IDEAL CONTRACEPTIVE Inexpensive Easy and simple to use with minimum side effects Rapidly reversible Readily available Highly effective.? Can be administered by non-healthcare personnel.
Contraceptive effectiveness• Difficult to determine :1. Perfect VS typical use (method failure and patient failure)2. Correct VS incorrect use3. long term VS short term
Pearl index• Method used for determination of pregnancy failure rate:Pregnancy rate = no. of pregnancies x100women/12 months of use
classifications A. Natural Methods • Periodic abstinence • Withdrawal • Lactational Amenorrhea Method • Standard days method • Calender rhythm method B. Barrier Methods C. Hormonal D Intrauterine Devices E.. Sterilization
Oral contraceptive pills• World wide used• very convenient method• Reversible methods
Combined• Composition• Combination of Estrogen & Progesterone• Ethinyl Estradiol (most commonly used nowadays)• Levonorgestrel, Norethindrone, …• Intake• 21 days: 1 pill/day• Last 7 days: free
Minipills• Used for 28 days, no breaks• Same time of the day
POP: Suitable for -• Older women,• Heavy smokers,• Hx/Predisposition to VTE,• Pts with HTN,Valvular heart ds., DM, or Migraine,• Breastfeeding women < 6mo postpartum (delay until =/> 3w postpartum to avoid risk of heavy bleeding).
Starting the POP• No previous contraception= start on day 1,• Changing from COC= start the day following last pill ( no pill-free period),• After childbirth= start anytime > 3w,• If weight > 70 kg= Consider Desogestrel or 2 tabs/d of any other POP( unlicensed)
Mechanism of action• Combined : most effective method because they inhibit midcycle gonadotropin surge and prevent ovulation• Progestin only pills: don’t mainly not inhibit ovulationBoth types act by -altering cervical mucus making it thick viscid and scanty -alter endometrium so not fit for implantation - alter ovarian responsiveness to gonadotropin stimulation
How to prevent ovulation?• Interfere with the release of GnRH from hypothalamus so it will suppress LH & FSH• In high concentration they will inhibit pituitary gland directly• Progestin only pills dont inhibit ovulation mainly because a lower dose of progestin is used in preparations less than combine forms it is important to be taken at the same time of the day to ensure that blood level do not fall below the effective levels
Short-term side-effects• OESTROGENIC EFFECTS • PROGESTOGENIC EFFECTS• Breast tenderness (3.6%), • Depression(3.9%),• Nausea ( 1.5%), • Premenstrual tension• Dizziness • Dry Vagina• Cyclical wt. gain • Sustained wt. gain• Bloating • Decreased libido• Vaginal discharge without • Lassitude infection • Acne• use a more progestogen- • Use a more oestrogen-dominant dominant pill pill
• Estrogen cause pigmentation and high level of estrogen may accelerate the development of gallbladder disease in young female but not increase the risk of acute cholelithiasis• Progestin : because they are structural related to testosterone they produce androgenic effects like increase weight and acnes
NONCONTRACEPTIVE BENEFITS• BENEFITS FROM ANTIESTROGENIC EFFECTS OF PROGESTERON: 1-decrease menses blood loss & improve anemia 2- risk of adeno CA of uterus 3- estrogen receptors in breast so risk begnin breast disease ?• BENEFITS FROM INHIBITION OF OVULATION (dysmenorrhea ) use as therapy of severe dysmenorrhea• OTHER BENEFITS: risk (PID,Rhumatoid a, bone loss)
Neoplastic effects• Breast CA• Endometrial CA : protection related to duration of use• Ovarian CA : decrease risk duration related• Liver adenoma and CA?• Pituitary adenoma : mask symptoms produced by prolactinoma amenorrhea and galactorrhea• colorectal CA: protection• Liver cyst and adenoma
Contraindications• Absolutes• Histoy of vascular disease (thromboembolism)• Systemic diseases (affect vascular system) SLE , DM with retinopathy or nephropathy• Undiagnosed uterine bleeding• Increase serum TGs• Heart failure rare because incidence of heart diseases are mostly after menopause• Smoking in female more than 35y
Contraindications• Relatives:• Migraine headache• Undiagnosed amenorrhea and depression• Smoking in female less than 35 y
VAGINAL RING• Steroids absorbed though vaginal epithelium directly into circulation• Contain ethniyl estradiol and etonogestreland• Place in vagina for 21 days and remove 7 days to allow withdrawal bleedings
TRANSDERMAL PATCH• It releases norelgestromin & ethinyl estradiol• Weekly applied, for 3 weeks, and the last week of the cycle is a patch-free week• Normal activities can be done while using the patch
• Sub dermal implants:• Need trained personal for insertion and removal.• Out patients procedure.• 99.5% effectiveness rate.• Requires no user motivation so compliance not problem.• Amennorhoea is common
• Subdermal implantation for continuous release• Effective for up to 3 years• Rapid return of fertility• Problems• Menstrual irregularity• Weight gain• Surgical implantation & removal
INJECTABLE SUSPENTIONS• Depomedroxyprogesteron(DMPA) IM,SC every 3 months doesnt increase risk of breast ca• Other types: medroxyprogesteron acetate (AMP)
IUD-IUD is the worlds most widely used method ofreversible birth control3 TYPES:1- Inert ( no longer recommended because ofpainful and heavy periods).2-Copper Releasing (paragard).3-Progesterone Releasing (IUS): A-Progestasert (progesterone T) 1976 - 2001. B-Mirena (levonorgestrel).
