Medical Bytes with Dr. K
It’s your life; it’s your responsibility
Seini was an 18 year old high school student. She had many friends who were sexually active. They insisted that she also experiment with this before leaving school. It was almost the end of the year and Seini was attending the prom with her classmate. The evening went well, Seini had a lot of alcoholic drinks and became quite drunk. Little did she realise that she did not get home that night. She ended up with her date and could not remember what had happened. Next month Seini missed her menstrual period. She took a pregnancy test, which to her great disappointment came back positive. Rita, 24, is adamant about using condoms for contraception, as she does not want to get pregnant. One night, however, the condom broke during intercourse. Rita was unaware that the emergency contraceptive pill existed (morning after pill). Rita and her husband were not ready to have a baby yet as they both had very demanding jobs, but Rita fell pregnant. They did not have a choice but to have the baby, as abortion is not legal in Fiji. Shelly, aged 30, was on the oral contraceptive pill and was careful to take it at the same time every day. She had been with a new partner for two months. Since that time she realised that she was having an abnormal vaginal discharge and lower abdominal pain. Shelly visited her doctor who did the appropriate tests and advised her that she had gonorrhea, a sexually transmitted infection. Shelly was using the contraceptive pill so she did not get pregnant, but got a sexually transmitted infection because her infected partner was not using a condom. All these women were different ages and in different situations, but they had one thing in common – contraceptive issues. World Contraceptive Day takes place on 26 September every year. The annual worldwide campaign centres around a vision where every pregnancy is wanted. Launched in 2007, World Contraceptive Day’s mission is to improve awareness of contraception and to enable young people to make informed choices on their sexual and reproductive health. Family planning information and access to preferred contraceptive methods for women and couples is essential for the well-being and autonomy of women, while supporting the health and development of communities. Allowing women to choose whether, when, and how many children to have achieves progress on global health goals. It also helps break the cycle of poverty and puts families, communities, and countries on a stronger, more prosperous and sustainable path (World Health Organization). Over the past 25 years, considerable progress has been made in women’s sexual and reproductive health, including increased contraceptive use spurred by the Millennium Development Goals (MDGs) and the 1994 International Conference on Population and Development (ICPD). Despite the positive global trends there are large differences among and within countries. More than 200 million women worldwide would like to avoid a pregnancy but are not using an effective method of contraception. Two very significant reasons for this include limited choice of methods and limited access to contraception particularly amongst young people, and poorer segments of populations or unmarried people. There may also be a fear of side effects, cultural or religious opposition, poor quality of available services, users and providers bias and gender based barriers. A woman’s ability to choose if and when to become pregnant has a direct impact on her health and wellbeing. Family planning allows spacing of pregnancies and can delay pregnancies in young women at increased risk of health problems and death from early childbearing. It prevents unintended pregnancies, including those of older women who face increased risks related to pregnancy. Family planning enables women who wish to limit the size of their families to do so. Evidence suggests that women who have more than 4 children are at increased risk of maternal mortality. By reducing rates of unintended pregnancies, family planning also reduces the need for unsafe abortion. Family planning allows people to make informed choices about their sexual and reproductive health. It represents an opportunity for women to pursue additional education and participate in public life, including paid employment. Additionally, having smaller families allows parents to invest more in each child. Children with fewer siblings tend to stay in school longer than those with many siblings. Family planning is key to slowing unsustainable population growth and the resulting negative impacts on the economy, environment, and national and regional development efforts. There are many different methods of contraception. The most effective reversible methods are the “fit and forget” long-acting reversible contraceptives (LARCS) - intrauterine devices and contraceptive implants. These are suitable for women of any age and can be used by most women even if they have any significant health issues. They can be removed easily at any time by a trained health professional and are immediately reversible on removal. However, they involve an insertion and removal procedure by a doctor or nurse and do not provide protection against sexually transmitted infections (STI’s). Intrauterine devices include a hormone releasing device or copper devices. The hormonal IUD is a small T-shaped device that is fitted inside the uterus (womb). Over five years it slowly releases a very low dose of progestogen hormone
into the uterus. Periods usually become lighter or may stop when using a hormonal IUD. The hormonal IUD is about 99.8% effective. The copper intrauterine device is made from plastic and copper and is fitted inside the uterus. It stops sperm from reaching the egg and any fertilised egg from sticking to the wall of the uterus and is 99.2% effective. They have no hormones and therefore have no effect on the normal female cycle but periods may become heavier when using a copper IUD. IUDs need to be replaced every 5-10 years depending on their type or can be removed easily at any time. The contraceptive implant is inserted directly under the skin, on the inner arm above the elbow, where it continuously releases a low dose of a progestogen hormone into the blood stream over three years. The implant works by preventing ovulation (egg release from the ovary). Devices need to be replaced every three years or can be removed earlier if required. Using an implant will change a woman’s usual bleeding pattern: for some women this will mean little or no bleeding at all but about 1 in 5 women have irregular or persistent bleeding. Implants are 99.9% effective. The contraceptive injection – Depot medroxyprogesterone acetate (DMPA) – is given by injection into a muscle every 12 weeks. It prevents pregnancy by stopping ovulation. Periods may stop while using DMPA and there may be a short delay in return to usual fertility. DMPA is 94-99.8% effective. Shorter acting hormonal methods include the combined oral contraceptive pill and the progesterone only pill (minipill). A regular prescription from your doctor is required and these do not provide protection against sexually transmitted infections. The combined oral contraceptive pill, commonly referred to as ‘The Pill’, is taken daily and contains the hormones oestrogen and a progestogen. These hormones are similar to those naturally produced by the female body. The pill may help with acne or heavy periods. The progestogen-only pill can be used by most women, even if they have any significant health issues. Pills rely on regular and consistent daily use to be effective. Barrier methods are condoms and the diaphragm. They prevent semen from entering the uterus and can be an effective method of contraception when used consistently and correctly. Condoms are the only method that provide protection against pregnancy and sexually transmitted infection. The male condom is a sheath made of latex or polyurethane, which is rolled onto the erect penis before sex. The male condom is 82-98% effective for pregnancy prevention and consistent use is very important if they are the sole method of contraception. Condoms can be used in conjunction with other methods to increase contraceptive effectiveness. Emergency contraception (EC) can reduce the risk of unintended pregnancy after unprotected sex. There are two types of EC - the emergency contraception pill (ECP), a pill containing a progestogen hormone and the Cu-IUD. Permanent contraception (sterilisation) for men or women involves a small operation by a surgical doctor with general or local anaesthesia. As you can see, there are so many available options for contraception. I urge you to make an appointment with your doctor to discuss the best possible option for you and your partner. Knowledge is power and we all need to empower ourselves so that we can make the best decisions. Wise words by Dr.Babatunde Osotimehin, Executive director of UNFPA“Family planning is not a privilege but a basic human right. By enabling women particularly the most disadvantaged and hardest to reach, to make informed choices about the number, timing, and spacing of their children, we help them exercise this right.”
“Knowledge is power and we all need to empower ourselves so that we can make the best decisions.”
DR. KRUPALI RATHOD TAPPOO is an Australian qualified General Practitioner, a Fellow of the Royal Australian College of General Practitioners and the Medical Coordinator for Fiji-based NGO Sai Prema Foundation. Dr. Krupali is based at Mitchells Clinic in Tappoocity Suva and has a special interest in women and children’s health.