Download Fertility control

‫د‪ 0‬بتول عبد الواحد هاشم‬
Contraception:
Classification:
Hormonal contraception:

 Combined oral contraception
 Combined hormonal patches
 Progestogen-only preparation
 -Progestogen-only pills
 -injectables
 -subdermal implants












Intrauterine contraception
Copper intrauterine device
Hormone-releasing intrauterine system(IUS)
Barrier methods
Condoms
Female barriers
Coitus interruptus
Natural family planning
Emergency contraception
Sterilization
Female sterilization
Vasectomy
 The number of failures per 100 women year(HWY): is
the number of pregnancies if 100 women were to use the
method for 1 year
 One- method failure is either to imperfect use (user
failure)- most common-, or to intrinsic method failure.

 Contraceptive method












HWY
COCP
POP
Depo provera
Implanon
Copper bearing IUD
LNIUS
Male condom
Female diaphragm
Persona
Natural family planning
Vasectomy
Female sterilization
failure rate per
0.1-1
1-3
0.1-2
0
1-2
0.5
2-5
1-15
6
2-3
0.02
0.13
HORMONAL CONTRACEPTIVE METHODS
COMBINED ESTROGEN AND PROGESTIN METHODS
Oral Contraceptive Pills (OCPs)
Formulations
 Modern preparations contain ethinyl estradiol in a daily
dose of between 20-35 mcg, higher doses of estrogen are
strongly linked to increased both arterial and venous
thrumbosis,
 Progestogens in the pills are classed as second
(norethisterone acetate or levonorgestrel) or third
generation (gestoden, desogestrel, norgestimate) or
antimineralocorticoides and
antiandrogenic(drospirenone).
 Monophasic pills have fixed estrogen/progesterone dose
 Biphasic and triphasic preparations have 2 or 3 incremental
doses of estrogen and progesterone.
 They either contain21 pills with 7 days pill-free period
 Or ED-every day preparations- that include 7 placebo pills
mechanism of contraception
 Oral contraceptives place the body in a pseudo-
pregnancy state by interfering with the pulsatile
release of follicle-stimulating
 hormone (FSH) and luteinizing hormone (LH)
from the anterior pituitary. This pseudo-pregnancy
state suppresses ovulation
 2- thickening the cervical mucus to render it less
penetrable by sperm and
 3-changing the endometrium to make it
unsuitable for implantation.
Decrease risk of serious diseases
 Ovarian cancer
 Endometrial cancer
 Ectopic pregnancy (combination pills only)
 Severe anemia
 Pelvic inflammatory disease
Improve quality-of-life problems
 Iron-deficiency anemia
 Dysmenorrhea
 Functional ovarian cysts
 Benign breast disease
 Osteoporosis (increased bone density)
 Rheumatoid arthritis
Treat/manage many disorders
 Dysfunctional uterine bleeding
 Control of bleeding in bleeding disorders and anovulation
 Dysmenorrhea
 Endometriosis
 Acne/hirsutism
 Premenstrual syndrome (PMS)
Contraindications to Combination Estrogen-Progesterone
Contraceptives
Absolute Contraindications
 Circulatory disease
 -ischemic heart disease
 -cerebrovasular accidents
 -significant hypertension
 -arterial or venous thrombosis
 -any acquired or inherited prothrombotic tendency
 -any significant risk factors for cardiovascular disease
 Acute or severe liver disease
 Estrogen dependant neoplasm, particularly breast cancer
 Focal migrane
Relative Contraindications
 Generalized migrane
 Long term immobilization
 Irregular undiagnosed vaginal bleeding
 Less severe risk of cardiovascular diseases e.g. obesity, heavy smoking, diabetes.
Side effects
 Minor side effects:
 CNS: headache, depression, loss of libido
 GIT: nausea, vomiting, weight gain, bloatedness,




gallstones, cholestatic jaundice
Genitourinary: irregular bleeding, vaginal discharge
(ectropion)
Growth of fibroids
Breast: mastalgia, increased risk of breast cancer.
Miscellaneous: chloasma, leg cramps
Serious side effects:
Venous thromboembolism:the higher dose estrogen in the pills
the higher prothrombotic tendency,3rd generation progestogens
have twice the risk of thrumboembolism(TE) than 2nd
generation progestogens.
 Risk of VTE
 5/100000 general population
 15/100000 2nd generation COC
 30/100000 3rd generation COC
 60/100000 pregnancy
Arterial disease:
 Cerebrovascular accident (CVA), Myocardial infarction (MI)
have extremely small increased risk of occurrence, however
smoker women more than 35 years old have increased risk for
such complications. Around 1% of women taking COC will
become significantly hypertensive and should be advised to stop
pills.
Breast cancer:
 Data shows small increase in risk of developing breast ca
among current COC users, this is more significant for
women in their 40s as the background risk for breast
cancer is higher.
 Beyond 10 years of stopping the pills there was no increased
risk of breast cancer for younger user.
Cervical cancer:
 Barrier methods confer some protection and any
association identified in epidemiological studies may be
simply the result of inadequate adjustment for sexual
behavior. Women with persistent infection with HPV using
hormonal contraception for more than 5 years had
increased relative risk of cervical cancer of 2.8.
 Recent evidence has suggested an increased risk of
adenocarcinoma among long term users but this is a rare
tumor.
Liver cancer:
 Benign hepatic adenoma is a rare consequence of COC
use
Ovarian, endometrial and colon cancer:
 COCP protects against ovarian cancer with 50%
reduced risk of epithelial type after 5 year of use the
protective effect last for at least 10 years after pill use
stops. The effect may be related to the reduction of
total number of ovulation and therefore rupture of
ovarian capsule. And COCP reduces the risk of
endometrial cancer the effect is strongly related to
duration of use and is sustained for perhaps as long as
15 years after stopping the pills. There is some evidence
to suggest that COC may confer protection against
colon cancer.
 How late are you? Less than 12 hr

