Download Contraception

CONTRACEPTION
Prepared by:
Dr/Elshiekh KKU,MD,ABHA
Introduction :
Family size is determined by a number of factors,
including social and religious customs, economic
aspirations, knowledge of contraception and the
availability of reliable methods to regulate
fertility.
Definitioin
The ability to control fertility by reliable
artificial methods has transformed both social
and epidemiological aspects of human
reproduction.
Mechanism of contraception:
By:
• Inhibition of ovulation
• Prevention of implantation of the fertilized ovum ◦
• Barrier methods of contraception, whereby the spermatozoa are
physically prevented from gaining access to the cervix.
The effectiveness of any method of contraception is measured
by the number of unwanted pregnancies that occur during
100 women years of exposure, i.e. during 1 year in 100 women
who are normally fertile and are having regular coitus.
Classification of contraception method;
A) Temporary method:
1-Barrier method of contraception
2-Intrauterine contraceptive Device
3-Hormonal contraception
4-Emergency contraception
5-Non medical contraception (physiological)
B)Permanent method
Sterilization
1- Barrier method:
Uses:
1- To prevents spermatozoa from reaching the female upper genital tract.
2- protection against sexually transmitted infection.
The Barrier method include the following :
1- male condom.
2-female condom .
3-Diphragm & cervical caps.
4-spermicide&sponges.
barrier methods
Male Condom
s
A male condom is a thin sheath made of latex or
other materials
-They have 97 - 9 8% effective with careful use.
-although typical failure rates can be as high as 15 pregnancies per 100
women years.
-Common causes of failure are:
leakage of sperm when the penis is withdrawn,
putting the condom on after genital contact,
use of lubricants that cause the latex to break
and mechanical damage.
Advantges of male condom:
No medical side-effects.
inexpensive, easily used.
Protecting against STDs.
Condoms can help men maintain an erection for a longer
period.
barrier methods
Strong, soft, transparent polyurethane sheath inserted in the vagina
before sexual intercourse
-Failure rate 21 %
15 cm long X 7 cm diameter
Characteristics of female condoms
- protection against STDs
-Available without a prescription
Are stronger than latex male condoms
(40% stronger)
Can be used with oil-based lubricants
Diphragm & cervical caps
A diaphragm is a shallow rubber dom
with a firm flexible rim
-These diaphragms vary in size from 45 mm to 100 mm in
diameter.) & inserted to cover the cervix and anterior vaginal
wall.
-The diaphragm must be inserted prior to intercourse and should
not be removed until at least 6 hours later.
- typical failure rates are between 8 and 10 pregnancies per 100
women years. .
Contraindication of diaphragm :
--Allergy to rubber, latex, or spermicide
(male & female )
--Frequent urinary tract or bladder infections
--Aanatomical abnormalities
The main advantage:
it is free of side effects to the woman, apart from
an occasional reaction to the contraceptive cream.
2-I N T R A U T E R I N E CONTRACEPTIVE
DEVICES
Defination:
A device inserted into the uterus (womb) to prevent
conception (pregnancy).
Mechanism of action:
Intrauterine devices (IUDs) prevent fertilization
primarily by interfering with the ability of sperm to survive
and to ascend the fallopian tubes, where fertilization
occurs.
Having a foreign body in the uterus, such as an IUD, causes
both anatomical and biochemical changes that appear
to be toxic to sperm
Types of device
Inert devices
Lippes loops, Saf-T-coils and Margulis spirals are plastic or plastic-coated devices. They have a
thread attached that protrudes through the cervix and allows the woman to check that the device
is still in place. Inert devices tend to be relatively large.
They are not now available but may still be found in situ in some older users
Pharmacologically active devices
The addition of copper to a contraceptive device produces a direct effect on the endometrium by
interfering with endometrial oestrogen-binding sites and depressing uptake of thymidine into
DNA. It also impairs glycogen storage in the endometrium. Examples of such devices are the
Copper-T or Copper-7 (first generation), the Multiload Copper-250 (second generation) and the
Copper-T 380 (third generation).
Devices containing progestogen
The levonorgestrel-releasing intrauterine system or Mirena®
contains 52 mg of levonorgestrel ; this provides protection
against pregnancy for 5 years with a failure rate of 0.3-1.1%,
comparable to third-generation copper devices
L i fe span of devices
The Cu T 380 is licensed for 8 years in the UK (13 in the USA). Other
copper devices and the Mirena® are licensed for 5 years. However,
IUDs do not need to be replaced in women over 40. They should be
left in place until 2 years after the menopause if this occurs under 50
and 1 year otherwise.
Contraindications
• Previous PID.
• Previous ectopic pregnancy.
• Known malformation of the uterus.
• Copper allergy (but could use an IUS).
