Contraception

Dr. A. Kumwenda
Texila American University
Monday 19th July, 2021
 Definition

 The term contraception includes all measures, temporary

or permanent, designed to prevent pregnancy due to the
coital act

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 An ideal contraceptive
 This should fulfil the following criteria:
 Widely acceptable,

 Inexpensive,

 Simple to use, safe, highly effective and

 Requiring minimal motivation, maintenance and

supervision.

 No one single universally acceptable method has yet

been discovered.
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 Methods of contraception

Permanent
Temporary

•Barrier
•Natural
•IUCDs
•Steroidal
contraception Female – BTL Male - vasectomy

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 An approach
 Faced with a number of options, it can be difficult to
choose the most suitable contraceptive

 A useful approach to consider is the following:

 Is she wishing to conceive?

 How devastating would it be for the woman to conceive, or

is the aim to space out the pregnancies?

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 An approach
 How reversible does the method need to be? Is she not
likely to want to get pregnant ever again, or in the next 5
years, or in a few months?

 Which methods seems acceptable to her?

 Are there any absolute or relative contraindications to the

method?

 Always discuss the risk of STIs and using condoms to

protect against them

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 History (all types of contraception)
 Age

 Current contraception

 Past contraception including likes, dislikes, myths

 Pregnancy – numbers, pregnancy induced problems,

types of delivery, whether currently lactating

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 History (all types of contraception)
 Past major illness – specifically HTN, CVA, SCD,
thromboembolic disease (TED)

 Allergies

 Regular medication

 Menstrual history

 Previous gynaecological history and any other symptoms

e.g post coital bleeding
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History (all types of contraception)

 STIs and sexual history, including last unprotected

sexual intercourse

 Smoking

 Cervical smear history

 Family history

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 Combined oral contraceptives (COCs)

 The most effective reversible method of contraception

and commonest form

 Consists of oestrogen (E) and progestin (P)

 The commonly used progestins in the COCs are either

levonorgestrel or norethisterone or desogestrel

 The estrogens are principally confined to either ethinyl-

estradiol or menstranol

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 Mechanism of action (1)

 Inhibition of ovulation:

 The release of gonadotropin releasing hormones from

the hypothalamus is prevented through a negative
feedback mechanism.

 There is thus no peak release of FSH and LH from the

anterior pituitary.

 So follicular growth is either not initiated or if initiated,

recruitment does not occur.

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 Mechanism of action (2)
 Producing static endometrial hypoplasia

 There is stromal edema, decidual reaction and regression

of the glands making endometrium nonreceptive to the
embryo.

 Alteration of the character of the cervical mucus

(thick, viscid and scanty) so as to prevent sperm
penetration.

 They thicken the cervical mucus, preventing sperm

penetration
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 Mechanism of action (3)

 Probably interferes with tubal motility and alters tubal

transport.

 Thus, even though accidental breakthrough ovulation

occurs, the other mechanisms prevent conception

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 Efficacy of COC
 Pregnancy rates are 0.1% when fully compliant

 Typical usage is associated with a 5.0% failure rate

during the first year of use

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 Contraindications and risks
 There are four categories in terms of eligibility:

 Unrestricted use

 Benefits generally outweigh the risk

 Risks generally outweigh the benefit (relative

contraindication)

 Unacceptable health risk and should not be used (absolute

contraindication)

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 Absolute contraindications to COC use
 Thrombophlebitis,  Undiagnosed abnormal
thromboembolic disorders, vaginal bleeding
CVA, coronary occlusion
 Known or suspected
 Markedly impaired liver pregnancy
function
 Smokers over the age
 known or suspected breast of 35 years
cancer

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 Relative contraindications to COC use
 Migraine headaches  H/O obstructive jaundice
in pregnancy
 Hypertension
 Sickle cell disease
 H/O gestational diabetes
 Diabetes mellitus
 Elective surgery
 Gall bladder disease
 Epilepsy

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 Clinical problems associated with COCs
 Breakthrough bleeding  Migraine headaches

 Amenorrhoea  Drugs that affect efficacy

 weight gain

 Acne

 Ovarian cysts

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 Patient selection (1)

 History & general examination should be thorough

 Examination of the breasts for any nodules, weight and

blood pressure are to be noted.

 Pelvic examination to exclude cervical pathology, is

mandatory. Pregnancy must be excluded.

 Cervical cytology to exclude abnormal cells, is to be

done.

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 Patient selection (2)
 Any woman of reproductive age group without any
systemic disease and contraindications listed, is a
suitable candidate for combined pill therapy.

 Growth and development of the pubertal and sexually

active girls are not affected by the use of “pill”.

