Family planning methods and STIs/RTIs - Sexually transmitted and other reproductive tract infections

Improving services for prevention and treatment of STI/RTI
Chapter 6. STI/RTI assessment during routine family planning visits

Family planning methods and STIs/RTIs

Most family planning methods do not protect against STIs. Table 6.1 presents estimates of contraceptive effectiveness and STI protection for common methods. Some contraceptive methods actually increase the risk of non-sexually transmitted RTI or their complications, and clients may abandon a method (and risk pregnancy) if they think it is causing problems. Yeast infection, for example, is more common in women using oral contraceptives, and bacterial vaginosis occurs more frequently in women using the diaphragm with spermicide. Health care providers should be aware of such method-related problems and be able to counsel patients about management or alternative methods.

Table 6.1. Family planning methods: protection from pregnancy and STIs

Method	Effectiveness^a in pregnancy prevention	Protection against STIs
Male condom	85�98%	Protects against most STIs, including HIV. Protection unproven against infections transmitted by skin-to-skin contact (HSV, HPV).
Female condom	79�95%	Laboratory studies show protection against STI/HIV. More human studies needed.
Spermicides	71�85%	Possible protection against bacterial STIs, no protection against viral STIs and HIV. May increase risk of HIV infection.
Diaphragm (with spermicides)	84�94%	Possible protection against bacterial STIs. Increased risk of bacterial vaginosis. Little is known about protective effect of diaphragm against HIV. Protective against cervical neoplasia. Spermicide use may increase risk of HIV infection.
Oral contraceptives	92�>99%	No protection against lower genital tract infections; reduced risk of symptomatic PID. No protection against viral STIs and HIV. Yeast infections more common.
Implantable contraceptives	>99%	No protection against bacterial or viral STIs and HIV.
Injectable contraceptives	>99%	No protection against lower genital tract infections; reduced risk of symptomatic PID. No protection against viral STIs and HIV.
IUD	>99%	No protection against bacterial or viral STIs and HIV. Associated with PID in first month after insertion.
Surgical sterilization (tubal ligation and vasectomy)	>99%	No protection against lower genital tract infections; reduced risk of symptomatic PID. No protection against viral STIs and HIV.

^a. Effectiveness in normal (�typical�) use.

Dual protection and emergency contraception

Only correct and consistent condom use provides reliable protection against STIs. Counselling on dual protection should thus always include promotion of condoms. When used consistently and correctly, condoms also provide good protection against pregnancy. Couples who want additional protection against pregnancy can combine condoms with another method, or use emergency contraception as back-up protection in the event of condom misuse or failure. Box 6.2 describes how to provide emergency contraception using different types of emergency contraceptive pills, including commonly available oral contraceptives.

Box 6.2. Use of emergency contraception

In many countries, special-purpose pills for emergency contraception (EC) are available. Regular birth control pills can also be used for EC. Each type or brand of birth control pill has a different amount of hormone, so the number of pills that make up a full dose will vary.

How to take emergency contraceptive pills: Ideally, take levonorgestrel-only or combined estrogen-progestogen as early as possible after unprotected intercourse, within 72 hours. Levonorgestrel-only or combined estrogen-progestogen can be used between 72 hours and 120 hours after unprotected intercourse. However, the patient should be advised that the effectiveness of emergency contraceptive pills is reduced the longer the interval between having unprotected intercourse and taking emergency contraceptive pills.

Emergency contraceptive pills may cause nausea and/or vomiting. These side-effects are much less common with progestogen-only (levonorgestrel) pills. Advise the woman to try eating something at the same time as she takes the pills and, if possible, to take a medicine that will prevent vomiting before taking the combined emergency contraceptive pills. If she vomits within two hours of taking the pills, she should take another dose immediately.

Copper-bearing IUDs are the most effective method of emergency contraception; they can be used within 5 days after unprotected intercourse. To use the IUD as an emergency contraceptive method, women must meet the medical eligibility requirements for regular IUD use. The IUD can then be used for continuing contraception, or removed at the next menses.

	Dose
Special-purpose levonorgestrel-only pills for emergency contraception	Preferably, take 1.50 mg of levonorgestrel in a single dose. Alternatively, take the levonorgestrel in 2 doses (1 dose of 0.75 mg of levonorgestrel, followed by a second dose of 0.75 mg of levonorgestrel 12 hours later).
Special-purpose combined pills for emergency contraception	Take 2 combined emergency contraceptive pills (50 �g of ethinylestradiol each). Repeat 12 hours later.
Low-dose combined pills	Take 4 low-dose birth control pills (30 �g of ethinylestradiol each). Repeat 12 hours later.
High-dose combined pills	Take 2 high-dose birth control pills (50 �g of ethinylestradiol each). Repeat 12 hours later.
Emergency contraceptive pills may cause nausea and/or vomiting. These side-effects are much less common with progestogen-only (levonorgestrel) pills. Advise the woman to try eating something at the same time as she takes the pills and, if possible, to take a medicine that will prevent vomiting before taking the combined emergency contraceptive pills. If she vomits within two hours of taking the pills, she should take another dose immediately. Copper-bearing IUDs are the most effective method of emergency contraception; they can be used within 5 days after unprotected intercourse. To use the IUD as an emergency contraceptive method, women must meet the medical eligibility requirements for regular IUD use. The IUD can then be used for continuing contraception, or removed at the next menses.

Intrauterine device (IUD)

For women with a high individual likelihood of exposure to gonorrhoea or chlamydial infection, IUD use is usually not recommended unless other more appropriate methods are unavailable or unacceptable. Other women at increased risk of STIs can generally use the IUD. Precautions to reduce risk of iatrogenic infection during IUD insertion are described in Box 6.3.

Box 6.3. Reducing risk of iatrogenic RTI with IUD insertion

Most of the increased risk of PID with IUD use occurs during the month following insertion. This risk may be reduced by taking precautions during the transcervical procedure (see Chapter 2).
Avoid unnecessary removal and re-insertions. For example, the Copper T380A provides safe and effective protection against pregnancy for 10 years. The effective duration of use varies for each type of IUD and the provider and client should be aware of the duration of effectiveness of the device chosen.

Any woman with signs of cervical infection (mucopurulent cervical discharge or cervical friability) should be treated for gonorrhoea and chlamydia using Treatment table 2 (Chapter 8); her partner should also receive treatment. The insertion of an IUD must be delayed until the infection is cured. The patient should also be counselled about dual protection.

Women with lower abdominal, uterine, adnexal or cervical motion tenderness should be treated for PID using Treatment table 3 in Chapter 8 and counselled about alternative contraceptive methods (emphasizing dual protection). Women who are at high individual risk for gonorrhoea or chlamydial infection should usually not use the IUD, unless other more appropriate methods are unavailable or unacceptable.

If a woman develops PID, purulent cervicitis, chlamydial infection or gonorrhoea while using the IUD, there is usually no need to remove the IUD while being treated for the infection if the woman wishes to continue IUD use.

Spermicides and diaphragm with spermicides

Women at high risk for HIV infection or those already HIV-infected should not use spermicides. Repeated and high-dose use of the spermicide nonoxynol-9 is associated with an increased risk of genital lesions, which may increase the risk of acquiring HIV infection. Women at high risk of HIV infection or those who are HIV-infected should not use the diaphragm with spermicides unless other more appropriate methods are unavailable or unacceptable.

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	Department of Reproductive Health and Research (RHR), World Health Organization Sexually transmitted and other reproductive tract infections A guide to essential practice	Preface/Full text PDF About the guide Abbreviations Glossary