Complication of IUD:
Complication :
1-Perforation of the uterus.
2-Pelvic pain.
Pain occurs either in a chronic low-grade form or as severe
dysmenorrhoea. The incidence is widely variable, with up to 50% of
women suffering some pain.
3-Vaginal Discharge
Vaginal discharge may be due to infection but most women with an IUD develop a
slight watery or mucoid discharge.
4-Ectopic pregnancy
5-abnormal uterine bleeding.
Increased menstrual loss occurs in most women with an IUD but can be tolerated by the
majority. However, in 15% of such women it is sufficiently severe to necessitate removal
of the device. It can be controlled by drugs such as tranexamic acid or trual bleeding
may also occur but if the loss is
3-HORMONAL
CONTRACEPTION
Hormonal Methods :
 Oral Contraceptives .
(Birth Control Pill)
 Injections .
 Skin paches .
 Vaginal ring .
oral contraceptives (Ocs)
Types of oral contraceptives (Ocs)
a (Combined oral contraceptives (COCs):
most widely used ,contain both:
- An estrogen :Ethinyl Estradiol
- A progestogen:(levonorgestrel is the most widely used
progestogen (
b (Progestin-only pills (POPS(:
 Contain only a progestogen, mostly levonorgestrel (no
estrogen).
 Especially suitable for breastfeeding women ,women with
contraindications
to
combined
OCPs(e.g.
thromboembolic or myocardial diseases .
- No absolut containdication for it.
EFFICACY
 The OC pills is a highly effective method of
reversible contraception.
 With perfect use, the combined OC is 99.9%
effective in preventing pregnancy.
Combined pill 
The combined pill contains (ethinyloestradiol) and 
progestogen.The pill is taken for 21 days started at
the 5th day of menstural , followed by a 7-day pillfree interval during which there is a withdrawal
bleed. Every-day (ED) preparations include seven
placebo pills that are taken instead of a pill-free week.
The concentration of the hormones may be the same
throughout the 21 days (monophasic preparations) or
vary across the cycle (biphasic and triphasic
preparations) in order to reduce breakthrough
bleeding.
Formulations
Formulations may be :
1. Monophasic (each tablet contains a fixed
amount of estrogen and progestin);
2. Biphasic (each tablet contains a fixed amount of
estrogen, while the amount of progestin
increases in the second half of the cycle); or
3. Triphasic (the amount of estrogen may be fixed
or variable, while the amount of progestin
increases in 3 equal phases).

MECHANISM OF ACTION OF HORMONAL
CONTRACEPTIVES
 Its main mechanism of action is to suppress :

gonadotrophin secretion.
Progestogen only pill
 Start at day 1 of the menstrual cycle
 Anytime you can be reasonably sure the patient is
not pregnant
 Postpartum:
 after 6 months if using lactational amenorrhea method
(LAM)
 after 6 weeks if breastfeeding but not using LAM
 immediately or within 6 weeks if not breastfeeding
 Postabortion (immediately)
 They are taken continuously on the basis of one tablet daily.
Because of the low dose, they should be taken at the same
time every day .
MECHANISM OF ACTION OF
HORMONAL CONTRACEPTIVE
 Combined and triphasic pills are by suppressing
gonado-trophin secretion and, in particular, the
luteinizing hormone peak. The endometrium
becomes unsuitable for nidation and the cervical
mucus becomes hostile. Progesterone-only pills
alter the endometrial maturation and affect
cervical mucus. Ovulation is suppressed in only
4 0% of women.
INDICATIONS
 for any woman seeking :
 a reliable, reversible, coitally-independent method of
contraception.
 for women who wish to take advantage of :

its noncontraceptive benefits.
NON-CONTRACEPTIVE BENEFITS
Cycle regulation
2. Decreased menstrual flow
3. Decreased dysmenorrhea
4. Decreased endometrial cancer
4. Decreased ovarian cancer
5. Decreased risk of fibroids
6. Possibly fewer ovarian cysts
7. Decreased acne
8. Decreased hirsutism
9. Possibly fewer cases of benign breast disease.
10. Protect against pelvic inflamatory diseases .
1.
INITIATION
INITIATION
1. PATIENT ASSESSMENT
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Before prescribing a OC, a complete general history should be
taken .
Then physical examination should doing .
2. COUNSELLING
Adequate counseling prior to initiation of OCs may help to
improve compliance (regular use) and adherence
(continuation).
Discussing risks and warning signs, including when to seek
medical care .
3. PRESCRIPTION
The OC is started during the first 5 days of the menstrual
cycle.
Side effects of oral contraceptives:-venous thrombosis : the risk increas .
-arterial disease : the risk increase .
-breast and cervical cacer : small increase in relative risk .
-gall stone formation & cholecystitis and glucose intolerance : the risk
increase .
