CONTRACEPTION
Nur Hafizah Ainaa Abu Hassan
WHAT IS CONTRACEPTION?
The deliberate use of artificial methods or other techniques to prevent
pregnancy.
Important that women are able to plan timing of children.
Aim of contraception is to prevent pregnancies from occurring while causing
the least amount of side effects to the patient.
IDEAL CONTRACEPTIVE
Highly 100%
effective
Acceptive
Cheap
Having noncontraceptive
benefits
Safe
Reversible
Simple to use
Requiring minimal
motivation,
maintainence
and supervision
NATURAL
METHOD
PERMANENT
HORMONAL
Rhythm
Method
ORAL
BARRIER
PARENTERAL
DEVICE
MECHANICAL
STERILIZATION
CHEMICAL
Coitus
Interruptus
COCP
Depo-Povera
Patch
Condom
LAM
Mini-Pill
Implant
Vaginal Ring
Diaphragm
IUCD
Cervical Cap
Emergency
Contraception
Sponge
FEMALE
Spermicides
MALE
Tubal Ligation
Vasectomy
TYPES OF CONTRACEPTION
TEMPORARY
NATURAL METHOD
Certain methods used to achieve and avoid pregnancies.
Based on observation of the naturally occurring signs and symptoms of
the fertile and infertile phases of a woman's menstrual cycle.
No drugs, devices, or surgical procedures are used.
WITHDRAWAL
RHYTHM METHOD
Coitus Interruptus
Effectiveness rate is 60-80%
Based on identification of the
fertile period of a cycle and to
abstain from sexual intercourse
during that period.
Failure due to
Requires partners co-operation.
Removal of penis from the vagina
before ejaculation occurs
Delay withdrawal
Presence of sperm in the preejaculatory fluid
Methods to determine:
a) Calendar Rhythm
b) Temperature Rhythm
c) Mucus Rhythm
a) CALENDAR
What? Predicting fertility based on
menstrual cycles
How? The first unsafe day is obtained
by substracting 20 days from lengths
of the shortest cycle and the last
unsafe day by deducting 10 days
from the longest cycle.
This technique works best when a
woman's menstrual cycle is very
regular.
b) MUCUS
Tracking changes in the amount
and texture of vaginal discharge,
which reflect rising levels of
estrogen in the body.
For the first few days after your
period, there is often no discharge,
but there will be a cloudy, tacky
mucus as estrogen starts to rise.
When the discharge starts to
increase in volume and becomes
clear and stringy, ovulation is near.
A return to the tacky, cloudy mucus
or no discharge means that
ovulation has passed
c) TEMPERATURE
What? lowest temp of the body at
rest (Body Basal Temperature)
How? Ovulation raises body temp
- 1 degree F, and temp will drop
if fertilization does not occur.
Require abstinence until the third
day of the rise of temperature.
BREAST FEEDING LACTATIONAL
AMENORRHEA (LAM)
Prolonged and sustained breastfeeding offers a natural protection of
pregnancy.
More effective in women who are amenorrhea than those who are
menstruating.
Risk of pregnancy who fully breastfeed an amenorrhea < 2% in the first 6
months.
HORMONAL
Hormonal compound taken in order to block ovulation and
prevent occurrence of pregnancy.
