FAMILY PLANNING 9%, a typical rate of 25% (MacKay, 2009

Cervical Mucus Method – Before ovulation each

month, the cervical mucus is thick and does not stretch
NATURAL METHOD
when pulled between the thumb and finger. Just
Abstinence – or refraining from sexual relations, has
before ovulation, mucus secretion increases. With
a theoretical 0% failure rate and is also the most
ovulation (the peak day), cervical mucus becomes
effective way to prevent STIs. However, clients,
copious, thin, watery, and transparent. It feels slippery
particularly adolescents, may find it difficult to adhere
and stretches at least 1 inch before the strand breaks, a
to abstinence, or they may completely overlook it as an
property known as spinnbarkeit.
option.
Symptothermal Method – The symptothermal
Calendar (Rhythm Method) – The calendar method
method of birth control combines the cervical mucus
requires a couple to abstain from coitus (sexual
and BBT methods. The woman takes her temperature
relations) on the days of a menstrual cycle when the
daily, watching for the rise in temperature that marks
woman is most likely to conceive (3 or 4 days before
ovulation. She also analyzes her cervical mucus every
until 3 or 4 days after ovulation).
day and observes for other signs of ovulation such as
Basal Body Temperature Method – Just before the
mittelschmertz (midcycle abdominal pain). The couple
day of ovulation, a woman’s basal body temperature
must abstain from intercourse until 3 days after the rise
has ovulated. She refrains from having coitus for the
in temperature or the fourth day after the peak of
next 3 days (the life of the discharged ovum). Because
mucus change, because these are the woman’s fertile
sperm can survive for at least 4 days in the female
days. The symptothermal method is more effective
reproductive tract, it is usually recommended that the
than either the BBT or the cervical mucus method
couple combine this method with a calendar method,
alone (ideal failure rate, about 2%).
so that they abstain for a few days before ovulation as
Ovulation Detection – Still another method to predict
well. The calendar method has an ideal failure rate of)
ovulation is by the use of an over-the-counter ovulation

detection kit. These kits detect the midcycle surge of Unfortunately, ejaculation may occur before
luteinizing hormone (LH) that can be detected in urine withdrawal is complete and, despite the care used,
12 to 24 hours before ovulation. Such kits are 98% to some spermatozoa may be deposited in the vagina.
100% accurate in predicting ovulation. Although they Furthermore, because there may be a few spermatozoa
are fairly expensive, use of such a kit in place of cervical present in preejaculation fluid, fertilization may occur
mucus testing makes this form of natural family even if withdrawal seems controlled. For these reasons,
planning more attractive to many women. Combining it coitus interruptus is only about 75% effective.
with assessment of cervical mucus is becoming the  Postcoital Douching – Douching following
method of choice for many families using natural family intercourse, no matter what solution is used, is
planning. ineffective as a contraceptive measure as sperm may
 Lactation Amenorrhea Method (L.A.M.) – As long as be present in cervical mucus as quickly as 90 seconds
a woman is breastfeeding an infant, there is some after ejaculation.
natural suppression of ovulation. Because women may  Hormonal Contraception – Hormonal
ovulate, however, but not menstruate, a woman may contraceptives are, as the name implies, hormones that
still be fertile even if she has not had a period since cause such fluctuations in a normal menstrual cycle
childbirth. If the infant is receiving a supplemental that ovulation does not occur.
feeding or not sucking well, the use of lactation as an Hormonal contraceptives may be administered orally,
effective birth control method is questionable As a rule, transdermally, vaginally, by implantation, or through
after 3 months of breastfeeding, the woman should be injection.
advised to choose another method of contraception HORMONAL CONTRACEPTION: Oral Route
(Burkman, 2007). • Oral contraceptives, commonly known as the
 Coitus Interruptus – Coitus interruptus is one of the pill, OCs (for oral contraceptive), or COCs (for
oldest known methods of contraception. The couple combination oral contraceptives), are composed of
proceeds with coitus until the moment of ejaculation. varying amounts of synthetic estrogen combined with a
Then the man withdraws and spermatozoa are emitted small amount of synthetic progesterone (progestin).
outside the vagina.
