‫تأشير احمد العُريبي ويا‬

‫اشوي اضافات من يمي‬

Learning objectives
 To know types, mechanism of action, and side effects
of combined contraception.
 2. to understand medical eligibility criteria of missed
pills.
 To know types and side effects of progesterone only
contraception.
Ti is a widely accepted, effective, & usually reversible
method of contraception. It’s introduced in 1956. 3
types:
1. combined oral contraceptive (COC).
2. Progesterone- only (minipills); contain either
Norgestril or Norethisterone, taken each day.
3. Seqential oral contraceptives.
1. COC:-

Formulations:- It contains both estrogen(usually Ethinyl

oestradiol or Menstranol) & a progesterone. Previously
use high dose pills (100 ug of estrogen), but now
decrease the dose of estrogen to 20-50 ug; most
women use 30-35 ug estrogen (low- dose pills). The
progesterone either 1st or 2nd or 3rd generation
 The pill is taken for 21 days followed by a 7-day break
during which time withdrawal bleeding usually occurs.
The pill should be taken at the same time each day,
bed time is convenient. If the woman forgets to take
the pill one night she can take it the next morning.
 Combined pills are available as monophonic
(preparation in which every pill in the pocket contains
the same dose of steroids); & biphasic & triphasic pills
; in which the dose of both steroids changes once or
twice during the cycle so that the regimen will mimics
the normal cycle.
Mode of action:-
‫مهم‬

 The principle mode of action of COC is the inhibition

of ovulation. Estrogen inhibits FSH (suppressing the
development of ovarian follicles, while progestogens
inhibit the development of LH surge.
 Additional contraceptive effects include changes in the
cervical mucus characteristics interfering with sperm
transport, a possible alteration in the tubal motility,
endometrial atrophy with impaired uterine receptivity.
Advantages:-
Non contraceptive benefits of coc :-

1. Menstrual periods are usually lighter, shorter & more

regular during the pill use, less painful & premenstrual
symptoms less troublesome.
2. Decrease the incidence of iron deficiency anemia by
decreasing menstrual blood loss.
3. Decrease incidence of benign breast lumps, functional
ovarian cysts, endometriosis, acne & possibly PID.
4. COC use protects against ovarian & endometrial
cancer (due to decrease in the number of ovulations &
therefore rupture of ovarian capsule).
 There is also a 50 per cent reduction in ovarian and
endometrial cancers which continues for 15 years after
stopping the CHC.
 5.There is a possible protective effect against
rheumatoid arthritis, thyroid disease and duodenal
ulceration.
 WHO medical eligibility criteria category 4 for
combined hormonal contraception
of OCCP (absolute)
raindication
* :

 CHC: UKMEC Category 4 – Unacceptable health risk and should

not be used Non-lactating
· ->Jweeks
women
lactating , -> 6 months
.

‫تأثير الحمل تبقى ما تروح ب سهولة ورا ما تجيب طفل‬

"ji
 Breastfeeding – <6 weeks postpartum & decrease ofto because risk of
pregnancy itself
DVT increase risk
DVT
 Smoking – aged ³35 years and smoking ³15 cigarettes per day
.

 Cardiovascular disease – multiple risk factors for arterial cardiovascular

disease
 Hypertension – blood pressure ³160 mmHg systolic and/or ³95 mmHg
diastolic; or vascular disease
Venous
 VTE – current (on anticoagulants) or past history
thromboembolism

 Major surgery with prolonged immobilisation

 Known thrombogenic mutations
 Current and history of ischaemic heart disease
 Stroke
 50 ‫ ولحد العمر‬35 ‫ثالث شروط لالستخدام حبوب منع الحمل ب وحدة عمرها فوگ‬
1- no smoker 2- no obese 3- no hypertension
‫ و هاهيه بعد تصير ما تاخد‬35 ‫اذا سمينة او مدخنة او عندها ضغط ف تاخد حبوب منع الحمل للحد سنة‬

relative risk factor ‫ بدون مضاعفات تعتبر‬Diabetes ‫ال‬

‫ وياها مضاعفات ف ما يصير انطي حبوب منع الحمل‬DM ‫بس اذا‬

 Valvular and congenital heart disease – complicated by

pulmonary hypertension, atrial fibrillation, history of subacute
bacterial endocarditis
 Migraine headaches – with aura at any age
 Breast disease – current breast cancer
 Diabetes – with nephropathy, retinopathy, neuropathy or other
vascular disease
 Viral hepatitis – active or flare
 Cirrhosis – severe decompensated disease
 Liver tumours – benign hepatocellular adenoma and malignant
hepatoma
 Systemic lupus erythematosus (SLE) – positive or unknown
antiphospholipid antibodies
Risks & side effects:-

