Contraception I. Contraception Overview II. Effectiveness III. Contraception Methods.
METHODS OF CONTRACEPTION
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Transcript of METHODS OF CONTRACEPTION
METHODS OF
CONTRACEPTION Aboubakr Elnashar Benha University Hospital, Egypt
I. Hormonal Methods
II. Intrauterine Device
III. Barrier Methods
IV. Natural Methods
V. Sterilization
Outline
I. Hormonal Methods
Advantages
Most effective, long-term reversible contraception available
Most methods offer complete privacy
Require no planning before intercourse
Disadvantages
Require a visit to a healthcare professional
May cause common hormonal side effects
Products containing estrogen may be associated with rare, but serious health risks
Not effective against STD
Daily Use
Oral Contraceptive Pill
– Combination pill
– Progestin-only pill
Nondaily Use
Injectable contraceptive
Contraceptive patch
Hormone-releasing
intrauterine system
Emergency Contraception
1. The Combination Pill
Contain Synthetic Estrogen/Progestin
Modern E2 Dosage ≤ 50 Mcg
Despite Diversity, Side Effects and Efficacies
Similar
Requires Patient Compliance
May Be Monophasic or Triphasic
Estrogens:
Ethinyl estradiol
Mestranol
Progestins:
Ethynodiol diacetate
Norethindrone acetate
Norethindrone
Norgestrel
Levonorgestrel
Desogestrel
Norgestimate
Drospirenone
2nd Generation
3rd Generation
Spironolactone Derived
Advantages:
Highly effective
Provides noncontraceptive health benefits
Private
Does not require vaginal insertion
Allows to control cycle
Disadvantages:
Must be taken daily
Side effects may lead to discontinuation
Associated with rare, but serious health risks, such as blood clots and stroke
Non-Contraceptive Benefits of OCPs
Improvement
Dysmenorrhea
Acne
Hirsutism
Anemia
Cycle Regulation
Reduction Risks
Colorectal Cancer (18-40%)
Endometrial Cancer
PID (10 – 70%)
Osteoporosis
Osteopenia
Cleveland Journal of Medicine 2004
Mechanism of Action
Suppresses LH / FSH Release
(E2 FSH, P LH)
Progestin Thickens Cervical Mucus and Alters
Endometrium
Major Effect Is Anovulation and Impairment of
Sperm Transport and Oöcyte Implantation
Side Effects
Breakthrough Bleeding (≤ 25%)
Amenorrhea
Breast Tenderness, Nausea
? HTN
? Weight Gain
Risks
Thromboembolism (≥ 35 yo, Smoker)
MI (Smokers Only):
< 15 cig/day: 3X Risk
> 15 cig/day : 21X Risk
Liver Adenomas (Very Rare)
2. The Contraceptive Patch (Evra Patch)
Advantages:
Efficacy comparable to OCPs
Weekly application encourages compliance
Does not require vaginal insertion
Disadvantages:
Application site reactions may occur
May not be as effective in women weighing more than 198 pounds
May produce side effects similar to OCPs, with higher rate of transient breast pain
Noncontraceptive health benefits theoretically similar to combination OCPs, but not as well documented
May be visible on the skin
OCP = Oral Contraceptive Pill
3. The Progestin-Only Pill
Progestins:
Norethindrone
Norgestrel
Advantages:
Useful for women with contraindications to estrogen
Use with postpartum women who are breastfeeding
Does not require vaginal insertion
Disadvantages:
Higher pregnancy rate than combination OCPs
More sensitive to missed pills than combination OCPs
Associated with abnormal bleeding and other side effects
4. Injectable Hormonal Contraception
Advantages:
Highly effective
Convenient three month administration schedule encourages adherence
Private
Useful when estrogen should be avoided
Decreases risk of endometrial cancer
Disadvantages:
Irregular bleeding and amenorrhea frequently occur
Weight gain, abdominal pain, and depression are common side effects
Prolonged use may decrease bone mass
Depo Provera:
-every 3 months
-Medroxyprogestin
Acetate 150 mg.
Types
Main Side-Effects:
Amenorrhea
AUB
Weight Gain
Hair Loss
5. Emergency Contraception Indications -standard of care for women not protected by efffective contraception. -No contraception was used -Condom broke, slipped, leaked etc…. -Missed more 2 or more days of ocp’s
-Highly effective 75%
-Effective up to 120 hours after unprotected sex -Will not disrupt or harm developing pregnancy
J Adolesc Health. 2004;35:66-70.
FDA Approved Emergency Contraceptive Kits
PREVEN KIT
- Contains 4 pills
- EE 50 ug.
- Levonorgestril
0.25 mg.
- 2 pills 12 hourly
for 2 doses
Plan B Kit
- contains 2 pills
- Levonorgestril
0.75 mg
- 1 pill 12 hourly for
2 doses
The Yuzpe Regimen:
Two Doses of:
EE 0.1 mg with
dl-norgestrel 1.0 mg
Administered 12
hours apart
First dose taken within 120
hours of unprotected
intercourse
The Combination Pill
Advantages:
Prevents approximately 75% of unintended pregnancies
Disadvantages:
Increased incidence of side effects due to high estrogen component
High rate of nausea (50%) and vomiting (20%) may limit adherence
EE = Ethinyl Estradiol
The Progestin-Only Pill
Advantages:
More effective than Yuzpe regimen
Better tolerated than Yuzpe regimen
May be taken as a single dose
May be preferable for women with history
of idiopathic thrombosis
Disadvantages:
Associated with a moderate degree of side
effects including nausea, vomiting,
dizziness, and fatigue
Plan B (levonorgestrel 0.75 mg)
Levonorgestrel:
Single dose of 1.5 mg or two doses of 0.75 mg taken 12 hours apart
First dose administered within 120 hours
ACOG GUIDELINES (Emergency Contraception)
-Should be offered or made available for (UPSI)
- Levonorgestril only regime is more effective &
less side effects than combined regime
- 1.5 mg Levonorgestril can be taken single dose
or 2 divided doses (0.75 mg) 12-24 hrs. apart
- An anti-emetic can be taken 1 hr before 1st dose
- Prescription of EC in advance can increase
availability and use.
