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Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 6: Hormonal Methods, IUDS, Fertility Awareness Methods, and Voluntary Surgical Contraception
Instructor: Emmanuel 'Dipo Otolorin, MD

Objectives

By the end of this lesson, participants will be able to:

1. Understand mechanisms of action of hormonal contraceptives, intrauterine devices (IUDs), fertility awareness methods and voluntary surgical contraception.
2. Describe hormonal methods of contraception (pills, injectables and implants)
3. Describe intrauterine devices (IUDs)
4. List fertility awareness methods
5. Describe male and female voluntary surgical contraception methods
6. Discuss the effect of hormonal contraceptives, intrauterine devices (IUDs), fertility awareness methods and voluntary surgical contraception on HIV course and transmission
7. Describe drug interactions between hormonal contraception and antiretroviral agents and their implications

Contraception for HIV-Infected Women

As discussed in previous lessons, women infected with HIV face a variety of reproductive health decisions involving their desire for pregnancy, their contraceptive practice, and choices and decisions if an unintended pregnancy occurs. HIV-infected women should be allowed to make these decisions freely. 

In both resource-poor and resource-rich countries, women who learned through voluntary counseling and testing (VCT) programs that they were HIV-positive report lower levels of desired fertility than women in the general population. Their knowledge about contraception and access to family planning services may be limited, however. Interventions to offer voluntary family planning can provide these women with more control over their reproductive lives and serve as a strategy to prevent perinatal HIV infection and prevent undesired pregnancy.

Hormonal Contraceptives

Hormonal contraceptives include a group of modern contraceptive devices such as oral contraceptives (the pill), injectables (e.g. Depo-Provera, “the shot”) and contraceptive implants (e.g. Norplant). 

Combined Oral Contraceptives (COCs) are pills that contain the hormones estrogen and progestin. Progestin-Only Pills (POPs) contain only the hormone progestin. Both COCs and POPs are taken daily. They suppress ovulation (monthly release of eggs), thicken the cervical mucus (preventing sperm penetration), change the endometrium (making implantation less likely), and reduce sperm transport in the upper genital tract (fallopian tubes). 

Depo-Provera(r) and Noristerat(r) are the two progestin-only injectable contraceptives (PICs) provided in most countries. Both are injections of the hormone progestin. They are administered every 3 or 2 months, respectively. PICs work by thickening cervical mucus, changing the endometrium, reducing sperm transport in the upper genital tract and suppressing ovulation.

The two combined injectable contraceptives (CICs), Cyclofem(r) and Mesigyna(r), are injections of the hormones estrogen and progestin, which are administered once a month. The mechanisms of action of CICs are similar to those of combined oral contraceptives

The Norplant implant system consists of six small flexible capsules made of Silastic(r) tubing, which are filled with a synthetic progestin (levonorgestrel). The capsules are inserted just under the skin on the inner side of a woman's upper arm using a minor surgical procedure. Norplant implants work by thickening cervical mucus, changing the endometrium and reducing sperm transport. They provide highly effective contraception for up to 5 years. 

Hormonal contraceptives can, generally, be used by women of any age whether or not they have had children. COCs should, however, not be used by women over the age of 35 years who smoke more than 15 cigarettes a day or have a history of hypertension and/or diabetes. Hormonal contraceptives can be started anytime when the provider is reasonably sure that a woman is not pregnant. While postpartum women who have decided not to breastfeed their babies can commence hormonal contraception after 3 weeks, women who have taken the informed decision to breastfeed their babies are advised not to use the COCs until their babies are over 6 months of age. This is because there is some theoretical concern that the baby may be at risk due to exposure to steroid hormones during the first 6 weeks postpartum. There is also some theoretical concern regarding the association between COC use up to 3 weeks postpartum and risk of thrombosis in the mother. In the first 6 months postpartum, use of COCs during breastfeeding diminishes the quantity of breast milk, decreases the duration of lactation, and may thereby adversely affect the growth of the infant. HIV positive women who take the informed decision not to breastfeed their babies can start using the COCs after 6 weeks postpartum.

Oral contraceptives also have a number of non-contraceptive benefits including decreased menstrual pain, decreased menstrual blood loss and decreased incidence of premenstrual syndrome (PMS). Other benefits include reduced incidence of acne, decreased incidence of benign breast disease, functional ovarian cysts, ovarian and endometrial cancers as well as decreased incidence of pelvic inflammatory disease.

