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Contraception

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Ob-Gyne Course

Ob-Gyne Course


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  • 1. CONTRACEPTION
    Dr. Mona A. Almushait
    Dean, Girl’s Centre
    Associate Professor, Medical College
    Consultant, Obstetrics & Gynaecology
    King Khalid University
    Abha, Saudi Arabia
  • 2. Methods of Contraception
  • 3. I.Combined Hormonal Products
    and
    Progestin–Only Injection and Pills
  • 4. Combined Estrogen and Progesterone Contraceptives
    4Different delivery systems are used to supply estrogen and progestin to provide contraception:
    • Oral contraceptive pills
    • 5. Monthly injections
    • 6. Transdermal patches
    • 7. Vaginal rings
  • Pills
  • 8. Mode of action:
      Combination of hormonal methods utilizes 2 main mechanisms of contraceptive action:
    • Suppression of the LH surge (to prevent ovulation) ->to inhibit ovulation
    • 9. Thickening of the cervical mucus (to prevent sperm entering the upper genital tract)
    • 10. Other mechanisms:
    -> slowing of tubal transport
    -> atrophy of the endometrium
     
  • 11. Complications of Estrogen–Containing Contraceptives:
    • Thromboembolism
    • 12. Post pill amenorrhea
    • 13. Cerebrovascular accidents
    • 14. Increased in Cholelithiasis (cholestatic jaundice)
    • 15. HTN
    • 16. Benign hepatic tumors (Hepatoma)
    • 17. Headache in the week off
  • Contraindications to the Use of Estrogen–Containing Contraceptives
    ABSOLUTE
    • Arterial thrombosis
    • 18. Venous thrombus (Thromboembolism)
    • 19. Pulmonary embolism
    • 20. Coronary vascular disease, IHD -> cardiomyopathy, vascular heart disease
    • 21. Past cerebrovascular accident
    • 22. Pulmonary HTN
    • 23. Current pregnancy
    • 24. Breast cancer within the last 5 years (Oestrogen–dependent Cancer)
  • ABSOLUTE
    • Endometrial cancer
    • 25. Hepatic tumor or abnormal liver function, Dubin–Johnson or Rotor syndrome, known gallstones
    • 26. Unexplained abnormal uterine bleeding
    • 27. Age >35 and cigarette smoking
    • 28. Uncontrolled hypertension
    • 29. History of melanoma
    • 30. Hyperlipidaemia, focal and crescendo migraine
    • 31. Trophoblastic disease
  • RELATIVE
    • Risk factor for arterial disease
    • 32. Complicated prolonged Diabetes -> F.H. of DM
    • 33. Estrogen–dependent neoplasm
    • 34. Depression, Hyperprolactinemia
    • 35. Severe varicose veins
    • 36. Hypertriglyceridemia
    • 37. increasing age, smoking, obesity, migraine
  • Progestin–Only Hormonal Methods of Contraception
    • The Progesterone only Pill (PoP) is also known as the Mini–Pill.
    • 38. The Progestin–only methods provide the greatest pregnancy protection of all reversible methods of contraception.
  • Mode of action:
    • PoPs thicken the cervical mucus to inhibit sperm entry through the cervical canal.
    • 39. Few women inhibit ovulation
    • 40. Twining the endometrium
    How to use?
    • PoPs are taken as a continuous preparation, in 28 day packs, with no break between packs.
    • 41. Taken at the same time each day
    • 42. Irregular bleeding in the first few months
    • 43. Most women continue to menstruate although some may have lighter periods and a few become amenorrhoeic. 
