Dr Junita ArisKlinik Kesihatan Segamat

Family Planning methods (Contraception)

Intentional prevention of conception or impregnation through the use of various devices, agents, drugs, sexual practices, or surgical procedures.

Contraception

CATEGORIES CLASSIFICATION

1 A condition for which there is no restriction for the use of contraceptive method

2 A condition where the advantages of using the method generally out weight the theoretical or proven risks

3 A condition where the theoretical or proven risks usually out weight the advantages of using the method

4 A condition which represent an unacceptable health risk of the contraceptive method is used

Contraception-WHO MEC

CATEGORY WITH CLINICAL JUDGEMENT

WITH LIMITED CLINICAL JUDGEMENT

1 USE THE METHOD IN ANY CIRCUMSTANCES

YES - USE THE METHOD

2 CAREFULLY USE THE METHOD

YES - USE THE METHOD

3 NOT USUALLY RECOMMENDED UNLESS NO OTHER MORE APPROPRIATE METHOD AVAILABLE

NO – DO NOT USED THE METHOD

4 METHOD NOT TO USED NO – DO NOT USED THE METHOD

Contraception-WHO MEC

Barrier method• Male condom• Female condom• Diaphragm• Cervical cap

Contraception

Hormonal Oral• POP• COCPInjectables• Depo provera• Noristerat

Device• Norplant• Implanon• IUCD copper LNG (levonorgestrel)

Contraception

Evra patch

Nuva ring

Contraception

SterilizationFemale –Tubal Ligation

Male -vasectomy

Contraception

Barrier method

Male condom

Typical use 15%Perfect use 2%

Male condom

Male condom

Male condom

What are the chances of getting pregnant while using a female condom?T

Typical use: 21 %

Perfect use: 5 %

Female Condom

• Female diaphragm

• Cervical cap

What are the chances of getting pregnant

Typical use: 20 %Perfect use: 9 %

Typical use: 10 %Perfect use : 4%

Female Condom

Male Condom Female condom

Rolled on the mans penisFit on the erect penis

Inserted into the woman’s vagina

Made of latex FC2 is made of nitrile and FC is made of polyurethane

Lubricant: Can include spermicide

Can be water-based only; cannot be oil-based

Located on the outside of condom

Lubricant: Can include spermicide

Can be water-based or oil-based

Located on the inside and outside of condom

Condom must be put on an erect penis Can be inserted prior to sexual intercourse, not dependent on erect penis

Male condom Female condom

Must be removed immediately after ejaculation

Does not need to be removed immediately after ejaculation

Covers most of the penis and protects the woman’s internal genitalia.

Covers both the woman’s internal and external genitalia and the base of the penis, which provides broader protection.

Latex condoms can decay if not stored properly

Is not susceptible to deterioration from temperature or humidity.

Recommended as one time use product. recommended for one time use

Benefits• Help protect against STIs, including HIV• No hormonal side effects

Side effectAllergic reaction to latex

Condom

HORMONAL

Combined oral contraceptive (COC)

- contains two steroid hormones-estrogen&progesterone

- Estrogen component of most modern COC is ethinyloestradiol(EE) in the dose range of 20-50microgram

- Progesterone component vary in different preparations

Combined oral contraceptive (COC)

• Progestogen Component– second generation(e.g.norethisterone and

levonorgestrel) – third generation(desogestrel and gestodene)

• Third generation have a higher affinity for the progesterone receptor and a lower affinity for androgen receptor- LESS SIDE EFFECT

Combined oral contraceptive

• In theory, they confer greater efficacy with fewer androgenic side effects

• Also have fewer effects on carbohydrate and lipid metabolism than second generation compounds

• However evidence has shown it has not resulted in a reduction in the risk of arterial wall disease or AMI

Combined oral contraceptive

• Monophasic-all 21 active pills contain same amount of oestrogen and progesterone

• Biphasic-21 active pills contain 2 different Oes/P combinations

• Triphasic-21 active pills containing 3 different Oes/P combinations

Combined oral contraceptive-types

Mechanism of action• Oestrogen component inhibits pituitary FSH

secretion-suppresses follicle growth; progesterone component inhibits the LH surge inhibits ovulation

• Cervical mucus becomes scanty and viscous-inhibits sperm transport

• The endometrium becomes atrophic and unreceptive to implantation

• Possibly direct effects on the fallopian tubes impairing sperm migration and ovum transport