don't worry.
Just take delayed pill at
once
and further
pills as
usual

more than 12 hr
take the Most recently delayed
now, discard any earlier pills
use extra precautions
for the next 7 days







how many pills are left in the pack after the most
recently delayed pill
,<7 pills
>7 pills
When you have finished
The pack, leave the usual 7D break
When you have finished the pack,
before starting next pack
start the next pack next day without a break
combined hormonal patches
Transdermal patch containing estrogen and
progestogen, are applied weekly for 3 wk after which
there is a patch –free wk. contraceptive patches have
the same risks/benefits as COC, although they are
more expensive, may have better compliance. limited
data suggests that the overall average estrogen
concentration is higher, Therefore, these patients
should be made aware of the possible increased risk
of thromboembolism, specifically DVT and PE in
combined hormonal patches users. There does not
appear to be an increased risk of heart attack and
stroke in these patients.
Vaginal Estrogen and Progestin Hormonal Contraception(NuvaRing):
The ring is placed in the vagina for 3 weeks (it is
likely effective for 4 weeks), and is removed for 1 week to
allow for a withdrawal bleed. Again, this hormone-free
period can be
skipped to allow for continuous dosing, typically for 3
months.
contraception(POCONTRACEPTION)
 Progesterone-only contraception consists of oral,
injectable, implantable, and intrauterine options (the
Mirena IUS)
 These all function primarily using the same
mechanisms: thickening the cervical mucus,
inhibiting sperm motility, and thinning the
endometrial lining so that it is not suitable for
implantation.higher dose progesterone-only methods
will also act centrally and inhibit ovulation.
The common side effects of PO methods include:
 Erratic or absent menstrual bleeding.
 Functional ovarian cyst(persistent follicle)
 Breast tenderness
 Acne
 Sexually transmitted infection hormonal
contraception may be associated with an increased
risk of Chlamydia and gonorrhea, especially with
depoprovera which causes hypoestrogenism, thinning
of vaginal epithelium may increase the risk of
infection.
Relative contraindications for use of POC:















Breast feeding at least 6 wk postpartum
Current DVT, PE
Previous breast cancer with no evidence of disease for 5 yr
Active viral hepatitis
Benign hepatic adenoma
Severe decompensated cirrhosis
Malignant hepatoma
Current or history of ischemic heart disease , stroke
Migraine with aura
Unexplained vaginal bleeding
Multiple risk factors for arterial cardiovascular disease
BP>160/100 mmHg
Vascular disease
Diabetes with nephropathy
Progestin-Only Oral Contraception Pills (The Minipill)
Suits women who cannot take the COC, but have
relatively higher failure rate, ideal for women at times
of lower fertility, if fail make those women at higher
risk of ectopic pregnancy. Older preparation contain
2nd generation at low dose, the newer ones contain 3rd
generation progestogen at higher dose to inhibit
ovulation. The POP is taken every day
without a break
:
 Particular indication for POP include:
 Breast feeding
 Older age
 Cardiovascular risk
 Diabetes
Injectables progestogens:
 Depot medroxyprogesteron acetate( depoprovera) 150 mg










injection last for12-13 wk
Norethisterone enanthate 200mg only last for 8wk
Depoprovera is highly effective method of contraception
Most women develop very light or absent menstruation
It improves PMS other menstrual problems like painful or heavy
periods.
Particularly suits patients with poor compliance
Particular side effects
Weight gain 3 Kg in the 1st year.
Delay in regaining fertility( 6mo.-1yr)
Persistent menstrual irregularities
With very long term use increases osteoporosis
The Effects of Depo-Provera Use
on Bone Mineralization








Bone density is decreased in women using Depo-Provera
The decrease in bone density is most rapid in the first year of use
The decrease in bone density increases with length of use
The decrease in bone density is reversible and occurs over 6 mo
to 2 years
There is no role for the use of bone density screening (DEXA) in
DMPA users
There is no role for the use of bisphosphonates, estrogens,
SERMS in DMPA users
Women on Depo-Provera should be encouraged to take calcium
and vitamin D, to
stop smoking, and to do regular weight-bearing ex
Subdermal implant:
 Implanon consist of single silastic rod that is inserted
locally under local anesthesia in to upper arm it
superseded the 6 rod implant norplant. It's highly
effective and there have been no genuine failures
reported with it.
 It lasts for 3 years, particularly benefit poor compliant
women who need reliable long term contraception,
with rapid regaining of fertility.
Patient management:
Careful teaching and explanation of the method,
detailed past medical and family history, examine the
BP, body weight. Doing pelvic and breast exam are not
necessary. Start with 30 mcg EE, 2nd generation
progestogens as these are safest and cheapest; explain
what to do if they miss taking their pills
 How late are you? Less than 12 hr

don't worry.
Just take delayed pill at
once
and further
pills as
usual

more than 12 hr
take the Most recently delayed
now, discard any earlier pills
use extra precautions
for the next 7 days







how many pills are left in the pack after the most
recently delayed pill
,<7 pills
>7 pills
When you have finished
The pack, leave the usual 7D break
When you have finished the pack,
before starting next pack
start the next pack next day without a break