Family Planning & Contraception

Liza Tarca-Cruz, MD
Department of Obstetrics and Gynecology
Emilio Aguinaldo College of M...
Family Planning or Contraception
“ a basic human right that benefits
everyone”
Tabbakh
Goal
• Enable couples and individuals to choose
– How many children they want
– When to have them

• Best Achieve
– Provid...
Our Role as Medical Experts
“First do no harm”
(primum non nocere, Hippocrates )

400 B.C
Philippines
Most Popular Contraception Method
Classification of Contraception
A.Natural or Fertility Awareness Method
1. Standard Days Method
2. Calendar Rhythm Method
...
Fertility Awareness Method
• Natural Family Planning (NFP)
– Sexual abstinence during fertile period

• Fertility Awarenes...
Natural or Fertility Awareness Method
• Fertility Awareness
– Fertile time of the menstrual cycle starts and ends
– Ovum i...
Standard Days Method
• Avoid unprotected intercourse
– Day 8 to 19

• Regular monthly cycles of 26 to 32 days
• Use of cyc...
Cycle Beads
Calendar Rhythm Method
• Counting the number of days in shortest
and longest menstrual cycle during 6 to 12
month span
How to tell when you may be fertile ?
fertile time
Subtract 18 from the shortest cycle & 11 from the
longest cycle.
e.g : ...
CALENDAR METHOD ( RHYTHM )
Chances of Pregnancy by Day of Intercourse
day zero is ovulation

-5 4

-3 -2

-1

0

0%

15%

...
Symptom Base Method
• Billings Method
– Cervical Mucus Method or Ovulation Method
• Cervical secretions or feeling of wetn...
Billings Method
• Avoid unprotected sex
when secretions begin
until 4 days after the peak
day.
• PEAK DAY - last day where...
Billings Method

A = Intermediate type mucous
B = Infertile type mucous
C = Fertile type mucous
Basal Body Temperature

- Rise in temperature of 0.40F of morning BBT
(OVULATION)
- Abstain from unprotected intercourse

...
Sympthotermal Method
• Change in cervical mucus ➡️ onset of
fertility
• Increase in BBT ➡️ end of fertility
2 Day Method
• Presence of any type
of secretion ➡️
considered fertile for
that day and the
following day
Effectivity
Lactation Amenorrhea
• Temporary method
• Ovulation is not possible during the first 10 weeks
postpartum
• Effects of brea...
Pathophysiology
• Prevents release of
egg during ovulation
• Prevents release of
ovulatory hormones
Artificial Method
A. Medical (Hormonal)
a. Short Acting
1. Combined Oral Pills
2. Progestin Only Pills

b. Long Acting
1.
...
Hormonal-Short Acting
Combined Oral Contraceptive
Pills
• Most widely used and most
successful reversible method of birth
...
Mechanism of Action COC
Mechanism of Action COC
• Progestin
– Prevents ovulation by suppressing LH
– Thickened mucus ➡️ retards sperm passage
– En...
Pill Usage
Missed a pill? What to do?
Combined Oral Contraceptive Pills
Drug Interaction
• Phenytoin & Rifampin ➡️ increase breakthrough bleeding &
reduce contr...
Combined Oral Contraceptive Pills
Beneficial Effects
•
•
•
•
•
•
•
•
•
•
•
•

Increase bone density
Decrease risk of ectop...
Combined Oral Contraceptive Pills
Adverse Effects
•
•
•
•
•
•

T4 and thyroid binding proteins are elevated
Plasma cortiso...
Combined Oral Contraceptive Pills
CONTRAINDICATED
• Thrombophlebitis, thromboembolic disease, DVT
• CVD, CAD
• Thrombogeni...
Hormonal-Short Acting
Progestin Only Pills
• Low dose progestin
• Safe for breastfeeding mothers & women who
could not use...
Progestin Only Pills
Benefits

Disadvantages

• Minimal effect on CHO
metabolism & coagulation
• Do not cause or
exacerbat...
Progestin Only Pills
Contraindicated
• Unexplained bleeding
• Breast cancer
• Liver tumor
• Pregnancy
• Acute liver diseas...
Hormonal-Long Acting
Combined Patch
• Continuously release progestin &
estrogen directly through the skin to
the blood str...
Where to apply?
Hormonal-Long Acting
Intravaginal or Transvaginal
Hormonal Contraceptive Ring
• Flexible polymer ring has an
outer diamete...
Hormonal-Long Acting
• How to insert/use transvaginal ring
Hormonal-Long Acting
Implants
• Small rods or capsules placed
under the skin of a woman’s
upper arm (subdermal)
• 3 to 7 y...
Implants
Hormonal-Long Acting
Injectable
Medroxyprogesterone
Acetate/Estradiol
Cypionate
•
•
•
•

Lunelle
1 injection monthly
Inhib...
Hormonal-Long Acting
Benefits

Disadvantage

• Returns to fertility after
discontinuance
• Less breakthrough
bleeding
• Am...
Hormonal-Long Acting
Progestin Only
Injectables
• DMPA – depot
medroxyprogesterone acetate
• The “shot” or “jab (150mg eve...
Progestin Only Injectables
Benefits
• Long duration of action
• Minimal to no impaiment
lactation
• Decrease ovarian and
e...
Progestin Only Injectables
• Contraindication
–
–
–
–
–

Thromboembolism
Stroke
Cerebro/Cardio VD
Pregnancy
Undiagnosed va...
Barrier Method-Condom

