CONTRACEPTIONCONTRACEPTION

.

IDEAL CONTRACEPTIVEIDEAL CONTRACEPTIVE

InexpensiveInexpensive Easy and simple to use with minimum side Easy and simple to use with minimum side

effectseffects Rapidly reversibleRapidly reversible Readily availableReadily available Highly effective.?Highly effective.? Can be administered by non-healthcare Can be administered by non-healthcare

personnel.personnel.

Contraceptive effectivenessContraceptive effectiveness

Difficult to determine :Difficult to determine :

1.1. Perfect VS typical use (method failure and Perfect VS typical use (method failure and patient failure)patient failure)

2.2. Correct VS incorrect use Correct VS incorrect use

3.3. long term VS short termlong term VS short term

Pearl indexPearl index

Method used for determination of pregnancy Method used for determination of pregnancy failure rate:failure rate:

Pregnancy rate = no. of pregnancies Pregnancy rate = no. of pregnancies x100women/12 months of usex100women/12 months of use

classificationsclassifications

A. Natural MethodsA. Natural Methods

Periodic abstinence Periodic abstinence

Withdrawal Withdrawal

Lactational Amenorrhea Method Lactational Amenorrhea Method B. Barrier MethodsB. Barrier Methods

C. HormonalC. Hormonal

D Intrauterine Devices D Intrauterine Devices

E.. Sterilization E.. Sterilization

HORMONAL HORMONAL CONTRACEPTIONCONTRACEPTION

ObjectivesObjectives

Combined pillsCombined pillsProgestin pills (minipills)Progestin pills (minipills)Subdermal patchesSubdermal patches InjectionsInjectionsVaginal ringVaginal ring

Oral contraceptive pillsOral contraceptive pills

World wide used World wide used

very convenient methodvery convenient method

Reversible methodsReversible methods

CombinedCombined

CompositionCombination of Estrogen & ProgesteroneEthinyl Estradiol (most commonly used

nowadays)Levonorgestrel, Norethindrone, …

Intake 21 days: 1 pill/dayLast 7 days: free

Minipills

Used for 28 days, no breaks

Same time of the day

Mechanism of actionMechanism of action

Combined :Combined : most effective method because they inhibit midcycle gonadotropin surge most effective method because they inhibit midcycle gonadotropin surge

and prevent ovulationand prevent ovulation

Progestin only pills:Progestin only pills: don’t mainly not inhibit ovulation don’t mainly not inhibit ovulation

Both types act by -altering cervical mucus making it thick viscid and scantyBoth types act by -altering cervical mucus making it thick viscid and scanty -alter endometrium so not fit for implantation-alter endometrium so not fit for implantation

- alter ovarian responsiveness to gonadotropin - alter ovarian responsiveness to gonadotropin stimulationstimulation

How to prevent ovulation?How to prevent ovulation?

Interfere with the release of GnRH from Interfere with the release of GnRH from hypothalamus so it will suppress LH & FSHhypothalamus so it will suppress LH & FSH

In high concentration they will inhibit pituitary gland In high concentration they will inhibit pituitary gland directlydirectly

Progestin only pills don't inhibit ovulation mainly Progestin only pills don't inhibit ovulation mainly because a lower dose of progestin is used in because a lower dose of progestin is used in preparations less than combine forms it is important preparations less than combine forms it is important to be taken at the same time of the day to ensure that to be taken at the same time of the day to ensure that blood level do not fall below the effective levelsblood level do not fall below the effective levels

Side effectsSide effects

Mostly caused by progestinMostly caused by progestin

Nausea Nausea

Breast tendernessBreast tenderness

Fluid retentionFluid retention

Depression Depression

HeadacheHeadache

acneacne

Estrogen cause pigmentation and high level of Estrogen cause pigmentation and high level of estrogen may accelerate the development of estrogen may accelerate the development of gallbladder disease in young female but not gallbladder disease in young female but not increase the risk of acute cholelithiasis increase the risk of acute cholelithiasis

Progestin : because they are structural related Progestin : because they are structural related to testosterone they produce androgenic effects to testosterone they produce androgenic effects like increase weight and acnes like increase weight and acnes

Metabolic effectsMetabolic effectscombinedcombined chemicalchemical clinicalclinical

HDLHDL increaseincrease cardiovascular cardiovascular disease ?disease ?

