Download THE HEALTH PROVIDERS ROLE IN CONTRACEPTION

Assoc. Prof. Dr.
NurverTurfaner
Department Of Family
Medicine
Contraceptive education is a major component
of good preventive health care, and should be
included as a part of all health maintenance
visits for women of reproductive age and all
men.
 The effective control of reproductivity is
required so that a woman may reach her
individualistic goals other than giving birth.
 On the other hand, the vast increase of human
population in this century is threatening human
being.
The Effects of Excessive
Birthgiving on Maternal Health
 For the mother: maternal death, complications of
pregnancy and delivery, gynecological diseases,
malnutrition, anemia
 For the child: infant death, low birth weight,
malnutrition, infectious diseases, retardation of
physical growth, congenital anomalies
Key points
 Pregnancy before 18 years, after 35 years old
 The short interval between deliveries;<2 years
 More than 4 deliveries
 All increase the complications of pregnancy,
delivery and post-pregnancy
FAMILY PLANNING
• Is having the number of children one can look
after when couples or individuals really want it.
• It helps to prevent unwanted pregnancies, to plan
ahead the interval between two pregnancies, to
decide when and what number of children the
family should have considering their age and
socio-economic status and to help couples who are
infertile to have babies.
BENEFITS
 Planning the interval between two pregnancies
freely and consciously
 Preventing abortions
 Decreasing maternal death
 Decreasing the negative effects of rapid
population growing on economic development,
nutrition,habitation, education and environmental
factors.
HORMONAL
CONTRACEPTIVES
• Hormonal contraceptives are among the most
popular, reversible methods.
• These methods include the combination oral
contraceptives (COCs, progestine only pills (POPs),
transdermal contraceptive patch, vaginal
contraceptive ring, injectable depot
medroxyprogesterone acetate (DMPA),
ethanogestrel implant, and the levonogestrel
intrauterine system.
COMBINATION ORAL
CONTRACEPTIVES
 Key Points: Very low dose pills have not been
shown to confer any added safety benefit, but
they do have comparable efficacy and potentially
decrease estrogenic side effects in women who
have not tolerated higher dose COCs.
COMBINATION ORAL
CONTRACEPTIVES
• Higher dose COCs should be reserved for patients
currently taking medications that can interfere
with the pills contraceptive effectiveness or for
short term treatment of certain menstrual
disorders.
• The risks and efficacy of the extended 91 day
regimen are similar to those associated with the
28 day regimen.
COMBINATION ORAL
CONTRACEPTIVES
 COCs can decrease menstrual cramping and blood
flow, eliminate ovulatory pain (mittelschmerz),
supress symptomatic endometriosis, and alter
menses.
 COCs can reduce vasomotor symptoms in
perimenopausal women.
 COCs can decrease acne and hirsutism.
COMBINATION ORAL
CONTRACEPTIVES
 The incidence of VTE increases slightly with COC
use, but it is significantly less than the risk of
VTE in pregnancy.
 If breakthrough bleeding persists after 3 months
of COC use, the patient should take a different
COC formulation.
COMBINATION ORAL
CONTRACEPTIVES
• COCs should not be used in women with focal
(asymmetric) neurologic auras, and they should be
discontinued in women who have progressive
headaches while taking them.
• COCs should not be prescribed for women who
have uncontrolled hypertension or smokers older
than 35 years.
PROGESTIN ONLY PILLS
• Key Points: POPs are associated with fever
serious complications than COCs.
• POPs are less effective, cause more breakthrough
bleeding, and confer fewer non-contraceptive
health benefits than COCs.
• POPs are preferable to COCs for lactating women.
• POPs may be used in women who have
contraindications to estrogens or are intolerant to
estrogenic side-effects
Transdermal Contraceptive Patch
• The patch is as effective as combination oral
contraceptives (COCs) and has similar side
effects, risks, and benefits with the exception of
effect unique to a transdermal system.
• The contraceptive patch is associated with fewer
contaceptive failures than contraceptive pills
because of better compliance.
Transdermal Contraceptive
Patch
• The patch is a good choice for women who have
troubles remembering to take pills daily.
• The patch may be less effetive in women weighing
more than 90 kg.
• Users may have breath symptoms, vaginal
spotting, and dismenorrhea in the first 2 months
of use.
• Local skin irritation is the second most common
side effect exprienced by patch users and often
lead to discontinuing the patch.