•Prevents pregnancy & STI
•Easy to use
• Practical
MALE CONDOM
• Failure rate: 3 or 4 couple-years of
exposure
• Lubricants used should be water based
– Oil based products c...
MALE CONDOM
• Maximal effectiveness
– condom must be used with every coital act
– place before contact of the penis with t...
Proper USE of MALE CONDOM
FEMALE CONDOM
• Pregnancy rate higher than male condom
• Polyurethane sheath with one flexible
polyurethane ring at each e...
Proper USE of FEMALE CONDOM
Barrier Method-Diaphragm

•Soft latex cup that covers the
cervix
•Spring along the rim to keep it in
place
•Used with sper...
Barrier Method-Cervical Cap

•Soft, deep, latex or rubber cup
that covers the cervix
•Prevents the sperm to enter the
cerv...
Barrier Method-Spermicides
• Physical barrier to sperm penetration
• Chemical spermicidal - sperm killing substance insert...
Barrier Method-Spermicides
• foaming tablets, melting or foaming suppositories, cans of
pressurized foam, melting film, je...
Barrier Method-Sponge
•
•
•
•
•
•
•

Plastic contains spermicides
Inserted 24 hours prior to intercourse, removed 6 hours ...
Lea’s Shield
• Reusable, washable
barrier made of silicone
• Placed against the cervix
• Inserted any time prior to
interc...
Barrier Method-IUD

-Insert near end of normal menses
-w/hold insertion for at least 8 weeks post partum
-RANDALL STONE CL...
Barrier Method-IUD
• copper-bearing intrauterine device
– small, flexible plastic frame with copper sleeves or wire around...
Barrier Method-IUD
• Paragard T 380A

• Mirena

– Copper
– 10 years
– Chemically inert
Chemically inert – nonabsorbable ma...
Barrier Method - IUD
IUD Insertion
Barrier Method-IUD
• Disadvantages
– Uterine perforation
– Dysmennorhea
– AUB
– Expulsion
– Iron deficiency anemia
– Infec...
Barrier Method-IUD
• Benefit
– Reversible method
– Fertility not impaired
– No increase risk of genital tract or breast ne...
Barrier Method-IUD
• Contraindicated
– Pregnancy
– Abnormal uterus
– Acute PID
– Postpartum endometritis or infected abort...
Emergency Contraception
• The Morning-After Pill
– diethylstilbestrol (DES)

• Yuzpe method (1974)
– 100 g ethinyl estradi...
Emergency Contraception
• Yuzpe
– COC + 2 POP
– 2 tabs w/in 72hrs then 12hrs after

• POP
– 1st dose w/in 72hrs then 12hrs...
Vasectomy
• Meant to be permanent
• Use another method for the first
3 months, until the vasectomy
starts to work (20 ejac...
Vasectomy
• One of the most effective methods but carries a small risk of
failure
– If semen is not examined 3 months afte...
Vasectomy
Through a puncture or small
incision in the scrotum, the
provider locates each of the
2 tubes that carries sperm...
Tubal Ligation
• Female sterilization
• Permanent
• Effectiveness varies slightly
depending on how the tubes are
blocked
•...
Tubal Ligation
• Reversal surgery is difficult, expensive,
and not readily available.
– often does not lead to pregnancy
Tubal Ligation
• 2 surgical approaches
Minilaparotomy - making a small
incision in the abdomen. The
fallopian tubes are br...
Conditions & Suggested Contraception
• Migraine
• Lactation

POP
POP (up to 6 months postpartum)
intermittent breastfeedin...
Condition and Unsafe Method
Condition
Smoke cigarettes and also
age 35 or older

Methods Not Advised
Combined oral contrac...
Condition and Unsafe Method
Condition
Methods Not Advised
Migraine headaches (a type
COCs, monthly injectables.
of severe
...
Contraceptionx 2 by liza tarca, md
Contraceptionx 2 by liza tarca, md
Contraceptionx 2 by liza tarca, md
Contraceptionx 2 by liza tarca, md
Contraceptionx 2 by liza tarca, md
Contraceptionx 2 by liza tarca, md
Upcoming SlideShare
Loading in …5
×