  • Benefits of Progesterone only Pill:(have little metabolic impact)
    • Safe -> when oestrogen–containing pills cause side effects, or contraindicated
    • 44. Older women
    • 45. Smokers, immediately post–partum, breastfeeding, risk of DVT, hypertension, migraine, or diabetes, PMS
    • 46. Pills most frequently used by breastfeeding women
    Side effects:
    • ↑ functional ovarian cysts
    • 47. ↑ risk of ectopic pregnancy
    • 48. Acne, headache, breast tenderness, nausea, irregular bleeding
    • 49. Weight change
    • 50. ↑ breast cancer diagnosis
  • Most common side effects:
    • Menstrual changes (Unpredictable spotting or bleeding)
    • 51. Amenorrhea, improve dysmenorrhea
    for mentally retarded woman -> good hygiene
    • Progestin–only Pills require very strict adherence to every 24hr administration.
    • 52. Failure rates of 3% to 9%
    • 53. Return to fertility ranges from immediate with pills and implants to slow with DMPA (Depo-Provera).
  • Depo-Provera
  • 54.
    • DMPA (Depo–Provera) 150 mg every 3 months, I.M.
    • 55. Serum level of DMPA is higher than with implants and IUDs
    • 56. DMPA
    • 57. Suppresses gonadotropins to inhibit ovulation
    • 58. Change cervix mucus (thickening)
    • 59. Twining endometrium
    • 60. Good for women using anticonvulsants which increased hepatic clearance of sex steroids
    • 61. The majority of women develop Amenorrhea
    • 62. Ovarian suppression
    • 63. Hypoestrogenism (Postmenopausal level)
    -> dry vagina, low bone mineral density
    • Return to ovulation takes a median time of 10 months
  • Advantages:
    • High efficacy
    • 64. No need to remember to take a pill
    • 65. Use when oestrogen contraindicates
    • 66. No ↑ed in ovarian cyst or risk of ectopic pregnancy because they inhibit ovulation
    Disadvantages:
    • Delayed of fertility, weight gain, irregular bleeding
    • 67. ↑ risk of Osteoporosis due to long term Medroxy progesterone acetate
    • 68.  
  • Contraindications:
    • Pregnancy
    • 69. Severe arterial disease
    • 70. Undiagnosed vaginal bleeding
    • 71. Liver disease
  • Transdermal Patch
  • 72.
    • It is a beige-colored patch applied once a week to the abdomen, buttock, upper outer arm, or upper torso (excluding breasts).
    • 73. The patch releases 150 mcg of norelgestromin and 20 mcg of ethinylestradiol to the bloodstream daily to inhibit ovulation.
    • 74. 3 consecutive 7-day patches (21 days) are applied, followed by 1 patch-free week per cycle. The patch contains 9 days of medication.
  • Advantages:
    • Very effective
    • 75. Rapidly reversible
    • 76. Excellent cycle control by 3 months of use
    • 77. Easy to use, start, and stop
    • 78. Extra protection built in; serum hormone levels will remain in the contraceptive range for up to 2 additional days
    Disadvantages:
    • Requires a prescription
    • 79. Concern about visibility of patch for some women
    • 80. Possible skin reactions
    • 81. Slight increase in risk of VTE compared with COCs
    • 82. Lack of protection against STIs
  • Vaginal Ring
  • 83.
    • Vaginal ring is a thin, transparent, flexible ring that contains oestrogen/progestogen hormones that are absorbed through vaginal mucosa.
    • 84. The ring is 92% to 99% effective for pregnancy prevention (typical to perfect use).
    • 85. It stops ovulation and thickens the cervical mucus.
    • 86. Worn continuously for three weeks followed by a week off, each vaginal ring provides one month of birth control.
  • Advantages:
    • Easy to use
    • 87. Can be worn for three weeks
    • 88. Effects fertility one month at a time
    Disadvantages:
    • Does not protect against sexually transmitted infections, including HIV/ AIDS
    • 89. Spotting
    • 90. Increased vaginal discharge
    • 91. Nausea
  • II. Barrier and Behavioral Methods
  • 92.
    • The advantage of these contraceptives is that they need to be used only at the time of intercourse.
    • 93. Most profoundly decreases their utilization and increases their failure rates in typical use.
  • Male Condom
  • 94. Advantages:
    • The condom is the best method for reducing the risk of STIs.