Vaginal Contraceptive Ring
 The NuvaRing is a soft, flexible ring made of
ethylene vinyl acetate that delivers 15 µg of
ethinyl estradiol and 120 µg of etonogestrel
in a controlled- release fashion.
 The woman inserts the vaginal ring and
typically leaves it in place for 3 weeks, then
removes it to allow a withdrawal bleed.
Vaginal Contraceptive Ring
• Advantages of the vaginal ring includes a simple
dosing schedule and a lower incidence of
breaktrough bleeding and nausea compared to
COCs.
• The risks of the vaginal ring are theoretically the
same as those for COCs,although no serious
events were reported in a 1 year multicenter
study.
• Although device related events rarely occur, they
were the most common cause of discontinuation in
clinical trials.
Injectable Depot
Medroxyprogesterone
Acetate
• By 6 months of use of injectable depot
medroxyprogesterone acetate(DMPA), most
women have decreased mensturual flow or no
menses, decreased menstrual cramps, and less
anemia.
• DMPA decreases pain in women with
endometriosis and decreases the risk of cicle-cell
crisis in womwn with cicle- cell disease.
• WHO suggest that there should be no restriction
on the ration of use of DMPA among women 18-45
years old.
Injectable Depot
Medroxyprogesterone
Acetate
• The manufacturer suggest that because of
potential loss of bone density, DMPA should not
be used longer than 2 years unless other birth
control methods are inadequate.
• Irrerular bleeding is especially common during the
first 6 months of DMPA use.
• Patients who discontinued DMPA can have a long
return to fertility.
Etonogestrel Implant
• Implanon is inserted subdermally in the inner upper
arm.
• Implanon is effective within 24 hours of insertion and
provides up to 3 years of highly reliable contraception.
• Implanon can be removed at any time, providing a
rapid return to fertility after removal.
• Implanon requires significantly less time and effort for
insertion and removal than norplant, reducing the risk
of related complications.
Levonorgestrel-Releasing
Intrauterine System
• The approved life span of the levonorgestrel-
releasing intrauterine system (LNG-IUS) is 5
years, although the protection with the system in
place may last at least 7 years.
• LNG-IUS can help treat heavy menses and
prevent the risk of anemia.
• Irregular bleeding or spotting is a common, selflimited side effect of the LNG-IUS within the
first several months of use.
Male Condoms
 Polyurethane condoms are thinner and stronger than
latex condoms, less likely to degrade when exposed to
oil-based products, and offer wearers icreased
sensivity.
 Polyurethan condoms cost more and may actually be
more likely to slip and break during intercourse than
latex condoms.
Male Condoms
• Latex and polyurethan condoms offer significant
protection against bacterial and viral sexually
transmitted infections; natural mebrane condoms
do not.
• Frequent exposure to nonoxynol 9 spermicide can
cause genital irritation without adding significant
benefit in protection against unpalanned
pregnancy or prevention of sexually transmitted
infections.
Male Condoms
 Non latex condoms are associated with a higher
rate of breakage compared to latex condoms.
However, non latex condoms still provide an
acceptable contaceptive alternative for people
with allergy, sensivity,or preferances that
prevent the use of latex condoms. Level of
evidence A.
Female Condoms
 The female condoms can be inserted up to 8 hours
before intercourse.
 It can be used safely by patients with sensitivity
or allergy to latex.
DIAPHRAGM
• The diaphragm is a dome-shaped, latex rubber cap
with a flexible ring that is filled with
contraceptive jelly or cream and inserted into the
vagina so that it is placed over the cervix.
• The diaphragm is a barrier device that prevents
sperm from entering the cervix.
• The use of spermicide with the diaphragm might
not increase contraceptive efficacy.
DIAPHRAGM
• The diaphragm works best for women with normal
shaped cervices and normal pelvic musculature;
diaphragm fitting requires a clinic visit.
• Women should insert the diaphragm immediately
before or up to 6 hours before intercourse and
should leave it in place at least 6 hours after
intercourse.
• Advantages are low cost, safety, and possible
protection from PID and fertility.
• Disadvantages include possible vaginitis, yeast
infections, and increased risk of UTIs.
CERVICAL CAP
• The Prentif cervical cap is no longer produced in the
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United States.
Two other FDA-approved barrier contraceptives, are
available by prescription only, the FemCap and Lea’s
Shield.
The FemCap is made of silicone rubber and comes in
one size.
Lea’s Shield and the FemCap are safe alternatives for
women with medical contraindications to hormonal
contraception.
The FemCap has a higher pregnancy failure rate but a
lower rate of urinary tract infections than the
diaphragm.
