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SALSO Series - Contraception

SALSO Series - Contraception

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  • 3. CATEGORIES CLASSIFICATION1 A condition for which there is no restriction for the use of contraceptive method2 A condition where the advantages of using the method generally out weight the theoretical or proven risks3 A condition where the theoretical or proven risks usually out weight the advantages of using the method4 A condition which represent an unacceptable health risk of the contraceptive method is used
  • 5.  Holistic approach should be taken when assisting woman in making contraceptives choices Services should be organized to optimized access and choices The method of birth control differ from each other in the timing of when they are used
  • 6.  Used specifically at the time of sexual intercourse e.g. condoms,diaphragm Other method must be working all the time to provide protection e.g. hormonal ,IUD and sterilization.
  • 7.  contains two steroid hormones- estrogen&progesterone Estrogen component of most modern COC is ethinyloestradiol(EE) in the dose range of 20- 50microgram Progesterone component vary in different preperations
  • 8.  Progestogen Component  second generation(e.g.norethisterone and levonorgestrel)  third generation(desogestrel and gestodene) Third generation have a higher affinity for the progesterone receptor and a lower affinity for androgen receptor- LESS SIDE EFFECT
  • 9.  In theory,they confer greater efficacy with fewer androgenic side effects Also have fewer effects on carbohydrate and lipid metabolism than second generation compounds However evidence has shown it has not resulted in a reduction in the risk of arterial wall disease or AMI
  • 10.  Either fixed dose or phasic Phasic-the dose of oestrogen and progesterone changes once(biphasic) or twice(triphasic) in each 21 day course Phasic preparations are designed to mimic the cyclical variations in hormone levels
  • 11.  Monophasic-all 21 active pills contain same amount of oestrogen and progesterone Biphasic-21 active pills contain 2 different Oes/P combinations Triphasic-21 active pills containing 3 different Oes/P combinations
  • 12.  Oestrogen component inhibits pituitary FSH secretion-suppresses follicle growth;progesterone component inhibits the LH surge  inhibits ovulation Cervical mucus becomes scanty and viscous- inhibits sperm transport
  • 13.  The endometrium becomes atrophic and unreceptive to implantation Possibly direct effects on the fallopian tubes impairing sperm migration and ovum transport
  • 14.  Effectiveness  Depends on user  < 1 pregnancy per 100 woman usedover first year (3 per 1000 woman) if used without mistake  Failure is greatest when woman starts a new pill pack 3 or more days later Convenience Reversibility  No delayed returning of fertility after COC stopped
  • 15.  Reduction of most menstrual cycle disorders:less heavy bleeding,therefore less anaemia,and less dysmenorrhoea Regular bleeding,the timing of which can be controlled:fewer symptoms of premenstrual tension overall;no ovulation pain
  • 16.  Fewer functional ovarian cysts Fewer extrauterine pregnancies Reduction in pelvic inflammatory ds Fewer symptomatic fibroids
  • 17.  Probable reduction in thyroid diseases Probable reduction in risk of rheumatoid arthritis
  • 18.  Reduced risk of cancers of ovary and endometrium Obvious beneficial social effects
  • 19.  Weight gain:ass with pills containing levonorgestrel(LNG) but not desogestrel or gestodene Carbohydrate metabolism:minor effects on insulin secretion Lipid metabolism:the effect on the ratios of total and LDL cholesterol to HDL cholesterol depends on the relative doses of Oestrogen/P rogestrogen and type of progesterone used
  • 20.  Venous disease: EE causes an alteration in clotting factors , promoting coagulation and increasing the relative risk of VTE in current COC users by 3- 4 fold compared to women not taking COC
  • 21.  COC containing 3rd generation progestogens(desogestrel and gestodene) possibly carry a small additional risk of VTE compared to that of 2nd generation Risk of VTE is increased by:obesity,immobility,age,congenital and acquired thrombophilias
  • 22.  Arterial disease:the relative risk of MI and haemorrhagic stroke in current users with hypertension or who smoke is increased more than in non smoking users without hypertension,who are at no greater risk than non users Relative risk of ischaemic stroke in normotensive current users who do not smoke is increased about 1.5-fold compared to non users.