    • 95. ↓transmission of STD, HIV, Chlamydia and Gonorrhea
    • 96. Can be easily obtained.
    Disadvantages:
    • Some people are allergic to latex. Polyurethane condoms can be used as an alternative.
    • 97. Loss of sensation or pleasure
    • 98. Slippage/breakage
  • Female barrier method
    Diaphragm and Cap
  • 99.
    • Diaphragms and Capsmust be fitted initially and prescribed by clinicians trained in their use.
    • 100. They must be filled and coated with spermicide and inserted before intercourse.
    • 101. 84% to 94% effective for pregnancy prevention.
    • 102. Must be left in place for at least six hours.
  • Advantages:
    • Easy use
    • 103. Protection from sexually transmitted infections
    • 104. Can be put into the vagina at any time before intercourse
    Disadvantages:
    • Cystitis
    • 105. Skin irritation
    • 106. Increased risk of bladder infection (diaphragm only)
    • 107. They do not prevent HIV transmission
  • Female barrier method
    Female Condom
  • 108.
    • A lubricated polyurethane pouch that is inserted inside the vagina during intercourse.
    Advantages:
    • Prevents the transmission of HIV and other STDs
    • 109. No hormonal side effects
    • 110. Can be used by people with latex sensitivities
    • 111. Does not affect future fertility
    Disadvantages:
    • Sometimes difficult to insert or use
    • 112. Friction/noise during intercourse
    • 113. Loss of sensation
    • 114. Can break or leak
  • Jelly
  • 115.
    • Contraceptive jelly is another form of concentrated spermicide (which is a chemical that kills sperm).
    • 116. Jellies come in tubes and are usually used with a diaphragm or cervical cap.
    • 117. It allows for immediate protection, which lasts for about 1 hour.
  • Vaginal Contraceptive Sponge
  • 118.
    • The contraceptive sponge is a small, donut-shaped foam sponge that contains a spermicide called Nonoxynol-9.
    • 119. It is a non hormonal vaginal barrier method of birth control that is fairly easy to insert.
  • Vaginal Contraceptive Foam
  • 120.
    • Foam is placed into the woman’s vagina using an applicator (similar to tampon insertion).
    • 121. It has two effects:
    • 122. It kills or destroys sperm which is why it is called spermicidal.
    • 123. It blocks the man’s fluids from entering the cervical canal, thus, stopping sperm from reaching the egg.
  • Advantages:
    • Foam is safe, no hormones are involved, and it is immediately reversible.
    • 124. Foam adds lubrication and moisture.
    Disadvantages:
    • Can be irritating to the vagina
    • 125. It is not protective against HIV
  • Film
  • 126.
    • Vaginal contraceptive film is a paper-thin translucent film that contains a spermicide and is used for birth control.
    • 127. The film is placed in the vagina on or near the cervix where it dissolves in seconds.
    • 128. It is effective for about one hour.
  • Nonoxynol–9 Suppositories
  • 129.
    • Drug name: Nonoxynol-9 suppository
    • 130. Major components:Nonoxynol–9
    • 131. Traits: White or milky white torpedo suppository
    • 132. Indication:Spermicidal products for vaginal contraceptive
  • Behavioral Methods
     
    • Natural family planning
    • 133. Tracking basal body temperature ↑0.5% (7 days before and 2 days after)
    • 134. Checking the consistency of cervical mucus
    -> Moist, sticky, white pre–ovulation, clear, copious and stretchy spinnbarkheit-> The most fertile time
    • Time in cycle
    ->Ovulation occurs every 12–16 days before a period
    -> Pain from ovulation, breast change -> less
    • Lactational amenorrheafor the first 6 months post partum, its failure rate is 2%
    • 135. Withdrawal or coitus interruptus
  • III. Progestin Implants and Intrauterine Devices
  • 136. Implanon
  • 137. Implant
    • Norplant contraceptive system, silastic implants placed in the s/c layer of the medical aspect of a woman’s upper arm to release steady amounts of Levenogestrel-> 5 years
    • 138. Have low circulatory levels of progestin
    • 139. Constant serum level -> contraceptive effects
    • 140. Suppress ovulation and change cx mucus
    • 141. Twining endometrium
    • 142. Etonogestrel–releasing implants
  • Disadvantages:
  • Intrauterine Contraceptive Devices
    Mirena
  • 148. Levenogestrel–Releasing Intrauterine System (LNG–IUS)
    • Contains 52 mg of Levenogestrel
    • 149. 20 µg of Levenogestrel every 24-hr.
