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	Diabetes
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Only women with diabetes of long-standing (> 20 years), who have arterial vascular problems (e.g., heart attack, stroke, kidney failure or retinopathy), should avoid using COCs or CICs. (WHO class 3/4) PICs: Women with diabetes of long-standing (> 20 years), who have arterial vascular problems, 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 COCs/CICs POPs/Implants IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	POPs and implants have a lower dose of progestin than PICs. They do not, therefore, pose an additional risk of blood clotting problems (estrogen effect). Although carbohydrate tolerance may change (slight decrease in glucose tolerance and increased insulin levels), COCs and CICs can be used safely. It is the progestin component (type and dose) of COCs and CICs that mainly is responsible for the effects on carbohydrate metabolism. Fortunately, the small changes induced by low-dose COCs, CICs, implants and POPs do not appear to be clinically significant.

PROBLEM	Drug Interactions - Antibiotics
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs, CICs, Implants and POPs: Women with problems requiring long-term use of rifampin or griseofulvin³ should avoid using these methods unless other more appropriate methods are not available or acceptable. (WHO class 3) There is no restriction for use with other antibiotics. (WHO class 1)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM PICs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	Long-term use of rifampin for tuberculosis causes the liver to metabolize estrogens and progestins more rapidly and may decrease the effectiveness of all hormonal methods except PICs. (The blood levels of progestins with use of PICs are sufficient to compensate for the increased metabolism.)

PROBLEM	Drug Interactions - Anticoagulants
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with problems requiring long-term use of anticoagulants should avoid using COCs and CICs unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM POCs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	The use of COCs or CICs in these women poses an additional risk of blood clotting problems (estrogen effect).

PROBLEM	Drug Interactions - Antiseizure drugs (barbiturates, carbamazepine and phenytoin but not valproic acid)
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs, CICs, Implants and POPs: Women using antiseizure drugs 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 PICs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	Long-term use of drugs for epilepsy (except valproic acid) causes the liver to metabolize estrogens and progestins more rapidly and may decrease the effectiveness of all hormonal methods except PICs. Overall, neither estrogens nor progestins appear to alter seizure activity and can be provided with caution. Development of intermenstrual bleeding or spotting may indicate a decreased level of sex steroid hormones (estrogens and progestin) due to interactions with antiseizure drugs. If this occurs, consider using a COC with a higher estrogen level (50 �g EE) or help the client choose another method (COC, CIC, implants or POP). The effectiveness of PICs is not decreased because blood levels of the progestins are sufficient to compensate for the increased metabolism.

PROBLEM	Ectopic Pregnancy - History
METHODS WHICH SHOULD BE USED WITH CAUTION	Implants, POPs and inert and progestin-releasing IUDs: Because POPs and both inert and progestin-releasing (Progestasert^{^�}) IUDs do not consistently block ovulation, women choosing these methods may have an even higher risk of another ectopic pregnancy. By contrast, the risk of ectopic pregnancy with copper-releasing IUDs (e.g., TCu 380A) and the LNG-releasing IUD is extremely low.
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM COCs/CICs PICs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	A woman who has had a prior ectopic pregnancy is at increased risk for another and should use a very effective contraceptive method, preferably one that blocks ovulation (e.g., COCs or injectables). Overall, the risk of ectopic pregnancy is extremely low with the TCu 380A IUD. Therefore, if the woman is not at high risk for GTIs, a copper-releasing IUD is appropriate. The risk of a subsequent ectopic pregnancy in women using no method of contraception is about 20% while in women using IUDs it is about 1–2%. Therefore, all methods provide more protection against ectopic pregnancy than using no method.

PROBLEM	Familial Hyperlipidemia (FH)
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with diagnosed FH probably should avoid using COCs or CICs unless other more appropriate methods are not available or acceptable. (WHO class 2/3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM POCs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	Although FH is a risk factor for vascular disease, routine screening is not indicated because of the rarity of this disease. Risk of vascular problems (e.g., heart attack, stroke, pulmonary embolism or blood clotting disorders) is increased if COCs or CICs are used by patients with FH.

PROBLEM	Gall Bladder Problems - (Biliary tract disease)
METHODS WHICH SHOULD BE USED WITH CAUTION	COCs and CICs: Women with gall bladder disease, including those being treated medically, should avoid using COCs or CICs unless other more appropriate methods are not available or acceptable. (WHO class 3)
APPROPRIATE CONTRACEPTIVE METHODS² (WHO Class 1, 2)	LAM POCs IUDs Barriers Spermicides NFP Withdrawal Voluntary sterilization
COMMENTS	Although COCs and CICs do not appear to cause gall bladder disease, they may shorten the time until the onset of disease in women with subclinical cases. This is most likely to occur within the first year of use.

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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