Combined oral
contraceptives (COCs)
• Nausea
• Dizziness
• Breast tenderness • Headaches
• Mood changes
• Weight gain
• Menstrual irregularities: spotting,
amenorrhea, breakthrough bleeding
Progestin-only pills
(POPS)
• Menstrual irregularities: Spotting or irregular
bleeding (if not breastfeeding), Amenorrhea
• Other side effects are similar to those of COCs,
but less common
Contraindications
 There are various contraindications to
the pill, some being more absolute than
others.
ABSOLUTE CONTRAINDICATIONS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Pregnancy & < 6 weeks postpartum if breastfeeding
Smoker over the age of 35 (≥ 15 cigarettes per day)
Hypertension (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg)
Current or past history of venous thromboembolism (VTE)
Ischemic heart disease
History of cerebrovascular accident
Complicated valvular heart disease
Migraine headache with focal neurological symptoms
Breast cancer (current)
Diabetes with retinopathy/nephropathy/neuropathy
Severe cirrhosis
Liver tumour (adenoma or hepatoma)
RELATIVE CONTRAINDICATIONS
1.
2.
3.
4.
5.
6.
7.
Adequately controlled hypertension
Hypertension (systolic 140–159mm Hg,
diastolic 90–99mm Hg)
Migraine headache over the age of 35
Currently symptomatic gallbladder disease
Mild cirrhosis
History of combined OC-related cholestasis
Users of medications that may interfere with
combined OC metabolism
Injectable contraceptives
Introduction
 Injectable contraceptives contain
hormonal drugs
that provide women with safe, highly effective,
and reversible contraceptive protection.
There are currently two main types:
1- Depo-Provera® contains 150 mg of medroxyprogesterone
acetate and is given as a 3-monthly intramuscular injection
2- Implanon® is a single Silastic rod containing etono-gestrel
that is inserted subdermally in the upper arm and is effective
for up to 3 years.
Mode of Action
 injectable contraceptives exert their contraceptive
effect mainly by suppressing ovulation.
 In addition, thickening of the cervical mucus
(mainly due to the progestagen) presents an
obstacle to sperm penetration.
 There are additional changes in the endometrium
that make it unfavourable to implantation;
however, the first two effects make fertilisation highly
unlikely.
Efficacy
The reported failure
rates are low, and come
within the narrow range
of
0.1% to 0.6%.
Beneficial Effects
 Prevention of pregnancy.
 Sickle cell disease: : fewer crises .
 Anaemia: increase haemoglobin
concentration, mainly by reducing menstrual
blood loss .
 Endometrial cancer: protect against this
form of cancer .
 against pelvic inflammatory disease
(PID).
Side effects of injectable contraceptives:
 Menstrual changes: should be clearly
explained to women before use (more
common with progestin-only injectables than
combined injectables)
 Spotting, irregular bleeding
 Prolonged or heavy bleeding
 Amenorrhea
 Weight gain
 Less common side effects include headaches,
dizziness, breast tenderness and mood
changes
Contra indication
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Pregnancy
Unexplained vaginal bleeding
Breast cancer
Complicated diabetes
Current or past history of ischaemic heart disease
Past cerebrovascular accident (stroke)
Active liver disease, cirrhosis, liver tumors
Breastfeeding mothers less than 6 weeks following
childbirth
Contraceptive Vaginal Ring
Contraceptive vaginal rings
 The contraceptive vaginal ring is a flexible,
soft, transparent ring .
 The ring can be easily inserted in the vagina
and removed by the women herself .
 After insertion, the ring is left in the vagina for
three weeks and then removed.
 The woman remains ring-free for one week
after which a new ring is inserted .
 The ring can be inserted any time during the
first 5 days of the menstrual cycle .
Contraceptive vaginal rings
 The method prevents pregnancy mainly
by inhibition of ovulation that is
achieved by a lower dose of ethinyl
estradiol than the oral pills
 It is highly effective, and induces good
cycle control. Most common causes for
discontinuation are a foreign body
sensation, coital problems and expulsion
of the device
contraceptive patch
contraceptive patch
 A contraceptive patch is a transdermal patch
applied to the skin that releases synthetic estrogen
and progestin hormones to prevent pregnancy.
 They have been shown to be as effective as the
combined oral contraceptive pill with perfect use ,
which means she does not release an egg that could
be fertilized by a man's sperm.
 The patch also thickens a woman's cervical mucus,
which makes it harder for sperm to enter the womb,
and the patch may be more effective in typical use.
Method of use
- A woman applies her first patch onto her upper outer arm,
buttocks, abdomen or thigh on either the first day of her
menstrual cycle .