LDLLDL decreasedecrease

TG TG increaseincrease

Progestin onlyProgestin only

HDLHDL decreasedecrease

LDLLDL increaseincrease

TGTG decreasedecrease

NONCONTRACEPTIVE BENEFITSNONCONTRACEPTIVE BENEFITS

BENEFITS FROM ANTIESTROGENIC EFFECTS BENEFITS FROM ANTIESTROGENIC EFFECTS OP PROGESTERON:OP PROGESTERON:

1-decrease menses blood loss & improve anemia1-decrease menses blood loss & improve anemia 2- risk of adeno CA of uterus2- risk of adeno CA of uterus 3- estrogen receptors in breast so risk 3- estrogen receptors in breast so risk begnin breast disease ?begnin breast disease ?

BENEFITS FROM INHIBITION OF OVULATION BENEFITS FROM INHIBITION OF OVULATION (dysmenorrhea )(dysmenorrhea )

use as therapy of severe dysmenorrheause as therapy of severe dysmenorrheaOTHER BENEFITS: risk (PID,Rhumatoid a, bone OTHER BENEFITS: risk (PID,Rhumatoid a, bone loss)loss)

complicationscomplications

CVS:CVS:

DVTDVT

Myocardial infarctionMyocardial infarction

StrokeStroke

Neoplastic effectsNeoplastic effects

Breast CABreast CA

Endometrial CA : protection related to duration of useEndometrial CA : protection related to duration of use

Ovarian CA : decrease risk duration relatedOvarian CA : decrease risk duration related

Liver adenoma and CA?Liver adenoma and CA?

Pituitary adenoma : mask symptoms produced by Pituitary adenoma : mask symptoms produced by prolactinoma amenorrhea and galactoria prolactinoma amenorrhea and galactoria

colorectal CA: protectioncolorectal CA: protection

Liver cyst and adenomaLiver cyst and adenoma

ContraindicationsContraindications

Absolutes Absolutes

HistoHistorry of vascular disease (thromboembolism)y of vascular disease (thromboembolism)Systemic diseases (affect vascular system) SLE , DM Systemic diseases (affect vascular system) SLE , DM with retinopathy or nephropathywith retinopathy or nephropathyUndiagnosed uterine bleeding Undiagnosed uterine bleeding Increase serum TGsIncrease serum TGsHeart failure rare because incidence of heart diseases are Heart failure rare because incidence of heart diseases are mostly after menopause mostly after menopause Smoking in female more than 35ySmoking in female more than 35y

ContraindicationsContraindications

Relatives:Relatives:

Migraine headacheMigraine headache

Undiagnosed amenorrhea and depressionUndiagnosed amenorrhea and depression

Smoking in female less than 35 ySmoking in female less than 35 y

LONG ACTING CONTRACEPTIONS

VAGINAL RINGVAGINAL RING

Steroids absorbed though vaginal epithelium Steroids absorbed though vaginal epithelium directly into circulationdirectly into circulation

Contain ethContain ethiinyl estradiol and etonogestrelandnyl estradiol and etonogestreland

Place in vagina for 21 days and remove 7 days Place in vagina for 21 days and remove 7 days to allow withdrawal bleedingsto allow withdrawal bleedings

TRANSDERMAL PATCH

It releases norelgestromin & ethinyl estradiol

Weekly applied, for 3 weeks, and the last week of the cycle is a patch-free week

Normal activities can be done while using the patch

Subdermal implantation for continuous release

Effective for up to 3 years Rapid return of fertility

ProblemsMenstrual irregularityWeight gainSurgical implantation & removal

INJECTABLE SUSPENTIONSINJECTABLE SUSPENTIONS

Depomedroxyprogesteron(DMPA)Depomedroxyprogesteron(DMPA)

IM,SC every 3 months IM,SC every 3 months

doesn't increase risk of breast ca doesn't increase risk of breast ca

Other types: medroxyprogesteron acetate Other types: medroxyprogesteron acetate (AMP)(AMP)

EMERGENCY CONTRACEPTIONEMERGENCY CONTRACEPTION

After intercourse and before implantationAfter intercourse and before implantationIndication: failure of condomsIndication: failure of condomsUnprotected intercourseUnprotected intercourseWithin 72 hours after unprotected intercourseLevonorgestrel Combined PrescriptionSingle dose, the earlier the betterPrevented 75% of unplanned pregnancies

IUD Emergency ContraceptionWithin 5 days after unprotected intercourseCopper IUD

NATURAL, PHYSICAL AND NATURAL, PHYSICAL AND SURGICAL METHODSSURGICAL METHODS

Periodic AbstinencePeriodic Abstinence

calendar methodcalendar method

Natural methodsNatural methods

Lactational amenorrheaLactational amenorrheaDefinitionDefinition

EfficacyEfficacy

AdvantagesAdvantages

DisadvantagesDisadvantages

Barrier methods of contraception Barrier methods of contraception

Two types : Two types :