Contraceptionx 2 by liza tarca, md

1,310
-1

Published on

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,310
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
82
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide
  • Sexually active women who do not use contraception has a pregnancy rate of almost 90% in a year. However, to those who does not desire pregnancy, fertility can now be regulated with variety of effective contraceptive methods but none of this is completely without side effects or categorically without danger.
  • World wide - 7 billion
    Nepal – 24.47 million
  • Write down the number of days in each of your last six menstrual cycles.
    Pick out the longest & the shortest of the six cycles
  • Hormonal contraceptives are available thru oral, injectable, transdermal patch and transvaginal ring
  • EE – 20 to 50ug (35 or less)
  • The mechanism of action is multiple but the most important is prevention of ovulation by suppressing the hypothalamic gonadotrophin releasing factors which in turn prevents the pituitary to secrete FSH and LH.
    The progestin content prevents ovulation by suppressing LH and thickening of the cervical mucus which subsequently retards the sperm passage. Also, progestin makes the endometrium not suitable for implantation.
    Estrogen on the other hand inhibits ovulation by suppressing FSH but stabilizes endometrium to prevent breakthrough bleeding.
  • Ideally, you begin your COC on the 1st day of you menstrual cycle.
    Traditionally, a Sunday start maybe done wherein women begins on the first Sunday that follows menses onset and back up method for 1 week to prevent conception.
    Quick start method, COCs are started on any day, regardless of the cycle timing but with a back up method for 1 week. This is done to prevent non compliance.
    As I have lectured with you during the earlier part of the semester, OCP are hormones which does not cause teratogenicity to the fetus if in case OCP was taken during the early stages of pregnancy.
  • For maximal efficacy, it should be taken same time of the day.
  • Protection against cancer decreases inversely with the time of exposure to COC
  • Testosterone decrease hence use in PCOs because it decrease androgenic activity resulting to treatment of hirsutism and acne
    Cervical dysplasia and cancer risk is decreased if discontinued
  • TE are estrogen related due to decrease protein C and S if used in patients with HPN, obesity, Dm, smokers and had sedentary life style
    Smoking is an independent factor for MI and OCP acts synergistically to increasethe risk especially after age 35.
  • Taken same time of the day for maximal effectiveness since mucus changes are not sustained longer than 24 hours.
  • Hormone levels remain in an effective range for up to 9 days so there is 2 days window period
    Contraindicated on obese > 90kg
  • After washing and drying your hands, remove NuvaRing from the foil pouch. Holding NuvaRing between your thumb and index finger, press the sides together. Insert NuvaRing while lying down, squatting, or standing with one leg up—whatever is most comfortable for you.
    Gently push the folded ring into your vagina. The exact position of NuvaRing is not important for it to be effective. If you feel discomfort, NuvaRing is probably not inserted back far enough into the vagina. Use your finger to gently push the NuvaRing farther into your vagina.
  • The implant is placed in the medial surface of the upper arm 6 to 8 cm from the elbow in the biceps groove within 5 days of onset of menses.
  • Protective against STD
    If sensitive to latex, may use lamb intestine condom which does not protect against STI or hypoallergenic condoms made from polyuethane which are said to have higherbreakage and slippage rate than latex
  • 1. Open the condom wrapper using the easy-tear edges. These are the zig-zag edges on either side of the wrapper that are designed to tear apart quickly and easily.
    Don't get carried away in your passion: don't shred open the foil, and stay away from scissors, teeth, machetes, or any other sharp instrument to open a condom wrapper, or you could tear the condom itself!
    If it's your last condom and you destroy it, party's over!
    2. Determine which way the condom is rolled. This can be difficult to do, particularly if you’re in the dark. Instead of trying to see which way the condom is rolled, feel it with your fingers: Placing one hand on either side, pinch the rolled ring of the condom between your thumb and fingers. Gently roll the condom in one direction with your fingers. If it resists rolling, this is not the direction in which you will want to unroll the condom over the penis. Gently roll the condom in the other direction with your fingers. If it begins to unroll, this is the direction in which you should unroll the condom over the penis.
    Cautionary tale: don't unroll more than one roll, as unraveling it will reduce the condom's efficacy—and make it frustratingly difficult to put on. Re-roll the condom after you’ve determined the proper unrolling direction.
    3. Tips up! Make sure the reservoir at the tip of the condom is pointing in the right direction. This reservoir should already be on the outer tip of the condom but can sometimes become inverted during packaging. Make sure the reservoir is oriented so that the rest of the condom rolls away from it.
    4. Lube it up. If the penis is uncircumcised, consider placing a small drop of water-based lubricant inside the reservoir. This can make the condom easier to apply to foreskin.[1]Make sure this is a very small drop, as you don’t want to compete with the sperm for space inside the reservoir tip.
    5. Make sure the penis is fully erect. A condom should always fit snugly over a penis, leaving no tight or baggy spots. If rolled over a penis that is not yet fully erect, it will fit awkwardly and be more likely to fall off or tear during sex. If more time is needed for a full erection, set the condom aside with the reservoir pointing up so that you know which way it should unroll. Pick it up again when you’re both ready.
    6. Pinch the entire reservoir at the tip of the condom shut. This eliminates the possibility of creating an air pocket inside the condom when it is worn, reducing the chance of breakage and providing the semen with a place to go during ejaculation.
    7. Roll the condom on. The condom should easily unroll down the length of the shaft. If it turns out that you are trying to put the condom on backwards, throw it away and start over. An erect penis produces fluid prior to ejaculation (called “pre-cum”) that can contain sperm. If a condom has been exposed to this fluid, flipping it over and re-applying it may cause pregnancy and/or the transmission of an STD. How you apply the condom will depend on whether or not the penis is circumcised. (Circumcised penis: Pinching the reservoir shut with one hand, place the condom against the tip of the erect penis. With your other hand, push pubic hair out of the way if necessary, then gently roll the condom down the entire shaft of the penis, smoothing out any air bubbles that may appear.
    Uncircumcised penis: Pinching the reservoir shut with one hand, place the condom against the tip of the erect penis. With your other hand, push pubic hair out of the way if necessary, roll the condom slightly over the tip of the penis to get it started, then gently pull back the foreskin. Slide your first hand from the reservoir tip down to the rolled ring of the condom and roll it down the entire length of the shaft. Use one hand to hold the bottom of the condom in place at the bottom of the shaft and then push the foreskin forward inside the condom with the other hand.[1] Smooth out any air bubbles if necessary)
    8. Smooth lubricant over the condom if necessary. Sexual lubrication decreases the risk of damage to not only the condom, but also to those having sex. Some lubricants even contain spermicides that can help reduce the risk of pregnancy. If your condom isn’t already lubricated, apply it to both the condom and the other partner, particularly if you are engaging in anal sex. Do not over-apply lube, as friction is necessary for stimulation.
    Never apply an oil- or petroleum-based lubricant to a latex condom, as they can cause it to deteriorate.[2] Water- and silicon-based lubricants are both safe to use with latex, but water-based lube washes off more easily and won’t stain your sheets.[3]