Combined oral contraceptive

• Effectiveness– Depends on user– < 1 pregnancy per 100 woman used over first year

(3 per 1000 woman) if used without mistake– Failure is greatest when woman starts a new pill

pack 3 or more days later• Convenience• Reversibility– No delayed returning of fertility after COC stopped

COC - contraceptive benefits

• Reduction of most menstrual cycle disorders: less heavy bleeding, therefore less anaemia, and less dysmenorrhoea

• Regular bleeding, the timing of which can be controlled: fewer symptoms of premenstrual tension overall; no ovulation pain

COC - non contraceptive benefits

• Fewer functional ovarian cysts• Fewer extra uterine pregnancies• Reduction in pelvic inflammatory ds• Fewer symptomatic fibroid• Reduced risk of cancers of ovary and

endometrium

COC - non contraceptive benefits

• Weight gain: pills containing levonorgestrel(LNG) but not desogestrel or gestodene

• Carbohydrate metabolism: minor effects on insulin secretion

• Lipid metabolism: the effect on the ratios of total and LDL cholesterol to HDL cholesterol depends on the relative doses of Oestrogen/Progestrogen and type of progesterone used

COC - limitation/side effects

• Venous disease:EE causes an alteration in clotting factors , promoting coagulation and increasing the relative risk of VTE in current COC users by 3-4 fold compared to women not taking COC

• COC containing 3rd generation progestogens (desogestrel and gestodene) possibly carry a small additional risk of VTE compared to that of 2nd generation

COC - limitation/side effects

Arterial disease• relative risk of MI and haemorrhagic stroke in

current users with hypertension or who smoke is increased more than in non smoking users without hypertension, who are at no greater risk than non users

• Relative risk of ischaemic stroke in normotensive current users who do not smoke is increased about 1.5-fold compared to non users.

COC - limitation/side effects

• Ideally the COCP should be started on the first day of menstrual bleeding, but can be started up to day 5 without the need for extra protection.

• It can be started at any other time IF THE PATIENT IS SURE SHE IS NOT PREGNANT, but additional protection e.g. condoms will be needed for the first 7 days.

COC - when to start

Past or present circulatorydisease• Proven past arterial or

venous thrombosis• IHD• Severe multiple risk

factors for venous or arterial disease

• Focal migraine• TIA• Artherogenic lipid

disorders

Disease of the liver

• Active liver ds (i.e.with abnormal liver function test)

• Liver adenoma or carcinoma

• Gallstones• Acute hepatic porphyrias

COC-Absolute Contraindication (WHO 4)

Others• Pregnancy• Undiagnosed genital tract bleeding• Oestrogen dependent neoplasms,e.g breast

cancer

COC-Absolute Contraindication (WHO 4)

• Undiagnosed oligomenorrhoea• Cigarette smoking above age 35• Diabetes• Non focal migraine• Sickle cell disease• Inflammatory bowel ds• Obesity(if ass with other risk factors)

COC-Relative Contraindication (WHO 2 & 3)

• Controlled by the woman• Stopped at any time without health provider help• Do not interfere with sexual activity• Safe and suitable for nearly all woman• At any age including adolescent, woman age > 40 • Following a miscarriage • Without pelvic examination• Without cervical cancer screening

Women like COC

Drug interactions - AntiTB( Rifampicin)- Antiepileptic

(barbiturates,phenytoincarbamazepine)

- Antibiotic (doxcycline, ampicillin)

COC-Drug Interactions

• Progestin-only pills (POPs)• Depo-provera• Norplant• Implanon

PROGESTOGEN ONLY CONTRACEPTIVES

Mechanisms of action• Suppress ovulation• Reduce sperm transport in upper genital tract

(fallopian tubes)• Thicken cervical mucus

preventing sperm penetration

PROGESTOGEN ONLY PILLS (POPs)

)

• Effective when taken at the same time daily• Immediately effective (<24 hours)• Do not interfere with intercourse• Do not affect breast feeding• Immediate return to fertility when stopped• If BF + LAM – near 100% effective• If not BF – 99.5% effective

POPs-Contraceptive benefits

• Few side effects• Convenient and easy to use• Client can stop use• Can be provided by trained non-medical staff• Contain no oestrogen

