2. World’s population expected to reach 9
billion by 2050.
India accounts for 17% of world’s
population.
3. 21% of all pregnancies resulting live births
are unplanned.
Around 2/5th
of all pregnancies are
unintended.
If unmet need for contraception
was met, we can avoid
◦ 55 million unwanted pregnancies(71%)
◦ 22 million fewer abortions
◦ 90,000 fewer maternal deaths
◦ 3,90,000 fewer children who would lose
their mothers.
4. Unawareness
Use of traditional methods
Side effects
High cost
Difficult mode of delivery
Fear of irreversibility of fertility
Length of effctiveness(inconvenience to take pills daily)
Fear of problems associated with amenorroea
5. Slow the pace of population growth
Slow the pace of population growth
Decrease abortion related complications and deaths
Cut down maternal care costs
Promote better maternal health
Improve the health of children through provision of
better nutrition and other care
……..beneficial to the society at large!!!
Po
8. All hormonal birth contol measures act via same
mechanism
Stops ovulation
Prevents uterus lining from build up
Making the cervical mucous thick to prevent
penetration of sperm
10. Type Estrogen Progestin
Mala N EE 30 ug Norgestrel 300 ug
Mala D EE 30 ug Levonorgestrel 150 ug
Ovral L EE 30 ug Levonorgestrel 150 ug
Ovral G EE 50 ug Levonorgestrel 250 ug
Novelon EE 30 ug Desogestrel 150 ug
Femilon EE 20 ug Desogestrel 150 ug
Loette EE 20 ug Levonorgestrel 100 ug
Yasmin EE 30 ug Drospirenone 3 mg
Yaz EE 20 ug Drospirenone 3 mg
11. Comparable in efficacy to monophasic pillsComparable in efficacy to monophasic pills
It was introduced with an aim of reducing the total dose ofIt was introduced with an aim of reducing the total dose of
hormones per cycle and to ↓ BTB.hormones per cycle and to ↓ BTB.
Better carbohydrate and lipid profile.Better carbohydrate and lipid profile.
Type Estrogen Progesterone
Triphasic-
Triquilar
EE – 30 ug (D1-6)
EE – 40 ug (D7-11)
EE – 30 ug (D12-21)
Levonorgestrel 50 ug
Levonorgestrel 75 ug
Levonorgestrel 125 ug
12. Reducing the dose to the lowest possible without
reducing efficacy (10 fold reduction)
Norethisterone 350μg
Norgestrel 75μg
Levonorgestrel(LNG) 30μg
Dosing shedule-
Started on 5th
day of menstruation normally
21 day of post partum period
Soon after abortion
Extra precaution for 2 days to be taken
13. POPs have no estrogen side effects.
POPs do not decrease breast milk production.
A woman’s periods may be lighter, shorter and
have less cramping.
POPs may be used by women:
Who are breastfeeding
Over 35 years who smoke
Have a history of blood clots in the veins
Have migraine headaches
Have a higher risk of heart attack or stroke
S/E- depression,irregular
bleeding,headache,migraine,weight gain,ectopic
pregnancy.
15. Estrogen-estradiol valarate along with newer progestin
(dienogest-DNG) is used.
Step down doses of estrogen and step up doses of progestin
preperation is used.
ADV-
-fewer spotting days,reduction in mean blood loss
-reduced breakthrough bleeding
-more increase in HDL(8%)
-stability in carbohydrate metabolism
-effective in treatment of heavy mensrrual bleeding
-significant improvement in Hb,hematocrit,ferritin levels
17. SEASONALE-
150µg of LNG + 30µg of
EE
Taken continuously for 84
days, break for 7 days
Fewer periods (4 in a year)
Pearl index- 0.78
Breakthrough bleeding/
spotting – First few cycles
CONTINUOUS-
For 365 days
No break
0.09mg LNG+20μg EE
Less side effects
associated with hormone
withdrawl
Diminished breakthrough
bleeding after 8-9 months
18. Decreased incidence of:
1. Pelvic pain,
2. Headaches,
3. Bloating/swelling, and
4. Breast tenderness for women who experience these
symptoms during the pill-free interval;
Improved control over symptoms of endometriosis and
polycystic ovary syndrome; and
Greater convenience due to fewer withdrawal bleeds
per year.