  • 23.  This risks increases with increasing oestrogen doses and is greatly elevated by hypertension and smoking
  • 24.  Breast cancer-there is a small increase in the risk of dev breast cancer while woman are taking COC and for a few years after discontinuing;diminishing to the background risk after 10 years
  • 25.  Ovarian&Endometrial cancer-there is >50% reduction in the risk of dev ovarian and endometrial cancer after 5 years of COC usage,which lasts up to 15 years after the pill is stopped
  • 26.  Cancer of the cervix-an observed increase in the incidence of both CIN and cervical cancer in COC users maybe related to greater sexual activity without the benefit of barrier contraception in these women
  • 27.  Trophoblast disease-recommended that all sex hormones should be avoided while HCG levels are raised.However no data to suggest an increase risk of trophoblastic ds in pregnancies following COC use
  • 28.  Inherited and acquired thrombophilias Past cerebral haemorrhage Vascular malformation of the brain Significant structural heart ds Pulmonary hypertension
  • 29.  Proven past arterial or venous thrombosis IHD Severe multiple risk factors for venous or arterial ds Focal migraine TIA Artherogenic lipid disorders
  • 30.  Active liver ds(i.e.with abnormal liver function test) Liver adenoma or carcinoma Gallstones Acute hepatic porphyrias
  • 31.  Pregnancy Undiagnosed genital tract bleeding Oestrogen dependent neoplasms,e.g breast cancer
  • 32.  Undiagnosed oligomenorrhoea Cigarette smoking above age 35 Diabetes Non focal migraine Sickle cell disease Inflammatory bowel ds Obesity(if ass with other risk factors)
  • 33.  Controlled by the woman Stopped at any time without health provider help Do not interfere with sexual activity
  • 34.  Safe and suitable for nearly all woman At any age including adolescent woman > 40 Following a miscarriage Without pelvic examination Without cervical cancer screening Without a breast examination
  • 35.  Progestin-only pills Depo-provera Norplant Implanon
  • 36. POP
  • 37.  Suppress ovulation Reduce sperm transport in upper genital tract (fallopian tubes) Thicken cervical mucus  preventing sperm penetration
  • 38.  Effective when taken at the same time daily ( 0.05-5 pregnancies per 100 ) Immediately effective (<24 hours) Do not interfere with intercourse Do not affect breast feeding Immediate return to fertility when stopped
  • 39.  Few side effects Convenient and easy to use Client can stop use Can be provided by trained nonmedical staff Contain no oestrogen
  • 40.  May decrease menstrual cramps May decrease menstrual bleeding May improve anaemia Protect against endometrial cancer Decrease benign breast disease Decrease ectopic pregnancy Protect against some causes of PID
  • 41.  Changes in menstrual bleeding pattern Some gain weight or loss may occur User dependent Must be taken at the same time daily Resupply must available Drugs interaction – epilepsy, TB Do not protect against STDs
  • 42.  POPs are not recommended unless other methods are not available or acceptable if woman ;  Is breastfeeding (<6/52 post partum)  Has unexplained vaginal bleeding (if suspected serious problem)  Has breast cancer (current / with h/o )  Is jaundiced (active, sx)
  • 43.  Is taking drugs for epilepsy (phenytoin/barbiturates) or TB (rifampicin) Has severe cirrhosis Has liver tumours Has had a stroke Has IHD
  • 44.  Blood pressure (<180/110) Uncomplicated DM ( < 20 yrs illness) Preeclampsia ( h/o) Smoking (any age / amount ) Surgery ( long bed rest) Thromboembolic disorders Valvular heart disease ( symptomatic)
  • 45.  Day 1 menstrual cycle Any time when sure pt is not pregnant Post partum  After 6/12 if using LAM  After 6/52 if breastfeeding but not using LAM  Immediately or within 6 weeks if not breastfeeding Postabortion (immediately)
  • 46.  Amenorrhoea (absence of PV bleeding or spotting) Bleeding or spotting Heavy or prolonged bleeding Lower abdominal/pelvic ( symptoms of pregnancy) Weight gain or loss ( change in appetite ) Headache Nausea/dizziness/vomiting
  • 47.  Evaluate for pregnancy, especially if amenorrhoea occurs after period of regular menstrual cycles If not pregnant, counsel and reassure client Do not attempt to induce bleeding with COCs.