POPs-Contraceptive benefits

• May decrease menstrual cramps• May decrease menstrual bleeding• May improve anaemia• Protect against endometrial cancer• Decrease benign breast disease• Decrease ectopic pregnancy• Protect against some causes of PID

POPs-Non Contraceptive benefits

• Changes in menstrual bleeding pattern• Some gain weight or loss may occur• User dependent• Must be taken at the same time daily• Resupply must available• Drugs interaction – epilepsy, TB• Do not protect against STDs

POPs-Limitations

• POPs are not recommended unless other methods are not available or acceptable if woman ;– Has unexplained vaginal bleeding (if suspected

serious problem)– Has breast cancer (current / with h/o )– Is jaundiced (active, sx)

POPs-condition requiring precaution (WHO Class 3)

• Is taking drugs for epilepsy (phenytoin/barbiturates) or TB (rifampicin)

• Has severe cirrhosis• Has liver tumours• Has had a stroke• Has IHD

POPs-condition requiring precaution (WHO Class 3)

• Blood pressure (<180/110)• Uncomplicated DM ( < 20 yrs illness)• Preeclampsia ( h/o)• Smoking (any age / amount )• Surgery (± long bed rest)• Thromboembolic disorders• Valvular heart disease (± symptomatic)

POPs-No Restriction

• Day 1 menstrual cycle• Any time when sure pt is not pregnant• Post partum– After 6/12 if using LAM– After 6/52 if breastfeeding but not using LAM– Immediately or within 6 weeks if not

breastfeeding

• Post abortion (immediately)

POPs-When to start

• Amenorrhoea (absence of PV bleeding or spotting)

• Bleeding or spotting• Heavy or prolonged bleeding• Lower abdominal/pelvic (± symptoms of

pregnancy)• Weight gain or loss ( change in appetite )• Headache• Nausea/dizziness/vomiting

POPs-Side effects which may require management

• Evaluate for pregnancy, especially if amenorrhoea occurs after period of regular menstrual cycles

• If not pregnant, counsel and reassure client

• Do not attempt to induce bleeding with COCs.

POPs- Management of Amenorrhea

• Reassurance

• Check for gynaecologic problem

• Short term treatment– COC for 1 cycle– ibuprofen

POPs : management of prolonged bleeding or spotting

• 28-42 pills/pack• Take one pill daily• No break in between packs• Within 3 hours of lowest at 20-24 hour after

ingestion; best taken at a time related to the usual time of intercourse and not 20 hours later

POPs

• Depo-provera (DMPA) – 150 mg of depot medroxyprogesterone acetate every 3/12

• Noristerat (NET-EN) : 200 mg of norethindrone enanthate give every 2/12

Injectable

• Highly effective (0.3 pregnancies per 100 women during first year of use)

• Rapidly effective (<24 hours) if started on D7 of menses

• Intermediate term method (2-3 monthd protection per injection )

• Do no interfere with intercourse

• Do not affect breast feeding

• Few side effects• No supplies needed by

the client• Can be provided by

trained non medical staff• Contain no oestrogen

Injectable-contraceptive benefits

• Changes in menstrual pattern

• Weight gain (~2 kg) is common

• If pregnancy occurs, it is more likely to be ectopic than nonuser

• Resupply must be available

• Must return for injections every 3 months(DMPA) or 2 months(NET-EN)

• Return to fertility may be delayed for 7-9 months (on average) after discontinuation

Injectable-limitations

• Women of any reproductive age who;– Have moderate to severe menstrual cramping– Take drugs for epilepsy or tuberculosis– Have high blood pressure or blood clotting

disorder– Prefer not or should not use estrogen– Cannot remember to take a pill every day– Prefer a method not related to intercourse

Injectable-Indications

• Initial injection :– Days 1 to 7 of the menstrual cycle– Anytime during the menstrual cycle when you can be

reasonably sure the client is not pregnant– Post partum :

• Immediately if not breast feeding• After six months if using LAM

• Reinjection– DMPA : up to 4 weeks early or late– NET-EN : up to 2 weeks early or late

Injectable-timing of injection

DMPA NET-ENDuration 3 months 2 monthsBleeding More amenorrhoea More irregularNeedle / pain Smaller / less Larger / moreReinjection window Up to 4 weeks Up to 2 weeksCost Cheaper More expensiveReturn to ovulation later sooner

Injectable-Comparison of DMPA and NET-EN

• The most common side effect - irregular bleeding in 70 percent of women in

the first year.- in 10 percent of women thereafter.