    9. Check the condom periodically during use for breaks. If a condom breaks or becomes loose during sex, replace it immediately and consider using emergency contraception such as the morning-after pill. The morning-after pill prevents pregnancy before it happens by delaying ovulation, blocking fertilization, or preventing an egg from implanting in the uterus; it is not an abortifacient.[4]
    10. Replace condom if alternating between different types of sex. If switching from anal to vaginal sex, for example, switch condoms to reduce the risk of infection. (Ex: e-coli from the rectum can cause bladder infections.[5])
    11. Immediately after ejaculation, withdraw penis and remove condom. Grasp the bottom of the condom with your hand and withdraw, preventing the condom from slipping off or spilling. Do not allow the penis to go flaccid within the condom before withdrawal, as this can cause the condom to fall off and remain inside the partner.
    12. Dispose of the condom discretely. Tie the open end in a knot to prevent spillage, wrap it in toilet paper or tissue, and throw it in a trash can.
  • Practice using the female condom. Though female condoms typically cost around $4 per condom and can only be used once, you should practice using the condom on your own instead of using it for the first time right before sex. Though inserting the condom is easy once you get the hang of it, you should try it on your own at least once or twice to make sure that you can get it right when the time comes.
    Remove the condom from the package. Once you've determined that the condom is ready for use, just tear the arrow at the top of the package and remove the female condom.
    Put spermicide or lubricant on the outside of the closed end. Using spermicides along with the female condom can further reduce your risk of pregnancy. Though the female condom will already be lubricated, extra lubricant can make it easier to insert and use the condom.
    Find a comfortable position. To insert the female condom, you'll have to find a position that works for you. It's just like inserting a tampon -- you have to get comfortable and have access to your vagina before you can insert the condom. You can try squatting on the ground, laying down, or placing one foot on top of a chair.
    Squeeze the sides of the inner ring together. Hold the sides together similarly to how you would hold a pencil. Though the condom will be a bit slippery because of the lubricant, make sure you have a reasonably firm grip before you insert it.
    Insert the inner ring and condom into your vagina. Insert it like a tampon. Push it up with your finger.
    Push the inner ring into the vagina until it reaches the cervix. Once it reaches the cervix, it will naturally expand and you won't be able to feel it anymore. Again, this is much like inserting a tampon -- if you can still feel it inside you, then you didn't put it in correctly.
    Pull out your finger. Make sure that the outer ring is hanging at least an inch outside the vagina. If it's hanging much further out, you may need to check if the inner ring is really inserted correctly.
    Insert your partner's penis into the female condom. Once you've inserted the condom and are ready for sex, have your partner guide his penis into the outer ring that is hanging outside of your vagina. You can help guide his penis into the condom correctly. Make sure that his penis is actually going into the condom instead of touching one wall of your vagina as well as the condom.
    Have sex. It's normal for the female condom to move from side to side once you're having sex. As long as the inner ring is still inserted and your man's penis is in the condom, you're good to go. If his penis has slipped out or the condom has come loose, you can comfortably reinsert it as long as the man hasn't ejaculated yet. Once the man ejaculates, you can remove and throw out the female condom. [5]If you hear a loud noise because of the condom during sex, you can apply more lubricant.
    Squeeze and twist the outer ring. Grasp the outer ring firmly before you twist it. This will keep the semen inside the pouch in the condom.[6]
    Gently remove the condom from your vagina or anus. Do this slowly while holding the twisted top of the condom together.
  • 1 size fits all
  • IUDs are the most commonly used method of reversible contraception world wide
  • Mechanism of action was not precisely defined however at first it was thought that the interference with successful implantation of fertilized ovum was believed to be main mode of IUD.
    Intense local endometrial inflammatory response is induced especially copper containing devices. Cellular and humoral components of this inflammation are expressed in endoetrial tissue and in fluid filling the uterine cavity and fallopian tubes which leads yo decreased sperm and egg viability.
    Progestin secreted by IUD causes glandular atrophy and stromal decidualization and viscous cervical mucus hindering sperm motility and inhibit ovulation.
  • Chemically active IUDs are most widely used.
    Framed IUD are commonly used because frameless IUDs have higher expulsion rate
  • Timing of insertion influences the ease of placement as well as pregnancy and expulsion rates. Insertion near the end of normal menstruation, when the cervix is usually softer and somewhat more dilated, may be easier, and at the same time may exclude early pregnancy. But insertion is not limited to this time. For the woman who is sure she is not pregnant and does not want to be pregnant, insertion is done at any time.
    The recommendation has been made, therefore, to wait for at least 6 to 8 weeks after delivery to reduce expulsion rates and to minimize the risk of perforation.
    Insertion of ParaGard T 380A. The uterus is sounded, and the IUD is loaded into its inserter tube not more than 5 minutes before insertion. A blue plastic flange on the outside of the inserter tube is positioned from the IUD tip to reflect this depth. The IUD arms should lie in the same plane as the flat portion of the blue flange. A. The inserter tube, with the IUD loaded, is passed into the endometrial cavity. A long, solid, white inserter rod abuts the base of the IUD. When the blue flange contacts the cervix, insertion stops. B. To release the IUD arms, the solid white rod within the inserter tube is held steady, while the inserter tube is withdrawn no more than 1 cm. C. The inserter tube, not the inserter rod, is then carefully moved upward toward the top of the uterus until slight resistance is felt. At no time during insertion is the inserter rod advanced forward. D. First, the solid white rod and then the inserter tube are withdrawn individually. At completion, only the threads should be visible protruding from the cervix. These are trimmed to allow 3 to 4 cm to extend into the vagina.
    Insertion of the Mirena intrauterine system. Initially, threads from behind the slider are first released to hang freely. The slider found on the handle should be positioned at the top of the handle nearest the device. The IUD arms are oriented horizontally. A flange on the outside of the inserter tube is positioned from the IUD tip to reflect the depth found with uterine sounding. A. As both free threads are pulled, the Mirena IUD is drawn into the inserter tube. The threads are then tightly fixed from below into the handle's cleft. In these depictions, the inserter tube has been foreshortened. The inserter tube is gently inserted into the uterus until the flange lies 1.5 to 2 cm from the external cervical os to allow the arms to open. B. While holding the inserter steady, the IUD arms are released by pulling the slider back to reach the raised horizontal mark on the handle but no further. C. The inserter is then gently guided into the uterine cavity until its flange touches the cervix. D. The device is released by holding the inserter firmly in position, and pulling the slider down all the way. The threads will be released automatically from the cleft. The inserter may then be removed and IUD strings trimmed.
  • Women should be examined about 1 month following insertion usually after menses to identify the tail from the cervix
    Instruct women to palpate the strings protruding from the cervix every month after menses
    Lost IUD can be seen by sonography, plain abdomen radiography, CT, MRI and hysteroscopy
    May give NSAID prior to insertion to prevent and lessen cramping and bleeding after insertion
    Annual hematocrit and hemoglobin measurement
  • Contraceptionx 2 by liza tarca, md