A-Minor S/E :-
1-
1.Disturbances of the menstrual cycle: either slight bleeding
or frank break through bleeding especially with low dose
pills. If frank through bleeding ˃ 2 times the can be
controlled by increasing the dose of estrogen or change to
another preparation contains different proportion of
estrogen to progesterone.
2-
Amenorrhea when high –dose pills. Exclude pregnancy &
sometimes can be treated by induction of ovulation.
2.Weight gain, fluid retention, headache, nausea, &
vomiting, chloasma, mood changes, loss of libido,
mastalgia, breast enlargement & greasy skin.
B-Serious S/E :

 1.CVS: on venous side; increase risk of venous

thrombosis & pulmonary embolism. In dose-
dependent pattern related to the amount of estrogen
in the pill. Estrogen increase platelet count & platelet
adhesiveness & decrease ant thrombin in blood.
 This risk is the most during the first year of CHC use.
On arterial side: including hypertension, CVA,&
coronary heart disease. Increase risk was only seen on
smoker woman on the pill.
2.Carbohydrate metabolism: high dose pills will decrease
carbohydrate tolerance.
3.Malignancy: small increase in breast cancer & that the
risk persisted for 10 years after stopping the pills
especially if she take the pills before the birth of the
first child.
Also small increase in the risk of carcinoma of cervix.
Liver cancer; benign hepatic adenoma is rare
complication.
Interaction with drugs:

 Effectiveness of the combined oral contraceptive pill

(COCP) (and all other methods) is not affected by
administration of most broad-spectrum antibiotics.

 Barbiturates, sulphonamide, rifampicin, phenytoin & most

anticonvulsants will increase activity of liver enzymes that
metabolize the steroids.
 Effect on pregnancy: no increase in the incidence of
congenital abnormality in woman who has taken the pills
after pregnancy has started.
 Follow up: B.P checked at 6, 12 months, then annually, Pap
smear annually .examine breast each year.
Missed-pill guidelines for COC
‫مو مشكلة‬
 If ONE pill has been missed (more than 24 hours and
up to 48 hours late) .
 Continuing contraceptive cover
 • The missed pill should be taken as soon as it is
remembered • The remaining pills should be
continued at the usual time.
 Minimizing the risk of pregnancy
 Emergency contraception (EC) is not usually
required.
If TWO OR MORE pills have been
missed (more than 48 hours late
 Continuing contraceptive cover •
 The most recent missed pill should be taken as
soon as possible •
 The remaining pills should be continued at the
usual time •
 Condoms should be used or sex avoided until
seven consecutive active pills have been taken.
 Minimising the risk of pregnancy

 If pills are missed in the first week (Pills 1 - 7) .

 EC should be considered if unprotected sex occurred in the pill-free

interval or in the first week of pill-taking

 If pills are missed in the second week (Pills 8 - 14)

 No indication for EC if the pills in the preceding 7 days have been taken
consistently and correctly (assuming the pills thereafter are taken
correctly and additional contraceptive precautions are used).

 .
 If pills are missed in the third week (Pills 15 - 21)

 OMIT THE PILL-FREE INTERVAL by finishing the

pills in the current pack (or discarding any placebo
tablets) and starting a new pack the next day.
 ‫ ما شرحتها دكتورة‬، ‫هاي ساليد و الي بعدها‬

Evra patch
 With this patch 20 μg of ethinyl estradiol and 150 μg of
norelgestromin are released every 24 hours.
 It is the first transdermal contraceptive applied once
weekly for 3 weeks followed by a patch-free week (3
weeks on, 1 week off).
 The Pearl index is 1.24 per 100 WY
NuvaRing
 releases 120 μg of etonogestrel (ENG) and 15 μg of ethinyl
estradiol daily. It is 54 mm in diameter and 4 mm thick.
 It is placed vaginally once every 3 weeks and following a 1-
week ring-free interval a new ring is inserted.
 Efficacy and cycle control are comparable to the COCs.
Side-effect profile is also similar to that of COCs.