  • 48.  Reassurance Check for gynaecologic problem Short term treatment  COC for 1 cycle  ibuprofen
  • 49.  ‘minipill’ Contain one-half to one-tenth as much progestin as COC Noriday Microva
  • 50.  28-42 pills/pack Take one pill daily No break in between packs Within 3 hours of lowest at 20-24 hour after ingestion; best taken at a time related to the usual time of intercourse and not 20 hours later
  • 51.  Depo-provera (DMPA) – 150 mg of depot medroxyprogesterone acetate every 3/12 Noristerat (NET-EN) : 200 mg of norethindrone enanthate given every two months
  • 52.  Highly effective (0.3 pregnancies per 100 women during first year of use) Rapidly effective (<24 hours) if started on D7 of menses Intermediate term method (2-3 monthd protection per injection ) Do no interfere with intercourse
  • 53.  Do not affect breast feeding Few side effects No supplies needed by the client Can be provided by trained non medical staff Contain no oestrogen
  • 54.  Changes in menstrual pattern Weight gain (~2 kg) is common If pregnancy occurs, it is more likely to be ectopic than nonuser Resupply must be available Must return for injections every 3 months(DMPA) or 2 months(NET-EN) Return to fertility may be delayed for 7-9 months (on average) after discontinuation
  • 55.  Women of any reproductive age who;  Have moderate to severe menstrual cramping  Take drugs for epilepsy or tuberculosis  Have high blood pressure or blood clotting disorder  Prefer not or should not use estrogen  Cannot remember to take a pill every day  Prefer a method not related to intercourse
  • 56.  Initial injection :  Days 1 to 7 of the menstrual cycle  Anytime during the menstrual cycle when you can be reasonably sure the client is not pregnant  Post partum :  Immediately if not breast feeding  After six months if using LAM Reinjection  DMPA : up to 4 weeks ealy or late  NET-EN : up to 2 weeks early or late
  • 57. DMPA NET-ENDuration 3 months 2 monthsBleeding More More irregular amenorrhoeaNeedle / pain Smaller / less Larger / moreReinjection Up to 4 weeks Up to 2 weekswindowCost Cheaper More expensiveReturn to later soonerovulation
  • 58.  Adequate training in counseling and provision Steady supply (DMPA, NET-EN, antiseptics and needle and syringes) Recommended infection prevention practices Correct disposal or processing of syringes System for notifying clients when return for injections Referral system supervision
  • 59.  Six thin, flexible capsules filled with levonorgestrel (LNG) that are inserted just under the skin of a woman’s upper arm
  • 60.  Highly effective (0.05-1 pregnancies per 100 women during the first year of use ) Rapidly effective (<24 hours) Long term method ( up to 5 years) Pelvic examination not required prior to use Do not interfere with intercourse Do not affect breastfeeding [Trussell et al 1996]
  • 61.  Immediate return to fertility on removal Few side effects Client needs to return to clinic only if problems No supplies needed by client Can be provided by trained nonphysician (nurse or midwive) Contains no oestrogen
  • 62.  Cause changes in menstrual pattern (irregular bleeding/spotting initially ) in most women. Require trained provider for insertion and removal Woman must return to healthcare provider or clinic for insertion of another set of capsules or removal
  • 63.  Woman cannot stop whenever she wants (provider dependent) Effectiveness may be lowered when certain drugs for epilepsy (phenytoin and barbiturates) or tuberculosis (rifampicin) are taken Cost effectiveness dependant on length of use Do not protect against STDs : (e.g HPV, HIV )
  • 64.  Wash client’s entire arm and hand with soap and water prior to antiseptic prep Use sterile or high-level disinfected instruments, surgical glovesvand other items. After use, decontaminate all items Place disposable (needle and syringe) and waste items in a puncture-proof container prior to disposal Clean and final process reusable items by sterilization (or high level disinfection)
  • 65.  Anytime you can reasonable sure the client is not pregnant Day 1-7 of the menstrual cycle Post partum  After 6 months if using LAM  After 6 weeks if breastfeeding but not using LAM  Immediately or within 6 weeks if not breastfeeding Post abortion (immediately or within the first 7 days)
  • 66.  Keep incision area dry for 48 hours Keep pressure bandage on for 48 hours and leave Band-Aid on until incision heals (3-5 days) Bruising, swelling and tenderness at insertion site are common Routine work can be done immediately. Avoid bumping on the area, carrying heavy loads or applying unusual pressure to incision site After healing, area can be touched and washed with normal pressure
  • 67.  Rate controlling membrane (0.06 mm) Length : 40 mm Core diameter : 2 mm Core : 40% EVA  60% etonogestrel Membrane : 100% EVA
