | | | \- Errors in recall, particularly | | | with long-acting reversible | | | contraceptives (LARCs) like | | | Implanon, can result in | | | unintended pregnancies due to | | | prolonged reliance on expired | | | devices​ | +-----------------------------------+-----------------------------------+ | On STI screening in this patient | I will offer her:\ | | | hiv, syphilis, hepatitis b, | | | hepatitis c, Chlamydia & | | | Gonorrhoea PCR | | | | | | Evidence\_\_\_ | +-----------------------------------+-----------------------------------+