CONTRACEPTION Dr SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT...

CONTRACEPTION CONTRACEPTION

Dr SALWA NEYAZICONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

Dr SALWA NEYAZICONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

FEMALE CONTRACEPTIONFEMALE CONTRACEPTION

Barrier MethodsBarrier Methods DiaphragmDiaphragm Cervical capCervical cap Female condomFemale condomHormonal Methods Hormonal Methods Oral contraceptive - Combined oestrogen/Oral contraceptive - Combined oestrogen/ progestogenprogestogen - Progestogen only- Progestogen only Depot progestogens – InjectionsDepot progestogens – Injections - Subcutaneous silicone- Subcutaneous silicone implantsimplants Vaginal - Silicone rings releasing oestrogen & Vaginal - Silicone rings releasing oestrogen &

progestogenprogestogen


Intra Uterine Devices Intra Uterine Devices InertInert Copper bearingCopper bearing Progestogen releasing.Progestogen releasing.

Natural Methods Natural Methods Rhythm Rhythm Breast feeding (while baby is totally breast fed)Breast feeding (while baby is totally breast fed)

Spermicides Spermicides Creams, Films, Foams, Jellies, Pessaries, SpongesCreams, Films, Foams, Jellies, Pessaries, Sponges (All of these are mainly Nonoxynol based.)(All of these are mainly Nonoxynol based.)


Surgical Methods Surgical Methods Laparoscopic sterilisation - RingsLaparoscopic sterilisation - Rings

- Clips- Clips

- Bipolar diathermy- Bipolar diathermy

- Laser- Laser Tubal ligationTubal ligation

Immunological MethodsImmunological Methods

- These are still at an investigative stage.- These are still at an investigative stage.

MALE CONTRACEPTIONMALE CONTRACEPTION

CondomCondom VasectomyVasectomy Male oral contraception with androgensMale oral contraception with androgens

and with cotton seed oiland with cotton seed oil Immunological contraception Immunological contraception

Still at Still at investigative investigative stagestage..

Relative popularity of methods

(National Opinion Poll, 1990, Schering Healthcare. (National Opinion Poll, 1990, Schering Healthcare. Women aged 16-44.) Women aged 16-44.)

Oral contraception 32%Oral contraception 32% No contraception 22%No contraception 22% Condoms 17% Condoms 17% Female sterilisation 12%Female sterilisation 12% Male sterilisation 12%Male sterilisation 12% IUCD 8%IUCD 8% Diaphragm/Cap 2%Diaphragm/Cap 2% Withdrawal 2%Withdrawal 2% Rhythm 0.5%Rhythm 0.5%

EFFECTIVENESS OF FAMILY PLANNINGEFFECTIVENESS OF FAMILY PLANNING

METHODMETHODAs commonly usedAs commonly usedUsed correctly & Used correctly & consistentlyconsistently

VasectomyVasectomy0.20.20.10.1

DMPADMPA0.30.30.30.3

♀♀SterilizationSterilization0.50.50.50.5

Cu IUCDCu IUCD0.80.80.60.6

Progestrone OCP Progestrone OCP /Breast feeding/Breast feeding

110.50.5

Lactational Lactational amenorrheaamenorrhea

220.50.5

Combined OCPCombined OCP6-86-80.10.1

Progestrone OCP Progestrone OCP /Not breast feeding/Not breast feeding

8-98-90.50.5

♂ ♂ CondomCondom141433

Coitus interruptusCoitus interruptus191944

Pregnancies /100 women /1st year of use

EFFECTIVENESS OF FAMILY PLANNINGEFFECTIVENESS OF FAMILY PLANNING

Diaphram with Diaphram with spermicidespermicide

202066

Fertility awareness Fertility awareness based methodbased method

20201-91-9

♀ ♀ CondomCondom212155

SpermicidesSpermicides262666

Cervical capCervical cap

Nulliparous womenNulliparous women202099

Cervical capCervical cap

Parous womenParous women40402626

No methodNo method85858585

COMBINED ORAL COMBINED ORAL CONTRACEPTIVE PILLSCONTRACEPTIVE PILLS

COMBINED ORAL CONTRACEPTIVE PILLSCOMBINED ORAL CONTRACEPTIVE PILLS

It was first introduced in 1960It was first introduced in 1960 It has been used by millions of women worldwideIt has been used by millions of women worldwide Two types of estrogens are usedTwo types of estrogens are used :ethinyl :ethinyl

estradioleestradiole

& mestranol. Mestranol is converted in the body to & mestranol. Mestranol is converted in the body to ethinyl estradioleethinyl estradiole

Several progestins of varying potency are used in Several progestins of varying potency are used in the combined OCPthe combined OCP

Types of progestins in C OCPTypes of progestins in C OCP Estrane Estrane Norethindrone, ethynodiol diacetate Norethindrone, ethynodiol diacetate Gonane Gonane Levonorgestrel, desogestrel, Levonorgestrel, desogestrel,

norgestimate ( gonans more potent)norgestimate ( gonans more potent)

PROGESTINS IN COCPPROGESTINS IN COCP

Progestins are also classified to 1Progestins are also classified to 1stst, 2, 2ndnd, 3, 3rdrd, , generation progestinsgeneration progestins

22ndnd levonorgestril levonorgestril 33rdrd desogestril & gestodenedesogestril & gestodene Norgestimate Norgestimate partly converted to levonorgestril partly converted to levonorgestril

included in 2included in 2ndnd or 3 or 3rdrd gp gp Newer progestins Newer progestins desogestril & norgestimate desogestril & norgestimate

have little or no androgenic activity have little or no androgenic activity VTE is 2 folds higher in preparation containing 3VTE is 2 folds higher in preparation containing 3rdrd

generation progestins when compared to 2generation progestins when compared to 2ndnd generationgeneration


Dosage & regimenDosage & regimen Estrogen Estrogen 20-35 20-35μμg/ dayg/ day Better cycle control with higher estrogen dosage Better cycle control with higher estrogen dosage

but the efficacy is the samebut the efficacy is the same Used for 3 wks with one wk gap when Used for 3 wks with one wk gap when

menstruation occurs menstruation occurs FormulationsFormulations Monophasic Monophasic contains fixed amount of estrogen contains fixed amount of estrogen

& progestin& progestin Biphasic Biphasic a fixed amount of estrogen, while the a fixed amount of estrogen, while the

progestin increases in the 2progestin increases in the 2ndnd half of the cycle half of the cycle Triphasic Triphasic the amount of estrogen may be fixed the amount of estrogen may be fixed

or variable, while the amount of progestin or variable, while the amount of progestin increases in 3 equal phases increases in 3 equal phases


Efficacy Efficacy C OCP is highly effective 99.9% in preventing C OCP is highly effective 99.9% in preventing

pregnancy. However the user failure rate is 3-8%pregnancy. However the user failure rate is 3-8% 30% of women miss 3 or more pills in the 130% of women miss 3 or more pills in the 1stst cycle of cycle of

useuse 47% miss 1 or more pills47% miss 1 or more pills ↑ ↑ body Wt may ↓ the efficacy of the pills ( not proven)body Wt may ↓ the efficacy of the pills ( not proven)