Hormonal contraceptives, particularly combined or injectable oral contraceptives (COCs and CICs), can have significant drug interactions, resulting in either decreased contraceptive effectiveness or increased or decreased concentration of the co-administered drug. Such drugs include antiretrovirals (e.g. nevirapine, nelfinavir, ritonavir, amprenavir, lopinavir/ritonavir, efavirenz) and drugs used to treat certain other conditions (e.g. tetracycline, rifampicin, tricyclic antidepressants, oral anticoagulants, methydopa, benzodiazepines). If an HIV-positive woman is on one of these ARV agents and uses a combined hormonal contraceptive method, an alternative or additional contraceptive method is recommended

Clinicians treating women who are at risk for drug interactions should review the need for possible use of alternative methods of contraception or dose adjustment for the interacting agent.

Fertility Awareness Methods

Lactational Amenorrhoea Method (LAM) is the use of breastfeeding as a contraceptive method. It is based on the physiologic effect of suckling to suppress ovulation. To use breastfeeding effectively as a contraceptive requires that the mother either feed the baby nothing but breast milk or, at the very least, breastfeed for almost all feedings. In addition the baby must be less than 6 months old and the mother's menses should not have returned.

To use Natural Family Planning (NFP), a couple voluntarily avoids sexual intercourse during the fertile phase of the woman's cycle (time when the woman can become pregnant) or has intercourse during the fertile phase to achieve pregnancy. There are four types of NFP: 

• Calendar (Rhythm) method
• Basal Body Temperature method
• Cervical Mucus
• Symptothermal methods.

In general, fertility awareness methods have a higher failure rate of 13-20% during typical use and do not protect against STIs/HIV/AIDS. They must be used in association with condoms to offer protection against transmission or acquisition of these infections. 

Intrauterine Contraceptive Device (IUD)

The most common intrauterine device (IUD) is a small T-shaped flexible device inserted into the uterine cavity (womb). IUDs can be inert, copper-releasing or progestin-releasing. Copper-releasing IUDs interfere with the ability of sperm to pass through the uterine cavity and with the reproductive process before ova reach the uterine cavity. Progestin-releasing IUDs also thicken the cervical mucus and change the endometrial lining.

IUDs are highly effective (0.5–1 pregnancies per 100 women during the first year of use for Copper T 380A). They become effective immediately after insertion. IUDs are inexpensive, do not interfere with intercourse and do not affect breastfeeding. Side effects are few and the client needs no additional supplies. Clients using non-progestin releasing IUDs may experience increased menstrual flow and duration. Also there is an increased risk of pelvic inflammatory disease if the client has or is at risk for STIs. Nonphysicians can provide IUDs. Fertility returns immediately after removal of the device. 

The non-contraceptive benefits of IUDs include a decreased incidence of menstrual cramps (progestin-releasing only), decreased menstrual bleeding (progestin-releasing only) and decrease incidence of ectopic pregnancy (except Progestasert). 

Recent studies of IUD use by HIV-infected women have not found an increased risk of either infection-related complications or HIV cervical shedding. Concerns that increased menstrual bleeding and possible increases in upper genital tract infections might put IUD users at higher risk for HIV have been raised but remain unproven. HIV-positive women with anemia may not be good candidates for non-progestin releasing IUDs.

To reduce the risk of pelvic inflammatory disease (PID) in IUD users, the client should be screened for the risk of sexually transmitted infections (STIs) and counseled about STI/HIV and PID risk factors. The provider should follow aseptic insertion procedures and perform a follow-up examination within 4-6 weeks after insertion.

Voluntary Surgical Contraception

Tubal occlusion is a voluntary surgical procedure for permanently terminating a woman's fertility. Tubal occlusion, which can be done by minilaparotomy or laparoscopy, blocks the fallopian tubes (tying and cutting, applying rings, clips or electrocautery) and sperm are thereafter prevented from reaching the ova and causing fertilization. The two most common female sterilization approaches are minilaparotomy, which is usually performed under local anesthesia with light sedation, and laparoscopy, which requires general anesthesia. Female sterilization does not affect breastfeeding or interfere with intercourse and it is free from the side effects associated with some temporary methods. No medical condition absolutely restricts a woman's eligibility for the method. 

Vasectomy is a voluntary surgical procedure for permanently terminating a man's fertility. Vasectomy can be done by the standard method or the no-scalpel technique that is the preferred method. Vasectomy blocks the vas deferens (ejaculatory duct) so that sperm are not present in the ejaculate. The method requires a simple surgical procedure and is performed under local anesthesia. Male sterilization is not castration; it does not affect the testes. The method does not interfere with intercourse or affect a man's sexual ability. No medical condition absolutely restricts a man's eligibility for the method. Male sterilization is generally safer and less expensive than female sterilization and it is a good way for men to share in the responsibility of family planning. Providers should encourage couples to discuss this option. 

Failure (pregnancy) rates for male and female sterilization are very low (0.2% to 0.5% during the first year of use for female sterilization or 1.8% over ten years of use; and 0.1% to 0.15% failure rate in the first year after vasectomy procedures).

