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FERTILITY CONTROL
Men and women have used contraception, in
one form or another, for thousands of years.
There is no one method that will suit
everyone, and individuals will use different
types of contraception at different stages
in their lives
The characteristics of the ideal contraceptive
method are:
• highly effective
• no side effects
• cheap
• rapidly reversible
• widespread availability
• acceptable to all cultures and religions
• easily distributed
• can be administrated by non- health care
personnel
Virtually all methods of contraception occasionally
fail and some are much more effective than others.
Failure rates are traditionally expressed as the number of
failures per 100 woman-years (HwY ), i.e. the number
of pregnancies if 100 women were to use the method for
1 year.
Failure rates for some methods vary considerably,
largely because of the potential for failure caused by
imperfect use (user failure) rather than an intrinsic
Classification
Methods not requiring medical cosultation:
1-coitus interruptus
2-safe period[Natural family planning]
3-vaginal spermicides
4-barrier methods include :
• Male condom
• Female barriers
Methods requring medical supervision
1-Hormonal contraception:
• Combined oral contraceptive methods
• Progesterone-only preparations :include
A-progesterone only pills
B-injectables
C-Subdermal implants
D-Hormone-releasing intauterine system
2-Intauterine device
3-Post-coital emergency contraception
4-occlusive diaphragms&caps
Perminant methods[sterilization]
• Female tubal occlusion
• Male vasectomy
Failre rate for contraception
Contraceptive method
Combined oral contraceptivepill
Progestogen -only pill
Depo-Provera
Implanon
Copper-bearing IUD
Levonorgestrel-releasing IUD
Male condom
Female diaphragm
Persona
Natural family planning
Vasectomy
Female sterilization
Failure rate /100 women year
1-0.1
3-1
2-0.1
o
2-1
0.5
5-2
15-1
6
3-2
0.02
0.13
Hormonal contraception
Combined oral contraceptive pills
Combined oral contraception (COC) - 'the pill' - was
first licensed in the UK in 1961. It contains a combination
of two hormones: a synthetic oestrogen and a
progestogen (a synthetic derivative of progesterone).
Since COC was first introduced, the doses of both
oestrogen and progestogen have been reduced dramatically,
which has considerably improved its safety
profile..
Combined oral contraception is easy to use and
offers a very high degree of protection against pregnancy,
with many other beneficial effects. It is mainly
used by young, healthy women.
Combined oral contraceptive pill
preparations
Formulations
Combined oral contraceptive pills contains both:
1-Synthetic Estrogen (Ethinyl estradiol mostly):
The dose of oestrogen varies from 50 to 15 μg
(microgram).
2-Synthetic progestogens
Either one of these :
*First generation(e.g. norethindrone).
*Second generation progestins (e.g.
levonorgestrel) .
*Third generation series including gestodene,
desogestrel and norgestimate.
Monophasic pills contain standard daily dosages
of oestrogen and progestogen.
Biphasic or triphasic preparations have two or three
incremental variations in hormone dose.
Current thinking is that biphasic
and triphasic preparations are more complicated for
women to use and have few real advantages.
Most brands contain 21 pills; one pill to be taken
daily, followed by a 7-day pill-free interval. There are
also some every-day (ED) preparations that include
seven placebo pills that are taken instead of having a
pill-free interval. For maximum effectiveness, COC
should always be taken regularly at roughly the same time
each day.
preparation
1. low-dose pills containing 30μg of ethinyl estradiol
2.high-dose pills contain contain 50 μg estrogen. Higher
dosages of oestrogen are strongly linked to increased
risks ofboth arterial and venous thrombosis
3.Yasmin
contains ethinyl estradiol and drospirenone.
Drospirenone has antimineralocorticoid activity. It can
help prevent bloating, weight gain, and hypertension,
but it can increase serum potassium.
Yasmin is contraindicated in patients at risk for
hyperkalemia and should not be combined with other
drugs that can increase potassium
Mode of action
Combined oral contraception acts both centrally and
peri pherally .
•centrally Inhibition of ovulation is by far the most
important effect. Both oestrogen and progestogen
suppress the release of pituitary follicle stimulating
hormone (FSH) and luteinizing
hormone (LH), which prevents follicular
development within the ovary and therefore
ovulation .
• Peripheral effects include
- making the endom trium atrophic and hostile to an
implanting embryo
- altering cervical mucus to prevent sperm
ascending into the uterine cavity.
Contraindications
Absolute contra indications
• Circulatory diseases:
- iscihaemic heart disease- cerebrovascular accident
- significant hypertension
- arterial or venous thrombosis
- any acquired or inherited pro-thrombotic tendency
- any Significant risk factors for cardiovascularpisease
• Acute or severe liver disease
• Oestrogen-dependent neoplasms, particularly breast
cancer
• -Breastfeeding <6 weeks post-partum
• -Smoking ≥15 cigarettes/day and age ≥35
• Focal migraine
Relative contra indications
• Generalized migraine
• Long-term immobilization
• Irregular vagli.nal bleedillg (until a diagnosis
has been made)
• Less severe risk factors for cardiovascular
disease,
e.g. obesity, heavy smoking, diabetes
Side effects
major side effects
1-Venous thromboembolism
Oestrogens alter blood clotting and coagulation in a
way that induces a pro-thrombotic tendency, although
the exact mechanism of this is poorly understood.