Indication Indication Any women seeking a reversible, reliable, coitally-Any women seeking a reversible, reliable, coitally-

independent method of contraception, in the absence of independent method of contraception, in the absence of contraindications contraindications


Mechanism of actionMechanism of action

Suppression of gonadotropin secretion Suppression of gonadotropin secretion inhibition of inhibition of ovulation ovulation (main mechanism)(main mechanism)

Development of endometrial atrophy making it Development of endometrial atrophy making it unreceptive to implantationunreceptive to implantation

Production of viscous Cx mucous that impede sperm Production of viscous Cx mucous that impede sperm transporttransport

Possible effect on the secretions & peristalsis of the Possible effect on the secretions & peristalsis of the fallopian tube interfering with ovum & sperm transportfallopian tube interfering with ovum & sperm transport


Absolute contraindicationsAbsolute contraindications < 6 Wk postpartum if breastfeeding< 6 Wk postpartum if breastfeeding Smoker ≥ 15 cigarettes/day, > 35 Y of ageSmoker ≥ 15 cigarettes/day, > 35 Y of age HPT systolic ≥ 160 mm Hg or diastolic ≥ 100 mm HgHPT systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg Current or past Hx of venous thromboembolism VTECurrent or past Hx of venous thromboembolism VTE Ischemic heart diseaseIschemic heart disease Hx of cerebrovascular accidentHx of cerebrovascular accident Complicated valvular heart disease (pulmonary HPT, Complicated valvular heart disease (pulmonary HPT,

atrial fibrilation, subacute bacterial endocarditis)atrial fibrilation, subacute bacterial endocarditis) Migraine headache with focal neurological symptomsMigraine headache with focal neurological symptoms Current breast cancerCurrent breast cancer Diabetes with retinopathy/ nephropathy/ neuropathyDiabetes with retinopathy/ nephropathy/ neuropathy Severe liver cirrhosisSevere liver cirrhosis Liver tumour ( adenoma or hepatoma) Liver tumour ( adenoma or hepatoma)


Relative contraindicationsRelative contraindications

Smoker Smoker < 15 cigarettes /day < 15 cigarettes /day >35 Y of age>35 Y of age Adequately controlled HPTAdequately controlled HPT HPT systolic 140-159 mm Hg, diastolic 90-99 mm HPT systolic 140-159 mm Hg, diastolic 90-99 mm

HgHg Migraine headache > 35 Y of ageMigraine headache > 35 Y of age Currently symptomatic gallbladder diseaseCurrently symptomatic gallbladder disease Mild liver cirrhosisMild liver cirrhosis Hx of C OCP related cholestasisHx of C OCP related cholestasis Medications that might interfere with OCP Medications that might interfere with OCP

metabolismmetabolism


Non-contraceptive Non-contraceptive benefitsbenefits

Cycle regulationCycle regulation ↓↓ ↓↓ menstrual flow menstrual flow ↓↓ ↓↓

anemiaanemia

↑↑ ↑↑ bone mineral densitybone mineral density ↓↓ ↓↓ dysmenorrheadysmenorrhea ↓↓ ↓↓ peri-menopausal peri-menopausal

symptomssymptoms ↓↓ ↓↓ acneacne ↓↓ ↓↓ hirsutismhirsutism ↓↓ ↓↓ ovarian ca 50% ↓↓ ovarian ca 50% ↓↓

after 5 Y of useafter 5 Y of use

↓↓ ↓↓ endometrial ca 50% ↓↓endometrial ca 50% ↓↓ ↓↓ ↓↓ risk of fibroidsrisk of fibroids Possibly ↓ ovarian cystsPossibly ↓ ovarian cysts Possibly ↓ benign breast Possibly ↓ benign breast

diseasedisease Possibly ↓ colorectal caPossibly ↓ colorectal ca ↓↓ ↓↓ incidence of salpingitisincidence of salpingitis ↓↓ ↓↓ incidence or severity of incidence or severity of

premenstrual syndromepremenstrual syndrome

SIDE-EFFECTS OF COMBINED OCPSIDE-EFFECTS OF COMBINED OCP

Minor side-effects commonly occure during the 1Minor side-effects commonly occure during the 1stst 3 cycles & may lead to unnecessary 3 cycles & may lead to unnecessary discontinuationdiscontinuation

1. Irregular bleeding1. Irregular bleeding (breakthrough bleeding/ (breakthrough bleeding/ spotting)spotting)

10-30% in the 110-30% in the 1stst month of use month of use improves with time over 3 cyclesimproves with time over 3 cycles amenorrhea 2-3% of the cyclesamenorrhea 2-3% of the cycles

2. Breast tenderness & nausea2. Breast tenderness & nausea Improve with timeImprove with time Less with lower estrogen dosageLess with lower estrogen dosage

SIDE-EFFECTS OF COMBINED OCPSIDE-EFFECTS OF COMBINED OCP

3-Wt gain3-Wt gain Placebo controlled trials have failed to show any Placebo controlled trials have failed to show any

association between wt gain & COCPassociation between wt gain & COCP

4-Mood changes4-Mood changes Women report depression & mood changesWomen report depression & mood changes Placebo controlled trials have failed to show any Placebo controlled trials have failed to show any

significantly increased risk of mood changes with significantly increased risk of mood changes with COCPCOCP

RISKS OF COCPRISKS OF COCP

1-Venous thromboembolism1-Venous thromboembolism VTE 3-4 X higher in users than nonusersVTE 3-4 X higher in users than nonusers Absolute risk of VTE in COCP users – Absolute risk of VTE in COCP users –

1-1.5/10 000/year1-1.5/10 000/year Risk of VTE is higher during the 1Risk of VTE is higher during the 1stst year of use than year of use than

subsequent yearssubsequent years Incidence of VTE in nonpregnant women is 0.3/ Incidence of VTE in nonpregnant women is 0.3/

10000/year at 20-24 Y------0.6 at 40-44 Y10000/year at 20-24 Y------0.6 at 40-44 Y Incidence of VTE in pregnancy is 13/ 10000 Incidence of VTE in pregnancy is 13/ 10000

deliveriesdeliveries The risk is attributed to the estrogen component of The risk is attributed to the estrogen component of

the pill & decline with lower dosagethe pill & decline with lower dosage


2- Myocardial infarction2- Myocardial infarction In the past with pills containing >50In the past with pills containing >50μμg ethinyl g ethinyl

estradiole --- 3X estradiole --- 3X ↑↑ in MI↑↑ in MI

Recent studies with pills containing < 50Recent studies with pills containing < 50μμg ethinyl g ethinyl estradiole ----- No significant ↑↑ riskestradiole ----- No significant ↑↑ risk


3-Stroke3-Stroke Some studies showed 2X Some studies showed 2X ↑↑ risk of stroke↑↑ risk of stroke Smoking & HPT Smoking & HPT ↑↑ risk of stroke↑↑ risk of stroke