  • 68. Implanon Norplant Norplant 1-3 years 1st year 5th yearCycles 73,429 157,729 10,855Pregnancies 0 24 9Pearl index 0 0.2 1.1
  • 69.  MOA-ovulation inhibition,supplemented by mucus and endometrial effects Duration of use is 3 years,with the unique distinction of a zero failure rate in pre marketing trials(95% CI ranges upto 7 in 10,000)
  • 70.  In international studies,serum levels tended to be lower in heavier women,but there were no failures,whatever the BMI Though much easier than Norplant to insert/remove,specific training is required Mean insertion time-1.1 minutes Mean removal time-2.6 minutes
  • 71.  Removal problems correlate with initially too- deep insertion. Beware particularly of the thin or very muscular woman with very little subcutaneous tissue.Insertion can easily permit a segment of the rod to enter the biceps muscle with deep migration following.
  • 72.  Natural cycle,day 1-5 is usual;if day 5 or any day later(assuming no sexual exposure up to that day)-recommended additional contraception for 7 days Following delivery or 2nd trimester miscarriage(not breastfeeding)-insertion on about day 21 is recommended
  • 73.  If breastfeeding insert after 6 weeks(manufacturer urges caution-uncertainty about the(probably nil) effects of the tiny amount of etonorgestrel reaching the breast milk must be discussed) 1st trimester miscarriage- insertion is best,or up to 7 days;day 7 or later an added method such as condom is recommended for 7 days
  • 74.  Acne Headache Abdominal pain Breast pain Dizziness Mood changes(depression,emotional lability) Libido decrease Hair loss
  • 75.  Any serious adv effect of COCs Recent breast cancer,not clearly in remission Acute porphyria,with hx of usual attack Recent trophoblatic ds until HCG levels are normal Known or suspected pregnancy Hypersensitivity to any component Undiagnosed genital tract bleeding
  • 76.  Immediate contraceptive efficacy Pearl index of 0 Rapid return to fertility after removal Progestogen-only bleeding pattern Less bleeding than Norplant Low incidence of side effects Benefits regarding dysmenorrhoea Low impact on metabolic parameters Easy and rapid insertion and removal
  • 77.  IUCDs have been used throughout the world for more than 3 decades Current usage as of Jan 2002-127 million women world wide Majority of users are in China In UK used by less than 5% of all contraceptive users
  • 78.  Non medicated  Lippes loop Medicated  Copper-releasing  Progestin-releasing
  • 79.  Copper releasing  Progestin releasing 1st generation  Progestasert  Copper seven  LevoNova (LNG 20)  Copper T 200  Mirena 2nd generation  Multiload 250  Nova T 3rd generation  Copper T380A  Multiload 375
  • 80.  Interfere with ability of sperm to pass through uterine cavity Thicken cervical mucus Change endometrial lining Interfere with reproductive process before ova reach uterine cavity
  • 81.  Highly effective (0.6-0.8 pregnancies per 100 women during the first year of use for copper T380A Effective immediately Long term method (up to 10 years protection with copper T380A) Do not interfere with intercourse Immediate return to fertility upon removal Do not affect breast feeding
  • 82.  Few side effects After follow up visit, client needs to return to clinic only if problems No supplies needed by client Can be provided by trained nonphysician Inexpensive (copper T380A)
  • 83.  Decrease menstrual cramps (progestin releasing only) Decrease menstrual bleeding (progestin releasing only) Decrease ectopic pregnancy (except Progestasert)
  • 84.  Pelvic examination required and screening for STDs recommended before insertion Required trained provider for insertion and removal Need to check for strings after menstrual period if cramping, spotting or pain Woman cannot stop use whenever she wants
  • 85.  Increase menstrual bleeding and cramping during the first few months (copper releasing only) May be spontaneous expelled Rarely (<1:1000) perforation of uterus during insertion Do not prevent all ectopic pregnancies May increase risk of PID and subsequent infertility
  • 86.  Pregnant Unexplained PV bleeding Current, recent PID Acute purulent discharge Distorted uterine cavity Malignant trophoblastic disease Known pelvic TB Genital tract cancer Active genital tract infection
  • 87.  IUCDs are not recommended unless other methods are not available / acceptable ;  Benign trophoblastic disease  More than one sexual partner  A partner who has more than one sexual partner
  • 88.  Anytime during the menstrual cycle when you can be reasonably sure the client is not pregnant Day 1 – 7 of the menstrual cycle Postpartum (immediately following delivery, during the first 48 hours postpartum or after 4- 6 weeks; after 6/12 if using LAM Postabortion (immediately / within first 7 days)- with no evidence of pelvic infection.
