Contraception junita

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o&g update course 2012 hospital segamat

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  • 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
  • Risk of VTE is increased by:obesity,immobility,age,congenital and acquired thrombophilia
  • Average 10 months after last DMPA Average 6 months after NET EN
  • if Deppo-Provera is started at a young age and is used more than two to five years - reversible S/E wear off take 12 to 14 weeks after stop depo
  • However almost half the women requesting reinsertion following expulsion,retain their second device
  • Weekly change for 3 weeks than off 1week Works primarily by preventing release of eggs from ovaries
  • Flexible ring placed in vagina Both hormones Kept for 3 weeks and removed 4 th week Preventing ovulation
  • Contraception junita

    1. 1. Dr Junita Aris Klinik Kesihatan Segamat Family Planning methods (Contraception)
    2. 2. Intentional prevention of conception or impregnation through the use of various devices, agents, drugs, sexual practices, or surgical procedures. Contraception
    3. 3. CATEGORIES CLASSIFICATION 1 A condition for which there is no restriction for the use of contraceptive method 2 A condition where the advantages of using the method generally out weight the theoretical or proven risks 3 A condition where the theoretical or proven risks usually out weight the advantages of using the method 4 A condition which represent an unacceptable health risk of the contraceptive method is used Contraception-WHO MEC
    4. 4. CATEGORY WITH CLINICAL JUDGEMENT WITH LIMITED CLINICAL JUDGEMENT 1 USE THE METHOD IN ANY CIRCUMSTANCES YES - USE THE METHOD 2 CAREFULLY USE THE METHOD YES - USE THE METHOD 3 NOT USUALLY RECOMMENDED UNLESS NO OTHER MORE APPROPRIATE METHOD AVAILABLE NO – DO NOT USED THE METHOD 4 METHOD NOT TO USED NO – DO NOT USED THE METHOD Contraception-WHO MEC
    5. 5. Barrier method • Male condom • Female condom • Diaphragm • Cervical cap Contraception
    6. 6. Hormonal Oral • POP • COCP Injectables • Depo provera • Noristerat Device • Norplant • Implanon • IUCD copper LNG (levonorgestrel) Contraception
    7. 7. Evra patch Nuva ring Contraception
    8. 8. Sterilization Female –Tubal Ligation Male -vasectomy Contraception
    9. 9. Barrier method
    10. 10. Male condom Typical use 15% Perfect use 2%
    11. 11. Male condom
    12. 12. Male condom
    13. 13. Male condom
    14. 14. What are the chances of getting pregnant while using a female condom?T Typical use: 21 % Perfect use: 5 % Female Condom
    15. 15. • Female diaphragm • Cervical cap What are the chances of getting pregnant Typical use: 20 % Perfect use: 9 % Typical use: 10 % Perfect use : 4% Female Condom
    16. 16. Male Condom Female condom Rolled on the mans penis Fit on the erect penis Inserted into the woman’s vagina Made of latex FC2 is made of nitrile and FC is made of polyurethane Lubricant: Can include spermicide Can be water-based only; cannot be oil- based Located on the outside of condom Lubricant: Can include spermicide Can be water-based or oil-based Located on the inside and outside of condom Condom must be put on an erect penis Can be inserted prior to sexual intercourse, not dependent on erect penis
    17. 17. Male condom Female condom Must be removed immediately after ejaculation Does not need to be removed immediately after ejaculation Covers most of the penis and protects the woman’s internal genitalia. Covers both the woman’s internal and external genitalia and the base of the penis, which provides broader protection. Latex condoms can decay if not stored properly Is not susceptible to deterioration from temperature or humidity. Recommended as one time use product. recommended for one time use
    18. 18. Benefits • Help protect against STIs, including HIV • No hormonal side effects Side effect Allergic reaction to latex Condom
    19. 19. HORMONAL
    20. 20. Combined oral contraceptive (COC)
    21. 21. - 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 preparations Combined oral contraceptive (COC)
    22. 22. • 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 Combined oral contraceptive
    23. 23. • 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 Combined oral contraceptive
    24. 24. • 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 Combined oral contraceptive-types
