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Consensus canadien sur la contraception (3e partie de 4) : chapitre 8 – contraception à progestatif seul

Published:March 31, 2016DOI:https://doi.org/10.1016/j.jogc.2016.03.005

      Résumé

      Objectif

      Fournir des lignes directrices aux fournisseurs de soins quant à l’utilisation de modes de contraception pour la prévention de la grossesse et quant à la promotion d’une sexualité saine.

      Issues

      Orientation des praticiens canadiens en ce qui concerne l’efficacité globale, le mécanisme d’action, les indications, les contre-indications, les avantages n’étant pas liés à la contraception, les effets indésirables, les risques et le protocole de mise en œuvre des modes de contraception abordés; planification familiale dans le contexte de la santé sexuelle et du bien-être général; méthodes de counseling en matière de contraception; et accessibilité et disponibilité des modes de contraception abordés au Canada.

      Résultats

      La littérature publiée a été récupérée par l’intermédiaire de recherches menées dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d’un vocabulaire contrôlé (p. ex. contraception, sexuality, sexual health) et de mots clés (p. ex. contraception, family planning, hormonal contraception, emergency contraception) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1994 et janvier 2015. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu’en juin 2015. La littérature grise (non publiée) a été identifiée par l’intermédiaire de recherches menées dans les sites Web d’organismes s’intéressant à l’évaluation des technologies dans le domaine de la santé et d’organismes connexes, dans des collections de directives cliniques, dans des registres d’essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

      Valeurs

      La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs (Tableau 1).

      Chapitre 8 : Contraception à progestatif seul

      Déclarations sommaires
      • 15.
        Les implants de progestatif comptent des taux d’échec aussi faibles que ceux de la contraception permanente. (II-2)
      • 16.
        L’insertion d’un implant immédiatement à la suite d’un accouchement ou d’un avortement constitue une façon efficace d’abaisser les taux de nouvelle grossesse chez les adolescentes et de nouvel avortement. (II-2)
      • 17.
        Les perturbations du cycle menstruel constituent l’effet indésirable le plus courant des modes de contraception à progestatif seul. (II-2) L’aménorrhée est très courante dans le cadre de l’utilisation d’acétate de médroxyprogestérone-retard et d’implants de progestatif. (II-2)
      • 18.
        L’utilisation de progestatifs administrés selon des doses contraceptives ne semble pas accroître le risque de thromboembolie veineuse, d’infarctus du myocarde ou d’accident vasculaire cérébral. (II-2)
      • 19.
        L’efficacité des implants de progestatif (ou de l’acétate de médroxyprogestérone) n’est pas amoindrie chez les femmes obèses ou présentant une surcharge pondérale. (II-2)
      • 20.
        La constatation d’un gain pondéral précoce dans le cadre de l’utilisation d’acétate de médroxyprogestérone-retard permet de prédire la poursuite du gain pondéral. (II-2)
      • 21.
        L’utilisation d’acétate de médroxyprogestérone-retard est associée à un délai quant à la reprise de l’ovulation. (II-2)
      • 22.
        L’utilisation d’acétate de médroxyprogestérone-retard est associée à une baisse de la densité minérale osseuse. Cette baisse atteint sa rapidité maximale au cours des deux premières années d’utilisation et semble être largement réversible à la suite de l’abandon du traitement à l’acétate de médroxyprogestérone-retard. (I) Nous ne disposons pas de données probantes solides indiquant que l’utilisation d’acétate de médroxyprogestérone-retard cause l’ostéoporose (II-2) ou qu’elle entraîne une hausse du risque de fracture. (II-2)
      • 23.
        Il n’a pas été démontré que l’utilisation de préparations à progestatif seul entraîne une baisse de la production de lait maternel. (I) Les petites quantités d’hormones stéroïdiennes sécrétées dans le lait maternel n’exercent pas un effet indésirable sur la croissance et le développement du nouveau-né. (II-2)
      • 24.
        L’utilisation d’acétate de médroxyprogestérone-retard est associée à une baisse des risques de cancer de l’endomètre et de cancer de l’ovaire. (II-2)
      Recommandations
      • 12.
        Le recours à des modes de contraception à progestatif seul devrait être envisagé chez les femmes qui présentent des troubles médicaux dans le cadre desquels la prise d’œstrogènes est contre-indiquée ou moins souhaitable, comme dans le cas des femmes qui ont récemment connu un accouchement, qui allaitent ou qui fument et qui sont âgées de plus de 35 ans. (III-A)
      • 13.
        Aucune restriction ne devrait être imposée quant à l’utilisation d’acétate de médroxyprogestérone-retard (y compris en ce qui a trait à la durée d’utilisation) chez les femmes en âge de procréer qui sont autrement admissibles à l’utilisation de ce mode de contraception. Les risques et les avantages globaux de la poursuite de l’utilisation d’acétate de médroxyprogestérone-retard devraient faire l’objet de discussions avec les utilisatrices à intervalles réguliers tout au long du traitement. (III-A)
      • 14.
        Des services de counseling traitant des perturbations du cycle menstruel devraient être offerts avant la mise en œuvre d’un mode de contraception à progestatif seul. (I-A)
      • 15.
        Les fournisseurs de soins devraient aviser leurs patientes des effets potentiels de l’acétate de médroxyprogestérone-retard sur la densité minérale osseuse et leur offrir des conseils en matière de « santé osseuse » (y compris en ce qui concerne la supplémentation en calcium et en vitamine D, l’abandon du tabagisme, la pratique d’exercices de port de poids et l’atténuation de la consommation d’alcool et de caféine). (III-A)
      • 16.
        En présence de saignements prolongés et/ou fréquents chez des utilisatrices de contraceptifs à progestatif seul, la présence d’une grossesse, d’une infection transmissible sexuellement ou d’une pathologie génitale devrait être écartée. (III-B)
      • 17.
        La possibilité d’une grossesse ectopique doit être écartée lorsqu’une grossesse en vient à se manifester chez une femme qui utilise un mode de contraception à progestatif seul. (III-A)

      Mots clés

      Abréviations:

      AMPR (acétate de médroxyprogestérone-retard), CDC (Centers for Disease Control and Prevention), CIU (contraceptif intra-utérin), COC (contraceptifs oraux combinés), CRAB (contraception réversible à action brève), CRAP (contraception réversible à action prolongée), DIU-Cu (dispositif intra-utérin au cuivre), DMO (densité minérale osseuse), ECR (essais comparatifs randomisés), ENG (étonogestrel), IMC (indice de masse corporelle), ITS (infections transmissibles sexuellement), LH (hormone lutéinisante), LNG (lévonorgestrel), OMS (Organisation mondiale de la santé), PPS (pilules à progestatif seul), TEV (thromboembolie veineuse), VIH (virus de l’immunodéficience humaine)
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