  • 89.  Copper releasing  Progestin releasing  Heavier menstrual  Amenorrhoea or very bleeding light menstrual  Irregular / heavy bleeding or spotting vaginal bleeding  Increased menstrual cramping or pain  Vaginal discharge
  • 90.  Pelvic examination to exclude CI,uterine sounding and to ensure careful placement in the uterine cavity is crucial Generally-procedure is straightforward and uncomplicated Evidence of continuing competence in IUCD fitting by 5 yearly recertification is provided within the Faculty of Family Planning of the RCOG postgrad training programme
  • 91.  Anxious women,nulliparous women and women with previous cervical surgery/stenosis may benefit from analgesia and/or paracervical block anaesthesia Paracervical block is associated with fewer vasovagal attacks,less pain at and after insertion and a lower removal rate for pain and bleeding in the first year
  • 92.  May occur anytime after insertion Most expulsions occur in the first year and particularly in the first 3 months Correct fundal placement is thought to reduce expulsion Expulsion rates are higher with an inexperienced operator,insertion under 6 weeks postpartum,nulliparous and in women with heavy painful periods
  • 93.  Higher expulsion rates in nulliparous women have not been observed in recent studies Women who expel an IUCD have a 3-fold increased risk of expelling the same or another device However almost half the women requesting reinsertion following expulsion,retain their second device
  • 94.  1.2/1000 insertion If pregnancy occurs as a sequel to a misplaced and perforated IUD,urgent retrieval is advisable to avoid bladder and bowel adhesions Contradictory evidence concerning risk with early postpartum fitting
  • 95.  Farley, T.M.M et al; PID rate very low ( 1.6 cases per 1000 women) Usually during the first 20 days after insertion
  • 96.  Levonorgestrel-releasing intrauterine system(LNG IUS) Releases about 20microgram per 24 hours of LNG from its polydimethylsiloxane reservoir,through a rate limiting membrane Licensed for 5 years
  • 97.  Contraceptive effects are local,through changes to the cervical mucus and utero-tubal fluid which impair sperm migration Endometrial changes impeding implantation Cumulative failure rate to 7 years was very low,1.1 per 100 women in the large Sivin study,even less to 5 years in Andersson et al(European multicentre trial)
  • 98.  Amount of LNG in blood is enough to give unwanted hormone type side side effect im some women;otherwise irregular light bleeding is the main problem Return of fertility is rapid and appears to be complete
  • 99.  Dramatic reduction in amount and,after the first few months,duration of blood loss Dysmenorrhoea is improved and PMS in some Ideal contraception for women with menorrhagia or who are prone to iron def anemia
  • 100.  Liver tumour or severe active hepatocellular ds Hypersensitivity to LNG Trophoblastic ds(while blood HCG levels are very high,no problem after recovery) Current breast cancer(usable on WHO 3 after 5 years in remission)
  • 101.  Woman can choose method of contraception that suite her needs All contraceptives method available should be explained at timing of consultation More receptive for any side effect experienced by the woman Woman with other associated problem, consultation to the expert should be made.