    1. 1. Family Planning & Contraception Liza Tarca-Cruz, MD Department of Obstetrics and Gynecology Emilio Aguinaldo College of Medicine – Medical Center Manila
    2. 2. Family Planning or Contraception “ a basic human right that benefits everyone” Tabbakh
    3. 3. Goal • Enable couples and individuals to choose – How many children they want – When to have them • Best Achieve – Providing safe and effective methods – Information dissemination
    4. 4. Our Role as Medical Experts “First do no harm” (primum non nocere, Hippocrates ) 400 B.C
    5. 5. Philippines
    6. 6. Most Popular Contraception Method
    7. 7. Classification of Contraception A.Natural or Fertility Awareness Method 1. Standard Days Method 2. Calendar Rhythm Method 3. Symptoms Based Method a. Temperature Rhythm Method b. Cervical Mucus Rhythm Method c. Sympthotermal Method B.Lactation Amenorrhea 1.Artificial Method 1. Medical or Hormonal 2. Barrier 3. Permanent Sterilization
    8. 8. Fertility Awareness Method • Natural Family Planning (NFP) – Sexual abstinence during fertile period • Fertility Awareness Combined Method (FACM) – Using barrier method during the fertile time
    9. 9. Natural or Fertility Awareness Method • Fertility Awareness – Fertile time of the menstrual cycle starts and ends – Ovum is fertilized 12 to 24 hours after ovulation – Ovulation may oocur 6 weeks post partum •Periodic Abstinence • Natural Family Planning
    10. 10. Standard Days Method • Avoid unprotected intercourse – Day 8 to 19 • Regular monthly cycles of 26 to 32 days • Use of cycle beads
    11. 11. Cycle Beads
    12. 12. Calendar Rhythm Method • Counting the number of days in shortest and longest menstrual cycle during 6 to 12 month span
    13. 13. How to tell when you may be fertile ? fertile time Subtract 18 from the shortest cycle & 11 from the longest cycle. e.g : shortest cycle is 26 days & longest cycle is 34 days, abstain from sexual relations from Day 8 (26-18=8) through Day 23 (34-11=23)
    14. 14. CALENDAR METHOD ( RHYTHM ) Chances of Pregnancy by Day of Intercourse day zero is ovulation -5 4 -3 -2 -1 0 0% 15% 26% 15% - 11% 20% 1 2 3 9% 5% 0%
    15. 15. Symptom Base Method • Billings Method – Cervical Mucus Method or Ovulation Method • Cervical secretions or feeling of wetness • Basal Body Temperature (BBT) – Slight body temperature rise after released of a fertilized egg – Temperature remains elevated until the start of next cycle • Symptothermal Method – Combination of BBT and Billings Method • 2 Day Method
    16. 16. Billings Method • Avoid unprotected sex when secretions begin until 4 days after the peak day. • PEAK DAY - last day where the secretions are clear, slippery, stretchy and wet
    17. 17. Billings Method A = Intermediate type mucous B = Infertile type mucous C = Fertile type mucous
    18. 18. Basal Body Temperature - Rise in temperature of 0.40F of morning BBT (OVULATION) - Abstain from unprotected intercourse from 1st day up to 3rd day after increase in BBT
    19. 19. Sympthotermal Method • Change in cervical mucus ➡️ onset of fertility • Increase in BBT ➡️ end of fertility
    20. 20. 2 Day Method • Presence of any type of secretion ➡️ considered fertile for that day and the following day
    21. 21. Effectivity
    22. 22. Lactation Amenorrhea • Temporary method • Ovulation is not possible during the first 10 weeks postpartum • Effects of breastfeeding with fertility • 3 criteria for effectiveness 1. Monthly menstruation has not returned 2. Exclusive or nearly exclusive breastfeeding 3. Baby is less than 6 months old
    23. 23. Pathophysiology • Prevents release of egg during ovulation • Prevents release of ovulatory hormones
    24. 24. Artificial Method A. Medical (Hormonal) a. Short Acting 1. Combined Oral Pills 2. Progestin Only Pills b. Long Acting 1. 2. A. B. Combined Patch Progesterone Implants Injectables Transvaginal Ring 1. Barrier Method 1. Condom 2. Diaphragm & Cervical Cap Spermicide cream & jelly d. Sponge e. Intra-uterine Device c. C. Permanent Methods a. Vasectomy b. Tubal Ligation
    25. 25. Hormonal-Short Acting Combined Oral Contraceptive Pills • Most widely used and most successful reversible method of birth control • Low doses of estrogen & progestin • Taken daily for 3 weeks and omitted for 1 week during which there is withdrawal uterine bleeding • Ethinyl Estradiol, Mestranol) • 19 Nortestosterone derivatives • Types • MONOPHASIC – type & dosage of hormone remains constant during the 21 days • MULTIPHASIC – dose varies during cycle
    26. 26. Mechanism of Action COC
    27. 27. Mechanism of Action COC • Progestin – Prevents ovulation by suppressing LH – Thickened mucus ➡️ retards sperm passage – Endometrium ➡️ unfavorable for implantation • Estrogen – Prevents ovulation by suppressing FSH – Stabilize endometrium ➡️ prevents breakthrough bleeding
    28. 28. Pill Usage
    29. 29. Missed a pill? What to do?