19. Include little information on :
1. Long-term safety (although there are long-term
data for comparable total estrogen- progestin doses
per month)
1. Slightly higher cost for medications (an extra 3 pill
packages per year for a 91-day cycle).
20. These potential disadvantages must be weighed against
the likely reduction in the:
1. Cost of sanitary supplies
2. Pain medication
3. Time off work or school
4. More breakthrough bleeding initially
5. Possible delay in the recognition of pregnancy
24. Carcinoma endometrium – protective !!!
◦ Use of COC for 12 months: 50% risk reduction
◦ Protection persists 20 yrs after discontinuation
Epithelial ovarian cancers – protective !!!
◦ Even 3-6 months use: 40% risk reduction (3 yr use- notable
impact, 10 yr use- 80% risk reduction)
◦ protection continues 20 yrs after stopping.
Colon & rectal carcinoma-protective!!!
- risk reduction by 37%!!!
Indirectly prevents choriocarcinoma by preventing
pregnancy
Carcinoma liver-no association!!!
25. Carcinoma cervix – no definite association !!!
◦ Detection bias due to increased screening with pap smear
◦ No significant increased risk of invasive carcinoma cervix
Carcinoma breast – controversial, caution !!!
◦ Current use: ↑early premenopausal ca breast, detection bias.
◦ Past use: ↓ incidence metastatic postmenopausal ca breast
◦ Known case of ca breast: COCs are C/I
◦ BRCA1BRCA1 && BRCA2BRCA2 carrierscarriers –50%50% risk reduction for ca ovaryvary
(baseline risk(baseline risk 45% & 25% in BRCA1BRCA1 && BRCA2BRCA2 respectively)
Clear the confusion !!!
Cancers and COCs
27. Should include the following:
1. Instructions on how to take the combined OC
2. Information on potential side-effects
3. Non-contraceptive benefits of the combined OC
4. Addressing common myths and misconceptions
5. Discussing risks and warning signs, including when to
seek medical care
6. Discussing what to do if pills are missed
7. Emphasizing dual protection (the combined OC with
condom use to prevent STIs and HIV infection)
8. Information about emergency contraception in the event
of missed pills
28. Progestin-only injectables:
◦ Depot-medroxyprogesterone acetate (DMPA; “Depo-
provera”; Megestron®
150 mg given IM every three months
also SQ formulation, lower dose (104 mg); CBD …
◦ NET-EN: norethindrone (or norethisterone) enanthate, Noristerat®)
given every two months
Combined injectable contraceptives (CICs, progestin plus
estrogen) — given monthly:
◦ Cyclofem® (MPA, 25mg plus estradiol, 5 mg)
◦ Mesigyna® (50 mg Norethindrone enanthate, plus 5 m.g.
estradiol)
30. effectiveness-0.1-0.4 preg/HWY
reversibility- 6 WKS
Injectable sustained released preperation of DMPA
available as uniject
Inhibits Ovulation,follicular formation,thicken cervical
mucous
150 mg ,in 3months (14 day grace period)
Delayed Ovulation After Discontinuation
Main Side-Effects:
◦ Amenorrhea
◦ AUB
◦ Weight Gain
◦ Hair Loss
31. most suitable for women that require an
estrogen free birth control method:
◦ women with a known sensitivity (allergic) to estrogen
◦ women over the age of 35 years who smoke
◦ women with migraine headaches
◦ women who are breastfeeding
◦ women who have endometriosis
◦ women who have sickle cell disease
◦ women taking anti-convulsant (for seizures)
medication
32. Reliable method of birth control.
Reduced risk of endometrial cancer and Pelvic
Inflammatory Disease (PID).
Reduced symptoms of endometriosis, PMS
and chronic pelvic pain,
Decreased incidence of seizures.
Possible decreased number of sickle cell crisis.
Periods may disappear after 9 to 12 months on
Depo-Provera.
Only need to get injection every 12 weeks.