    25. 25. Mechanism of action • 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 • The endometrium becomes atrophic and unreceptive to implantation • Possibly direct effects on the fallopian tubes impairing sperm migration and ovum transport Combined oral contraceptive
    26. 26. • Effectiveness – Depends on user – < 1 pregnancy per 100 woman used over 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 COC - contraceptive benefits
    27. 27. • 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 COC - non contraceptive benefits
    28. 28. • Fewer functional ovarian cysts • Fewer extra uterine pregnancies • Reduction in pelvic inflammatory ds • Fewer symptomatic fibroid • Reduced risk of cancers of ovary and endometrium COC - non contraceptive benefits
    29. 29. • Weight gain: 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/Progestrogen and type of progesterone used COC - limitation/side effects
    30. 30. • 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 • COC containing 3rd generation progestogens (desogestrel and gestodene) possibly carry a small additional risk of VTE compared to that of 2nd generation COC - limitation/side effects
    31. 31. Arterial disease • 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. COC - limitation/side effects
    32. 32. • Ideally the COCP should be started on the first day of menstrual bleeding, but can be started up to day 5 without the need for extra protection. • It can be started at any other time IF THE PATIENT IS SURE SHE IS NOT PREGNANT, but additional protection e.g. condoms will be needed for the first 7 days. COC - when to start
    33. 33. Past or present circulatory disease • Proven past arterial or venous thrombosis • IHD • Severe multiple risk factors for venous or arterial disease • Focal migraine • TIA • Artherogenic lipid disorders Disease of the liver • Active liver ds (i.e.with abnormal liver function test) • Liver adenoma or carcinoma • Gallstones • Acute hepatic porphyrias COC-Absolute Contraindication (WHO 4)
    34. 34. Others • Pregnancy • Undiagnosed genital tract bleeding • Oestrogen dependent neoplasms,e.g breast cancer COC-Absolute Contraindication (WHO 4)
    35. 35. • Undiagnosed oligomenorrhoea • Cigarette smoking above age 35 • Diabetes • Non focal migraine • Sickle cell disease • Inflammatory bowel ds • Obesity(if ass with other risk factors) COC-Relative Contraindication (WHO 2 & 3)
    36. 36. • Controlled by the woman • Stopped at any time without health provider help • Do not interfere with sexual activity • Safe and suitable for nearly all woman • At any age including adolescent, woman age > 40 • Following a miscarriage • Without pelvic examination • Without cervical cancer screening Women like COC
    37. 37. Drug interactions - AntiTB( Rifampicin) - Antiepileptic (barbiturates,phenytoin carbamazepine) - Antibiotic (doxcycline, ampicillin) COC-Drug Interactions
    38. 38. • Progestin-only pills (POPs) • Depo-provera • Norplant • Implanon PROGESTOGEN ONLY CONTRACEPTIVES
    39. 39. Mechanisms of action • Suppress ovulation • Reduce sperm transport in upper genital tract (fallopian tubes) • Thicken cervical mucus preventing sperm penetration PROGESTOGEN ONLY PILLS (POPs)
    40. 40. ) • Effective when taken at the same time daily • Immediately effective (<24 hours) • Do not interfere with intercourse • Do not affect breast feeding • Immediate return to fertility when stopped • If BF + LAM – near 100% effective • If not BF – 99.5% effective POPs-Contraceptive benefits
    41. 41. • Few side effects • Convenient and easy to use • Client can stop use • Can be provided by trained non-medical staff • Contain no oestrogen POPs-Contraceptive benefits
    42. 42. • 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 POPs-Non Contraceptive benefits
    43. 43. • 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 POPs-Limitations
    44. 44. • POPs are not recommended unless other methods are not available or acceptable if woman ; – Has unexplained vaginal bleeding (if suspected serious problem) – Has breast cancer (current / with h/o ) – Is jaundiced (active, sx) POPs-condition requiring precaution (WHO Class 3)
    45. 45. • Is taking drugs for epilepsy (phenytoin/barbiturates) or TB (rifampicin) • Has severe cirrhosis • Has liver tumours • Has had a stroke • Has IHD POPs-condition requiring precaution (WHO Class 3)
    46. 46. • 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) POPs-No Restriction
    47. 47. • 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 • Post abortion (immediately) POPs-When to start
    48. 48. • 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 POPs-Side effects which may require management