- The patch is used on a weekly 28-day cycle,
- similar to birth control pills. Each box
- contains three patches. A patch is worn for a
- 7-day period, then removed and replaced with
- a new patch. Every new patch should be
- applied on the same day of the week. After
- using three patches in a row, no patch is worn
- during the fourth week. This "hormone-free"
-week allows a woman to get her menstrual
How effective is it?
 When used correctly, the patch is 99%
effective. It may be less effective in
women weighing more than 90 Kg .
 patch within 24 hours of getting her
menstrual period.
 3% failure rate with typical use .
4- Emergency contraception:
 Emergency contraception (EC), or emergency
postcoital contraception, refers to contraceptive
measures that, if taken after sex, may prevent
pregnancy ,ECPs are effective when used shortly
before intercourse, and are licensed for use up to 72
hours after sexual intercourse .
Emergency contraception
Forms of EC include:
Emergency contraceptive pills (ECPs):
sometimes referred to the "morning-after pill"—
are drugs that act both to prevent ovulation or
fertilization and possibly post-fertilization
implantation of blastocyte(emberyo).
(IUDs):
usually used as a primary contraception method,
but sometimes used as emergency contraception
Types of ECPs:
 The progestin-only method uses the progestin levonorgestrel such as
Levonelle , NorLevo & Postinor-2.
The combined uses large doses of both estrogen and progestin, taken as two
doses at a 12-hour interval. This method is now believed to be less effective
and less well-tolerated than the progestin-only method.
 The drug mifepristone may be used as an ECP or as abortion pill. Higher
doses of mifepristone can disrupt implantation and, unlike levonorgestrel,
mifepristone is effective in terminating established pregnancies. So it is used
also for abortion .
 Ulipristal acetate (Ellaone), a drug similar to mifepristone.
 Morning-after pills (ECPs) are not to be confused with mifepristone used as
an “abortion pill"
Side effects:
 The most common side effect reported by users of
emergency contraceptive pills was nausea; vomiting .
abdominal pain, fatigue, headache, dizziness, and
breast tenderness. Side effects usually do not occur
for more than a few days after treatment, and they
generally resolve within 24 hours.
 Temporary disruption of the menstrual cycle is also
commonly experienced.
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5-NONMEDICAL METHODS OF
CONTRACEPTION:
 It depends on the physiology of the mens. Cycle . The most
fertile phase occur at the time of ovulation which occur
between day 12 & day 14 .
 There are natural methods of family planning include the
following :
1)Rhythm method: avoid mid-cycle intercourse for 3-4 days
either side the mid-cycle.
2)Coitus interruptus ( withdrawal ) :relies on withdrawal of penis
before ejaculation .
3)Lactational Amenorrhoea : breastfeding is the most important
means of the family planning . Ovulation resumes on average 46 months later in women who continue to breastfeed & during
the 1st 6 months after birth .
Sterilization:
 Female Sterilization
Sterilization is a permanent means of contraception. Tubal
ligation (also known as tubal sterilization). A procedure called
hysteroscopic sterilization is another method of permanent
female sterilization.
 Tubal ligation;
involves closing off the fallopian tubes to prevent the egg from
reaching the uterus, where it can be fertilized. The ends of the
fallopian tubes are closed off by burning them (using electro
cauterization or electro coagulation) with a laser, or by putting clips
or bands around them.
There are 3 methods of tubal ligation; the most common
are the minilaparotomy and laparascopy:
 A minilaparotomy : involves making a small incision in the abdomen,
locating the tubes, and cutting and closing them off.
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 A laparoscopic tubal ligation: involves inflating the abdomen with
carbon dioxide or nitrous oxide gas, making a small incision in the
abdominal wall, and inserting a fiberoptic light and an instrument
that coagulates the tubes with an electric current or puts a clip or
plastic band around the end of each tube. Laparascopy requires a
smaller incision than a minilaparatomy, is less painfulTubal
sterilization .
 Tubal sterilization is reversible. With microsurgical techniques, the
success rate of reversal surgery is about 75-85% in women who are able
to undergo reversal surgery.. Thus, despite the fact that it is reversible,
female sterilization is considered a permanent method of
contraception.
Male Sterilization:
 Vasectomy
 A vasectomy is considered a permanent method of birth control. A
vasectomy prevents the release of sperm when a man ejaculates.
During a vasectomy, the vas deferens from each testicle is clamped, 
cut, or otherwise sealed. This prevents sperm from mixing with the
semen that is ejaculated from the penis. An egg cannot be fertilized
when there are no sperm in the semen. The testicles continue to
produce sperm, but the sperm are reabsorbed by the body. (This also
happens to sperm that are not ejaculated after a while, regardless of
whether you have had a vasectomy.) Because the tubes are blocked
before the seminal vesicles and prostate, you still ejaculate about the
same amount of fluid