35. Effectiveness-0.8-1.3 preg/HWY
28 day regimen
Replaced every week
No patch free interval if only LNG 40μg is in it
21 day regime
Replaced every week
7 day patch free interval if EE 30μg+LNG 100 μg
ADV
Once a week dosing
,good compliance
Avoid first pass
metabolism
Progestin with minimal
androgenicity
DISADV
Patch is noticeble
High cost
Minor skin reaction
Room temperature storage is
necessory
36.
37. Nestorone(NES) a progestin is used
Applied in dose 2.3 mg/day once for 21 days with
7 free days
Antiovulatory mechanism
Adv-
-no skin irritation
-regular bleeding pattern maintained
-No serious adverse events
38.
39. MDTS-metered dose transdermal system
Spray delivers drug in skin with the aid of safe
enhancers forms reservoir in skin
drug slowly absorbed in the circulation over a period of
hours
Antiovulatory mechanism
3×90μl of NES(norethisterone) daily once application
S/E- bruising at the site,breast
tenderness,tearfullness,tiredness,headaches,dizziness
,vagueness.
40.
41. Norplant®
6 capsules
Effective 7 yrs
1-yr failure: 0.05%
(1 in 20,000); 5-yr.
failure 1.6%
Reg. approval in
62 countries
Insertion time: 4.3
min (0.8-18.0)
Removal time: 10.2
min (1.3-50m)
Cost: $27
Jadelle ®
2 rods
Effective 5 years
1-yr failure: 0.05%
(1 in 20,000); 5-yr
failure 1.1%
Regulatory approval
in 11 countries
Insertion time: 2 min
Removal time:4.9
min ± 3.5 minutes
Cost: $29
[Sinoplan: $5]
Implanon®
1 rod
Effective 3 years
Regulatory approval
in in 25 countries
Insertion time: 1.1
min (0.03-5.0)
Removal time:2.6
min (0.2 – 20.0)
Cost: comparable;
AID RFA out now
42.
43. Effectiveness- 92-97%
Failure rate- 1.2-1.5 preg/HWY
NES 150μg+15μg EE/day
21day/7 day
ADV-
-reused for a year
-reduced cost
-excellent bleeding
control
-rapid return of fertility
-no changes in weight
DISADV-
-feeling of ring on place
-difficulty in remembering to
reinsert
44.
45. C31G Glyminox 1% Gel(savvy)
50-60% effective
1.2-1.5 preg/HWY
Vaginal microbicide(carrageenan,betacyclodextrin)
contraceptive along with spermicidal agent(nonoxynol-
9)
Applied 15 minutes prior to intercourse
Prevent from sexually transmitted diseases
MOA-
-boost bodies natural defense against infection
-damage and disable disease pathogen
-entry and fusion inhibitors
-replication inhibitors
ADV-
-women can control theselves its use
-No serious side effects
46. Failure rate-0.1-2.5
IUD impregnated with SPRM(selective
progesterone receptor modulator)-ulipristil
Act by suppression of ovulation,endometrial
atrophy
47. ESSURE- a spring like device plugged into
fallopian tube
QUINARINE- a chemical compound gel like
introduced
The ADINA procedure- a plastic implant is
inserted into a lesion in fallopion tube and tissue
grows into it and plug the tube
49. Suppression of gonadotropin releasing hormone from
the hypothalamus and the gonadotropins, LH and FSH,
from the pituitary gland.
-Decreased LH-decreased testosterone production from
Leydig cells, low intratesticular testosterone level,
decreased Sertoli cell function and suppression of
spermatogenesis
-Decreased FSH results in Sertoli cell dysfunction and
impaired spermatogenesis ,
Decreased in spermatozoa production occurs via:
-Decreased proliferation of spermatogonia
-accelerated germ cell apoptosis
-defective spermiation
51. NON HORMONAL
o Target sertoli cell-Indenopyridines(CDB4022) with
GNRH antagonist
o Spermatid sertoli cell interaction-Adjudin
o HE6 epididymal duct specific protein receptor
o CRISP-1 preventing initiation of capacitation during
sperm transit and maturation
o Catspers –allow Ca++
entry in sperm tail
o CAMP-necessory for capacitation
o IZUMO-sperm specific membrane protein responsible
for sperm egg fusion
RISUG- a clear gel injected in vas blocks it
IVD-intra vas devices
52. Safe, effective and acceptable contraceptive vaccines
may be an attractive addition to the currently available
range of family planning methods in that they would:
Confer long-term (but not permanent) protection
following a single course of immunization.