• The estrogen acts to suppress follicle stimulating 6. ovarian cysts, and ectopic pregnancies
hormone (FSH) and LH, thereby suppressing ovulation. 7. Fibrocystic breast disease
The progesterone action complements that of estrogen 8. Possibly osteoporosis,
by causing a decrease in the permeability of cervical 9. endometriosis,
mucus, thereby limiting sperm motility and access to 10. uterine myomata (fibroid uterine tumors),
ova. Progesterone also interferes with tubal transport and
and endometrial proliferation to such degrees that the 11. progression of rheumatoid arthritis
possibility of implantation is significantly decreased. 12.Colon cancer
• COCs must be prescribed by a physician, nurse • COCs are packaged with 21 or 28 pills in a
practitioner, or nursemidwife after a pelvic convenient dispenser. It is generally recommended that
examination and a Papanicolaou (Pap) smear. When the first pill be taken on a Sunday (the first Sunday after
used correctly, they are 99.7% effective in preventing the beginning of a menstrual flow), although a woman
conception. Women who forget to take them as may choose to begin on any day. Beginning pills as soon
scheduled, however, experience a failure rate of 95%. as they are prescribed this way (a Quick Start system)
• Oral contraceptives have non-contraceptive rather than have to wait for a set day may increase
benefits such as decreased incidences of: compliance.
1. Dysmenorrhea, because of lack of ovulation • After childbirth, a woman should start the
2. Premenstrual dysphoric syndrome and contraceptive on the Sunday closest to 2 weeks after
acne, because of the increased progesterone levels birth; after an elective termination of pregnancy, she
3. Iron deficiency anemia, because of the should start on the first Sunday after the procedure.
reduced amount of menstrual flow Because COCs are not effective for the first 7 days,
4. Acute pelvic inflammatory disease (PID) and the advise women to use a second form of contraception
resulting tubal scarring during the initial 7 days on which they take pills.
5. Endometrial and ovarian cancer,

.• A woman prescribed a 21-day cycle brand takes a pill • Side Effects and Contraindications:
at the same time every day for 21 days. Pill taking by 1. Nausea
this regimen will end on a Saturday. The woman would 2. Weight gain
then not take any pills for 1 week. She would restart a 3.Headache
new month’s supply of pills on the Sunday 1 week after 4.Breast tenderness
she stopped. A menstrual flow will begin about 4 days 5.Breakthrough bleeding (spotting outside the
after the woman finishes a cycle of pills. menstrual period
• To eliminate having to count days between pill 6.Monilial vaginal infections
cycles, most brands of OCs are packaged with 28 pills— 7.Mild hypertension
21 active pills and 7 placebo pills. With these brands, a 8.Depression
woman starts a second dispenser of pills the day after • COCs are not routinely prescribed for women with
finishing the first dispenser. There is no need to skip a history of thromboembolic disease or a family history
days because of the placebo tablets. Menstrual flow of cerebral or cardiovascular accident, who are over 40
will begin during the 7 days on which she is taking the years of age, or who smoke because of the increased
placebo tablets. tendency toward clotting as an effect of increased
• For ovulation suppressants to be effective, estrogen.
women must take them consistently and • COCs can interfere with glucose metabolism. For
conscientiously. Women who have difficulty this reason, women with diabetes mellitus or a history
remembering to take a contraceptive in the morning of liver disease, including hepatitis, are evaluated
may find it easier to take a daily pill at bedtime or with individually before COCs are prescribed.
a meal (the time of day makes no difference; it is the • COCs may interact with several drugs such as
consistency that is important) (Box 6.5). Also, some acetaminophen, anticoagulants, and some
women find that taking pills at bedtime rather than in anticonvulsants, reducing their therapeutic effect so
the morning eliminates any nausea they otherwise women may be advised to temporarily change their
experience. method of birth control while prescribed these drugs.
• Mini Pills – Oral contraceptives containing only The efficiency of transdermal patches is equal to that of
progestins are popularly called mini-pills. The COCs, although they may be less effective in women
progesterone content thickens cervical mucus and who weigh more than 90 kg (198 lb)
helps prevent sperm entry into the uterine cervix. • Patches may be applied to one of
Ovulation may occur but, because the endometrium following four areas: upper outer arm, upper
does not develop fully, implantation will not take place. torso (front or back, excluding the breasts),
They have the disadvantage of causing more abdomen, or buttocks. They should not be
breakthrough bleeding than combination pills. They are placed on any area where makeup, lotions, or
taken every day, even through the menstrual flow. creams will be applied; at the waist where
Because it does not interfere with milk production, bending might loosen the patch; or anywhere
they may be taken during breastfeeding. the skin is red or irritated or has an open lesion.