4-Gallbladder disease4-Gallbladder disease COCP COCP ↑↑ secretion of cholic acid in bile ↑↑ secretion of cholic acid in bile ↑↑ incidence of ↑↑ incidence of

gallstone formationgallstone formation No significant ↑↑ risk of gallstone formation in COCP usersNo significant ↑↑ risk of gallstone formation in COCP users

5-Breast cancer5-Breast cancer Still controversialStill controversial A large meta-analysis 1996 A large meta-analysis 1996 significant ↑ risk of breast significant ↑ risk of breast

ca in women currently taking the COCP( Relative Risk ca in women currently taking the COCP( Relative Risk 1.24 ) & in the 11.24 ) & in the 1stst 10 Y after discontinuing it 10 Y after discontinuing it


5-Breast cancer5-Breast cancer Cumulative breast ca risk up to age 35 is 2 / 1000Cumulative breast ca risk up to age 35 is 2 / 1000

with COCP --------------------------------------- 3 / 1000with COCP --------------------------------------- 3 / 1000 It It is not known whether this ↑ is due to the pills or due to is not known whether this ↑ is due to the pills or due to

delaying the 1delaying the 1stst full term birth full term birth More recent study > 9000 women More recent study > 9000 women no significant ↑↑ no significant ↑↑

in breast ca riskin breast ca risk

No ↑↑ risk with different dosage of estrogen, longer No ↑↑ risk with different dosage of estrogen, longer periods of use, or with different progestin componentsperiods of use, or with different progestin components

No ↑↑ risk in Pt with family Hx of breast caNo ↑↑ risk in Pt with family Hx of breast ca

No ↑↑ risk in Pt who started using the pills at an earlier No ↑↑ risk in Pt who started using the pills at an earlier ageage

↑↑ ↑↑ risk in Pt who carry BRCA1, BRCA2 genesrisk in Pt who carry BRCA1, BRCA2 genes


6-Cervical cancer6-Cervical cancer One study One study ↑↑ risk of Cx ca in long term COCP users ↑↑ risk of Cx ca in long term COCP users

who are HPV positivewho are HPV positive A review of 28 studies of women with Cx ca A review of 28 studies of women with Cx ca ↑↑ risk of ↑↑ risk of

Cx ca with ↑↑ duration of COCP useCx ca with ↑↑ duration of COCP use Probably due to ↑↑ risk of HPV (a major risk factor for cx Probably due to ↑↑ risk of HPV (a major risk factor for cx

ca) that might be related to sexual behavior which differs ca) that might be related to sexual behavior which differs in users & non users of COCPin users & non users of COCP

Another study HPV + ve women follwed up for 10 years Another study HPV + ve women follwed up for 10 years showed no increased riskshowed no increased risk

MYTHS & MISCONCEPTIONMYTHS & MISCONCEPTION

Women on COCP should have periodic pill breaksWomen on COCP should have periodic pill breaks

Fact Fact this would this would ↑↑ risk of unwanted pregnancies & ↑↑ risk of unwanted pregnancies & cycle iregularitiescycle iregularities

COCP affects future fertilityCOCP affects future fertility

Fact Fact fertility restored 1-3 M after stopping the fertility restored 1-3 M after stopping the pillspills

COCP causes birth defects if a woman becomes COCP causes birth defects if a woman becomes pregnant while taking itpregnant while taking it

Fact Fact There is no evidence that it causes birth There is no evidence that it causes birth defectsdefects

MYTHS & MISCONCEPTIONMYTHS & MISCONCEPTION

COCP must be stopped in all women >35 YCOCP must be stopped in all women >35 Y

Fact Fact Healthy non-smoking women can continue Healthy non-smoking women can continue taking the pills untill menopausetaking the pills untill menopause

COCP causes acneCOCP causes acne

Fact Fact it improves acne due it improves acne due ↓ circulating free ↓ circulating free androgensandrogens

INITIATIONINITIATION

Patient assessmentPatient assessment A thorough Hx to exclude contraindications, A thorough Hx to exclude contraindications,

smoking & medicationssmoking & medications BPBP Pelvic exam not mandatory before prescribing Pelvic exam not mandatory before prescribing

COCPCOCP No routine lab screening is requiredNo routine lab screening is requiredCounselling Counselling Instructions on how to use the pills Instructions on how to use the pills To start in the 1To start in the 1stst 5 days of the cycle 5 days of the cycleQuick start method Quick start method any day of the cycle any day of the cycle

requires the use of back up method of requires the use of back up method of contraception for the 1contraception for the 1stst wk wk

COUNSELLINGCOUNSELLING

Women who use 21 –day preparation should be Women who use 21 –day preparation should be cautioned not to exceed the 7 day pill-free cautioned not to exceed the 7 day pill-free interval between packsinterval between packs

Discussing what to do if a pill is missedDiscussing what to do if a pill is missed Information about side-effects, risks & non-Information about side-effects, risks & non-

contraceptive benefits of COCPcontraceptive benefits of COCP Addressing common myths & misconceptionsAddressing common myths & misconceptions Discussing warning signs & when to come to the Discussing warning signs & when to come to the

hospitalhospital The use of COCP in a continuous fashionThe use of COCP in a continuous fashion Vaginal administration of COCP Vaginal administration of COCP avoids 1 avoids 1stst pass pass

metabolism by the liver metabolism by the liver less side-effects less side-effects COCP must be stopped 4 wks prior to major COCP must be stopped 4 wks prior to major

surgery or users should be given antithrombotic surgery or users should be given antithrombotic prophylaxisprophylaxis

TROUBLESHOOTINGTROUBLESHOOTING

1-Breakthrough bleeding1-Breakthrough bleeding To continue on the same pills with the To continue on the same pills with the

expectation that it will improve with time (rather expectation that it will improve with time (rather than switching to another preparation)than switching to another preparation)

If bleeding persists beyond 3 M (or new onset of If bleeding persists beyond 3 M (or new onset of bleeding in a long term user ) rule out other bleeding in a long term user ) rule out other causes of bleeding:causes of bleeding:

-irregular taking of the pills-irregular taking of the pills

-pregnancy-pregnancy

-infections-infections

-uterine or Cx pathology-uterine or Cx pathology

-malabsorption/ diarrhea , vomitting-malabsorption/ diarrhea , vomitting

-concomitant use of medications-concomitant use of medications

TROUBLESHOOTINGTROUBLESHOOTINGManagement of breakthrough bleedingManagement of breakthrough bleeding Oral estrogens: premarine 1.25 mg or estradiole -17 ß /7 days Oral estrogens: premarine 1.25 mg or estradiole -17 ß /7 days

Change the another preparation with different progestin Change the another preparation with different progestin

2-Missed pills2-Missed pills Take the pill as soon as you remember ( this means taking 2 in Take the pill as soon as you remember ( this means taking 2 in

1 day)1 day) If 2 pills in a row missed in the 1If 2 pills in a row missed in the 1stst 2 wks of the pack 2 wks of the pack take 2 take 2

/day for 2 days/day for 2 days If 2 pills in a row missed in the 3If 2 pills in a row missed in the 3rdrd wk of the pack wk of the pack through the through the

remainder of the pack & start a new one / use back up remainder of the pack & start a new one / use back up contraception in the first 7 days of the new packcontraception in the first 7 days of the new pack