ORAL CONTRACEPTIVE PILL
Oestrogen
Progestogen
Ethinyl oestradiol (common)
Mestranol (rare)
Desogestrel
Norethisterone
Ethynodiol
Norgestimate
Gestodene
Levonorgestrel
HORMONAL CONTRACEPTION
ORAL
COMBINE
COCP
PARENTERAL
SINGLE
POP
INJECTABLES
Depo-Povera
DEVICE
IMPLANTS
IUCD
Implanon
Mirena coil
Norplant
Cooper Coil
VAGINAL RING
TRANSDERMAL
PATCH
MODE OF ACTION
Prevent Ovulation
Prevents pituitary
secretion of FSH
and LH
Suppression of hypothalamic
gonadotropin-releasing
factors
cervical mucus
penetrability
Inhibit implantation
Inhibit ovum
transport in
tube
Failure rate: 1%
Progestin prevents ovulation
suppress luteinizing hormone
thicken cervical mucus (thick, viscid
and scanty) retarding sperm
passage endometrium unfavorable
to implantation (endometrium non
receptive to the embryo)
Estrogen prevents ovulation
suppress follicle-stimulating hormone
stabilize the endometrium prevents
breakthrough bleeding
COMBINED ORAL CONTRACEPTIVE PILL
Oral contraceptives consist of a combination of an estrogen and a progestational
agent : Eithylestradiol (20mcg 35mcg) and a progestogen (Levonorgestrel/
norethisterone/ desogestrel)
Meant to be taken for 21 days with a pill-free week
taken daily for 3 weeks and then omitted for 1 week, during which time there is
withdrawal uterine bleeding
Low dose pills now more commonly used :
Mercilon, Loette, Yasmin, Diane
99% effective if used correctly.
ADVANTAGES
Reversible
Intercourse
unaffected
Reduce incidence
of ovarian and
endometrial cancer
Controlled timing
(menses)
DISADVANTAGES
Effective only if
taken consistently
Effectiveness is
reduced by;
phenytoin
antibiotic like
ampicillin
Vomiting and
diarrhea - impair
absorption
SIDE EFFECT
Nausea/ Vomitting
Mastalgia
Thromboembolism
Strokes
Weight gain
Headache
Hypertension
CONTRAINDICATION
History of
cardiovascular
disease
Hypertension
Obesity
Migraine
Chronic hepatitis
Breast cancer
PROGESTIN ONLY PILL (MINI-PILL)
Small dose of progestogen daily without break.
Levonorgestrel 75 g
Norethsterone 350 g
Desogestrel 75 g
Failure rate 2-3 %
Contraceptive effect by;
Alterations in cervical mucus and effects on the endometrium.
The first pill has to be taken on the first day of the cycle then continuously and regularly
and at the same time of the day to be maximally effective
No breaks between packs.
Older women
Lactation
Smokers over 35
Intolerance or
contraindication
s to oestrogen
Hypertension
CONTRAINDICATION
Acne
Mastalgia
Headache
Disturbance of
menstrual cycle
Functional
ovarian cysts
develop
Must be taken at
the same or
nearly the same
time daily
INDICATION
DISADVANTAGES
ADVANTAGES
Absence of
major metabolic
disturbance
Excellent choice
for lactating
women
Easy to take
Reduced the risk
of PID and
endometrial
cancer
Pregnancy
Unexplained
uterine bleeding
Recent breast
cancer
Arterial disease
Thromboembolic
disease
INJECTABLE PREGESTIN INTRAMUSCULARLY
DEPO-POVERA
Depo medroxyprogesterone
acetate (every 3 months)
Absorbed more slowly
NORGEST
Norethisterone oenanthate
(2 monthly)
Dose:
150mg IM, every 12 weeks
reach active levels within 24
hrs
levels decrease by 4 5
months
undetectable by 7 9
months
INDICATION
CONTRAINDICATION
ADVANTAGES
DISADVANTAGES
Good option for women
who find it difficult to
remember to take pill
Useful if oestrogen is
contraindicated
Lactation
High risk for osteoporosis
Same as POP
Safe during lactation
No estrogen related side
effect
Menstrual symptoms
reduced
Protective against
endometrial cancer
Diminised anemia
Irreguler bleeding
Delay in return of fertility
of 6 months
Injections
Depression
Weight Gain
Low failure rate (<1%)
Reduce risk of ovarian
and endometrial cancer
Long term use (>2 years)
can lead to decreased
bone density
IMPLANON
Progestin only delivery system containing:
Etonorgestrel 68mg
Single closed capsule Sub dermal implant40mm x 2mm road, inserted on day 1-5 of the
menstrual cycle
into the non-dominant arm in between the head of
the biceps and triceps
It release hormone about 60 mcg, gradually
reduced to 30 mcg/ day over 3 years.