    30. 30. Combined Oral Contraceptive Pills Drug Interaction • Phenytoin & Rifampin ➡️ increase breakthrough bleeding & reduce contraceptive effectiveness • Ascorbic Acid ➡️ competes for active sulfate in the intestinal wall & increases the bioavailability of ethinyl estradiol results to breakthrough bleeding • Ovulation – occurs 3 months after discontinuance • Postpill amenorrhea – if COC are stopped
    31. 31. Combined Oral Contraceptive Pills Beneficial Effects • • • • • • • • • • • • Increase bone density Decrease risk of ectopic pregnancy Fewer premenstrual complaints Reduction on various benign breast disease Improvement of acne Decrease incidence & severity of acute salphingitis Reduce menstrual blood loss & anemia Improved dysmenorrhea for endometriosis Decreased risk of endometrial & ovarian cancer Inhibition of hirsutism progression Prevention of atherogenesis Improvement in rheumatoid arthritis
    32. 32. Combined Oral Contraceptive Pills Adverse Effects • • • • • • T4 and thyroid binding proteins are elevated Plasma cortisol are also increased Increase serum levels of triglycerides and total cholesterol Decrease testoterone Increase risk of cervical dysplasia and cancer Lower plasma level of ascorbic acid, folic acid, vitamin B6, B12, niacin, riboflavin and zinc • Increase risk of thromboembolism if used with CVD patient, > 35 years old and smokers • Increase risk of Chlamydia trachomatis infection • Cervical mucorrhea
    33. 33. Combined Oral Contraceptive Pills CONTRAINDICATED • Thrombophlebitis, thromboembolic disease, DVT • CVD, CAD • Thrombogenic cardiac valvulopathies & arrythmias • DM w/ vascular involvement • Uncontrolled HPN • Breast, endometrial, hepatic CA • AUB • Pregnancy • Cholestatic jaundice • Major surgery with prolonged immobilization
    34. 34. Hormonal-Short Acting Progestin Only Pills • Low dose progestin • Safe for breastfeeding mothers & women who could not use estrogen like with CVD • Minipills or POPs • Do not inhibit ovulation • Thickens the cervical mucus ➡️ block sperm • Effects on endometrium • Disrupting menstrual cycle by preventing release of fertilized eggs • Taken same time of the day for maximal effectiveness • If taken 4 hours late ➡️ BACK UP CONTRACEPTION x 48 hours
    35. 35. Progestin Only Pills Benefits Disadvantages • Minimal effect on CHO metabolism & coagulation • Do not cause or exacerbates HPN • Contraception failure • Ectopic pregnancy • Irregular uterine bleeding – Amenorrhea, spotting, breakthrough bleeding, menorrhagia) • Functional ovarian cyst
    36. 36. Progestin Only Pills Contraindicated • Unexplained bleeding • Breast cancer • Liver tumor • Pregnancy • Acute liver disease • Carbamazepines, Phenobarbital, Phenytoin, Rifampicin, Griseofulvin
    37. 37. Hormonal-Long Acting Combined Patch • Continuously release progestin & estrogen directly through the skin to the blood stream • A new patch is worn every week for 3 consecutive weeks • No patch on the 4th week so menstruation ensues • Works primarily by preventing release of ovulated eggs • 150ug progestin norelgestrinon + 20ug ethinyl estradiol • First 2 cycle – dysmenorrhea, breast tenderness & breakthrough bleeding
    38. 38. Where to apply?
    39. 39. Hormonal-Long Acting Intravaginal or Transvaginal Hormonal Contraceptive Ring • Flexible polymer ring has an outer diameter 54mm & 4mm cross section • Releases Ethinyl estradiol 15ug and Etonogestrel 120ug/day • Inhibits ovulation • Ring is placed w/in 5 days of onset of menses & removed after 3 weeks of use for 1 week to allow w/drawal bleeding • Ring replaced w/in 3 hours within intercourse • Complications: vaginitis, ring related events, leukorrhea
    40. 40. Hormonal-Long Acting • How to insert/use transvaginal ring
    41. 41. Hormonal-Long Acting Implants • Small rods or capsules placed under the skin of a woman’s upper arm (subdermal) • 3 to 7 years effectiveness • Safe for breastfeeding beginning 6 weeks post partum • Thickens the cervical mucus & delay release of eggs from the ovary • Progestin suppress ovulation • NORPLANT – levonorgestrel (6) • JADELLE (2) • IMPLANON (1) – 68mg Etonogestrel
    42. 42. Implants
    43. 43. Hormonal-Long Acting Injectable Medroxyprogesterone Acetate/Estradiol Cypionate • • • • Lunelle 1 injection monthly Inhibits ovulation Supress endometrial proliferation • Estradiol reach peak level 34 days post injection & decline leading to w/drawal bleeding to 20-25days after injection
    44. 44. Hormonal-Long Acting Benefits Disadvantage • Returns to fertility after discontinuance • Less breakthrough bleeding • Amenorrhea more frequent • Decrease lactation • Weight gain
    45. 45. Hormonal-Long Acting Progestin Only Injectables • DMPA – depot medroxyprogesterone acetate • The “shot” or “jab (150mg every 3 months) • Depo-provera, Depo, Megestron & Petogen • NET EN – Norethindrone Enanthate • Noristerat, Syngestal (200mg every 2 months) • Intramuscular or subcutaneous (upper outer quadrant buttocks) • Inhibit ovulation, increase viscosity of cervical mucus, endometrium unfavorable for implantation