Intrauterine Contraception Devices: 1. Most commonly used reversible - Method of Contraception worldwide - effective > 97%. - The newer devices have failure rate < 0.5%
2. Copper bearing IUCD - Consist of a plastic frame with copper wire around the stem. - Surface of the copper determine the effectiveness and active life of the device. - Most IUCD licensed for use over 5-10 years and because of gradual absoption of copper, these IUCD renewed after 3-5 years. Copper Salt give some protection against bacterial infection.
Mechanism of Action:- All IUCD cause a foreign body reaction in the endometrium with increased prostaglandin production and Leucocyte infeltration. This reaction enhanced by copper which effect endometrial enzymes and oestrogen uptake and also inhibit sperm transport.- Alteration of uterine and tubal fluid impairs the viability of the gametes.- The progesterone IUCD (LNG.IUS) cause endometrial suppression and change in the cervical mucus and utro tubal fluid impair sperm migration.
Clinical uses• Long-term contraception• Women with contraindications to COC• Emergency contraceptive (1:1000 )• menorrhagia , endometriosis, chronicpelvic pain, dysmenorrhea , anemia.
EMERGENCY CONTRACEPTION• After intercourse and before implantation• Indication: failure of condoms• Unprotected intercourse• Within 72 hours after unprotected intercourse• Levonorgestrel Combined Prescription• Single dose, the earlier the better• Prevented 75% of unplanned pregnancies• IUD Emergency Contraception• Within 5 days after unprotected intercourse• Copper IUD
Barrier methods of contraception Two types : 1. Physical barrier methods, such as condoms, diaphragm, and cervical caps, that prevent pregnancy by blocking the entry of sperm into the upper genital tract; 2. Chemical barrier methods (spermicides) that kill or inactivate sperm on contact. ( less effective , used in combination , no STDs protection )
Barrier methods of contraception• easily available, reversible, and have fewer side effects than hormonal methods.• effective and acceptable if used consistently and correctly.• Protect against STD
Natural Methods:1.) Calendar Method (Safe period) - relies upon the fact that there are certain days during the menstrual cycle when conception can occur following ovulation, the ovum is viable within reproductive tract for a maximum of 24 hrs.- The life spam of sperm is longer 3 days.- During 28 day menstrual cycle, ovulation occur around day 14. This means that coitus must be avoided from 8th to 17th day.- Failure rate is high so many couples find it difficult to adher to this method.
2.) Ovulation method (The billing’s method)- Ovulation prediction can be enhaced by several complementary methods including *Basal body temperature (BBT) rise in progesterone following ovulates – rise temp. BBT 0.2-0.4 C, until the onset of menstruation . * Cervical mucus – several days before ovulation mucus appearance of raw egg white, clear, slippery and stretchy (spinnbarkeit). The final day of fertile mucus is considered to be the day when ovulation is most likely to occur and abstinence must be maintained from first day of fertile mucus until 3 days after the peak day. The end of the fertile period is characterized by appearance of (infertile mucus) which is scanty and viscous.
*Failure rate of natural method mucus and BBT and Calendar method 2.8 %.3-personal fertility monitors: small devices able to detect urine concentration of oestrone and LH indicate start and end of fertile period.- Failure rate 6.2%.- Disadvantage – provide no protection from STD .
How to use Standard Days Method Every morning move the rubber ring to the next bead. THE RED BEAD is day 1 of cycle. Always move the ring in On the first day of your the direction of the period, move the rubber arrow. ring onto the red bead. WHITE BEAD Each bead DAYS Mark a calendar to help represents a day are days when remember. of your you CAN get menstrual cycle pregnant. BROWN BEAD Use a condom or DAYS do NOT have are days when sex on these pregnancy days to prevent is unlikely. pregnancy. You can have sex on these days. No condom needed. Are you ready to When your next period choose this starts, move the ring to the red method? bead again. Skip over any
What to remember• Move the rubber ring one bead forward every day• Always use condoms or avoid sex on fertile “white bead” daysCome back if:• You get your period early Dark brown (it starts before you put the ring on bead the dark brown bead)• You get your period late Last brown bead (it does NOT start by the day after you put the ring on the last brown bead)• You have unprotected sex Anything else I can repeat or explain? on a fertile “white bead” day Any other questions?