If 3 pills in a row missed If 3 pills in a row missed follow steps above follow steps above If intercourse occurred after missing a pill If intercourse occurred after missing a pill use emergency use emergency

contraceptioncontraception


3-Amenorrhea3-Amenorrhea It occurs in 2-3% of COCP usersIt occurs in 2-3% of COCP users Pregnancy should be ruled outPregnancy should be ruled out It is not dangerous It is not dangerous no need for Rx no need for Rx If not acceptable by Pt If not acceptable by Pt change preparation change preparation

Add oral estrogen for 10 daysAdd oral estrogen for 10 days

4-Chloasma4-Chloasma Darkening of the facial skin Darkening of the facial skin Changing to another preparation will not help Changing to another preparation will not help It may never completely disappear It may never completely disappear Use of sunscreen to prevent further darkeningUse of sunscreen to prevent further darkening

TROUBLESHOOTINGTROUBLESHOOTING5-Breast tenderness & galactorrhea5-Breast tenderness & galactorrhea Often resolves with continued useOften resolves with continued use ↓ ↓ caffeine intake may helpcaffeine intake may help ↓ ↓ estrogen contentestrogen content Galactorrhea is rare Galactorrhea is rare if it happens if it happens check check

prolactin levelprolactin level6-Nausea6-Nausea ↓ ↓ with timewith time Taking the pill with food or bedtimeTaking the pill with food or bedtime ↓ ↓ estrogen contentestrogen content If it occurs in a long time user If it occurs in a long time user rule out pregnancyrule out pregnancy7-Pregnancy7-Pregnancy Pills must be stopped immediatelyPills must be stopped immediately There is no ↑ risk of birth defectsThere is no ↑ risk of birth defects

Metabolism & Drug interactionsMetabolism & Drug interactions

Ethinyl estradiole is metabolized at several sites: Ethinyl estradiole is metabolized at several sites: 1-Sulphated at the intestinal wall1-Sulphated at the intestinal wall

2-Hydroxylated in the liver then conjugated with 2-Hydroxylated in the liver then conjugated with glucuronides & pass to enterohepatic circulationglucuronides & pass to enterohepatic circulation

Anticonvulsants (phenytoin or carbamazepine) Anticonvulsants (phenytoin or carbamazepine)

women should use 50 women should use 50 μμg E estradiole pillg E estradiole pill

Monitor phenytoin level as COCP may inhibit its Monitor phenytoin level as COCP may inhibit its metabolismmetabolism

Rifampicin & griseofulvin Rifampicin & griseofulvin contraceptive filurecontraceptive filure Other antibiotics do not appear to affect the Other antibiotics do not appear to affect the

efficacy of COCPefficacy of COCP

TRANSDERMAL CONTRACEPTIVE PATCHTRANSDERMAL CONTRACEPTIVE PATCH

Delivers 150Delivers 150μμg norgestimate & 20 g norgestimate & 20 μμg E estradioleg E estradiole daily daily One patch is applied weekly for 3 wks followed by One patch is applied weekly for 3 wks followed by

one patch-free-wkone patch-free-wk Pearl index with perfect use Pearl index with perfect use o.7 o.7 with typical use with typical use 0.88 0.88 Women weighing more than 90 kg Women weighing more than 90 kg ↑ risk of ↑ risk of

pregnancypregnancy Mechanism of action similar to COCPMechanism of action similar to COCP Irregular bleeding in the 1Irregular bleeding in the 1stst M of use is more 18% for the M of use is more 18% for the

patch than COCP 11% / Amenorrhea is rarepatch than COCP 11% / Amenorrhea is rare Breast symptoms are more 22% in the 1Breast symptoms are more 22% in the 1stst 2 cycles of the 2 cycles of the

patch use than COCP usepatch use than COCP use Local skin reaction 20%Local skin reaction 20%

VAGINAL CONTRACEPTIVE RINGVAGINAL CONTRACEPTIVE RING

A flexible transparent ring 54 mm diameter /4 A flexible transparent ring 54 mm diameter /4 mm cross-sectional diametermm cross-sectional diameter

Releases 15Releases 15μμg E estradiole & o.12 mg of g E estradiole & o.12 mg of desogestrel (etonogestrel)/ daydesogestrel (etonogestrel)/ day

Ring is used for 3 wks continuous followed by one Ring is used for 3 wks continuous followed by one ring-free wkring-free wk

Pearl index 0.65-1.18Pearl index 0.65-1.18 Irregular bleeding 6.4 % less than COCP Irregular bleeding 6.4 % less than COCP

especially in the 1especially in the 1stst cycle cycle Headache 11.8%, nausea 4.5%, breast Headache 11.8%, nausea 4.5%, breast

tenderness 2.8%tenderness 2.8% Vaginitis 13.7% (5% Rx related), coital problem or Vaginitis 13.7% (5% Rx related), coital problem or

expulsion 1-2.5%expulsion 1-2.5%

COMBINED INJECTABLE CONTRACEPTIONCOMBINED INJECTABLE CONTRACEPTION

Monthly injectable contraceptive composed of 5 Monthly injectable contraceptive composed of 5 mg estradiole cypionate & 25 mg mg estradiole cypionate & 25 mg medroxyprogestrone acetatemedroxyprogestrone acetate

Less breakthrough bleeding Less breakthrough bleeding

Amenorrhea 14.6% compared to 3.3 in COCP Amenorrhea 14.6% compared to 3.3 in COCP usersusers

Wt gain 4 pounds/yearWt gain 4 pounds/year

PROGESTIN ONLY HORMONAL PROGESTIN ONLY HORMONAL CONTRACEPTIONCONTRACEPTION

INJECTABLE PROGESTININJECTABLE PROGESTIN

DEPOT MEDROXYPROGESTRONE ACETATEDEPOT MEDROXYPROGESTRONE ACETATE

Introduced in 1967 & used by millions of women Introduced in 1967 & used by millions of women worldwideworldwide

Highly effective with a failure rate Highly effective with a failure rate < 0.3% / year< 0.3% / year

Mechanism of actionMechanism of action Inhibiting the secretion of pituitary gonadotropins Inhibiting the secretion of pituitary gonadotropins

suppression of ovulationsuppression of ovulation 1ry mechanism1ry mechanism ↑↑ ↑↑ viscosity of Cx mucousviscosity of Cx mucous Induces endometrial atrophyInduces endometrial atrophy

DMPA INDICATIONSDMPA INDICATIONS

Any women seeking reliable, reversible, coitally Any women seeking reliable, reversible, coitally independent method of contraception in the independent method of contraception in the absence of contraindicationsabsence of contraindications

Women who have difficulty complying with other Women who have difficulty complying with other methods / it does not require daily attentionmethods / it does not require daily attention

Women with contraindication to estrogensWomen with contraindication to estrogens Women >35 Y who smokeWomen >35 Y who smoke Women with migraine headacheWomen with migraine headache Women who are breastfeedingWomen who are breastfeeding Women with endometriosisWomen with endometriosis Women with sickle cell diseaseWomen with sickle cell disease Women taking anticonvulsant medicationsWomen taking anticonvulsant medications Mentally handicapped womenMentally handicapped women