1. Physical barrier methods, such as condoms, 1. Physical barrier methods, such as condoms, diaphragm, and cervical caps, that prevent pregnancy diaphragm, and cervical caps, that prevent pregnancy by blocking the entry of sperm into the upper genital by blocking the entry of sperm into the upper genital tract;tract;

2. Chemical barrier methods (spermicides) that kill 2. Chemical barrier methods (spermicides) that kill or inactivate sperm on contact. ( less effective , used or inactivate sperm on contact. ( less effective , used in combination , no STDs protection ) in combination , no STDs protection )

Barrier methods of contraceptionBarrier methods of contraception

easily available, reversible, and have fewer easily available, reversible, and have fewer side effects than hormonal methods.side effects than hormonal methods.

effective and acceptable if used consistently effective and acceptable if used consistently and correctly.and correctly.

Protect against STD Protect against STD

Male condoms Male condoms

It is one of the most popular mechanical It is one of the most popular mechanical barriers. Among all of the barrier methods, the barriers. Among all of the barrier methods, the condom provides the most effective protection condom provides the most effective protection of the genital tract from STDs. Its usage has of the genital tract from STDs. Its usage has increass because of the concern regarding the increass because of the concern regarding the acquisition of HIV and STDs. acquisition of HIV and STDs.

Male condoms Male condoms

Increasing the efficacy : Increasing the efficacy :

reservoir tip reservoir tip

The addition of spermicidalThe addition of spermicidal

lubricant to the condom. (water-based not oil-lubricant to the condom. (water-based not oil-based)based)

the addition of an intravaginal spermicidal the addition of an intravaginal spermicidal agentagent. .

Female condomsFemale condoms

It contains 2 flexible rings. The ring at the It contains 2 flexible rings. The ring at the closed end of the sheath serves as an insertion closed end of the sheath serves as an insertion mechanism and internal anchor that is placed mechanism and internal anchor that is placed inside the vaginal canal. The other ring forms inside the vaginal canal. The other ring forms the external patent edge of the device and the external patent edge of the device and remains outside of the canal after insertion.remains outside of the canal after insertion.

Female condoms Female condoms

- Mechanism of action : - Mechanism of action : Prevents passage of sperm Prevents passage of sperm

and infections into the vaginaand infections into the vagina( protection against STDs )( protection against STDs )

Can be inserted up to 8 hours Can be inserted up to 8 hours prior to intercourse; can remain inprior to intercourse; can remain inplace up to 8 hours place up to 8 hours

Female condomsFemale condoms

- Efficacy - Efficacy

Pregnancy rates for the female condom range Pregnancy rates for the female condom range between 5 and 21 per 100 women per year. between 5 and 21 per 100 women per year. (higher than male condoms)(higher than male condoms)

To increase efficacy Simultaneous use of both the To increase efficacy Simultaneous use of both the female and male condom is not recommended female and male condom is not recommended

Re-use is not recommended .Re-use is not recommended .

DiaphragmDiaphragm

The diaphragm is a shallow latex cupThe diaphragm is a shallow latex cup with a spring mechanism in its rim to hold itwith a spring mechanism in its rim to hold it in place in the vaginain place in the vagina

It is inserted before intercourse so that theIt is inserted before intercourse so that theposterior rim fits into the posterior fornix andposterior rim fits into the posterior fornix andthe anterior rim is placed behind the pubic bone.the anterior rim is placed behind the pubic bone.

Spermicidal cream is applied to the inside of theSpermicidal cream is applied to the inside of the dome, which fits against the vaginal wall. dome, which fits against the vaginal wall.

Diaphragm Diaphragm

It prevents pregnancy by acting as a barrier to the passage of It prevents pregnancy by acting as a barrier to the passage of semen into the cervix semen into the cervix

provides effective contraception for 6 hours. provides effective contraception for 6 hours.

After intercourse, the diaphragm must be left in place for at After intercourse, the diaphragm must be left in place for at least 6 hours.least 6 hours.

Effectiveness depends on the age of the user, continuity of use, Effectiveness depends on the age of the user, continuity of use, and the use of spermicide along with the diaphragm. Failure and the use of spermicide along with the diaphragm. Failure rate is estimated to be 20% . rate is estimated to be 20% .

