Oral contraceptive pills emerged in the United States in the mid-1960s. This was just the beginning of a series of methods that emerged with a view to preventing pregnancy. New routes of administration have been studied and used. At the Family Planning Outpatient Clinic of the Women's Hospital - Caism, at Unicamp, a reference center for women in the Campinas macro-region, the most modern contraceptives on the market are being offered. Patients can even count on long-lasting methods today, such as copper IUDs (intra-uterine devices), mainly with levonorgestrel, called mirena, which is effective for five years, in addition to the implanon subdermal implant, which inhibits women's ovulation. for three years.
According to Ilza Monteiro, gynecologist at Caism and professor at the Department of Tocogynecology at the Faculty of Medical Sciences (FCM), the focus of this outpatient clinic is to offer cutting-edge technology in contraception based on research with great scientific evidence. Furthermore, the service fulfills an important training role for Tocogynecology and Family Health doctors and residents. “We follow the concept here that LARCs (Long-Acting Reversible Contraception) are the most effective methods to prevent unplanned pregnancies, as they are long-acting, reversible contraceptives.”
The majority of women who arrive at Unicamp, says the professor, generally come with an indication of using the Mirena IUD, as this device is not yet distributed in the basic network. Many of them come with a history of having many children due to pill failure, heavy uterine bleeding or because they were unable to get an IUD. “The copper IUD is provided by the SUS to patients, but doctors lack training in this procedure and few units offer the method”, she explains.
The Caism Family Planning Outpatient Clinic has just reinforced its training for resident doctors to insert IUDs, which is done regularly. “The expectation is to also increase training for the placement of subdermal implants”, says the doctor, who is responsible for the outpatient clinic.
Worldwide, the most used non-surgical contraceptive methods are IUDs, implants, contraceptive pills and the male condom. In the Brazilian public network, the pill is the most accepted method. “Unfortunately, 53% of pregnancies in the country occur due to method failure”, explains the gynecologist. Studies, however, show that long-term methods are more effective and often safer.
At the moment, there are monthly injections on the market, which contain estrogen and progestogen – whose commercial names are mesigyna, cyclofemina, depomês, among others. The hospital, in this case, receives donations from companies on a monthly basis of depot medroxyprogesterone acetate (depo provera), which is effective quarterly, in addition to offering more traditional methods. The service is currently participating in a prominent study that aims to reduce the amount of depo provera hormone.
The difference at Unicamp is that patients actively participate in choosing the method that best suits their lifestyle. They undergo family planning counseling, work also recommended by European and North American countries. The intention is to provide them with information so that they can make a conscious decision, given that contraceptive methods impact their lives, whether by altering the bleeding pattern or even comfort.
Good news, reveals Ilza, is that the rate of continued use of methods by women treated at Caism is very good: it is above 80%. “On average, in the literature, this rate is between 50% and 60%. This number is believed to be significant due to the strategy of offering LARCs at no cost. Women who are well educated about unplanned pregnancies tend to choose LARCs.”
Caism places about 15 IUDs per day, except on Thursdays. Implants, even though they are the only viable method for some women, have limited distribution, because the clinic depends on donations. On the other hand, at all appointments, all women can carry male condoms with them.
Advance
Ilza remembers that Unicamp has always had a pioneering role in family planning and that FCM professor Aníbal Faúndes played a leading role in the first tests with the Mirena IUD in Brazil, alongside Finnish researcher T. Luukkainen, in the 1980s.
She explains that the non-governmental organization (NGO) Population Council was interested in knowing the acceptance rates of the method, as it seeks, through partnerships, solutions that lead to more effective policies, programs and technologies in preventing unplanned pregnancy, one of the biggest factors related to poverty in the world.
These tests showed good acceptance, and mirena stood out with advantages: the device did not interact with other medications, as it was introduced into the uterus and did not depend on remembering to take it daily, like the pill. It was only up to the woman to regularly check the device.