DMPA CONTRAINDICATIONSDMPA CONTRAINDICATIONS

Absolute contraindicationsAbsolute contraindications PregnancyPregnancy Unexplained vaginal bleedingUnexplained vaginal bleeding Current breast caCurrent breast ca

Relative contraindicationsRelative contraindications Severe liver cirrhosisSevere liver cirrhosis Active viral hepatitisActive viral hepatitis Benign hepatic adenomaBenign hepatic adenoma

DMPA NON-CONTRACEPTIVE BENIFITSDMPA NON-CONTRACEPTIVE BENIFITS

Amennorrhea Amennorrhea (55-60% at 12 M / 68% at 24 M )(55-60% at 12 M / 68% at 24 M ) with subsequent reduction in dysmenorrhea & with subsequent reduction in dysmenorrhea & anemiaanemia

↓↓ ↓↓ risk of endometrial carisk of endometrial ca ↓↓ ↓↓ symptoms associated with endometriosis, PMS, & symptoms associated with endometriosis, PMS, &

chronic pelvic painchronic pelvic pain ↓↓ ↓↓ incidence of seizuresincidence of seizures Possible ↓↓ risk of PIDPossible ↓↓ risk of PID Possible ↓↓ incidence of sickle cell crisis Possible ↓↓ incidence of sickle cell crisis

DMPA SIDE-EFFECTSDMPA SIDE-EFFECTS

1- Menstrual cycle disturbance1- Menstrual cycle disturbance Irregular bleeding Irregular bleeding ↓ in frequency & amount over ↓ in frequency & amount over

timetime Abnormally heavy or prolonged occurred only in 1-2%Abnormally heavy or prolonged occurred only in 1-2% Amennorrhea 55-60% at 12 MAmennorrhea 55-60% at 12 M

68% at 24 M68% at 24 M

2-Hormonal side effects2-Hormonal side effects Headache 17%Headache 17% AcneAcne ↓↓ ↓↓ libidolibido NauseaNausea Breast tendernessBreast tenderness

DMPA SIDE-EFFECTSDMPA SIDE-EFFECTS

3-Weight gain3-Weight gain 56% 56% ↑↑ Wt ( mean gain 4.1 kg) ↑↑ Wt ( mean gain 4.1 kg) possibly through possibly through

appetite stimulation & a mild anabolic effectappetite stimulation & a mild anabolic effect

- 2.5 kg in 1- 2.5 kg in 1stst Y Y

-3.7 kg in 2 Y-3.7 kg in 2 Y

-6.3 kg in 4 Y-6.3 kg in 4 Y 44% ↓ Wt or maintained (mean loss 1.7 kg)44% ↓ Wt or maintained (mean loss 1.7 kg)

4-Mood effects4-Mood effects Prospective studies did not demonstrate ↑ depressive Prospective studies did not demonstrate ↑ depressive

symptomssymptoms Some women discontinue use because of mood Some women discontinue use because of mood

changeschanges

DMPA RISKSDMPA RISKS

1-Delayed return of fertility1-Delayed return of fertility An average of 9 months delay before restoration of An average of 9 months delay before restoration of

full fertility after last injectionfull fertility after last injection Rate of conception 50% at 10 M, 90% at 24 MRate of conception 50% at 10 M, 90% at 24 M

2-Reduction in bone mineral density2-Reduction in bone mineral density A mean loss of BMD at the lumbar spine 0.87-3.5%A mean loss of BMD at the lumbar spine 0.87-3.5% Does not induce osteoporosisDoes not induce osteoporosis It improves after discontinuation of use It improves after discontinuation of use Comparison of past users to controls did not Comparison of past users to controls did not

demonstrate any deference demonstrate any deference

3-VTE, CVD, Stroke 3-VTE, CVD, Stroke No No ↑ risk↑ risk

DMPA DOSAGE & ADMINISTERATIONDMPA DOSAGE & ADMINISTERATION

150 mg IM every 12 Wks150 mg IM every 12 Wks

Started during the 1Started during the 1stst 5 days of menses or within 5 days of menses or within 5 days of stopping COCP5 days of stopping COCP

Effective within 24 hrs of injection if given during Effective within 24 hrs of injection if given during the 1the 1stst 5 days of the cycles 5 days of the cycles

If given later than D5 of the cycle If given later than D5 of the cycle back up back up method of contraception must be used for 1 wkmethod of contraception must be used for 1 wk

DMPA TROUBLESHOOTINGDMPA TROUBLESHOOTING

1- Menstrual cycle disturbance1- Menstrual cycle disturbance If irregular bleeding persists after the 1If irregular bleeding persists after the 1stst 6 M of 6 M of

use use rule out other causes of abnormal bleeding rule out other causes of abnormal bleedingManagement optionsManagement options ↑↑ ↑↑ DMPA dosage DMPA dosage 225-300 mg for 2-3 injections 225-300 mg for 2-3 injections ↓↓ ↓↓ interval between dosageinterval between dosage Supplemental estrogen therapy :Supplemental estrogen therapy : 0.625 conjugated equine estrogen po –28 days0.625 conjugated equine estrogen po –28 days 1-2 mg 17ß-estradiole po –28 days1-2 mg 17ß-estradiole po –28 daysTransdermal estrogen 50-100 Transdermal estrogen 50-100 μμg 17ß-estradiole g 17ß-estradiole

patch for 25 dayspatch for 25 days Nonsteroidal anti-inflammatory Nonsteroidal anti-inflammatory ibuprofen 400- ibuprofen 400-

800 mg bd for 10 days800 mg bd for 10 days Adding COCP for 1-3 MAdding COCP for 1-3 M

DMPA TROUBLESHOOTINGDMPA TROUBLESHOOTING

2-Late injection2-Late injection <<14 wks since last injection it can be given14 wks since last injection it can be given ≥ ≥ 14 wks since last injection14 wks since last injection -ve serum ß hcg, no intercourse for last 10 days-ve serum ß hcg, no intercourse for last 10 days give the injectiongive the injection back up contraception must be used for 2 wksback up contraception must be used for 2 wks ≥ ≥ 14 wks since last injection14 wks since last injection -ve serum ß hcg,intercourse within the last 10 D-ve serum ß hcg,intercourse within the last 10 D give the injectiongive the injection back up contraception must be used for 2 wksback up contraception must be used for 2 wksRepeat serum ß hcg –2 wksRepeat serum ß hcg –2 wksNot teratogenic if inadvertently given during Not teratogenic if inadvertently given during

pregnancypregnancy

ORAL PROGESTINSORAL PROGESTINSPROGESTIN ONLY PILL / MINIPILLSPROGESTIN ONLY PILL / MINIPILLS

Package contains 28 tabPackage contains 28 tab Started on the 1Started on the 1stst day of the menstrual cycle/ or any day of the menstrual cycle/ or any

day if pregnancy excludedday if pregnancy excluded Must be used at the same time every day within 3 Must be used at the same time every day within 3

hrshrs A back up contraception must be used for 7 daysA back up contraception must be used for 7 days Norethindrone 0.35 mg Norethindrone 0.35 mg micronor micronor Must be used continuously Must be used continuously no pill-free interval no pill-free interval Perfect use failure rate Perfect use failure rate 0.5% 0.5% Typical use failure rate Typical use failure rate 5-10% (It must be taken 5-10% (It must be taken

the same time every day)the same time every day) It can be used immediately postpartum with no It can be used immediately postpartum with no

effect on lactationeffect on lactation

PROGESTIN ONLY PILLPROGESTIN ONLY PILL

IndicationsIndications It can be used for any women seeking reliable, It can be used for any women seeking reliable,

reversible, coitally independent method of reversible, coitally independent method of contraception in the absence of contraindicationscontraception in the absence of contraindications