Effect on Pregnancy: • Vaginal Insertion:
If a woman taking an estrogen/progestin A. A (NuvaRing) is a silicone ring that surrounds the
combination COC suspects that she is pregnant, she cervix and continually releases a combination of
should discontinue taking any more pills if she intends estrogen and progesterone.
to continue the pregnancy. High levels of estrogen or B. It is inserted vaginally by the woman and left in place
progesterone might be teratogenic to a growing fetus for 3 weeks, then removed for 1 week (Roumen, 2007).
• Transdermal Route: Menstrual bleeding occurs during the ring-free week.
• Transdermal contraception refers to The hormones released are absorbed directly by the
patches that slowly but continuously release a mucous membrane of the vagina.
combination of estrogen and progesterone. C. Fertility returns immediately after discontinuing
Patches are applied each week for 3 weeks. No using the ring. Women may need to make out a
patch is applied the fourth week. During the calendar that they post conspicuously to remind
week on which the woman is patch free, a themselves to remove and replace the ring.
menstrual flow will occur. After the patch-free • Implantation:
week, a new cycle of 3 weeks on/1 week off • Five subdermal implants, rods the size of pencil
begins again lead are embedded just under the skin on the inside of
the upper arm. • Injection: Medroxyprogesterone acetate
• The rods contain etonogestrel, the metabolite of (DepoProvera [DMPA]
desogestrel, the same progestin that is used in the • A single intramuscular injection of
NuvaRing. Once embedded, the implants appear as medroxyprogesterone acetate (DepoProvera [DMPA]),
irregular lines on the skin, simulating small veins. Over a progesterone, given every 12 weeks inhibits
the next 3 to 5 years, the implants slowly release the ovulation, alters the endometrium, and changes the
hormone, suppressing ovulation, stimulating thick cervical mucus (Box 6.8). The effectiveness rate of this
cervical mucus, and changing the endometrium so that method is almost 100%, making it an increasingly
implantation is difficult. popular contraceptive method (Chrousos, 2008). Do
• A major advantage of this long-term reversible not massage the injection site after administration as
contraceptive is that compliance issues associated with you want the drug to absorb slowly from the muscle.
COCs are eliminated. It also offers an effective and Because DepoProvera contains only progesterone, it
reliable alternative to the estrogen-related side effects can be used during breastfeeding.
of COCs. Sexual enjoyment is not inhibited, as may • Potential side effects are similar to those of
happen with condoms, spermicides, diaphragms, and subdermal implants: irregular menstrual cycle,
natural family planning methods. Implants can be used headache, weight gain, and depression. Depo-Provera
during breastfeeding without an effect on milk may impair glucose tolerance in women at risk for
production. diabetes. Because there also may be an increase in the
• A disadvantage of the implant method is its cost risk for osteoporosis from loss of bone mineral density,
($500 on average) and side effects such as: advise women to include an adequate amount of
• Weight gain calcium in their diet (up to 1200 mg/day) and to engage
• Irregular menstrual cycle such as spotting, in weight-bearing exercise daily to minimize this risk,
breakthrough bleeding, amenorrhea, or prolonged rules that are good for all women.
periods • Two disadvantages are that a woman must return to
• Depression a health care provider for a new injection every 4 to 12
• Scarring at the insertion site weeks for the method to remain reliable, and the
• Need for removal return to fertility is often delayed by 6 to 12 months.
 Intrauterine Device (IUD) – An intrauterine device a condition not conducive to sperm survival.
(IUD) is a small plastic object that is inserted into the They do not protect against STIs.
uterus through the vagina (Postlethwaite et al., 2007). • Another form of spermicidal protection is a
IUDs became popular as a method of birth control in film of glycerin impregnated with a spermicidal
the 1980s, and although still a popular choice agent that is folded and inserted vaginally. On
worldwide, IUDs are used by only a small number of contact with vaginal secretions or precoital
U.S. women. Few manufacturers continue to provide penile emissions, the film dissolves and a
them since several lawsuits were filed in association carbon dioxide foam forms to protect the
with the increased incidence of pelvic inflammatory cervix against invading spermatozoa.
disease (PID) in women using one particular brand, now • Sponges are foam-impregnated synthetic
no longer available. sponges that are moistened to activate the
 Barrier Methods – Barrier methods are forms of birth impregnated spermicide and then inserted
control that work by the placement of a chemical or vaginally to block sperm access to the cervix.
other barrier between the cervix and advancing sperm Well liked by most users, they are easy to insert
so that sperm cannot enter the uterus or fallopian and have an efficiency rate of 80% (ideal) and a
tubes and fertilize the ovum. A major advantage of typical use failure rate of about 60%
barrier methods is that they lack the hormonal side (Cunningham et al., 2008). They should remain
effects associated with COCs. However, compared with in place for 6 hours after intercourse to ensure
COCs, their failure rates are higher and sexual sperm destruction.
enjoyment may be lessened. 2. Mechanical Barriers
1. Chemical Barriers • Mechanical barriers, such as a diaphragm,
• A spermicide is an agent that causes the death work by blocking the entrance of sperm into the
of spermatozoa before they can enter the cervix. cervix.