DiaphragmDiaphragm

Relative Contraindications :Relative Contraindications :

- Latex allergy Latex allergy

- Uterine prolapseUterine prolapse

- Repeated UTIsRepeated UTIs

DiaphragmDiaphragm

Disadvantages :Disadvantages :

- Prolonged use increase the risk of UTIProlonged use increase the risk of UTI

- More than 24 hours use is not recommended More than 24 hours use is not recommended due to the possible risk of TSS. due to the possible risk of TSS.

- Might cause vaginal erosions if not placed properly .Might cause vaginal erosions if not placed properly .

- Requires a professional fitting (trained provider is needed) .Requires a professional fitting (trained provider is needed) .

Cervical cap Cervical cap

a cup-shaped latex device that fits over the a cup-shaped latex device that fits over the base of the cervix. base of the cervix.

The cap must be filled one third full with The cap must be filled one third full with spermicide prior to insertion spermicide prior to insertion

Inserted 8 hours before coitus and can be left Inserted 8 hours before coitus and can be left in place for as long as 48 hours. in place for as long as 48 hours.

Cervical cap Cervical cap

Acts as both mechanical barrier to sperm and as a chemical agent Acts as both mechanical barrier to sperm and as a chemical agent with the use of spermicide .with the use of spermicide .

Pregnancy rates range between 4 and 36 per 100 women per year.Pregnancy rates range between 4 and 36 per 100 women per year.

Effectiveness depends on the parity of women due to the shape of Effectiveness depends on the parity of women due to the shape of the cervical os. the cervical os.

Disadvantages : cervical erosions and vaginal spotting , risk for Disadvantages : cervical erosions and vaginal spotting , risk for TSS , requires professional fitting and training for use , high failure TSS , requires professional fitting and training for use , high failure rate , and candidates must have a history of normal results of pap rate , and candidates must have a history of normal results of pap smears. smears.

Spermicides Spermicides

consist of a base combined with either consist of a base combined with either nonoxynol-9 or octoxynol nonoxynol-9 or octoxynol

Surfactant that destroys the sperm cell Surfactant that destroys the sperm cell membrane membrane

Forms available : vaginal foams, suppositories, Forms available : vaginal foams, suppositories, jellies, films, foaming tablets, and creams. jellies, films, foaming tablets, and creams.

SpermicidesSpermicides

Failure rate is about 26% within the 1Failure rate is about 26% within the 1stst year of use. year of use.

Advantages : ease of application , available over the Advantages : ease of application , available over the counter , inexpensive and it augments the counter , inexpensive and it augments the contraceptive efficacy of the cervical cap and contraceptive efficacy of the cervical cap and diaphragm .diaphragm .

Disadvantages : minimal protection against STDs , Disadvantages : minimal protection against STDs , risk of vaginal irritation and allergic reaction.risk of vaginal irritation and allergic reaction.

IUDIUD-IUDIUD is the world's most widely used is the world's most widely used method of reversible birth controlmethod of reversible birth control . .

3 TYPES:3 TYPES:

1- Inert ( no longer recommended because 1- Inert ( no longer recommended because of painful and heavy periods).of painful and heavy periods).

2-Copper Releasing (paragard).2-Copper Releasing (paragard).

3-Progesterone Releasing (IUS):3-Progesterone Releasing (IUS):

A-Progestasert (progesterone T) A-Progestasert (progesterone T) 1976 - 1976 - 20012001..

B-Mirena (levonorgestrel). B-Mirena (levonorgestrel).

Clinical usesClinical uses

Long-term contraceptionLong-term contraception

Women with contraindications to COC Women with contraindications to COC

Emergency contraceptive (Emergency contraceptive (1:1000 )1:1000 )

menorrhagia , endometriosis, chronic menorrhagia , endometriosis, chronic

pelvic pain, dysmenorrhea , anemia.pelvic pain, dysmenorrhea , anemia.

Mechanism of ActionMechanism of ActionThese mechanisms have not been defined precisely and are the These mechanisms have not been defined precisely and are the subject of ongoing controversy . It has several effects on the subject of ongoing controversy . It has several effects on the reproductive system : reproductive system :

- The Mirena is intended to initially release a daily dose of 20 - The Mirena is intended to initially release a daily dose of 20 micrograms levonorgestral (a progestin). micrograms levonorgestral (a progestin).

- Inhibition of ovulation.- Inhibition of ovulation.

-Cervical mucus is changed to obstruct passage of sperm Cervical mucus is changed to obstruct passage of sperm through the cervix.through the cervix.