Efficacy 99%
Long-lasting (3 years)
Difficult to
remove
No effect on
lactation
Not
biodegradable
Not user
dependent
History of
cardiovscular
disease
Headache
Mood change
Depression
CONTRAINDICATION
Longevity of
effectiveness
Menstrual
irregularity
ADVERSE EFFECT
Surgical
DISADVANTAGES
ADVANTAGES
Reversible
Hypertension
Obesity
Migraine
Chronic
hepatitis
Breast cancer
NORPLANT I
NORPLANT I
: Six capsules (Five years)
NORPLANT II
: Two capsules (Three years)
Rods : 4 cm long with diameter of 2.5 mm.
Each rod contains 75mg of levonorgestrel.
It release 50 mcg of levonogestrel / day.
Administration;
Under LA
6 slicone rubber rods
Effective within 6 hours of insertion
5 years action
VS.
NORPLANT II
PATCH (EVRA)
Delivers 150 g progestin norelgestromin + 20 g of ethinyl estradiol daily.
Patch (Evra) is applied to :
Buttocks
Upper outer arm
Lower abdomen
Upper torso (avoiding the breasts)
A new patch is applied weekly for 3 weeks
followed by a patch-free week to allow for withdrawal bleeding
The patch was slightly more effective than a low-dose oral contraceptive in
preventing pregnancy.
ADVANTAGES
DISADVANTAGES
Dysmenorrhea
Well tolerated
Breast tenderness
Breakthrough bleeding in
the first two
Safe overall
3% of women
application site reaction
severe enough to limit usage
INTRAVAGINAL RING
Flexible polymer ring
Contains ethinyl estradiol + etonogestrel
Released rates: 15 g and 120 g per day,
Highly effective failure rate was 0.65 per
100 woman-years
The ring is placed within 5 days of the onset
of menses and is removed after 3 weeks of
use for 1 week to allow withdrawal bleeding.
Breakthrough bleeding is
uncommon.
20% of women, 35% of men
reported being able to feel the
ring during intercourse.
If this is bothersome, may be
removed for intercourse BUT
should be replaced within 3
hours.
EMERGENCY CONTRACEPTIVE PILL
Each pill contain Levonorgestrel and Ethinyl estradiol
After unprotected intercourse
Highly effective and decrease the risk of pregnancy by 75%
100 women had unprotected intercourse during the second to third week
of their menstrual cycle, 8 would be expected to conceive.
Contain high dose of contraceptive hormones
Take within 72 hours of SI
Dosage:
1. Take 2 pills per dose
2. Another 2 pills 12 hours later
MECHANISM OF ACTION
Side effects
Preventing
implantation
Disrupt
fertilization
Stop ovulation
inhibition or delay
of ovulation
sperm penetration,
and tubal motility
alteration of the
endometrium
Nausea and
vomiting are major
problems due to
the estrogen in
these regimens
INTRAUTERINE CONTRACEPTION SYSTEM (MIRENA)
Device contain progestogen- releasing rod,
(reservoir releasing levenorgestrel 20
microgram 12 hourly)
Levonorgestrel released directly into uterine
cavity from a T-shaped plastic intra uterine
device
Most effective contraceptive, failure rates
<2/1000
MODE OF ACTION
Thickens cervical mucus
Thins endometrium
Local inflammatory reaction
NON-CONTRACEPTIVE
USES
Menorrhagia
To oppose oestrogen in HRT
To oppose effects of
Tamoxifen on endometrium
SIDE EFFECT
Minimal
Amenorrhoea (20%)
Irregular bleeding (up to 6
months)
PMS like symptoms (rarely)If
conception occurs risk of
ectopic pregnancy
COOPER IUCD
Copper effects are by causing a toxic effect to
sperm and the egg
Licensed for use for up to 10 years
99% effective
Has an increased risk of infection associated
with the first 3 weeks of insertion
Copper IUCD associated with increased
menstrual loss
Occasionally can have problem of missing
strings, lost IUCD that may require investigation
or surgical exploration/ removal
Pregnancy
Current STI or PID
Distortion of the
shape of uterine
cavity
Severe
dysmenorrea
Valvular heart
disease
Cooper allergy
Heavy periods
SIDE EFFECTS
CONTRAINDICATION
BENEFITS
Does not require
a person to take
medication
Good for those
with a contraindication to
taking oestrogen
Useful for patients
who are not
compliant to
taking medicines
Pain
Menstrual loss
Expulsion <3%
Uterine
perforation 1 in
1000
Salpingitis 1.5-7.5
per 1000
Endometritis
TIME OF INSERTION
INTERVAL
POSTABORTAL
POSTPARTUM
6 Weeks following
childbirth or
abortion
2-3 days after the
period is over
During lactational
amenorrhea can
be anytime
Immediately
following
termination of
pregnancy
Prevent uterine
synechia
6 weeks following
child birth when
the uterus will be
involuted to near
normal size
POSTPLACENTAL
DELIVERY
Immediate
insertion can be
done
Rate of expulsion is
high
BARRIER METHODS
Prevent pregnancy by blocking the egg and sperm from meeting
Barrier methods have higher failure rates than hormonal methods due
to design and human error.