 However, women have reported more vaginal symptoms of

vaginitis, leukorrhoea, foreign body sensation, coital
problems and expulsion.
Progesterone- only contraception:

Available as oral pills, implants, long acting injectables,

& recently hormone – releasing IUCD. injectables progestogens
implant progestogens

Mechanism of action: cervical mucus

+
endometrial atrophy
inhibit ovulation (high doses)

Given in high doses e.g. injectables, progestogens inhibit

ovulation. In low doses; ovulation may be inhibited
often inconsistently. By all routes progestogens affect
cervical mucus reducing sperm penetrability &
transport & all have an effect on the endometrium
which probably compromises implantation.
S/E:
All low dose progesterone – only methods are associated with
high incidence of irregular bleeding because ovulation
inhibited inconsistently .Also progestogens may alter the
vasculature of the endomrtium increase the chance of
bleeding.
Efficacy:
 POP has a higher failure rate than COC.
 Failure rates for traditional POPs vary from 0.3 to 8.0 per
100 WY. The decrease efficacy is due in part that many
women continue to ovulate & in part because the POP has
a shorter half- life in the circulation.
Indications of POP:

1.In women in whom estrogen is absolutely or relatively

contraindicated as women with CVS risk factors,
migraine, D.M or mild hypertension.
2. Lactating women since estrogen impairs milk
production.
 ‫ ما شرحتهن دكتورة‬29 ‫ الى‬24 ‫من ساليد‬

 POP: UKMEC Category 3 – Risks generally outweigh

benefits
 Current and history of ischaemic heart disease and stroke –
continuation of the method
 Past history of breast cancer and no evidence of recurrence for 5
years
 HIV – on antiretroviral therapy (drug interactions)
 Cirrhosis – severe (decompensated)
 Liver tumours – hepatocellular adenoma and malignant
hepatoma
 SLE – positive or unknown antiphospholipid antibodies
 POP: UKMEC Category 4 – Unacceptable health
risk and should not be used
 Breast disease – current breast cancer
S/E:

1.Irregular vaginal bleeding.

2.High incidence of functional ovarian cysts due to effect
on ovarian activity.
3.Headache, nausea, bloating, breast tenderness & mood
changes, oily skin & acne.
4.Long –term risks: very small increase in the risk of
carcinoma breast after prolonged use of POP (Depo-
Provera confers a high degree of protection against
endometrial ca.).
Missed-pill guidelines for POPs
 TRADITIONAL POPS (Micronor*, Noriday*, Norgeston*,
Femulen
 >3 hours late (>27 hours since the last pill was taken)

 Take a pill as soon as remembered.

 If more than one pill has been missed just take one pill.
Take the next pill at the usual time. This may mean taking
two pills in one day. This is not harmful. An additional
method of contraception (condoms or abstinence) is
advised for the next 2 days (48 hours after the POP has
been taken).
DESOGESTREL-ONLY (Cerazette*)

 >12 hours late

 (>38 hours since the last pill was taken)

 Take a pill as soon as remembered. If more than one

pill has been missed just take one pill. Take the next
pill at the usual time. This may mean taking two pills
in one day. This is not harmful. An additional method
of contraception (condoms or abstinence) is advised
for the next 2 days (48 hours after the POP has been
taken).
Inject able progestogens:

2 types: 1. Depo-Provera (medroxy-proesterone acetate

given in a dose of 150 mg every 12 weeks. ‫ اشهر‬3 ‫ابرة وحدة كل‬
2.Norethisterone –enanthate 200 mg given every 8
weeks. subcutaneous
Subcutaneous DMPA (Sayana Press) 104 mg given
subcutaneously every 13 weeks. It can be injected into
the upper anterior thigh or anterior abdomen .
S/E:
‫مهم‬
1.Irregular vaginal bleeding (treated by administration of
estrogen simply by adding the combined pills).
2.Amenorrhea.
3.Delayed fertility; it may take 1 year for normal fertility
to return following cessation of depo provera.
Osteoporosis
 4.Decrease bone marrow density (BMD); Amenorrhea
→hypooestrog. →↓BMD.
 5.Weight gain + fluid retention , loss of libido , ….
 The average weight gain among women using DMPA is
between 2 and 6 kg.
PROGESTOGEN-ONLY IMPLANT
 Nexplanon
 is the only POI available in the UK. It has replaced Implanon.
 It is a single rod which contains 68 mg of etonorgestril ENG in a
membrane of ethylene vinyl acetate. It is licensed for 3 years.
 Nexplanon is radio-opaque
 . Nexplanon® is a flexible rod (40 mm × 2 mm) and is inserted
 subdermally 8 cm above the medical epicondyle, usually of the
non-dominant arm.
 Insertion
 is conducted under local anaesthesia using a specially designed
insertion device.
Mode of action injectables progestogens
implant progestogens inhibit ovulation

 The main mode of action is inhibition of ovulation .