    46. 46. Progestin Only Injectables Benefits • Long duration of action • Minimal to no impaiment lactation • Decrease ovarian and endoetrial cancer Disadvantage • Irregular menstrual bleeding • Prolonged anovulation after of discontinuance • Delayed fertility resumption • Menses may not resume up to 1 year • Increase risk cervical CA • Breast tenderness • Weight gain • Decrease bone density - REVERSIBLE
    47. 47. Progestin Only Injectables • Contraindication – – – – – Thromboembolism Stroke Cerebro/Cardio VD Pregnancy Undiagnosed vaginal bleeding – Breast CA – Liver Disease
    48. 48. Barrier Method-Condom •Prevents pregnancy & STI •Easy to use • Practical
    49. 49. MALE CONDOM • Failure rate: 3 or 4 couple-years of exposure • Lubricants used should be water based – Oil based products can destroy latex condoms
    50. 50. MALE CONDOM • Maximal effectiveness – condom must be used with every coital act – place before contact of the penis with the vagina – Withdrawal must occur with the penis still erect – The base of the condom must be held during withdrawal – Either an intravaginal spermicide or a condom lubricated with spermicide should be employed
    51. 51. Proper USE of MALE CONDOM
    52. 52. FEMALE CONDOM • Pregnancy rate higher than male condom • Polyurethane sheath with one flexible polyurethane ring at each end –Open ring remains outside the vagina –Closed internal ring is fitted under symphysis DO NOT USE SIMULTANEOUS WITH MALE CONDOM SINCE FRICTION LEADS TO SLIPPING, TEARING & DISPLACEMENT
    53. 53. Proper USE of FEMALE CONDOM
    54. 54. Barrier Method-Diaphragm •Soft latex cup that covers the cervix •Spring along the rim to keep it in place •Used with spermicidal creams/jelly or sponge for effectiveness •Inserted few hours before intercourse ➡️ add spermicide •Should not be remove <6hrs, and not stay >6hours ➡️ TSS •Increase rate UTI
    55. 55. Barrier Method-Cervical Cap •Soft, deep, latex or rubber cup that covers the cervix •Prevents the sperm to enter the cervix •Best used with spermicides •Compatible to diaphragm
    56. 56. Barrier Method-Spermicides • Physical barrier to sperm penetration • Chemical spermicidal - sperm killing substance inserted deep into the vagina, near the cervix prior to sexual intercourse • Nonoxynol 9 – most popular • benzalkonium chloride, chlorhexidine, menfegol, octoxynol-9, and sodium docusate • Duration of Efficacy: 1 hour • Non teratogenic
    57. 57. Barrier Method-Spermicides • foaming tablets, melting or foaming suppositories, cans of pressurized foam, melting film, jelly, and cream – Jellies, creams, and foam from cans can be used alone, with a diaphragm, or with condoms. – Films, suppositories, foaming tablets, or foaming suppositories can be used alone or with condoms • causing the membrane of sperm cells to break, killing them or slowing their movement
    58. 58. Barrier Method-Sponge • • • • • • • Plastic contains spermicides Inserted 24 hours prior to intercourse, removed 6 hours post intercourse Moistened with water and inserted into the vagina so that it rests against the cervix Used only once not widely available Less effective Nonoxynol 9 impregnated disc – 2.5cm thick, 5.5cm wide • May cause irritation and vaginitis
    59. 59. Lea’s Shield • Reusable, washable barrier made of silicone • Placed against the cervix • Inserted any time prior to intercourse and must be left in place for at least 8 hours afterwards
    60. 60. Barrier Method-IUD -Insert near end of normal menses -w/hold insertion for at least 8 weeks post partum -RANDALL STONE CLAMP
    61. 61. Barrier Method-IUD • copper-bearing intrauterine device – small, flexible plastic frame with copper sleeves or wire around it • trained health care provider inserts it into a woman’s uterus through her vagina and cervix ➡️ reduce pelvic infection • causing a chemical change that damages sperm and egg before they can meet ➡️ interfere implantation • Local inflammatory response (uterus) ➡️ Lysosomal Activation & Inflammatory Actions ➡️ SPERMICIDAL • Effectiveness: Equivalent to BTL
    62. 62. Barrier Method-IUD • Paragard T 380A • Mirena – Copper – 10 years – Chemically inert Chemically inert – nonabsorbable material (polyethylene) impregnated in Barium Sulfate (for radioopacity) Chemically active – continuous elution of copper or progestational agent – Levonogrestel – 5 years – Reduce menstrual loss – Treat menorrhagia – Reduce dysmenorrhea, PID
    63. 63. Barrier Method - IUD
    64. 64. IUD Insertion
    65. 65. Barrier Method-IUD • Disadvantages – Uterine perforation – Dysmennorhea – AUB – Expulsion – Iron deficiency anemia – Infection NEVER ASSUME THAT THE DEVICE HAS BEEN EXPELLED UNLESS IT WAS SEEN!
    66. 66. Barrier Method-IUD • Benefit – Reversible method – Fertility not impaired – No increase risk of genital tract or breast neoplasia – No loss of bone mineral density and weight gain
