Contraceptive methods and types of contraception. Including missed pills management and emergency contraception. For education purposes.

1. CONTRACEPTION
DR MOHD HAZIZUL BIN AB SAMAD
P86464
1

2. OVERVIEW
• INTRODUCTION
• TYPES OF CONTRACEPTION
• HORMONAL CONTRACEPTION
• NON-HORMONAL CONTRACEPTION
• WHO MEDICAL ELIGIBILITY CRITERIA FOR
CONTRACEPTION
• HOW AND WHEN TO TAKE CONTRACEPTION
• MISSED PILL
• PREGNANT WITH IUD
• EMERGENCY CONTRACEPTION 2

3. INTRODUCTION
• Contraception: Practice of using artificial methods to avoid
becoming pregnant when having sex.
• Birth Control: The practice of controlling the number of
children a person has, using various methods of
contraception.
• Purpose: To help prevent Unintended Pregnancy.
• Unintended pregnancy
• Either unwanted- pregnancy occurred when no children or no
more children were desired.
• Or mistimed- pregnancy occurred earlier than desired.
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4. TYPES OF CONTRACEPTION
HORMONAL
• COCP.
• PATCH.
• VAGINAL RING.
• POP.
• DMPA.
• IMPLANT.
• LNG-IUS.
4

5. TYPES OF CONTRACEPTION
NON-HORMONAL
• NATURAL- ABSTINENCE, COITUS
INTERRUPTUS, CALENDAR RHYTHM.
• BARRIER- CONDOM, SPERMICIDE,
DIAPHRAGM & CERVICAL CAP.
• COPPER INTRAUTERINE DEVICE.
• PERMANENT- VASECTOMY, TUBAL
LIGATION.
5

6. COMBINED ORAL CONTRACEPTIVE PILLS
• Available Formulary:
• Marvelon- Ethinyl Estradiol(EE) 30µg + Desogestrel
150µg
• Mercilon- EE 20µg + Desogestrel 150µg
• Yasmin- EE 30µg + Drospirenone 3mg
• Yaz- EE 20µg + Drospirenone 3mg
• Loette- EE 20µg + Levonorgestrel 100µg
• Microgynon/Nordette- EE 30µg + Levonorgestrel
150µg
• Regulon- EE 30µg + Desogestrel 150µg
• Rigevidon- EE 30µg + Levonorgestrel 150µg
• Loette- EE 20µg + Levonorgesrel 100µg
• Diane 35- EE 35µg + Cyproterone acetate 2mg
• Gynera- EE 30µg + Gestodene 75µg
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7. COMBINED TRANSDERMAL PATCH
• Applied to skin- upper shoulder, buttock, abdomen, or upper arm.
• Once a week for 3 weeks.
• No patch on 4th week to allow for withdrawal bleed.
• Easy to use, non-invasive but does not protect against STD.
• Typical use failure rate: 7%
7

8. COMBINED VAGINAL RING
• Ring shape, 2 inches in diameter.
• Inserted into vagina, left in place for 21 days.
• 7 ring-free days to allow withdrawal bleed.
• Irritation in the vagina and cervix may occur.
• Does not protect against STD.
• Typical use failure rate: 7%.
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9. PROGESTOGENS ONLY METHODS
• Progestogen-only Pills (POP):
• Noriday- Norethisterone 350µg
• Cerazette- Desogestrel 75µg
• Progestogen-only Injectable Contraception (POIC):
• Depot Medroxyprogesterone Acetate (DMPA)- 12weeks
• Norethisterine Enanthate (NET-EN)- 8weeks
• Typical use failure rate: POP 7%, POIC 4%
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10. LARC
• Intrauterine Device:
• Non-hormonal: intrauterine device with copper.
• Multiload- cu 250: effective for 3 years.
• Multiload- cu 375: effective for 5 years.
• Nova T: effective for 5 years.
• Copper T 380A: effective for 10 years.
• Typical use failure rate: 0.8%.1
10
1. CDC-Reproductive Health: Contraception.
https://www.cdc.gov/reproductivehealth/contraception/index.htm

11. LARC
• Intrauterine Device:
• Hormonal: intrauterine system (IUS)- MIRENA.
• 52mg Levonogestrel.
• Released at a rate of 20µg/day.
• Effective for 5 years
• Typical use failure rate: 0.1-0.4%.1
11
1. CDC-Reproductive Health: Contraception.
https://www.cdc.gov/reproductivehealth/contraception/index.htm

12. LARC
• Subdermal contraceptive implant
• Implanon®/Implanon NXT.
• Biodegradable single rod implant.
• 68mg etonogestrel.
• Initial release 60-70µg/day, reduced to
20-30µg at the end of 3 years.
• Effectiveness comparable or even
better than sterilization. (99.95%
effective)
• Typical use failure rate: 0.01%.1
12
1. CDC-Reproductive Health: Contraception.
https://www.cdc.gov/reproductivehealth/contraception/index.htm

13. BARRIER METHODS
• Male Condom:
• Latex/rubber sheath that cover penis and
collect semen.
• Prevent sperms from entering vagina.
• Also protects against STD.
• Cheap, easy to use, easily available in
drugstores/convenient stores.
• Typical use failure rates: 13%.1
13
1. MyHealth KKM. Contraception. http://www.myhealth.gov.my/en/contraception/
2. CDC-Reproductive Health: Contraception.
https://www.cdc.gov/reproductivehealth/contraception/index.htm