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 Non-contraceptive benefits of oral
contraceptives (Ocs)

 These can broadly be grouped into two main

categories:

 Benefits that incidentally accrue when OC are specifically

utilized for contraception &

 Benefits that result from the use of OCs to treat problems

or disorders

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 Non contraceptive benefits of OCs

 Regulation of menstrual  Less PID

cycle
 Less rheumatoid arthritis
 Less endometrial cancer
 Increased bone density
 Less ovarian cancer
 Less endometriosis
 Fewer ectopic pregns.
 Less benign breast disease
 More regular menses
 Fewer ovarian cysts
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 OC as treatment
 Heavy menstrual bleeding  Hormone therapy for
(HMB) hypothalamic amenorrhoea

 Dysmenorrhoea  Functional ovarian cysts

 Endometriosis prophylaxis  Reduction of premenstrual

syndrome
 Acne & hirsutism

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 How to prescribe the Pill (1)

 New users should normally start their pill packet on

day one of their cycle.

 One tablet is to be taken daily preferably at bed time

for consecutive 21 days.

 It is continued for 21 days and then have a 7 days

break, with this routine there is contraceptive
protection from the first pill.

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 How to prescribe the Pill (2)
 7 of the pills are dummies and contain either iron or
vitamin preparations.

 However, a woman can start the pill up to day 5 of the

bleeding.

 In that case she is advised to use a condom for the next

7 days.

 The pill should be started on the day after abortion.

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 How to prescribe the Pill (3)
 Following childbirth in non-lactating woman, it is started
after 3 weeks and in lactating woman it is to be
withheld for 6 months

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 Missed pills (1)
 It is easy to forget a pill or be late in taking it

 COC users need to know what to do if they forget to

take pills

 When a woman forgets to take one pill, she should

take the missed pill at once and continue the rest as
schedule. Nothing to worry.

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 Missed pills (2)
 When she misses 2 pills in the first week (days 1–7),
she should take 2 pills on each of the next 2 days and
then continue the rest as schedule.

 Extra precaution has to be taken for next 7 days either by

using a condom or by avoiding sex

 If 2 pills are missed in the 3rd wk (days 15–21) or if > 2

active pills are missed at any time, another form of
contraception should be used as back up for next 7 days
as mentioned above.

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 Missed pills (3)
 She should start the next pack without a break.

 If she misses any of the 7 inactive pills (in a 28-day pack

only) she should throw away the missed pills; take the
remaining pills one a day and start the new pack as
usual.

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 The Progestin-only Pill (POP) - minipill

 POP is devoid of any estrogen compound.

 It contains very low dose of a progestin

 It has to be taken daily from the first day of the cycle

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 Mechanism of action
 It works mainly by making cervical mucus thick and
viscous, thereby prevents sperm penetration.

 It also has the effect of thinning the endometrium,

inhibiting implantation

 Ovulation is affected in 60% of women on POP – 1/3 do

not ovulate but 2/3 experience variable interference

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 Efficacy

 Efficacy increases with age as fertility declines

 It is more likely to fail in women > 70kg.

 During breastfeeding, efficacy approaches 100%

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 How to prescribe the minipill
 The first pill has to be taken on the 1st day of the cycle &
then continuously.

 It has to be taken regularly & at the same time of the day.

 There must be no break between the packs.

 Delay in intake for >3 hrs, the woman should have

missed pill immediately & the next one as schedule.

 Extra precaution with condoms should be in place for next

2 days
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 Advantages of the POP (1)
 Side effects attributed to estrogen in the COCP are totally
eliminated

 No adverse effect on lactation and hence can be suitably

prescribed in lactating women

 Easy to take as there is no “On and Off” regime

 It may be prescribed in patient having (medical disorders)

hypertension, fibroid, diabetes, epilepsy, smoking & history
of thromboembolism
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 Advantages of the POP (2)
 Reduces the risk of PID and endometrial cancer

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 Disadvantages of POP (1)
 Irregular bleeding – commonest

 Increased risk of ectopic pregnancy

 Worsening acne

 Breast tenderness

 Weight gain

 Headaches
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 Disadvantages of POP (2)
 Increased risk of benign functional ovarian cysts and
pelvic pain (as interference with ovulation in 60%)

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Contraindications

 Pregnancy

 Unexplained vaginal bleeding

 Recent breast cancer

 Arterial disease

 Thromboembolic disease.

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 Injectable progestin
 The preparations commonly used are:
 Depomedroxy progesterone acetate (DMPA) and

 Norethisterone enanthate (NET-EN).

 Both are administered intramuscularly (deltoid or

gluteus muscle) within 5 days of the cycle.