MALE CONDOM
Most common and effective
when used properly
Latex and Polyurethane
Benefit
risk of venereal infection
Controlling the spread of HIV
Perfect effectiveness rate = 97%
Combining condoms with
spermicides raises effectiveness
levels to 99%
FEMALE CONDOM
Made as an alternative to male
condoms
Polyurethane
Physically inserted in the vagina
Perfect rate = 95%
Woman can use female
condom if partner refuses
SPERMICIDES
Chemicals kill sperm in the vagina
Different forms:
Jelly
Film
Foam
Suppository
Some work instantly, others require
pre-insertion
Only 76% effective (used alone),
should be used in combination
with another method i.e., condoms
DIAPRAGHM
CERVICAL CAP
Perfect Effectiveness Rate = 94%
Perfect effectiveness rate = 91%
Typical Effectiveness Rate = 80%
Typical effectiveness rate = 80%
Latex barrier placed inside vagina
during intercourse
Latex barrier inserted in vagina
before intercourse
Fitted by physician
Caps around cervix with suction
Spermicidal jelly before insertion
Fill with spermicidal jelly prior to use
Inserted up to 18 hours before
intercourse and can be left in for a
total of 24 hours
Can be left in body for up to a
total of 48 hours
Must be left in place six hours after
sexual intercourse
SPONGE
The sponge is inserted by the
woman into the vagina and covers
the cervix blocking sperm from
entering the cervix.
The sponge also contains a
spermicide that kills sperm
STERILIZATION
Medical techniques that intentionally leave a person unable to reproduce
in the future.
Generally permanent birth control techniques that surgically disrupt the
normal passage of ova or sperm.
STERILIZATION
45% couples between 40-45 years
Have completed family
Have no other acceptable method
Female sterilisation (laparoscopic/
mini-lap or during CS)
failure 1:200, not 100% reversible
10% risk of ectopic pregnancy
Male sterilisation
failure 1:10 000, not 100% reversible
TUBAL LIGATION
A small incision is made in the
abdomen to access the fallopian
tubes.
Fallopian tubes are cut, tied,
cauterized, blocked, burned, or
clipped shut to prevent the egg
from traveling through the tubes
Recovery usually takes 4-6 days
Failure rates vary by procedure,
from 0.8%-3.7%
May experience heavier
periods
VASECTOMY
A small incision is made to access the
vas deferens, the tube the sperm
travels from the testicle to the penis,
and is sealed, tied, or cut
No-scalpel Vasectomy (NSV)
Faster and easier recovery than a
tubal ligation
Failure rate = 0.1%, more effective
than female sterilization
After a vasectomy, a male will still
ejaculate, but there wont be any
sperm present
During a vasectomy
(cutting the vas) a
urologist cuts and ligates
(ties off) the ductus
deferens. Sperm are still
produced but cannot exit
the body. Sperm
eventually deteriorate
and are phagocytized. A
man is sterile, but
because testosterone is
still produced he retains
his sex drive and
secondary sex
characteristics.
CONCLUSION
There are many forms of contraception available
Important to know the advantages and disadvantages of these options
Useful to see what is being advised for our post-natal patients and relate the
types of contraception recommended with each individual patient