Women with contraindication to estrogenWomen with contraindication to estrogen Women > 35 Y who smokeWomen > 35 Y who smoke Women having migraine headache with Women having migraine headache with

neurological symptomsneurological symptoms Women who have unwanted side-effects of COCPWomen who have unwanted side-effects of COCP Breast-feeding women Breast-feeding women


Mechanism of actionMechanism of action

1-Main mechanism is alteration of Cx mucous1-Main mechanism is alteration of Cx mucous ↓↓ ↓↓ volume of mucousvolume of mucous ↑↑ ↑↑ viscosityviscosity alter its molecular structure alter its molecular structure

Little or no sperm penetrationLittle or no sperm penetration

Sperm motility is impaired Sperm motility is impaired ↓↓ fertilization↓↓ fertilization

2- Ovulation is suppressed in 60% of the women2- Ovulation is suppressed in 60% of the women

3-Endometrial changes 3-Endometrial changes ↓↓ implantation↓↓ implantation

PROGESTIN ONLY PILL CONTRAINDICATIONSPROGESTIN ONLY PILL CONTRAINDICATIONS

Absolute ContraindicationsAbsolute Contraindications PregnancyPregnancy Current breast cancerCurrent breast cancer

Relative ContraindicationsRelative Contraindications Active viral hepatitisActive viral hepatitis Liver tumors Liver tumors


Non contraceptive benefitsNon contraceptive benefits ↓ ↓ menstrual flowmenstrual flow 10% amenorrhea10% amenorrhea ↓ ↓ dysmenorrhea, PMSdysmenorrhea, PMS

Side-effectsSide-effects Irregular bleeedingIrregular bleeeding

spotting –12% spotting –12% 1 1stst month month

--3% --3% 18 months 18 months

40 % continue to have regular cycles40 % continue to have regular cycles Hormonal side-effectsHormonal side-effects

Headache, bloating, acne, breast tenderness Headache, bloating, acne, breast tenderness

POPPOP

RisksRisks Not associated with any major morbidityNot associated with any major morbidity No No ↑ risk of VTE, stroke or MI↑ risk of VTE, stroke or MI

Myths & misconceptionMyths & misconception It can only be used with breast feedingIt can only be used with breast feeding

Fact Fact It can be used in any women seeking reliable, It can be used in any women seeking reliable, reversible method of contraceptionreversible method of contraception

POP is not an effective method of contraceptionPOP is not an effective method of contraception

Fact Fact When used correctly it is safe & effective with a When used correctly it is safe & effective with a failure rate of only 0.5% failure rate of only 0.5%

POP TROUBLESHOOTINGPOP TROUBLESHOOTING

1-Irregular bleeding1-Irregular bleeding A common side effect A common side effect Pregnancy, infection & genital pathology must be Pregnancy, infection & genital pathology must be

ruled outruled outRx optionsRx options Non steroidal anti-inflammatory for 10 daysNon steroidal anti-inflammatory for 10 days Switching toCOCPSwitching toCOCP Adding a short course of estrogenAdding a short course of estrogen 0.625 mg conjugated equine estrogen 0.625 mg conjugated equine estrogen

(premarine) for 28 days(premarine) for 28 days1-2 mg micronized 17ß-estradiole—28 days1-2 mg micronized 17ß-estradiole—28 daysTransdermal 50-100 Transdermal 50-100 μμg 17ß-estradiole patch –25 g 17ß-estradiole patch –25

daysdays Antiprogestinic agents Antiprogestinic agents mifepristone mifepristone

POP TROUBLESHOOTINGPOP TROUBLESHOOTING

2-Missed pill2-Missed pill To be taken as soon as possibleTo be taken as soon as possible Next pill to be taken at the regular timeNext pill to be taken at the regular time If delayed > 3hrs If delayed > 3hrs use back up contraception for use back up contraception for

48 hrs48 hrs If 2 or more pills missed in a row If 2 or more pills missed in a row 2 pills/day for 2 pills/day for

2 days 2 days back up contraception for 48 hrsback up contraception for 48 hrs Emergency contraception must be used if Emergency contraception must be used if

intercourse occurred after a missed pillintercourse occurred after a missed pill

3- Drug interactions 3- Drug interactions anticonvulsants may anticonvulsants may ↓↓ ↓↓ effectiveness of POPeffectiveness of POP

PROGESTIN IMPLANTSPROGESTIN IMPLANTS

NORPLANT NORPLANT Levonorgestril Levonorgestril Implanon Implanon Etonogestrel Etonogestrel Highly effective failure rate 0.1% / yearHighly effective failure rate 0.1% / year 6 rods implanted under the skin 6 rods implanted under the skin effective for effective for

5 years5 years Women Women < 70 kg effective for 7 Y pearl index < 2< 70 kg effective for 7 Y pearl index < 2 Reversible contraceptionReversible contraception Mechanism of action Mechanism of action

Suppression of ovulationSuppression of ovulation

Endometrial atrophyEndometrial atrophy

Rendering Cx mucous impermeable to spermsRendering Cx mucous impermeable to sperms Prolonged irregular bleeding the major side effectProlonged irregular bleeding the major side effect

INTRAUTERINE INTRAUTERINE CONTRACEPTIVE DEVICES CONTRACEPTIVE DEVICES

IUCDIUCD

IUCDIUCD

Nonmedicated IUCD ( Multiload)Nonmedicated IUCD ( Multiload) Copper IUD( Nova T)Copper IUD( Nova T) Levonorgestrel – releasing IUD (Mirena)Levonorgestrel – releasing IUD (Mirena)

EfficacyEfficacy Failure rate of Nova T Failure rate of Nova T 1.26 % /year 1.26 % /year

----------------Mirena ----------------Mirena 0.09 % /year 0.09 % /year Ectopic pregnancy rate Ectopic pregnancy rate 0.25 %/year0.25 %/year

------------------Mirena ------------------Mirena 0.02 %/year0.02 %/year Effective for 5 yearsEffective for 5 years

IUCD MECHANISM OF ACTIONIUCD MECHANISM OF ACTION

Prevention of fertilization Prevention of fertilization the chief mechanismthe chief mechanism Inhibition of implantationInhibition of implantation Presence of foreign body & copper Presence of foreign body & copper biochemical biochemical

& morphological changes in the endometrium & morphological changes in the endometrium adversely affect sperm transportadversely affect sperm transport