 The injection should be deep, and the site not to be

messaged.

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 Injectable contraception: Depo-provera
 Comes as microcrystals, suspended in an aqueous
solution

 Correct dose is150 mg IM (gluteal or deltoid) every 3

months

 Relies on higher peaks of progestin to inhibit ovulation

and thicken cervical mucus.

 The progestin level is high enough to block the LH

surge

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 Injectable contraception: Depo-provera
 The injection should be given within the first 5 days of
the current menstrual cycle, otherwise a back-up method
is necessary for 2 weeks

 The injection must be given deeply in muscle and not

massaged

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 Injectable contraception: Depo-provera

 Easy to use, no daily or  Free from eostrogen

coital acton required related problems

 Safe no serious health  Private use not

effects detectable

 Effective as  Enhances lactation

sterilization, IUCD &
implant contraception  Has noncontraceptive
benefits

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 Injectable contraception: Depo-provera
 Irregular menstrual  Can’t be removed
bleeding
 Return to fertility is delayed
 Breast tenderness
 Regular injections required
 Weight gain
 No STI/HIV protection
 Depression

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Depo-provera – absolute contraindications

 Pregnancy

 Unexplained genital bleeding

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 Barrier methods:
 There are 4 barrier methods and these are:

 Male & female condoms, the diaphragm and the cap

 They work by preventing sperm deposition in the vagina

or sperm penetration in the cervical canal

 The objective is achieved by mechanical devices or by

chemical means which produce sperm immobilization, or
by combined means

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 Efficacy
 Male condoms, if used according to instructions are 98%
effective

 Condom failure rate is often much higher owing to user

failure

 For female condoms, failure rate is 5%

 For the diaphragm, failure rate is 4-8/100 in 1 year (92-

96% effective)

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 Condoms (1)
 Made of polyurethane or latex.

 Polyurethane condoms are thinner and suitable to those

who are sensitive to latex rubber.

 The most widely practiced method used by the male.

 Protection against STIs is an additional advantage.

 Occasionally, the partner may be allergic to latex.

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 Condoms (2)
 suitable for couples wanting to space their families &
have contraindications to oral contraceptives or IUCD

 Note: They must be used correctly every time to be

highly effective

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Advantages of condoms (1)
 Only need to use during sex

 Easily available and cheaper

 No medical side effects unless allergy to latex

 Easy to carry, simple to use and disposable

 Protect against most STIs and pre-malignant

cervical changes

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 Disadvantages of condoms (2)
 May accidentally break or come off inside the vagina

 May decrease sensation, making sex less enjoyable for

both or either partner

 Allergic reaction (Latex)

 Both partners need to be motivated – psychological

barrier

 Female condoms can be noisy

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 Disadvantages of condoms (3)
 Poor reputation.

 Many people associate condoms with immoral sex,

adultery or sex with prostitutes

 May embarrass some people to buy, ask partner to use,

put on, take off, or throw away the condoms

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 Precautions with condoms

1. To use a fresh condom for every act of coitus.

2. To cover the penis with condom prior to genital contact.

3. Create a reservoir at the tip.

4. To withdraw while the penis is still erect.

5. To grasp the base of the condom during withdrawal

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 Diaphragm
 An intravaginal device made of latex with flexible metal
or spring ring at the margin

 It should completely cover the cervix

 Ill fitting and accidental displacement during intercourse

increase the failure rate

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Advantages of diaphragm
 Cheap

 Can be used repeatedly for a long time

 Reduces PID / STIs to some extent

 Protects against cervical pre-cancer and cancer

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 Disadvantages of diaphragm (1)
 Less effective

 Forward planning

 Messy

 Requires help of a doctor or paramedical person to

measure the size required

 Requires fitting – about 3 hrs before intercourse

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Disadvantages of diaphragm (2)

 Risk of vaginal irritation and urinary tract infection

 Discomfort – occasionally vaginal abrasions

 Increased risk of candidiasis

 Not suitable for women with uterine prolapse

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 Spermicides (1)
 Available as vaginal foams, gels, creams, tablets and
suppositories

 These agents mostly cause sperm immobilization

 The cream or jelly is introduced high in the vagina with

the help of the applicator soon before coitus.

 Foam tablets (1–2) are to be introduced high in the

vagina at least 5 minutes prior to intercourse.

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 Spermicides (2)
 In isolation, not effective, but enhances the efficacy of
condom or diaphragm when used along with it.