SPERMICIDES
• The active ingredient in spermicides in nonoxynol
9, which disrupts the cell membrane of sperm.
• Spermicides are sold over the counter in the
United States and are available in several delivery
systems.
• The spermicide-containing sponge (Today Sponge)
is available over the counter, is inserted by the
patient, and is left in the vagina for at least 6
hours after intercourse.
SPERMICIDES
• The sponge is effective immediately and up to 24
hours after insertion; it should not be left in the
vagina for more than 30 hours after intercourse.
• Studies of nonoxynol 9 and its effect on STI and
HIV transmission have yielded conflicting results.
• WHO and CDCP have recommended against the
use of spermicides with nonoxynol 9 alone for the
sole purpose of preventing sexually transmitted
infections.
FERTILITY AWARENESSBASED METHODS
• Fertility awareness-based methods rely on
identifying potentially fertile days; couples must
abstain from intercourse or use barrier
contraception on fertile days to prevent
pregnancy.
• Fertility awareness methods can be used to aid
couples who are trying to conceive. They can also
be used to detect fertility problems.
FERTILITY AWARENESSBASED METHODS
 These methods are not recommended for women
with menstrual irregularities, persistent
reproductive tract infections, or other medical
conditions that can affect the signs of fertility.
THE LACTATIONAL
AMENORRHEA METHOD
• The lactational amenorrhea method (LAM) is
nearly 98% effective as a contraceptive method
for women who exclusively or almost exclusively
breast-feed and who have not experienced their
first post-partum menses for the first 6 months
after birth.
• Exclusive and almost exclusive breast-feeding
means the baby receives no or only small amounts
of liquids infrequently in addition to breast milk.
THE LACTATIONAL
AMENORRHEA METHOD
• Successful use of LAM as a contraceptive method
is highly dependent upon consistent suckling
stimulation at the breast.
• LAM provides health benefits for the infant and
the mother, as well as promoting bonding between
the mother and infant.
• LAM is a less reliable method of contraception
after 6 months post-partum or if supplemental
feedings have been introduced, and women should
be encouraged to seek an additional method of
pregnancy prevention at this time.
COITUS INTERRUPTUS
( WITHDRAWAL)
• Coitus interruptus involves withdrawing the penis
from the vagina before ejaculation.
• Coitus interruptus requires a high-degree of
motivation, commitment, and self-control during
the time of intercourse when both partners may
be highly excited, making it prone to incorrect or
inconsistent use.
• The effectiveness of this method, even with
perfect use, is uncertain.
STERILIZATION
• Essure is a coil device with polyethylene fibers that is
placed into the proximal fallopian tubes and results in
a fibrotic tissue growth reaction, effectively causing
occlusion of the tubes.
• Vasectomy is a male sterilization procedure during
which the vas deferens is resected, clipped, or
occluded to prevent sperm from moving from the
testes into the seminal fluid.
• No-scalpel vasectomy is faster and less invasive than
traditional vasectomy, requires few instruments, and
can be performed easily in the outpatient setting.
Emergency Contraception
• Emergency contraception is any method of
pregnancy prevention used after an act of
inadequately protected intercourse.
• Widespread use of emergency contraception could
greatly reduce the rate of unintended pregnancy.
• Methods of emergency contraception inclue the
Yuzpe method (combined hormonal), a progestinonly regimen, or placement of a copper-T
intrauterine device.
Emergency Contraception
• Emergency contraception is not an abortifacient
because it does not act to disrupt an established
pregnancy.
• A progestin-only regimen has a lower incidence of
side effects, is more effective, and easier to use
than the combined hormonal regimen.
• Recent evidence indicates that the progestin-only
regimen can be given as a single dose of 1.5 mg
levonogestrel up to 120 hours after an
inadequately protected intercourse with good
efficacy.
Emergency Contraception
If a combined hormonal regimen is used for
emergency contraception, an antiemetic
medication should be taken an hour before the
first dose of combined hormonal pills.
• Physcian who wish to increase the availability and
use of emergency contraception can offer
advanced discription for it.(Level of evidence:A).
Abstinance
• The definition of abstinance can vary from
forgoing all sexual behavior to refraining only
from vaginal or anal intercourse. Abstinance can
also be primary or secondary.
• Patient who choose to abstain often need support
and encouragement.
• Patient who choose abstinance should also be
encouraged to practice negotiating and planning
skills before entering into an intimate
relationship.
THANK YOU FOR YOUR
ATTENTION