Copper ion have direct effect on sperm mobility Copper ion have direct effect on sperm mobility ↓↓ in its ability to penetrate Cx mucous↓↓ in its ability to penetrate Cx mucous

Levonorgestrel releasing devices Levonorgestrel releasing devices weak foreign weak foreign body reaction & endometrial decidualization & body reaction & endometrial decidualization & glandular atrophy glandular atrophy estrogen & progestrone estrogen & progestrone receptors are receptors are ↓↓ ↓↓ Cx mucous becomes thick & Cx mucous becomes thick & impermeable to sperms impermeable to sperms ovulation may be ovulation may be inhibited in some womeninhibited in some women

INDICATIONS FOR IUCDINDICATIONS FOR IUCD

In the absence of contraindications may be In the absence of contraindications may be considered for any woman seeking a reliable, considered for any woman seeking a reliable, reversible, coitally independent method of reversible, coitally independent method of contraceptioncontraception

Women seeking long term birth controlWomen seeking long term birth control A method requiring less complianceA method requiring less compliance Women with contraindications to estrogenWomen with contraindications to estrogen Breast feeding womenBreast feeding women Copper IUCD used for postcoital contraception Copper IUCD used for postcoital contraception

within 7 dayswithin 7 days LNG- IUCD LNG- IUCD ↓↓ menstrual flow & cramping ↓↓ menstrual flow & cramping suitable suitable

for women with menorrhagia & dysmenorrheafor women with menorrhagia & dysmenorrhea

IUCD CONTRAINDICATIONSIUCD CONTRAINDICATIONS

Absolute contraindicationsAbsolute contraindications PregnancyPregnancy Current, recurrent or recent (within 3 M) PID or Current, recurrent or recent (within 3 M) PID or

sexually transmitted diseasesexually transmitted disease Puerperal sepsisPuerperal sepsis Immediate post septic abortionImmediate post septic abortion Severely distorted uterine cavitySeverely distorted uterine cavity Unexplained vaginal bleedingUnexplained vaginal bleeding Cx or endometrial caCx or endometrial ca Malignant trophoblastic diseaseMalignant trophoblastic disease Copper allergy Copper allergy Copper -IUCDCopper -IUCD Breast ca Breast ca LNG -IUCD LNG -IUCD

IUCD CONTRAINDICATIONSIUCD CONTRAINDICATIONS

Relative contraindicationsRelative contraindications Risk factor for sexually transmitted diseases or Risk factor for sexually transmitted diseases or

HIVHIV Impaired response to infections:Impaired response to infections:

-HIV +ve women-HIV +ve women

-Women on corticosteroid Rx-Women on corticosteroid Rx 48hrs- 4 wks postpartum48hrs- 4 wks postpartum Ovarian caOvarian ca Benign gestational trophoblastic diseaseBenign gestational trophoblastic disease

IUCD NON-CONTRACEPTIVE BENIFITSIUCD NON-CONTRACEPTIVE BENIFITS

Nonmedicated IUCD or copper IUCD Nonmedicated IUCD or copper IUCD ↓ risk of ↓ risk of endometrial caendometrial ca

LNG-IUCD LNG-IUCD ↓ menstrual blood loss 74-97% ↓ menstrual blood loss 74-97% improved Hbimproved Hb

LNG-IUCD users LNG-IUCD users ↓ hysterectomy for menorrhagia ↓ hysterectomy for menorrhagia 64-80%64-80%

LNG-IUCD LNG-IUCD ↓ dysmenorrhea ↓ dysmenorrhea --------------- --------------- protects against enometrial protects against enometrial

hyperplasiahyperplasia in women on tamoxifen in women on tamoxifen -------------- -------------- beneficial effects in fibroid related beneficial effects in fibroid related

menorrhagia menorrhagia

IUCD SIDE EFFECTSIUCD SIDE EFFECTS

1-Bleeding1-BleedingCopper / nonmedicated IUCDCopper / nonmedicated IUCD Irregular menstrual bleeding Irregular menstrual bleeding ↑↑ ↑↑ amount of menstrual bleeding 65% in copper IUCD amount of menstrual bleeding 65% in copper IUCD

usersusers NSAID or tranexamic acid NSAID or tranexamic acid ↓↓menstrualblood loss↓↓menstrualblood loss The days of bleeding or spotting ↓↓ overtime 13 days The days of bleeding or spotting ↓↓ overtime 13 days

inth 1inth 1stst months months 6 days at 1 year 6 days at 1 year Discontinuation due to bleeding Discontinuation due to bleeding 20% 20% LNG-IUCDLNG-IUCD ↓↓↓↓menstrualblood loss 74-97%menstrualblood loss 74-97% Spotting 16 days at 1 M Spotting 16 days at 1 M ↓↓ 4 days at 12 M↓↓ 4 days at 12 M Discontinuation due to bleeding Discontinuation due to bleeding 14% 14% Amenorrhea 16-35% at 12 M Amenorrhea 16-35% at 12 M


2-Pain or dysmenorrhea2-Pain or dysmenorrhea 6% discontinue use due to pain6% discontinue use due to pain Pain may be physiologicalPain may be physiological LNG-IUCD LNG-IUCD ↓↓ dysmenorrhea↓↓ dysmenorrhea

3-Hormonal LNG-IUCD3-Hormonal LNG-IUCD DepressionDepression AcneAcne HeadacheHeadache Breast tendernessBreast tenderness Low incidence ,maximal at 3 M then ↓↓Low incidence ,maximal at 3 M then ↓↓ No change in WtNo change in Wt


4-Functional ovarian cysts/ LNG-IUCD4-Functional ovarian cysts/ LNG-IUCD 30% of users30% of users Resolve spontaneously Resolve spontaneously

IUCD RISKSIUCD RISKS

1-Uterine perforation1-Uterine perforation A rare complication at insertionA rare complication at insertion 0.6-1.6/1000 insertion0.6-1.6/1000 insertionRisk factorsRisk factors Postpartum insertionPostpartum insertion Inexperienced operatorInexperienced operator Immobile uterusImmobile uterus Extremely ante or retro –verted uterusExtremely ante or retro –verted uterus2-Expulsion2-Expulsion 2-10% in the 12-10% in the 1stst year of use year of use 5 year expulsion 5 year expulsion 5.8-6.7 5.8-6.7 Risk factors: postpartum insertion, Risk factors: postpartum insertion,

nulliparity,previous expulsion(30% chance)nulliparity,previous expulsion(30% chance)