- Absence of bleeding is common in 80 percent of women after two years.

Injectable-Side effects

Less common side effects:Increased appetite and weight gainHeadachesSore breastsNauseaDepressionNervousnessDizzinessSkin rashes or spotty darkening of the skinHair loss or increased hair on face or bodyIncreased or decreased sexual desire

Injectable-Side effects

• Vaginal dryness• Bone loss (reduce bone density)• If pregnancy is desired, it takes 12 to 18 weeks

to get pregnant after the last shot is taken (sometimes longer)

• In the rare case that pregnancy occurs during the use of Depo Provera, there is an increased chance that the pregnancy will be ectopic.

Injectable-Side effects

Types• Non medicated– Lippes loop

• Medicated– Copper-releasing– Progestin-releasing

Intrauterine contraceptive device (IUCD)

• Copper releasing• 1st generation– Copper seven– Copper T 200

• 2nd generation– Multiload 250– Nova T

• 3rd generation– Copper T380A– Multiload 375

• Progestin releasing• Progestasert• LevoNova (LNG 20)• Mirena

Chance of getting pregnantCopper:

Typical use: 0.8 percent

Perfect use: 0.6 percentProgesterone:

Typical use: 0.2 percent

Medicated IUCDs

• Effective immediately• Long term method (up to 10

years protection with copper T380A)

• Do not interfere with intercourse

• Immediate return to fertility upon removal

• Do not affect breast feeding

Mirena• Decrease menstrual cramps

(progestin releasing only)• Decrease menstrual

bleeding (progestin releasing only)

IUCD-Benefits

• Increase menstrual bleeding and cramping during the first few months (copper releasing only)

• May be spontaneous expelled

• Rarely (<1:1000) perforation of uterus during insertion

• Do not prevent all ectopic pregnancies

• May increase risk of PID and subsequent infertility

• Pelvic examination required and screening for STDs recommended before insertion

• Required trained provider for insertion and removal

• Need to check for strings after menstrual period if cramping, spotting or pain

• Woman cannot stop use whenever she wants

IUCD-Limitations

• Natural cycle, day 1-5 is usual; if day 5 or any day later(assuming no sexual exposure up to that day)-recommended additional contraception for 7 days

• Following delivery or 2nd trimester miscarriage(not breastfeeding)-insertion on about day 21 is recommended

IUCD-Timing

• Copper releasing– Heavier menstrual bleeding– Irregular / heavy vaginal

bleeding– Increased menstrual

cramping or pain– Vaginal discharge

• Progestin releasing– Amenorrhoea or very light

menstrual bleeding or spotting

IUCD-Side effects

• May occur anytime after insertion

• Most expulsions occur in the first year and particularly in the first 3 months

• Correct fundal placement is thought to reduce expulsion

• Expulsion rates are higher with an inexperienced operator,

• insertion under 6 weeks postpartum, nulliparous and in women with heavy painful menses

• Higher expulsion rates in nulliparous women have not been observed in recent studies

• Women who expel an IUCD have a 3-fold increased risk of expelling the same or another device

IUCD-Expulsion

The increased dose of estrogen (> 60% than the pills) from the patch is associated with blood clots .

EVRA patch

`

• women with a history of blood vessel disease such as diabetes, heart disease or high blood pressure should not take this medication.

EVRA patch

• Etonogestrel/EE(0.120 mg /0.015 mg per

day)

Nuva Ring

Various types Contraceptive Efficacy (100 women in 1 year use)

Abstinence 100% effective

Implants 0.05

Vasectomy 0.1

Levonorgestrel IUD 0.2

Tubal ligation 0.5

Injectable 0.3

Oral Hormone 0.3

Copper IUCD 0.6

LAM (6 months) 0.9

Male condom 2 (correct and consistent use)

Withdrawal 4

Diaphragms with spermicide 6

Contraception

Mosteffective

Leasteffective

• Within 72 H since last unprotective SI1)Levonorgestrel (Prostinor) 0.75 mg bd or 1.5 mg od 1 day only

2)>72 H up to 5 days IUCD (copper)

Emergency contraception

• Woman can choose method of contraception that suite her needs

• All contraceptives method available should be explained at timing of consultation

• More receptive for any side effect experienced by the woman

• Woman with other associated problem, consultation to the expert should be made.

Summary

Thank you