    67. 67. Barrier Method-IUD • Contraindicated – Pregnancy – Abnormal uterus – Acute PID – Postpartum endometritis or infected abortion (past 3 months) – Uterine or cervix malignancy – Abnormal papsmear – AUB – Untreated cervicitis, vaginitis, bacterial vaginosis – Multiple sexual partners – Susceptible infections, genital actinomyosis – History of ectopic pregnancy – IUD not removed – Copper ➡️ Wilson’s Dse., Copper Allergy – Mirena ➡️ breast CA, acute liver disease, hypersensitivity
    68. 68. Emergency Contraception • The Morning-After Pill – diethylstilbestrol (DES) • Yuzpe method (1974) – 100 g ethinyl estradiol plus 1.0 mg dL-norgestrel • Plan B (1999) – first progestin-only emergency contraceptive
    69. 69. Emergency Contraception • Yuzpe – COC + 2 POP – 2 tabs w/in 72hrs then 12hrs after • POP – 1st dose w/in 72hrs then 12hrs after • Ovrette – 20 pills w/in 72hrs then 12hrs after • Copper IUD – Postcoital contraception – Inserted up to 5 days after unprotected intercourse • Misoprostol/Epostane – Block progesterone production – Interfere w/ progesterone action – Menstruation – implantation prevented • Inhibition or delay ovulation • Alteration of endometrium, sperm penetartion, tubal motility • SE: nausea/vomiting – estrogen related • If (+) vomiting w/in 2hours – repeat dose
    70. 70. Vasectomy • Meant to be permanent • Use another method for the first 3 months, until the vasectomy starts to work (20 ejaculations) • Very effective after 3 months but not 100% • Safe, simple, convenient surgery • No effect on sexual ability or feelings • Works by closing off each vas deferens, keeping sperm out of semen • Semen is ejaculated, but it cannot cause pregnancy
    71. 71. Vasectomy • One of the most effective methods but carries a small risk of failure – If semen is not examined 3 months after the procedure to see if it still contains sperm, pregnancy rates are about 2 to 3 per 100 women over the first year after their partners have had a vasectomy. – If semen was examined after vasectomy, less than 1 pregnancy per 100 women over the first year after their partners have had vasectomies (2 per 1,000).
    72. 72. Vasectomy Through a puncture or small incision in the scrotum, the provider locates each of the 2 tubes that carries sperm to the penis (vas deferens) and cuts or blocks it by cutting and tying it closed or by applying heat or electricity (cautery).
    73. 73. Tubal Ligation • Female sterilization • Permanent • Effectiveness varies slightly depending on how the tubes are blocked • Fertility does not return because sterilization generally cannot be stopped or reversed • fallopian tubes are blocked or cut Eggs released from the ovaries cannot move down the tubes do not meet sperm
    74. 74. Tubal Ligation • Reversal surgery is difficult, expensive, and not readily available. – often does not lead to pregnancy
    75. 75. Tubal Ligation • 2 surgical approaches Minilaparotomy - making a small incision in the abdomen. The fallopian tubes are brought to the incision to be cut or blocked. Laparoscopy - inserting a long thin tube with a lens in it into the abdomen through a small incision. This laparoscope enables the doctor to see and block or cut the fallopian tubes in the abdomen
    76. 76. Conditions & Suggested Contraception • Migraine • Lactation POP POP (up to 6 months postpartum) intermittent breastfeeding – use effective contraception as soon as 3 weeks postpartum • CVD, HPN, smoker POP • > 35 y.o IUD, COC, DMPA
    77. 77. Condition and Unsafe Method Condition Smoke cigarettes and also age 35 or older Methods Not Advised Combined oral contraceptive pills (COCs). If you smoke heavily, monthly injectables. Known high blood pressure COCs, monthly injectables. If severe high blood pressure, 2- and 3month injectables. Fully or nearly fully COCs, monthly injectables. breastfeeding in first 6 months 2- and 3-month injectables, Breastfeeding in first 6 implants, progestin-only pills (POPs). weeks COCs, monthly injectables. First 21 days after childbirth, Wait until 6 weeks after childbirth to not breastfeeding fit diaphragm correctly. Certain uncommon serious COCs, injectables, POPs, diseases of the heart, blood vessels, implants. Ask your provider. or liver, or breast cancer.
    78. 78. Condition and Unsafe Method Condition Methods Not Advised Migraine headaches (a type COCs, monthly injectables. of severe Ask your provider. headache) and also age 35 or older. Gall bladder disease COCs. Ask your provider. Certain uncommon IUD. Ask your provider. conditions of female organs Sexually transmitted IUD. Use condoms even if infections of the cervix, very high also using another method. individual risk of getting these Women with HIV, including infections, pelvic inflammatory women with AIDS and those on disease (PID), or untreated AIDS treatment, can generally use any family planning method they choose. Known pregnancy No method needed.
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×