 Thickening of the cervical mucus prevents sperm
penetration into the upper reproductive tract.
 It also brings about changes in the endometrium
making the environment unfavourable for
implantation .
Side effects
 irregular bleeding and oligomenorrhoea/ amenorrhoea.
 Weight gain .
 Mood changes and loss of libido can occur.
 Acne can improve, occur or worsen whilst using the
implant.
 Complications with removal
 include deeply sited, non-palpable, broken or migrated
implants. As Nexplanon contains barium sulphate it is
radio-opaque. Hence it can be identified on X-rays.
Ultrasound and MRI can also be used to locate the
implants.
 Emergency contraception
‫مهم‬
- Copper IUCD : used up to 5 days after coitus or 5 days after ovulation
- Levonorgestrel : used up to 3 days after coitus
- ellaone-ulipristal acetate : used up to 5 days after coitus

Is any drug or device used after intercourse to prevent pregnancy, to

prevent implantation of a fertilized egg.
1Yuzpe regimen. 2 tablets of high –dose estrogen (100ug) & 500ug
levonorgestrel repeated after 12 hours. S/E nausea & vomiting. The dose
should be given within 72 hours of coitus.
 2.Levonorgestrel 1.5 mg once up to 3 days. Replace yuzpe regimen.
 it works mainly by inhibiting ovulation. It prevents follicular rupture.
 It can be used more than once in a cycle.
Copper  3.IUCD is highly effective postcoital contraception with failure rate <

1%. It is used up to 5 days after coitus.or 5 days after ovulation

 should be the first-line choice, particularly if the woman intends to
continue the IUD as long-term contraception .
 When used for EC, its effect on the endometrium is thought to prevent
implantation if fertilization has occurred
 4. ellaone-ulipristal acetate
 30mg single dose tablet
 If vomiting occurs within 3 hours, another tablet should be taken.
Ulipristal is not recommended to be used more than once per cycle as
the safety of efficacy of repeated exposure has not been assessed
 .
 Is progesterone receptor modulator .
 Its primary mode of action is thought to be inhibition or delay of
ovulation. It can prevent ovulation after the LH surge has started.
 Effective up to 120 hours after coitus.
 Levo norgestrel effective 69%
 Ulipristal 85%.
 Oral EC is much less effective than the Cu-IUD for EC and is estimated
to prevent only two-thirds of pregnancies.
 • Effective ongoing contraception should be started after EC.
Sterilization:

 Sterilisation is a permanent and usually an irreversible

method of contraception .
1-Female sterilization
 It involves blocking both fallopian tubes by laprotomy,
mini-laprotomy, & more commonly by laparoscope or
via hysteroscopy.
Bilateral salpingectomy or hysterectomy may be
preferable when there is coexistent gynecological
pathology.
Methods of tubal occlusion:
 1.Ligation (using absorbable or non- absorbable sutures)
 The Pomeroy technique is the most widely used ligation
technique .
2.Electrocautery.
3.Rings.
4.Clips.
5.Laser (co2 laser).
 6.Chemical agents instilled into fallopian tubes e.g.
quinacrine.
 The failure rate for female sterilisation is 1 in 200.
Hysteroscopic sterilisation
 Micro-inserts made from nickel–titanium and stainless
steel are inserted hysteroscopically through the cornual
ends of both tubes.
 This can be performed under local anaesthesia and/or
intravenous sedation. These generate fibrosis around the
devices and the tubes are occluded by 3 months after the
procedure.
 Additional contraception needs to be used until a
hysterosalpingogram is performed at 3 months to confirm
full occlusion of the tubes.
 It is an irreversible procedure and the failure rates quoted
are the same as for the other methods of tubal occlusion.
Complications:

A-Immediate complications
1. Complication of G.A.
2. Vascular damage or damage to bowel or other internal
organs especially with electrocautery.
3. Gas embolism.
4. Thrombo-embolism.
 5. Wound infection.
B- Long –term complications
 1.Menstrual disorders. There is no evidence to suggest
that there is an increased incidence of bleeding
problems and consequently an increased hysterectomy
rate after tubal occlusion.

2.Abdominal pain & dysparunia (more common after

cautery).
3.Psychological problems & psycho-sexual problems.
4.Bowel obstruction from adhesions (very rare).
Vasectomy (male sterilization)
Division or occlusion of the vas deferens prevents the passage of
sperm using clips or diathermy or injection of sclerosing agents
as silicone.
 Efficacy: failure rate is 1 in 2000.
 The procedure can be carried out under a local anaesthetic and is
safer than female sterilisation. Following the procedure, men
should be advised to use effective contraception until two
consecutive semen samples 4 weeks apart confirm azoospermia.
(The first sample should be taken at least 8 weeks after surgery.)
Complications
A-Immediate
1. Scrotal hematoma, wound infection.
2. Up to 2 % men fail to have azospermia in which case vasectomy
repeated.
B- Late complications
1.Antisperm antibody; it is harmless unless restoration of
fertility is desired.
2.Small inflammatory granuloma.
 3.Cancer
 There is no increase in testicular or prostatic cancers
following the vasectomy operation [B].
 4.Heart disease
 There is no increased incidence of heart disease associated
with vasectomy.