The copper IUD is an effective method also available in Family Planning. One of its problems is that it can increase menstrual bleeding, leading to a higher rate of anemia. Mirena has the opposite effect: it reduces bleeding due to levonorgestrel, a drug capable of suppressing menstruation. It is almost the same size as the copper IUD, and the insertion procedure is quick in approximately 80% of women, lasting an average of five minutes. “Even though it brings moderate discomfort to women treated at our outpatient clinic, around 85% of them have no complaints of relevant pain and the rest can resort to anesthesia”, reports the professor.
As mirena reduces bleeding, it is recommended for women with menstrual cramps and endometriosis. In addition to providing a contraceptive effect, they improve your quality of life, as menstrual complications are reduced. The failure rate is only 0,3 in every 1.000 women.
The expected rate of IUD expulsion is two to three in every 100 women in the first year of use. For those who bleed more, the expulsion rate is slightly higher: around eight out of every 100 women, and should be monitored more frequently.
The IUD can be used by any woman and, especially, by teenagers. The idea is to avoid unplanned pregnancies, which take teenagers out of school early and whose consequences can be socially reflected. When using pills, these women may have higher failure rates (3 in every 1.000 women) as they forget to take them, and this forgetfulness can lead to unplanned pregnancies.
In some cases, it is not possible to insert the IUD, in others the woman does not want to use the intrauterine method and prefers to use the implanon – a very well-accepted and effective method, especially because it is implanted in the arm and does not move.
The implanon is a type of cylindrical silicone reservoir – a tube – that is applied under the skin, in the triceps region. It is implanted on an outpatient basis under local anesthesia, releasing the tube. To remove it, a small incision is made using local anesthesia. It is considered one of the most effective methods at the moment.
The American College of Pediatrics and the American College of Gynecology recommend that younger women use LARCs, with an emphasis on IUDs and implants. This procedure is already indicated even before the use of the oral pill is prescribed, which has become a second line in the approach to contraception.
The IUD can be adopted by women who have not had children. More or less 25% of outpatient patients do not have children. The suggestion then is to use the IUD, due to its long-lasting appeal.
Therefore, family planning counseling is essential when choosing methods. It emerged as a necessity when contraceptive methods were devised. Making women have less fear and fewer myths was a way of ensuring that they continued to use these methods, according to Ilza.
“We have an extremely efficient public service that brings cutting-edge medicine here. This outpatient clinic is the result of the work of the Tocogynecology Department, the researchers who preceded us (Aníbal Faúndes, José Aristodemo Pinotti, Juan Díaz, Carlos Petta) and Professor Luís Bahamondes, who with incessant work has maintained an open channel with the WHO and the Population Council, of which we are partners in the work of offering contraceptive safety and effectiveness for women”, highlights the professor.
Warmth
Family Planning counseling was initially carried out in groups, where women spoke about their doubts and received educational material prepared by professionals in the area. Then it became individual and now it has become collective again.
A group is formed with all the women who are being seen for the first time. According to nurse Elaine Garcia, who works at this outpatient clinic, the vast majority of them already come with an indication of a method from the health center. “However, it will not necessarily be the choice”, she informs.
She says that women are welcomed in a room with several mattresses positioned on the floor, so they can relax their pelvis and talk about the methods. As most of them have been seeking the placement of IUDs and implants, the conversation generally revolves around both methods. “We explain how they work, the mechanism of action, the side effects, the precautions, what changes in the couple’s relationship and the possible discomfort of the procedure.”
In this room, women are given creams based on essential oils with pleasant fragrances to be used on the hands, stomach or sole of the foot. “Aromatherapy helps a lot. When a woman is anxious, she contracts her muscles more and holds her breath. With the cream, she feels more comfortable. A hot water bottle is also used after insertion of the IUD, as a non-pharmacological method of analgesia, to relieve pain”, highlights Elaine.
Then, patients undergo an interview, in which their personal data is collected. They then receive the IUD or implant, returning to the outpatient clinic between 45 and 60 days after the procedure, and continue with follow-up in the basic network.