The higher the dose of oestrogen within COc, the
greater the risk of venous thromboembolism (VTE).
Type of progestogen also affects the risk of VTE, with
users of COC containing third-generation progestogens
being twice as likely to sustain a VTE.
.
The risks ofVTE are:
• 5 per 100 000 for normal population,
• 15 per 100 000 for users of second-generation
COC,
• 30 per 100 000 for users of third-generation
COC,
• 60 per 100 000 for pregnant women
2-Arterial disease
*1 per cent of women taking coc will become significantly
hypertensive and they should be advised to stop taking
COC
*The risk of myocardial infarction and thrombotic
stroke in young, healthy women using low-dose cac
is extremely small.
*Cigarette smoking will, however,
increase the risk, and any woman who smokes must
be advised to stop COC at the age of 35 years. Around
.
3-Mortality
There is increased mortality in women using the
pills over women not using it.this is related to
age&smoking habits.Death is most often the
result of pulmonary embolism,cerebral or
coronary thrombosis.
Women who are under 35 years,do not smoke
or have hypertention or diabetes have no
exess mortality
In women over 35 years who are on pill the
exess mortality rises&rises more in women
who smoke or have hypertention
4-Carcinogenic effect
• Breast cancer
Advising women about the association between
breast cancer and COC is very difficult. Most data do
show a slight increase in the risk of developing breast
cancer among current COC users (relative risk
around l. 24). This is not of great significance to
young women, as the background rate of breast cancer
is very low at their age. However, for a woman in
her forties, these are more relevant data, as the background
rate of breast cancer is higher. The same data
also showed that beyond 10 years after stopping coc
there was no increase in breast cancer risk for former
coc users
• Cervical cancer
More than five years of pill use may be associated
with small increase risk of cervical carcinoma.
• Liver cancer
Benign hepatic adenoma is a rare consequence of
COC use.
Minor side effects
Central nervous system
Gastrointestinal
Genitourinary system
Breast
miscellaneous
Depression
Headaches
Loss of libido
Nausea and vomiting
Weight gain
Bloatedness
Gall-stones
Cholestatic jaundice
Cystitis
Irregular bleeding
Vaginal discharge
Growth of fibroids
Breast pain
Increased risk of
breast cancer
Chloasma (facial
pigmentation)
Leg cramps
How to use pills
The patient begins taking the pills on the first
day of menstrual cycle then in the next cycles
they are administered in fifth day of the cycle
and continue for 21 days, each day at the
same time, then discontinued for 7 days to
allow for withdrawal bleeding that mimics the
normal menstrual cycle which occur after 3-5
days from stopping pills
If pills are missed
How late
are you?
Less than
12 hours
late
More than
12 hours
late
Don't worry. Just take
the delayed pill at
once, and further
pills as usual
• Take the most
recently
delayed pill now
• Use extra
precautions
(condom, for instance)
for the next 7 days
Drug interaction
*This can occur with enzyme-inducing agents such
as some anti-epileptic drugs increase activity of
hepatic enzyme so reduce efficacy of COC .
Higher dose oestrogen coc containing 50 Mg
ethinyl oestradiol may need to be prescribed
*Some broad-spectrum antibiotics Ampicillin,
Amoxicillin, Tetracycline , Neomycin can alter
intestinal absorption of COC and reduce its
efficacy. Additional contraceptive measures
should therefore be recommended during
antibiotic therapy and for 1 week thereafter
*Steroids ,Ascorbic acid (Vitamin C) and
acetaminophen may elevate plasma ethinyl
estradiol so increse its efficacy
Positive health benefits
*COC users generally have light, pain -free, regular bleed
and therefore COC can be used to treat heavy or
painful periods i .e menorrhagia & dysmenorrhea
*It will also improve premenstrual syndrome
(PMS)
*reduce the risk of pelvic inflammatory
disease (PID).
*decreased incidence of benign breast lump
*decrease number of functional ovarian cyst
*less endometriosis
*COC offers long-term protection
against both ovarian and endometrial cancers.
*It can also be used as a treatment for acne.
Combined oestrogen and progesterone
vaginal ring
It is soft ring that a woman can insert into
vagina; and the Women who use Ring leave
the ring in place for 3 weeks during a month.
During the 4th week, the ring is removed for 7
days.
A new ring is used for each cycle.
Combined hormonal patches
A contracept ive t ransdermal patch containing oestrogen
and progestogen has been developed and releases
norelgestromin 150 Mg and ethinylestradiol 20 Mg per
24 hours.
Patches are applied weekly for 3 weeks, after
which there is a patch-free week.
Cont raceptive patches have the same risks and benefits
as COC and, alt hough they are relatively more
expensive, may have better
compliance.