PocketGuide: Medical Problems

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PocketGuide for Family Planning Service Providers

Medical Problems

Drug Interactions - Anticoagulants
Drug Interactions - Antiseizure Drugs
Ectopic Pregnancy
Familial Hyperlipidemia
Gall Bladder Problem
Headaches
Hepatitis
High Blood Pressure
HIV/AIDS
Ischemic Heart Disease/ Stroke

PROBLEM	Headaches - Migraine
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Only women with migraine headaches that cause focal neurologic symptoms should not use COCs or CICs. (WHO class 4)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM POCs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	In women with severe, recurrent vascular (migraine) headaches who also have focal neurological symptoms (e.g., unable to speak for short intervals, temporary weakness or blurred vision), use of COCs and CICs may pose an additional risk for stroke (estrogen effect). For women prone to severe headaches, POPs are recommended over implants (which cannot be stopped easily) and PICs (their effects persist for several months after injection).

PROBLEM	Hepatitis
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with active (symptomatic) hepatitis should not use COCs or CICs. (WHO class 4) POCs: Women with active (symptomatic) hepatitis should avoid using POCs unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	COCs, CICs and POCs may be used by women who are asymptomatic (i.e., liver function has been normal for 3 months) or are carriers.

PROBLEM	High Blood Pressure
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with blood pressure (BP): > 180/110 should not use COCs or CICs. (WHO class 4) >160/100 but < 180/110 should avoid using COCs or CICs unless other more appropriate methods are not available or acceptable. (WHO class 3) < 160/100 can use COCs or CICs. (WHO class 2) COCs and CICs: Women with vascular disease as well as high BP should not use either COCs or CICs. (WHO class 4) PICs: Women with BP >180/110 should avoid using PICs unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM POPs/Implants IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	Low-dose COCs and CICs cause little or no BP change in healthy clients. It is reasonable to consider their use in women who already have high BP. Use should be stopped if monitoring during the first few months reveals a marked increase in BP or if vascular disease develops. In hypertensive women with underlying arterial vascular disease, COC or CIC use poses an additional risk for blood clotting problems (estrogen effect). Because of the higher blood levels of progestin with use of PICs, high-density lipoproteins (HDLs) may be lowered. As a consequence there is theoretical concern about this action in women with underlying high blood pressure and arterial vascular problems (e.g., ischemic heart disease, neuropathy or retinopathy).

PROBLEM	HIV/AIDS
METHODS WHICH SHOULD BE USED WITH CAUTION	IUDs: Women with HIV/AIDS should avoid using IUDs unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM COCs/CICs POCs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	WHO recommends not using an IUD because these women, who already are immunosuppressed, may theoretically be at more risk of getting STDs (e.g., HBV) with an IUD in place. Individuals seropositive for HIV, or who have AIDS, always should use a condom (male or female) to reduce the chance of spreading the disease.

PROBLEM	Ischemic heart disease or Stroke (current or history)
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with underlying arterial vascular disease should not use COCs or CICs. (WHO class 4) Implants and PICs: Because these methods theoretically pose an additional risk, their use should be avoided unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM POPs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	In women with documented arterial vascular disease (heart attack or stroke), use of COCs or CICs may pose an additional risk (estrogen effect). Some studies have reported decreased HDLs with POCs, especially DMPA. The clinical significance of these findings is not known at present.

PROBLEM	Liver tumors (adenoma and hepatoma)
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with liver tumors should not use COCs or CICs. (WHO class 4) POCs: Women with liver tumors should avoid using these methods unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	COCs and CICs may increase the risk of benign liver tumors and substantially increase the risk of hepatoma. Because liver tumors (benign and malignant) are rare in women of reproductive age, routine screening (e.g., ultrasound) is not needed. The concern with CICs is less than that with COCs because the first-pass effect on the liver is eliminated. (The hormones in CICs initially pass directly from the injection site to the heart without first passing through the liver.) According to WHO, progestins (POCs) do not increase the risk of benign liver tumors; however, it is not clear whether progestins increase the risk of hepatoma.

PROBLEM	Malaria - Acute
METHODS WHICH SHOULD BE USED WITH CAUTION	Voluntary sterilization: Should be delayed until the client is recovered.
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM COCs/CICs POCs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	All reversible contraceptive methods can be used. Although VS is a minor surgical procedure, it should not be performed when the client is sick.

PROBLEM	Schistosomiasis (acute)
METHODS WHICH SHOULD BE USED WITH CAUTION	Voluntary sterilization: Should be delayed until the client is recovered.
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM COCs/CICs POCs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	Despite theoretical concern about an increase in blood loss during initial months of both IUD and POC use, no reversible contraceptive methods pose an increased risk. Although VS is a minor surgical procedure, it should not be performed when the client is sick.

¹ For women with life-threatening medical problems who are in mutually faithful relationships, vasectomy often is the safest long-term method for the couple.
² Most appropriate methods are boldfaced.
³ Because griseofulvin usually is used only for a short period of time (2 to 4 weeks), women taking it for fungal infections can continue to use these methods. They should use a backup method while taking griseofulvin and until the start of the next menstrual period after stopping the antibiotic.
⁴ Definitions of heavy smoking vary internationally. Throughout this PocketGuide the WHO definition, 20 cigarettes or more per day, is used.

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