Contraception and HIV Risk

The male or female condom is the only contraceptive method proven to reduce the risk of all sexually transmitted infections (STIs), including HIV. Hormonal contraceptives, IUDs, fertility awareness methods and voluntary surgical sterilization do not protect against STIs/HIV/AIDS. On the other hand, investigators are working to determine if hormonal contraceptives or IUDs themselves might increase a woman's risk of HIV. Some studies have suggested that contraceptives containing high levels of progestins, including injectables and some oral contraceptives, may increase a woman's risk of HIV by promoting certain physiological changes. All hormonal contraceptives contain progestins, which are synthetic versions of the hormone progesterone, and also may contain estrogen. Progesterone has been found to cause endometrial, cervical mucus, and bleeding changes that might affect STI/HIV risk. Estrogen alters the degree of cervical ectropion, which may affect users' susceptibility to certain infections including HIV. 

Concerns have been raised about possible increased risk of HIV transmission or acquisition in hormonal contraceptive users. There is evidence that both COCs and progestin-only contraceptives may increase genital tract HIV shedding. Furthermore, combined hormonal contraceptives have been associated with increased cervical ectopy, which has also been linked with genital tract HIV shedding. Similarly, ectopy or other epithelial changes due to hormonal contraception or associated effects on immune response may increase susceptibility to HIV. Data from epidemiological studies are conflicting and inconclusive regarding the relationship of these methods and HIV transmission. At the current time, given their effectiveness, overall safety, and ease of use, hormonal methods of contraception remain an appropriate option for HIV-infected or at-risk women. These women should be counseled that these contraceptives do not protect against HIV transmission and consistent condom use should be encouraged.

A Kenyan study of HIV-positive women found that use of oral contraceptives and the three-month injectable depo-provera (DMPA) might be associated with increased endocervical shedding of HIV. Another study, among prostitutes in Nairobi, Kenya, concluded that oral contraceptives might increase the risk of HIV infection. However, methodological questions concerning both studies have been raised, making it difficult to interpret the results. Other studies have shown no association between use of hormonal contraception and increased risk of HIV, including a study of Rwandan women attending prenatal and pediatric clinics and a study of Kenyan women attending family planning clinics in Nairobi. Again, concerns that increased menstrual bleeding and possible increases in upper genital tract infections might put IUD users at higher risk for HIV have been raised but remain unproven. 

Further data are required before definitive conclusions can be made regarding use of hormonal methods or IUDs and the risk of HIV. Family planning providers should inform clients that hormonal contraceptives and IUDs do not protect against STDs, including HIV, and that use of male or female condoms is strongly recommended for the protection of both partners. Furthermore, because of the theoretical concerns about increased risks of STIs and PID and increased risks of transmission to uninfected partners, particularly for immunosuppressed women, the WHO currently recommends that IUDs should not be used by HIV infected women unless other more appropriate methods are not available or acceptable.

Next Week's Lesson: 
Other Reproductive Health Issues

Additional Reading

1. Family Health International (FHI). HIV-positive women have different needs. Network 20(4). (2001).
2. International Planned Parenthood Federation (IPPF). Medical Bulletin 35(1) (February 2001). (Available online at www.ippf.org/medical/bulletin/pdf/e0102.pdf.)
3. WHO. Improving access to quality care in family planning. Medical eligibility criteria for contraceptive use. Second edition. On the WHO website.
4. Martin, H.L. et al. Hormonal contraception, sexually transmitted diseases, and the risk of heterosexual transmission of human immunodeficiency virus type 1. The Journal of Infectious Diseases 178:1053-1059 (1998).
5. Mati, J.K.G. et al. Contraceptive use and the risk of HIV infection in Nairobi, Kenya. International Journal of Gynecology and Obstetrics 48:61-67 (1995).
6. PATH (Program for Appropriate Technology in Health). Hormonal contraception, IUDs, and HIV risk. Outlook 17(1) (April 1999). (Available online at www.path.org/outlook/html/17_1.htm#featureHormonal).
7. Allen, S. et al. Human immunodeficiency virus infection in urban Rwanda: demographic and behavioral correlates in a representative sample of childbearing women. Journal of the American Medical Association 266(12): 1657-1663 (1991).
8. Costello Daly, C. et al. Contraceptive methods and the transmission of HIV: implications for family planning. Genitourinary Medicine 70:110-117 (1994).
9. Curtis et al. Contraception for women in selected circumstances. OBGYN 2002;99:1100-12.
10. Brabin L. Interaction of the female hormonal environment, susceptibility to viral infections and disease progression. AIDS patient Care STDs 2002;16:211-21.
11. Morrison CS et al. Is the Intrauterine Device appropriate contraception for HIV-1 infected women? BJOG 2001;108:784-90.