    49. 49. • 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. POPs- Management of Amenorrhea
    50. 50. • Reassurance • Check for gynaecologic problem • Short term treatment – COC for 1 cycle – ibuprofen POPs : management of prolonged bleeding or spotting
    51. 51. • 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 POPs
    52. 52. • Depo-provera (DMPA) – 150 mg of depot medroxyprogesterone acetate every 3/12 • Noristerat (NET-EN) : 200 mg of norethindrone enanthate give every 2/12 Injectable
    53. 53. • 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 • 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 Injectable-contraceptive benefits
    54. 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 Injectable-limitations
    55. 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 Injectable-Indications
    56. 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 early or late – NET-EN : up to 2 weeks early or late Injectable-timing of injection
    57. 57. DMPA NET-EN Duration 3 months 2 months Bleeding More amenorrhoea More irregular Needle / pain Smaller / less Larger / more Reinjection window Up to 4 weeks Up to 2 weeks Cost Cheaper More expensive Return to ovulation later sooner Injectable-Comparison of DMPA and NET-EN
    58. 58. • The most common side effect - irregular bleeding in 70 percent of women in the first year. - in 10 percent of women thereafter. - Absence of bleeding is common in 80 percent of women after two years. Injectable-Side effects
    59. 59. Less common side effects: Increased appetite and weight gain Headaches Sore breasts Nausea Depression Nervousness Dizziness Skin rashes or spotty darkening of the skin Hair loss or increased hair on face or body Increased or decreased sexual desire Injectable-Side effects
    60. 60. • Vaginal dryness • Bone loss (reduce bone density) • If pregnancy is desired, it takes 12 to 18 weeks to get pregnant after the last shot is taken (sometimes longer) • In the rare case that pregnancy occurs during the use of Depo Provera, there is an increased chance that the pregnancy will be ectopic. Injectable-Side effects
    61. 61. Types • Non medicated – Lippes loop • Medicated – Copper-releasing – Progestin-releasing Intrauterine contraceptive device (IUCD)
    62. 62. • Copper releasing • 1st generation – Copper seven – Copper T 200 • 2nd generation – Multiload 250 – Nova T • 3rd generation – Copper T380A – Multiload 375 • Progestin releasing • Progestasert • LevoNova (LNG 20) • Mirena Chance of getting pregnant Copper: Typical use: 0.8 percent Perfect use: 0.6 percent Progesterone: Typical use: 0.2 percent Medicated IUCDs
    63. 63. • 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 Mirena • Decrease menstrual cramps (progestin releasing only) • Decrease menstrual bleeding (progestin releasing only) IUCD-Benefits
    64. 64. • 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 • 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 IUCD-Limitations
    65. 65. • 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 IUCD-Timing
    66. 66. • Copper releasing – Heavier menstrual bleeding – Irregular / heavy vaginal bleeding – Increased menstrual cramping or pain – Vaginal discharge • Progestin releasing – Amenorrhoea or very light menstrual bleeding or spotting IUCD-Side effects
    67. 67. • 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 menses • 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 IUCD-Expulsion
    68. 68. The increased dose of estrogen (> 60% than the pills) from the patch is associated with blood clots . EVRA patch
    69. 69. ` • women with a history of blood vessel disease such as diabetes, heart disease or high blood pressure should not take this medication. EVRA patch
    70. 70. • Etonogestrel/EE (0.120 mg /0.015 mg per day) Nuva Ring
    71. 71. Various types Contraceptive Efficacy (100 women in 1 year use) Abstinence 100% effective Implants 0.05 Vasectomy 0.1 Levonorgestrel IUD 0.2 Tubal ligation 0.5 Injectable 0.3 Oral Hormone 0.3 Copper IUCD 0.6 LAM (6 months) 0.9 Male condom 2 (correct and consistent use) Withdrawal 4 Diaphragms with spermicide 6 Contraception Most effective Least effective
    72. 72. • Within 72 H since last unprotective SI 1)Levonorgestrel (Prostinor) 0.75 mg bd or 1.5 mg od 1 day only 2)>72 H up to 5 days IUCD (copper) Emergency contraception
    73. 73. • 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. Summary
    74. 74. Thank you

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