IUCD RISKSIUCD RISKS

3-Infection3-Infection Risk is Risk is ↑↑ only in the 1↑↑ only in the 1stst few months after insertion few months after insertion Inverse relation between infection & time since insertionInverse relation between infection & time since insertion Risk of PID 3.8 in 1Risk of PID 3.8 in 1stst month month Baseline risk at 4 MBaseline risk at 4 M4-Filure4-Filure If a woman become pregnant with an IUCD If a woman become pregnant with an IUCD exclude exclude

ectopicectopic Abortion is ↑↑ in women pregnant with IUCD in placeAbortion is ↑↑ in women pregnant with IUCD in place Copper IUCD Copper IUCD abortion 75% if left in situabortion 75% if left in situ Live birth 89% if IUCD removedLive birth 89% if IUCD removed Preterm delivery ↑↑ in women pregnant with IUCD in Preterm delivery ↑↑ in women pregnant with IUCD in

placeplace

IUCD MYTHS & MISCONCEPTIONIUCD MYTHS & MISCONCEPTION Nulliparous woman can not use IUCDNulliparous woman can not use IUCD IUCD IUCD ↑↑ risk of ectopic↑↑ risk of ectopicFact Fact IUCD work primerly by preventing IUCD work primerly by preventing

fertilization fertilization Ectopic in IUCD users : nonusersEctopic in IUCD users : nonusers 0.02-0.25/100WY:0.12-0.5/100WY0.02-0.25/100WY:0.12-0.5/100WY IUCD IUCD ↑↑ risk of infertility↑↑ risk of infertilityFact Fact Women who discontinue IUCD use concieve Women who discontinue IUCD use concieve

at the same rate of women who never used IUCDat the same rate of women who never used IUCD IUCD IUCD ↑↑ risk of long term PID↑↑ risk of long term PIDFact after the 1Fact after the 1stst M the risk of infection is not higher M the risk of infection is not higher

than non users/ PID than non users/ PID < 2/ 1000 year of use< 2/ 1000 year of use IUCD are not effective contraceptivesIUCD are not effective contraceptivesFact LNG –IUCD as effective as tubal ligation Fact LNG –IUCD as effective as tubal ligation

INITIATIONINITIATION

CounsellingCounselling Inserted any time during a menstrual cycle once Inserted any time during a menstrual cycle once

pregnancy excludedpregnancy excluded During menses During menses exclude pregnancy & mask exclude pregnancy & mask

insertion related bleedinginsertion related bleeding Infection & expulsion ↑ with insertion during mensesInfection & expulsion ↑ with insertion during menses It can be removed any day of the menstrual cycleIt can be removed any day of the menstrual cycle Cost effectiveness of gonorrhea & chlamydia screening Cost effectiveness of gonorrhea & chlamydia screening

is not clearis not clear If there is mucpurulent discharge Cx swabs must be If there is mucpurulent discharge Cx swabs must be

taken & insertion delayedtaken & insertion delayed Antibiotic prophylaxis is not indicatedAntibiotic prophylaxis is not indicated

FOLLOW UPFOLLOW UP

A follow up visit must be scheduled in 6 wks then A follow up visit must be scheduled in 6 wks then yearlyyearly

Women must be instructed to come if;Women must be instructed to come if; IUCD thread can not be feltIUCD thread can not be felt She feels the lower end of the IUCDShe feels the lower end of the IUCD ? Pregnant? Pregnant Abdominal pain, fever or unusual dischargeAbdominal pain, fever or unusual discharge Pain or discomfort during intercoursePain or discomfort during intercourse Sudden change in menstrual periodSudden change in menstrual period Wants to remove the device or concieve Wants to remove the device or concieve


1-Lost string1-Lost string Speculum examSpeculum exam Exclude pregnancyExclude pregnancy Cx canal exploredCx canal explored U/SU/S Plain X rayPlain X ray

2- Pregnancy2- Pregnancy Exclude ectopic Exclude ectopic If she wishes to continue the pregnancy If she wishes to continue the pregnancy

remove IUCDremove IUCD If string missing If string missing u/s u/s if in the uterus if in the uterus no no

attempt to remove itattempt to remove it


3-Amenorrhea /delayed menses3-Amenorrhea /delayed menses Exclude pregnancyExclude pregnancy 35% of LNG –IUCD users have amenrrhea35% of LNG –IUCD users have amenrrhea4-Pain & abnormal bleeding4-Pain & abnormal bleeding Exclude pregnancy, partial expulsion, perforationExclude pregnancy, partial expulsion, perforation NSAID may helpNSAID may help Bleeding Bleeding ↓ overtime↓ overtime If it persists or worsen If it persists or worsen removal removal5-Difficulty removing IUCD5-Difficulty removing IUCD Paracervical blockParacervical block Cx dilatationCx dilatation U/SU/S HystroscopyHystroscopy


6-Sexually transmitted disease with IUCD in situ6-Sexually transmitted disease with IUCD in situ AntibioticsAntibiotics RemovalRemoval

7-Actinmycosis on PAP smear7-Actinmycosis on PAP smear It is a vaginal commensalIt is a vaginal commensal 20% in in Cx smears of copper IUCD users 20% in in Cx smears of copper IUCD users 3% in LNG-IUCD users3% in LNG-IUCD users Removal is not necessary if asymptomaticRemoval is not necessary if asymptomatic If symptomatic If symptomatic remove IUCD after starting remove IUCD after starting

antibiotics / continue Ab Rxantibiotics / continue Ab Rx

EMERGENCY CONTRACEPTIONEMERGENCY CONTRACEPTION Copper IUCD can be inserted up 7 days after Copper IUCD can be inserted up 7 days after

intercourseintercourse Levonorgestrel 0.75 mg , 2doses 12 hrlyLevonorgestrel 0.75 mg , 2doses 12 hrly or 1.5 mg single dose or 1.5 mg single dose similar efficacy similar efficacy Yuzpe method Yuzpe method 2 doses 100 2 doses 100μμg E estradiole & g E estradiole &

500 500 μμg levonorgestrel (Ovral) g levonorgestrel (Ovral) Hormonal contraception must be started as soon Hormonal contraception must be started as soon

as possible max 5 daysas possible max 5 days Women should be evaluated for pregnancy if Women should be evaluated for pregnancy if

menses does not occur after 21 days menses does not occur after 21 days Mechanism of action Mechanism of action Hormonal contraception Hormonal contraception

interferes with ovulationinterferes with ovulation other mechanisms could be interference with other mechanisms could be interference with

sperm mobility or transport, endometrial sperm mobility or transport, endometrial receptivity, fertilization or zygot development receptivity, fertilization or zygot development

EMERGENCY CONTRACEPTIONEMERGENCY CONTRACEPTION

EffectivenessEffectiveness Yuzpe Yuzpe 75% reduction in pregnancy(8 75% reduction in pregnancy(82)2)

pregnancy rate 3.2% pregnancy rate 3.2% LNG LNG 89% reduction89% reduction

pregnancy rate 1.1%pregnancy rate 1.1% Effectiveness Effectiveness ↓↓ with ↑↑ delay between intercourse ↓↓ with ↑↑ delay between intercourse

& contraception& contraception IUCD more effective IUCD more effective 98.7%98.7%

Side effectsSide effects LNG have lower incidence of nausea(23 vs 50%), LNG have lower incidence of nausea(23 vs 50%),

vomitting (5.6vs 18.8%), dizziness (11.2vs16.7%), vomitting (5.6vs 18.8%), dizziness (11.2vs16.7%), fatigue (16.9vs28.8%)than Yuzpe fatigue (16.9vs28.8%)than Yuzpe

CONTRACEPTION Dr SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT...

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Transcript of CONTRACEPTION Dr SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT...