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Gynecology 5th year, 1st & 2nd lectures (Dr. Muhabat Salih Saeid)

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The lecture has been given on Nov. 10th & 22nd, 2010 by Dr. Muhabat Salih Saeid.

The lecture has been given on Nov. 10th & 22nd, 2010 by Dr. Muhabat Salih Saeid.

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  • 1. Contraception Dr.Muhabat Salih Saeid MRCOG
  • 2. Learning Objectives
    • Recognize common adverse effects of estrogen and progestin
    • In a patient case be able to provide a recommendation for symptom management
    • Identify contraindications to contraceptive options
  • 3. Contraception Definition
    • Contraception generally implies the prevention of pregnancy following sexual intercourse by
      • inhibiting viable sperm from coming into contact with a mature ovum
      • by preventing a fertilized ovum from successfully implanting in the endometrium .
  • 4. Commonly used methods
    • Reversible contraception
      • Oral contraceptives
      • Long acting injectable or implantable progestins
      • Combined estrogen patch
      • Condoms, spermicides, diaphragms, withdrawal, periodic abstinence, and IUD’s
  • 5. Properties of Contraceptive Desired by Patients
    • Highly effective
    • Prolonged duration of action
    • Rapidly reversible
    • Privacy of Use
    • Protection against STD’s
    • Easily accessible
  • 6. Oral Contraceptives
    • Introduced to the US in 1960
    • Works through the manipulation of normal physiologic feedback mechanisms of the menstrual cycle by varying amounts of estrogen and/or progestin.
    • Proven to be a very effective and popular method of birth control.
  • 7. The Pill
    • Advantages
      • Easy to use
      • Dependable
      • No additional appliances
      • Can regulate menstrual flow and decrease cramps and other symptoms of menses
  • 8. Missed pills
    • Missed 1 day:ASAP and next pill at regular time
    • Missed 2 days: 2 when she remembers, 2 the next day, use back up until her next period
    • More than 2 days: Restart and use a back up method
  • 9. Contraindications
    • History of cerebrovascular disease
    • Uncontrolled hypertension
    • DVT or PE
    • Migraines worsened by estrogen
    • Estrogen dependent neoplasm
    • Ischemic heart disease
    • IDDM w/ complications
    • Breast Cancer
    • Impaired liver function
    • Smokers>35y/o
  • 10. Estrogen
    • Inhibits ovulation by suppressing of pituitary release of FSH/LH (negative feedback)
    • Inhibits implantation by altering secretions within the uterus
    • Accelerates ovum transport
    • Induction of luteolysis: degeneration of corpus luteum prevents normal implantation and placental attachment
  • 11. Estrogenic Side Effects
    • Nausea
    • Weight gain
    • Fluid retention
    • Pulmonary emboli
    • Hypertension
    • Thromboembolic complications
    • Stroke
    • Increase in bile cholesterol
  • 12. Progesterone
    • Inhibits ovulation by disruption of HPO function and by modification of mid-cycle FSH/LH surge
    • Inhibits implantation by suppressing the endometrium
    • Production of thick cervical mucus
    • Prevention of sperm penetration
    • Slows ovum transport
  • 13. Progestin Side Effects
    • Increased appetite
    • Depression, fatigue, lethargy
    • Acne, oily skin
    • Hirsutism
    • Headache
    • Weight gain
    • Decreased libido
    • Increased LDL, decreased HDL
    • Hypertension
  • 14. Noncontraceptive benefits
    • Relief from menstruation-related problems
      • Decreased cramps
      • Decreased ovulatory pain
      • Decreased menstrual blood loss
    • Disease prevention
      • Ovarian and endometrial cancer
      • Ovarian cysts
      • Ectopic pregnancy
      • Pelvic inflammatory disease
      • Benign breast disease
  • 15. Contraindications
    • History of cerebrovascular disease
    • Uncontrolled hypertension
    • DVT or PE
    • Migraines worsened by estrogen
    • Estrogen dependent neoplasm
    • Ischemic heart disease
    • IDDM w/ complications
    • Breast Cancer
    • Impaired liver function
    • Smokers>35y/o
  • 16. Transdermal Contraception
    • Ortho Evra
      • Norelgestromin and Ethinyl Estradiol
      • Similar to OC’s
    • Not recommended in patients >198lbs, less effective
    • Applied every 7 days for 3 weeks followed by patch free week
    • Convenience, increased compliance
  • 17. Ortho Evra
    • If a patch comes off????
    • <24 hours
      • Reapply
      • use a new patch
    • >24 hours
      • apply a new patch
      • use this day as the new patch change day
      • use a back up method until 7 consecutive days
    • Patient Education
    • Similar side effects to OC’s