 There may be occasional local allergic manifestations

either in the vagina or vulva

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Fig 1 - Spermicide

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 Intrauterine contraception

 Types of IUDS

 Copper IUDs - TCu-380A, Tcu-220C, Nova T, Mulitload-

375

 Hormone-releasing IUDs

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 Implant contraception - Norplant
 Progestin circulating at levels 1/4 to 1/10th of those in
COC, prevents conception by suppressing ovulation and
thickening cervical mucus to inhibit sperm penetration

 Side effects include changes in menstrual patter, weight

gain, headache, and effects on mood

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 The mechanism of action

 Suppression at both the hypothalamic and pituitary LH

surge necessary for ovulation

 The constant level of progestin has a marked effect on

the cervical mucus

 Suppression of the estradiol-induced cyclic maturation

of the endometrium and eventually causes atrophy

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 Disadvantages of Norplant
 Disruption of bleeding  Implants can be visible
patterns in up to 80% of under the naked eye
users
 Does not protect
 Implants must be inserted against STI/HIV
and removed in a surgical
procedure by trained  Acne
personnel

 30% of pregnancies are

ectopic

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 Absolute contraindications

 Active thrombophlebitis or  Benign or malignant liver

thromboemboilc tumours
phenomena
 Known or suspected
 Undiagnosed genital breast cancer
bleeding

 Acute liver disease

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 Implanon

 A single implant 4 cm long contains 60 mg of 3-keto

desogestrel

 The hormone is released at a rate of about 60 micro

grams per day

 Is designed to be provide contraception for 2-3 years

 Efficacy and side effects are similar to those or norplant

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 Jadelle
 Two rods containing 75mg LNG effective for 5 years

 Rods are easier and more convenient to insert and

remove

 Norplant and Jadelle are bioequivalent over 5 years

of use

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 Periodic abstinence
 Is keyed to the observation of naturally occurring signs
and symptoms of the fertile phase of the menstrual cycle.

 It takes into account the viability of sperm in the female

reproductive tract and the life span of the ovum

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 Methods of periodic abstinence

 Rhythm of Calender method

 Cervical Mucus method

 Symptothermal method

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 Periodic abstinence

 Periodic abstinence is associated with good efficacy

when used correctly and consistently and the following
rules are observed:

 No intercourse during mucus days

 No intercourse within 3days after peak fecundity

 No intercourse during times of stress

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 Withdrawal

 Involves removal of the penis from the vagina before

ejaculation takes place

 1st year failure rate - 18%

 Some sperm may be released before ejaculation

 Is a better method than using no method at all

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 Lactational Amennorrhoea Method (LAM)
 High concentrations of prolactin work at both central and
ovarian sites to produce lactational amenorrhoea and
anovulation

 Elevated levels of prolactin inhibit the pulsatile secretion

of GnRH

 Only amenorrhoeic women who exclusively breastfeed

at regular intervals, including at nighttime, during the first
6 months have the contraceptive protection equivalent to
the provided by oral contraception

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 LAM
 With menstruation or after 6 months, the risk of
ovulation increases

 Supplemental feeding increases the risk of ovulation

(and pregnancy) even in amenorrheic women

 Total protection against pregnancy is achieved by

exclusively b/feeding for 10 weeks

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Permanent contraception

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Female sterilization – tubal ligation

 This is a permanent method where a woman’s fallopian

tubes are ligated, excised, or coagulated

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Advantages of female sterilization

 Very effective- failure rate 1:1,000

 Permanent method
 Nothing to remember
 No interference with sex
 Increased enjoyment –no worries
 No effect on milk production in breast feeding women
 No health risks
 Can be done soon after delivery

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 Disadvantages of female sterilization

 Painful on operation site for few days

 Uncommon complications of surgery;

 Infection /superficial or internal, and bleeding
 Anaesthetic risks
 Ectopic pregnancy
 Requires trained staff
 No protection against STIs and HIV

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Male sterilization - vasectomy

 This is a permanent method where males vas

deferens are cut and ligated

 Easy to perform, less expensive

 Able to test for effectiveness

at any time

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Advantages of vasectomy
 Very effective- failure rate 1/700
 Permanent
 Nothing to remember after 20 ejaculations or three
months
 No interference with sex (man still has normal
erections and ejaculates)
 Increased enjoyment
 No apparent long term health risks

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 Disadvantages of vasectomy
 Complications of surgery
 Discomfort for 2-3 days
 Pain in the scrotum

 Brief feeling of faintness

 Bleeding

 Blood clots in the scrotum

 Requires some one trained

 Not immediately effective- unless after 20 ejaculations
or after 3 months
 No STI/ HIV protection

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 Counselling for sterilization
 Consider reason for request

 Permanent

 Irreversible

 Explain procedure

 Failure rate

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End!

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