    • 150. T–shape
    • 151. Effective for at least 5 years
  • Mode of action:
    • Thickens the cx mucus
    • 152. Twins the endometrium->atrophic endometrium
    • 153. Inhibition of ovulation
    • 154. Amenorrhea for 2–3 months after irregular bleeding
    • 155. Fertility returns immediately on removal
    • 156. ↓ Dysmenorrhea
    • 157. ↓ PID
    • 158. ↓ E.P.
    • 159. Reduction in menstrual blood 70%–90%
  • Disadvantages:
    • Irregular bleeding for the first 3 months
    • 160. ↑ functional ovarian cyst
    • 161. Expulsion and perforation
    Contraindications:
    • Pregnancy
    • 162. Active liver disease
    • 163. Severe arterial disease
    • 164. Undiagnosed irregular bleeding
    • 165. Mechanical heart valves
    • 166. Untreated STD
    • 167. Hx of ovarian or endometrial carcinoma
  • Copper T380A I.U.D.
  • 168. Mode of action of Copper T380A I.U.D.:
    • Copper is spermicidal
    • 169. Motility is severely compromised and the ability of the sperm to fertilize the egg is inhibited by the presence of copper ions.
    • 170. Inflammatory changes to prevent implantation.
    • 171. I.U.C.D. inserted in the first 7 days of cycle
    • 172. With antibiotics cover Azithromycin 1g single dose and Doxycyclone 100g
    • 173. Pregnancy with I.U.C.D.
    • 174. ↑ E.T, remove coil, miscarriage
  • Advantages:
    • Long term efficacy
    • 175. Lack of hormonal side effects
    Disadvantages:
  • Contraindications to the Use of Combined Hormonal Methods
    • History of heart attack,stroke, and breast cancer
    • 180. Labile hypertension
    • 181. Advanced diabetes
    • 182. Hepatic failure
    • 183. Migraine with aura
    • 184. Unexplained uterine bleeding
  • IV. Female sterilization and Vasectomy
  • 185. Sterilization
    • Permanent sterilization is the most common method of birth control used.
    • 186. Mini laparotomy sterilization
    • 187. Laparoscopic sterilization
    Disadvantages:
    • Does not protect against sexually transmitted infections, including HIV/AIDS
    • 188. Requires surgery
    • 189. Has risks associated with surgery
    • 190. May not be reversible
    • 191. Possible regret
    • 192. Possibility of Post Tubal Ligation Syndrome
    Advantages:
    • Permanent birth control
    • 193. Immediately effective
    • 194. Requires no daily attention
    • 195. Not messy
    • 196. Cost-effective in the long run
  • filshie clip tubal ligation
    • One common form of laparoscopic (camera) sterilization is the use of Filshie clips to occlude both fallopian tubes.
    Hulka clip sterlization
    • One common form of female sterilization is the use of Hulka clips to block the fallopian tubes.
  • Vasectomy (interruption of the vas deferens)
    • It is a minor surgical procedure wherein the vasadeferentia of a man are severed, and then tied/sealed in a manner which prevents sperm from entering the seminal stream.
  • Risks include:
    • Infection
    • 197. Bleeding
    • 198. Scrotal pain or swelling at the time of the procedure
    There are no long–term hormonal, metabolic, or autoimmune effects associated with Vasectomy.
  • 199. Thank You !