Such agents are not only actively spermicidal but
also change the vaginal pH to a strong acid level,
DIAPHRAGM – is a circular rubber disk that is They are contraindicated in any woman who
placed over the cervix before intercourse. A has:
Lea’s Shield, made of silicone rubber and bowl •An abnormally short or long cervix
shaped, is a new design. Although use of a •A previous abnormal Pap smear
spermicide is not required for diaphragms, use •A history of TSS
of a spermicidal gel with a diaphragm combines •An allergy to latex or spermicide
a barrier and a chemical method of •A history of pelvic inflammatory disease,
contraception. With this, the failure rate of the cervicitis, or papillomavirus infection
diaphragm is as low as 6% (ideal) to 16% •A history of cervical cancer
(typical use). •An undiagnosed vaginal bleeding
Side Effects and Contraindications. CONDOM – • is a latex rubber or synthetic
• Diaphragms may not be effective if the uterus sheath that is placed over the erect penis
is prolapsed, retroflexed, or anteflexed to such before coitus to trap sperm. Condoms have an
a degree that the cervix is also displaced in ideal failure rate of 2% and a typical failure rate
relation to the vagina. Intrusion on the vagina of about 15%, because breakage or spillage
by a cystocele or rectocele, in which the walls occurs in up to 15% of uses (Kaplan & Love-
of the vagina are displaced by bladder or Osborne, 2007). • Latex condoms have the
bowel, may make insertion of a diaphragm additional potential of preventing the spread of
difficult. Users of diaphragms may experience a STIs, and their use has become a major part of
higher number of urinary tract infections (UTIs) the fight to prevent infection with human
than nonusers, probably because of pressure immunodeficiency virus (HIV). Recommend
on the urethra. them for any partners who do not maintain a
CERVICAL CAP – Caps are made of soft rubber, monogamous relationship. To be effective,
are shaped like a thimble with a thin rim, and condoms must be applied before any
fit snugly over the uterine cervix. The failure penilevulvar contact, because even
rate is estimated to be as high as 26% (ideal) to preejaculation fluid may contain some sperm. A
32% (typical use). The precautions for use are condom should be positioned so that it is loose
the same as for diaphragm use except they can enough at the penis tip to collect the ejaculate
be kept in place longer. without placing undue pressure on the
 condom. The penis (with the condom held VASECTOMY – a small incision or puncture
carefully in place) must be withdrawn before it wound is made on each side of the scrotum.
begins to become flaccid after ejaculation. If it The vas deferens at that point is then located,
is not withdrawn at this time, sperm may leak cut and tied, cauterized, or plugged, blocking
from the now loosely fitting sheath into the the passage of spermatozoa. Vasectomy can be
vagina. Some men find that condoms dull their done under local anesthesia in an ambulatory
enjoyment of coitus; setting, such as a physician’s office or a
FEMALE CONDOM – are latex sheaths made of reproductive life planning clinic. The man
polyurethane and prelubricated with a experiences a small amount of local pain
spermicide. The inner ring (closed end) covers afterward, which can be managed by taking a
the cervix, and the outer ring (open end) rests mild analgesic and applying ice to the site.
against the vaginal opening. The sheath may be TUBAL LIGATION – where the fallopian tubes
inserted any time before sexual activity begins are occluded by cautery, crushing, clamping, or
and then removed after ejaculation occurs. Like blocking, thereby preventing passage of both
male condoms, they are intended for one-time sperm and ova. A fimbriectomy, or removal of
use and offer protection against both the fimbria at the distal end of the tubes, is
conception and STIs. another possible but little used technique.
3. SURGICAL METHODS – Surgical methods of Tubal ligation has a 99.5% effectiveness rate
reproductive life planning, often called (Cunningham et al., 2008). Although the reason
sterilization, include tubal ligation for women is not clear, tubal ligation is associated with a
and vasectomy for men. Tubal ligation is chosen decreased incidence of ovarian cancer.
by about 28% of all women in the United States
of childbearing age as their contraceptive of
choice. Vasectomy is the contraceptive method
of choice for about 11% of men, making these
two procedures the most frequently used
methods of contraception in the United States
for couples older than 30 years of age.