II. IUD
ParaGard (CuT380A),
Very Effective (~ TL), Reversible
Risks OVERBLOWN
Does Not Protect Against STD’s
Can Remain for ≤ 10 Years
Mechanisms of Action
NOT ABORTIFACIENT!!!!!!!!
Prevents Conception:
– Sperm Transport Inhibited
– Sperm Survival / Capacitation
Diminished
Prevents Implantation: hCG Levels = 0
Work-up
History: STD’s, Sexual History, Ectopic
PEx: Size / Configuration of Uterus
Cervical Cultures, Pap
Counseling
Contraindications
High Risk for STD’s
Abnormal Uterine Bleeding
Current Pelvic Infection (GC, Chl)
Actinomyces on Pap
???Nulliparity
Pregnancy
Wilson’s Dz, Cu Allergy (both rare)
Complications
PID: Usually 20 Insertional Contamination
– Unproven Role for Prophylactic ABx
Hypermenorrhea
Expulsion
Perforation (< 0.1%)
Failure: IUD Should be Removed
??Ectopic
1. The Copper Intrauterine Device (IUD)
Advantages:
Highly effective
May be efficacious if inserted up to 7 days after intercourse
Generally well tolerated
Disadvantages:
Not cost effective for short-term use
Not recommended for women with a sexually transmitted disease
2. Multi load with IUCD inserter
3. Levonorgestrel Intrauterine System
Advantages:
Highly effective
Stays in place for up to five years, limiting adherence concerns
Private
Decreases menstrual blood loss
Disadvantages:
Requires professional insertion and removal
Abnormal bleeding, dysmenorrhea, and pelvic, abdominal and back pain
May not be appropriate for women with increase STD risk
III. Barrier Methods
Advantages
- Preferred by many who have occasional intercourse
- Useful alternatives for those who want to avoid hormonal side effects
- Some methods available without prescription
- Some methods offer limited protection against sexually transmitted disease
Disadvantages
-Not as effective as hormonal methods
-Efficacy is highly dependent on consistent and correct
use
-Require fitting by healthcare provider
-Require vaginal insertion and removal by the patient
that may be difficult or unacceptable
-Require concomitant use of spermicide
-Associated with an increased risk of urinary tract
infection and toxic shock syndrome
Diaphragm
Cervical Cap
Types
Male Condom
Spermicide
Advantages:
Can be inserted hours before intercourse
Does not require removal between acts of intercourse
1. Diaphragm
Disadvantages: -Should not be used with suspected or confirmed latex
allergy
-Requires prescription and fitting by healthcare provider
-Requires insertion and removal
-Spermicide must be applied before each use
-Must stay in place for at least six hours after last intercourse
-May increase risk of urinary tract infections and toxic shock
syndrome
2. Male Condom
Advantages:
Provides greater protection against STDs than any other method of contraception
Provides substantial protection against pregnancy when used with a spermicide
Does not require a prescription
Can be used with other methods
Inexpensive and widely available
Disadvantages:
Can only be used for one act of intercourse
Can break or slip during use
May decrease sexual pleasure
May interfere with spontaneity
Requires cooperation of male partner
IV. Natural Methods
1-Natural family planning techniques (Fertility Awareness Methods) 2-Contraceptive effect of breast feeding (Lactational Amenorrhea Method) 3- Withdrawal
1. Rhythm-standard days method (SDM)
For women with menstrual
cycles between 26 & 32 days.
Avoid unprotected IC day #9-
19
70-80% effective
Assumes ovulation about day
#14
2. Withdrawal Method
80-90% effective
Always available
Requires motivation,
sense of timing
Some sperm present in
pre-ejaculatory fluid
Psychological issues
V. Sterilization
Surgical sterilization
Permanent, irreversible
>99% effective
METHODS OF TUBAL LIGATION Procedure Timing Technique
Minilaparotomy •Post Partum
•Post Abortion
•Interval
•Mechanical Devices
(Clips, Rings)
•Tubal Ligation or Excision
Laparoscopy •Interval Only
•Electrocoagulation
(Unipolar, Bipolar)
•Mechanical Devices
(Clips, Rings)
Laparotomy In conjunction with other surgery (cesarean section, salpingectomy, ovarian cystectomy etc.)
•Mechanical Devices
(Clips, Rings)
•Tubal Ligation or Excision Female Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-160
Pomeroy Procedure Tied
Cut
Final result
Filshie Clip
Hulka Clip
Monopolar Coagulation
Laparoscopic
•Proposed in 1937 by Anderson
•Complications
•Bowel Burn
•Longer portion of
tube is damaged
•Failures and ectopic
pregnancy
1. Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8
Failure Rate:7.5/1000
Bipolar Coagulation Laparoscopic
Introduced in 1973 by Jacques Rioux
Benefits
•Most Common method
of Laparoscopic
sterilization
Complications
•Formation of uteroperitoneal fistulas
•High rate of Ectopic Pregnancy
•Potential for Bowel Burns
•Reversals are potentially more difficult due to the extent of tube damage
1. Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170
Failure Rate:24.8/10001