Be free of overt pharmacological activity and the
metabolic and endocrine disturbances that often
accompany other methods of birth control.
Not require insertion of a device or implant.
Remain effective without continuous conscious action
by the user.
Be inexpensive to manufacture.
53. ANTI-SPERM VACCINES
-Research has focused on two types of sperm
antigens:
Functional antigens as the enzymes known to be
required for sperm metabolism (lactic
dehydrogenase-X) , involved in sperm-egg
interactions and the processes leading to
fertilization (acrosin and hyaluronidase).
Structural antigens such as the molecules
expressed on the sperm cell membrane and which
may be involved in gamete interaction and fusion.
54. ANTI-OVUM VACCINES
antigen-focused on the surface antigen zona
pellucida (ZP), the jelly-like glycoprotein coat
surrounding the egg.
To date, however, no convincing data have been
presented to indicate that it can inhibit fertility
without causing an inflammatory reaction in the
ovary which might be indicative of a risk of acute
ovarian disturbances or long-term
immunopathology.
55. ANTI-CONCEPTUS VACCINES
placenta-specific antigens
structural antigens, forming part of the trophoblast cell
membrane
-Pregnancy-specific ß1 glycoprotein (SP-1) an
antifertility effect was observed when female baboons
and cynomolgus monkeys were actively immunized
with human SP-1, in the majority of cases (50-80%),
this effect was manifested as a late abortion.
Another placental antigen PP-5,when animal is
actively immunized with human PP-5 and a substantial
reduction in fertility was shown.
functional antigens, such as placental hormones, have
been evaluated.
56. HORMONAL PLACENTAL ANTIGENS
human chorionic gonadotrophin (hCG)-production or function
of hCG can be inhibited immunologically, the corpus luteum
would regress
One type of anti-hCG vaccine, developed by the Population
Council in New York and by the National Institute of
Immunology (NII) in New Delhi, is based on the whole beta
subunit of the hormone (ß-hCG) (21,22). The other type of
anti-hCG vaccine, developed with support from the WHO Task
Force on Vaccines for Fertility Regulation, is based on a
portion (the carboxyterminal peptide or CTP) of the beta
subunit of the hormone (ß-hCG-CTP)
All of these anti-hCG vaccines require multiple injections to
achieve and maintain levels of immunity that are considered
effective.
57. Endocr Rev. 2008 June; 29(4): 465–493.doi:
10.1210/er.2007-0041
Contraception. 2010 November ; 82(5): 471–475.
doi:10.1016/j.contraception.2010.03.010
Home |2008 Archive |July 2008 |Barbieri 93 (7): 2439
Special Programme of Research, Development and
Research Training in Human Reproduction,World
Health Organization, 1211 Geneva 27, Switzerland
Expert opinion,Emerging Drugs(2011)16(2):373-387
Shaw’s textbook of Gynaecology
Editor's Notes
- As discussed in previous slide – the estrogen side effects may include an increased PMS symptoms – e.g. bloating, mood swings
The POPs do not decrease breast milk production and the small amounts of progestin in the breast milk do not affect the baby
----- Meeting Notes (02/12/12 12:23) -----
myths
Depo-Provera may be used for women who require an estrogen-free method of contraception.
Due to the risk of osteoporosis (weak, porous bones) this method is not recommended for all women.
In addition to the contraception provided by Depo-Provera it also has other health benefits, which are listed on the slide.
Jadelle clinical trials begin in Chile, Dominican Republic, Egyupt, Finland, Singapore, Thailand and USA
Current FDA approval is 5 years for Norplant and 3 years for Jadelle
Jadelle approved in Indonesia, Thailand and USA for 3 years; Finland, France, Iceland, Luxemburg, Netherlands, Norway, Spain and Sweden for 5 years.