INFO Reports, World Health Organization Updates Guidance on How To Use Contraceptives

			World Health Organization Updates Guidance on How To Use Contraceptives
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April 2005 • Issue No. 4

Key Points
New Guidance Updates Previous Recommendations
WHO Simplifies the Missed-Pill Recommendation

Vasectomy Procedure Effective after Three Months
Duration of Norplant Implants Extended to Seven Years for Most Women
Emergency Contraception Advice Expanded
Guidance for Cu-IUDs Extended To the LNG-IUD
Bibliography
Acknowledgements
Subscription and Ordering Information

KEY POINTS

The World Health Organization (WHO) issued new guidance in 2004 on how to use certain contraceptives safely and effectively, including the following:

A woman who misses combined oral contraceptive pills should take a hormonal pill as soon as possible and then continue taking one pill each day. This basic guidance applies no matter how many hormonal pills a woman misses. Only if a woman misses three or more hormonal pills in a row will she need to take additional steps (see WHO Simplifies the Missed-Pill Recommendation). The new guidance simplifies the missed-pill rules issued by WHO in 2002.

Men should wait three months after a vasectomy procedure before relying on it. Previous guidelines advised men to wait either three months after the procedure or until they had had at least 20 ejaculations, whichever occurred first. Recent studies have shown, however, that the 20-ejaculation criterion is not a reliable gauge of vasectomy effectiveness. A three-month waiting period is more reliable (see Vasectomy Procedure Effective after Three Months).

Norplant^® implants can remain in place for up to seven years in women weighing less than 70 kg. Regulatory agencies generally have approved Norplant implants for a maximum of five years of use. Recent evidence shows that the implants remain effective for seven years for most women. Heavier women may need to have them removed after four or five years (see Duration of Norplant Implants Extended to Seven Years for Most Women).

Emergency contraceptive pills (ECPs) should be taken as soon as possible after unprotected sex but can be taken up to 120 hours later. WHO recommends that a woman take ECPs as soon as possible after having unprotected sex—ideally within 72 hours. Taking them even as late as 120 hours after unprotected sex can help prevent pregnancy. The longer a woman waits to take ECPs, however, the less likely they are to be effective (see Emergency Contraception Advice Expanded).

A single dose of levonorgestrel alone is the best regimen for emergency contraception. WHO recommends three options for ECP regimens. The preferred regimen is 1.5 mg of levonorgestrel in a single dose. This regimen is best both because people tend to prefer and comply with single-dose regimens and because the levonorgestrel-only option has fewer side effects than the combined estrogen-levonorgestrel option. Two other regimens are acceptable alternatives if the single dose of levonorgestrel is not available (see Three dosage options under Emergency Contraception Advice Expanded).

The new WHO recommendations reflect consensus reached at a meeting of family planning experts in April 2004 at WHO headquarters in Geneva, Switzerland. The Expert Working Group of 29 international family planning specialists from 15 countries comprised clinicians, epidemiologists, policy makers, and program managers (see box below).

Source of Evidence Related to WHO Recommendations

In this issue of INFO Reports, the citations to research studies come from systematic reviews conducted on behalf of the WHO Secretariat for the April 2004 Expert Working Group Meeting. The Expert Working Group reviewed this evidence in considering and reaching its decisions about the Selected Practice Recommendations.

In general, these systematic reviews selected articles that were:

Found through searches of MEDLINE, POPLINE, and similar bibliographic databases;
Published in peer-reviewed journals through February 2004; and
Reported studies, systematic reviews of studies, or meta-analyses that examined the biomedical and behavioral components of the questions posed to the Expert Working Group, from which the Selected Practice Recommendations stemmed.

These systematic reviews were conducted by: Kathryn Curtis and Anshu Mohllajee of the US Centers for Disease Control and Prevention; Mary Lyn E. Gaffield of WHO; and Kavita Nanda of Family Health International.

Participants in the 2004 WHO Expert Working Group include: Yasmin H. Ahmed, Halida Akhter, Marcos Arevalo, Tsungai Chipato, Maria del Carmen Cravioto, Soledad Diaz, John Guillebaud, Kerstin Hagenfeldt, Ezzeldin Othman Hassan, Robert Hatcher, Mihai Horga, Douglas Huber, Roy Jacobstein, Pisake Lumbiganon, Pamela Lynam, Trent MacKay, Polly Marchbanks, Olav Meirik, Noel McIntosh, Helen Rees, Roberto Rivera, Fred Sai, Pramilla Senanayake, James Shelton, Irving Sivin, Connie Smith, Fatiha Terki, Marcel Vekemans, and Edith Weisberg.

Updating the WHO recommendations. To ensure that WHO’s guidance stays current, new research articles whose study objectives concern topics addressed by the Selected Practice Recommendations or Medical Eligibility Criteria are identified by the online system CIRE (Continuous Identification of Research Evidence). Any updates to current WHO guidance appear on WHO’s Web site. Records of all articles that CIRE has identified can be found at http://www.infoforhealth.org/cire/cire_pub.pl. Visitors to this Web page can sign up for e-mail notification when CIRE posts new records. Also, The Pop Reporter e-zine, at http://www.infoforhealth.org/popreporter/current.shtml, notifies its readers of new postings. Free subscription is available at http://prds.infoforhealth.org/signup.php.

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