Male condoms• It is one of the most popular mechanical barriers. Among all of the barrier methods, the condom provides the most effective protection of the genital tract from STDs. Its usage has increass because of the concern regarding the acquisition of HIV and STDs.
Male condoms• Increasing the efficacy :• reservoir tip• The addition of spermicidal lubricant to the condom. (water-based not oil-based)• the addition of an intravaginal spermicidal agent
Female condoms• It contains 2 flexible rings. The ring at the closed end of the sheath serves as an insertion mechanism and internal anchor that is placed inside the vaginal canal. The other ring forms the external patent edge of the device and remains outside of the canal after insertion.
Female condoms- Mechanism of action :• Prevents passage of spermand infections into the vagina( protection against STDs )• Can be inserted up to 8 hoursprior to intercourse; can remain inplace up to 8 hours
Female condoms- Efficacy• Pregnancy rates for the female condom range between 5 and 21 per 100 women per year. (higher than male condoms)• To increase efficacy Simultaneous use of both the female and male condom is not recommended• Re-use is not recommended .
Diaphragm• The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina• It is inserted before intercourse so that theposterior rim fits into the posterior fornix andthe anterior rim is placed behind the pubic bone.• Spermicidal cream is applied to the inside of the dome, which fits against the vaginal wall.
Diaphragm• It prevents pregnancy by acting as a barrier to the passage of semen into the cervix• provides effective contraception for 6 hours.• After intercourse, the diaphragm must be left in place for at least 6 hours.• Effectiveness depends on the age of the user, continuity of use, and the use of spermicide along with the diaphragm. Failure rate is estimated to be 20% .
Diaphragm• Disadvantages :- Prolonged use increase the risk of UTI- More than 24 hours use is not recommendeddue to the possible risk of TSS.- Might cause vaginal erosions if not placed properly .- Requires a professional fitting (trained provider is needed) .
Cervical cap• a cup-shaped latex device that fits over the base of the cervix.• The cap must be filled one third full with spermicide prior to insertion• Inserted 8 hours before coitus and can be left in place for as long as 48 hours.
Cervical cap• Acts as both mechanical barrier to sperm and as a chemical agent with the use of spermicide .• Pregnancy rates range between 4 and 36 per 100 women per year.• Effectiveness depends on the parity of women due to the shape of the cervical os.• Disadvantages : cervical erosions and vaginal spotting , risk for TSS , requires professional fitting and training for use , high failure rate , and candidates must have a history of normal results of pap smears.
Spermicides• consist of a base combined with either nonoxynol-9 or octoxynol• Surfactant that destroys the sperm cell membrane• Forms available : vaginal foams, suppositories, jellies, films, foaming tablets, and creams.
Spermicides• Failure rate is about 26% within the 1st year of use.• Advantages : ease of application , available over the counter , inexpensive and it augments the contraceptive efficacy of the cervical cap and diaphragm .• Disadvantages : minimal protection against STDs , risk of vaginal irritation and allergic reaction.
Sterilization• Sterilization :female sterilization and male vasectomy are permenant metod of contaception and highly effective• They are generally chosen by relatively older couple who are sure that they copleted their family.• Also individual who carry a genetic disorder may choose to be strlizer.• 28% of reproductive age women undergo tubal ligation and 10% of men undergo vasectomy.• Sterilization methods include: 1- Vasectomy in males. 2- Tubal Ligation in females .
Tubal Ligation• This involve mechanically blockage of both fallopian tube to prevent the sperm reaching and fertilizing the oocyte• sterilization performed by laparoscopically(under GA) or through a suprapubic “mini-laparotomy”• Failure rate: 0.5%
Tubal LigationAdvantages:• intended to be permanent• highly effective• safe• quick recovery• lack of significant long-term side effects• cost effective
Tubal Ligation Disadvantage:• possibility of patient regret• difficult to reverse• future pregnancy could require assisted reproductive technology (such as IVF)• more expensive than vasectomy
Cont.Complication:A women may experienced anasthetic problem or may be damage to intra-abdominal during the procedure. NOTE:ectopic pregnancy can be a late complicationsand any sterilized women who misses her period and has symptom of pregnancy should seekmedical advice.
VasectomyMechanism of action:Vasectomy involve division of the vas deferens on each side to prevent the release of sperm during ejaculation.Easier than tubal ligation.Usually done under local anesthesia.• Failure rate: 0.1%.
VasectomyAdvantages:• permanent• highly effective• safe• quick recovery• lack of significant long-term side effects• cost effective; less expensive than tubal ligation
VasectomyDisadvantages:• reversal is difficult, expensive, often unsuccessful• not effective until all sperm cleared from thereproductive tract (may take up to 12 w)• no protection from STDs
Cont.Complication of vasectomy:Immediately bleeding, wound infection and hematoma may occur.At the cut of vas deferns small lump will apear as a result of a local inflammation response this is called sperm granuloma it needs surgica excision.
Cont.some men develop anti-sperm antibody following vasectomy