- endometrial thinning which inhibits implantation of embryosendometrial thinning which inhibits implantation of embryos

Absolute ContraindicationsAbsolute Contraindications

-Pregnancy.Pregnancy.-Post partum puerperal sepsis-Post partum puerperal sepsis-Immediately post-septic abortion-Immediately post-septic abortion

-Undiagnosed abnormal vaginal bleeding. -Undiagnosed abnormal vaginal bleeding.

-Suspected gynecological malignancy.-Suspected gynecological malignancy.

((Cervical cancer, Cervical cancer, Endometrial cancer)Endometrial cancer)

--Current STDsCurrent STDs. .

--CurrentCurrent PID. PID.

-anatomical abnormalities-anatomical abnormalities

Sterilization Sterilization

Sterilization :female sterilization and male vasectomy are permenant Sterilization :female sterilization and male vasectomy are permenant metod of contaception and highly effective metod of contaception and highly effective

They are generally chosen by relatively older couple who are sure that They are generally chosen by relatively older couple who are sure that they copleted their family.they copleted their family.Also individual who carry a genetic disorder may choose to be Also individual who carry a genetic disorder may choose to be strlizer.strlizer.

28% of reproductive age women undergo tubal ligation and 10% of 28% of reproductive age women undergo tubal ligation and 10% of men undergo vasectomy.men undergo vasectomy.Sterilization methods include:Sterilization methods include:

1- Vasectomy in males.1- Vasectomy in males.

2- Tubal Ligation in females .2- Tubal Ligation in females .

Tubal LigationTubal LigationThis involve mechanically blockage of This involve mechanically blockage of both fallopian tube to prevent the both fallopian tube to prevent the sperm reaching and fertilizing the sperm reaching and fertilizing the oocyteoocyte

sterilization performed by sterilization performed by laparoscopically(under GA) or through laparoscopically(under GA) or through a suprapubic “mini-laparotomy”a suprapubic “mini-laparotomy”

Failure rate: 0.5%Failure rate: 0.5%

Tubal LigationTubal Ligation

AdvantagesAdvantages::

• • intended to be permanentintended to be permanent• • highly effectivehighly effective• • safesafe• • quick recoveryquick recovery• • lack of significant long-term side effectslack of significant long-term side effects• • cost effectivecost effective

Tubal LigationTubal Ligation

Disadvantage:Disadvantage:

• • possibility of patient regretpossibility of patient regret

• • difficult to reversedifficult to reverse

• • future pregnancy could require assisted reproductive future pregnancy could require assisted reproductive technology (such as IVF)technology (such as IVF)

• • more expensive than vasectomymore expensive than vasectomy

Cont.Cont.

Complication:Complication:A women may experienced anasthetic problem or may A women may experienced anasthetic problem or may

be damage to intra-abdominal during the procedure.be damage to intra-abdominal during the procedure.

NOTENOTE::

ectopic pregnancy can be a late complications ectopic pregnancy can be a late complications

and any sterilized women who misses her period and and any sterilized women who misses her period and has symptom of pregnancy should seek has symptom of pregnancy should seek

medical advice.medical advice.

VasectomyVasectomy

Mechanism of actionMechanism of action::

Vasectomy involve division of the vas deferens on each Vasectomy involve division of the vas deferens on each side to prevent the release of sperm during side to prevent the release of sperm during ejaculation.ejaculation.

Easier than tubal ligation.Easier than tubal ligation. Usually done under local anesthesia.Usually done under local anesthesia.

Failure rate: 0.1%.Failure rate: 0.1%.

VasectomyVasectomyAdvantages:Advantages:

• • permanentpermanent• • highly effectivehighly effective• • safesafe• • quick recoveryquick recovery• • lack of significant long-term side effectslack of significant long-term side effects• • cost effective; less expensive than tubal ligationcost effective; less expensive than tubal ligation

VasectomyVasectomyDisadvantages:Disadvantages:

• • reversal is difficult, expensive, often reversal is difficult, expensive, often unsuccessfulunsuccessful

• • not effective until all sperm cleared from the not effective until all sperm cleared from the

reproductive tract (may take up to 12 w)reproductive tract (may take up to 12 w)

• • no protection from STDsno protection from STDs

Cont.Cont.

Complication of vasectomy:Complication of vasectomy:Immediately bleeding, wound infection and hematoma Immediately bleeding, wound infection and hematoma

may occur.may occur.

At the cut of vas deferns small lump will apear as a At the cut of vas deferns small lump will apear as a result of a local inflammation response this is called result of a local inflammation response this is called

sperm granulomasperm granuloma it needs surgica excision. it needs surgica excision.

Cont.Cont.

some men develop anti-sperm antibody some men develop anti-sperm antibody following vasectomy following vasectomy

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