    • Same incidence of drug interactions
    • Apply to abdomen, buttock, upper outer arm, and upper torso
    • Back up method should be used until after the first 7 days of consecutive administration
  • 18. Implants
    • Progestin only (Norplant)
    • Prevents ovulation
    • More effective than the Pill
  • 19. Implant
    • Advantages
      • Convenience
      • Eliminate user error
      • No menses or very light
      • Decreased cramping
  • 20. Implant
    • Problems
        • Difficulty in removing
      • Side effects
        • Similar to the pill
        • Changes in menstrual bleeding
        • Headaches
      • Side effects
        • wt. gain
        • Acne
        • breast tenderness
        • hair growth
        • ovarian cysts
  • 21. Implant
    • Contraindications
      • Liver disease
      • Breast cancer
      • Cardiovascular disease
      • Unexplained vaginal bleeding
      • Pregnant
      • Smokers
  • 22. Injectable Contraceptives
    • Depo-Provera
      • Medroxyprogesterone acetate
      • 150mg/ml
      • Progestin only
    • Inhibits ovulation for 3 months
    • IM injection 5 days w/in onset of menstrual bleeding and Q12 weeks
  • 23. Depo-Provera
    • Advantages
    • Highly effective 99.7%
    • Increased compliance
    • Amennorrhea
      • Reduced risk of anemia
    • Decreased menstrual cramps/pain
    • No drug interactions w/ anticonvulsants
    • Disadvantages
    • Break through bleeding
    • Weight gain
    • Headache
    • Depression
    • Decreased HDL
    • Risk of ectopic pregnancy
    • Contraception reversible in 4-13months
  • 24. Barrier Methods
    • The condom
    • Female condom
    • Diaphragm
    • Cervical cap
    • Sponge
  • 25. IUD
    • Intrauterine device
    • Copper and plastic (Copper T-380A) 10 years
    • Plastic and Progesterone (progestasert IUD) 1 year
    • 90-96 % effective in use
    • Increased risk of PID
  • 26. Spermicides
    • Nonoxynol-9
    • Use in combination with barrier methods of contraception
      • Foam
      • gel
      • Film
      • Creams, jellies and suppositories
  • 27. Fertility Awareness Methods
    • Calendar or rhythm method
      • Midway in cycle
    • Basal body temperature (BBT) method
      • Increase in body temperature
    • Cervical Mucous Method
      • Clear slippery mucous
    • Symptothermal method
      • Combination of BBT and Cervical Mucous methods
  • 28. Sterilization
    • For Women
      • Tubal ligations
        • Cut and seal the fallopian tubes
      • Hysterectomy
        • Removal of the uterus
    • For Men
    • Vasectomy
      • Vas deferens are cut and sealed
  • 29. Emergency Contraception
    • Emergency Contraception Pill (ECP)
    • Copper IUD
  • 30. Emergency Contraception
    • Indications :
    • Unprotected intercourse
      • Condom slipped/broke
      • Missed pills
    • Sexual assault
    • Preven
      • 50µg EE and 0.25mg levonorgestrel
    • Plan B
      • 0.75mg levonorgestrel
  • 31. Patient Education
    • Prescribing Info .
    • First dose must be taken within 72 hours of unprotected intercourse
    • Second dose is 12 hours later
    • Side Effects
      • Nausea
      • Vomiting
      • Breast Tenderness
    • Reglan (metoclopramide) 1 hour prior can reduce n/v
    • Repeat dose if vomiting occurs w/in 1 hr of admin.
  • 32. Abortion
    • Spontaneous abortion (miscarriages)
    • Induced abortion
  • 33. Injectable Contraceptives
    • Depo-Provera
      • Medroxyprogesterone acetate
      • 150mg/ml
      • Progestin only
    • Inhibits ovulation for 3 months
    • IM injection 5 days w/in onset of menstrual bleeding and Q12 weeks
  • 34. Depo-Provera
    • Advantages
    • Highly effective 99.7%
    • Increased compliance
    • Amennorrhea
      • Reduced risk of anemia
    • Decreased menstrual cramps/pain
    • No drug interactions w/ anticonvulsants
    • Disadvantages
    • Break through bleeding
    • Weight gain
    • Headache
    • Depression
    • Decreased HDL
    • Risk of ectopic pregnancy
    • Contraception reversible in 4-13months
  • 35. Implantable Contraception
    • Norplant
    • Subdermal progestin implant
    • 6 implantable capsules filled w/ levonorgestrol
    • Requires physician administration
    • Effective for 5 years
    • Every 3 yrs for women weighing >154lbs
  • 36. Norplant
    • Advantages
    • Convenience
    • Highly effective
    • Decreased menstrual cramps
    • Fertility rapidly returns
    • Disadvantages
    • Irregular period
    • Headache
    • Depression
    • Weight gain
    • Pain/itching @ site
    • Site infection
    • Ectopic pregnancy
    • Removal difficulties
  • 37.                                                                                                                           TTTTT