14. BARRIER METHODS
14
• Female Condom:
• Plastic (polyurethane) sheath with flexible
ring at each end.
• Covers the vaginal canal; ring at closed end
holds the sheath inside, ring at open end
stays outside vaginal opening.
• Prevent sperms from entering vagina and
protects against STD.
• Not easily available and not popular.
• Typical use failure rate: 21%.
1. MyHealth KKM. Contraception. http://www.myhealth.gov.my/en/contraception/
2. CDC-Reproductive Health: Contraception.
https://www.cdc.gov/reproductivehealth/contraception/index.htm

15. BARRIER METHODS
• Spermicidal:
• Tablet, film, jelly or cream.
• Inserted inside vagina within 1hr prior to
SI.
• Leave in place at least 6-8hrs after SI.
• Kill sperm or making sperm unable to
move towards the egg.
• Provide protection against some STDs
but not HIV.
• Typical use failure rate: 21%
• Diaphragm/cervical cap:
• Soft rubber cups placed inside vagina to
cover cervix.
• Block sperms from entering uterus and
tubes.
• Spermicidal usually added to give better
protection.
• Comes in different sizes.
• May protect against some STDs.
• May increase incidence of UTI.
• Typical use failure rate: 17% 15
1. MyHealth KKM. Contraception. http://www.myhealth.gov.my/en/contraception/
2. CDC-Reproductive Health: Contraception.
https://www.cdc.gov/reproductivehealth/contraception/index.htm

16. MALE STERILIZATION
VASECTOMY
• Permanent.
• >99% effectiveness.
• Fever risks than female sterilization.
(especially if female partner carries
significant medical disorder).
• Does not interfere with sexual drive or
performance.
• Confirm occlusion by semen analysis.
• Late failure and chronic pain- rare. 16

17. FEMALE STERILIZATION
BILATERAL TUBAL LIGATION
• Permanent.
• >99% effectiveness.
• Laparotomy or laparoscopy.
• Reversal not always possible.
• Timing:
• 48hrs post term delivery,
• In conjunction with C-Section, or
• Immediately following uncomplicated first
trimester miscarriage. 17

18. WHO MEDICAL ELIGIBILITY CRITERIA
FOR CONTRACEPTIVE USE
FIFTH EDITION 2015
18

19. WHO MEC FOR CONTRACEPTION
19

20. 20

21. SUMMARY TABLE
CONDITION COC CIC P/R POP DMPA
NET-
EN
LNG/ET
G
Implant
LNG
IUD
Cu-
IUD
WHO CATEGORY (1, 2, 3, 4)
CARDIOVASCULAR DISEASE
Multiple Risk Factors
(older age, smoking, diabetes, hypertension, obesity,
dyslipidemia
3/4 3/4 3/4 2 3 2 2 1
Stroke 4 4 4 2 3 2 2 1
Ischaemic heart disease
4 4 4 2 3 2 2 1
HYPERTENSION
History of hypertension where BP cannot be evaluated
(including PIH)
3 3 3 2 2 2 2 1
Adequately controlled, or BP 140-150/90-99 3 3 3 1 2 1 1 1
BP ≥160/100 4 4 4 2 3 2 2 1
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22. 22
SUMMARY TABLE
CONDITION COC CIC P/R POP DMPA
NET-
EN
LNG/ET
G
Implant
LNG
IUD
Cu-
IUD
WHO CATEGORY (1, 2, 3, 4)
DIABETES
Diabetes mellitus 2 2 2 2 2 2 2 1
OBESITY
BMI ≥30kg/m2 2 2 2 1 1 1 1 1
HEADACHE
Non-migrainous 1 1 1 1 1 1 1 1
Migraine with aura 4 4 4 2 2 2 2 1
SMOKING
<35 years old 2 2 2 1 1 1 1 1
≥35 years old 3 3 3 1 1 1 1 1
HIV
WHO stage 3 or 4 1 1 1 1 1 1 3 3

23. 23
SUMMARY TABLE
CONDITION COC CIC P/R POP DMPA
NET-
EN
LNG/ET
G
Implant
LNG
IUD
Cu-
IUD
WHO CATEGORY (1, 2, 3, 4)
SEXUALLY TRANSMITTED INFECTIONS
Gonorrhoea/Chlamydia 1 1 1 1 1 1 4 4
Other STIs and vaginitis 1 1 1 1 1 1 2 2
Increase risk of STIs 1 1 1 1 1 1 2/3 2/3
VENOUS THROMBOEMBOLISM
History 4 4 4 2 2 2 2 1
Acute 4 4 4 3 3 3 3 1
Major surgery with prolonged immobilization 4 4 4 2 2 2 2 1
MEDICATIONS
Anticonvulsants (barbiturates, carbamazepine,
oxcarbazepine)
3 3 3 3 1-2 2 1 1
Rifampicin/Rifabutin 3 3 3 3 1-2 2 1 1
Anti-retroviral therapy 1-2 1-2 1-2 1-2 1-2 1-2 2/3 2/3

24. BEST TIME TO START
24

25. WHEN TO START
POP
• Up to Day 5 of menses. If started at other
time additional contraception.
• Postpartum- Day 21.
• Surgical abortion- the same day.
• Medical abortion- second part.
• Following miscarriage- immediately.
POIC
• Postpartum- Day 21.
• Within 5 days of surgical abortion,
second part of medical abortion or
following miscarriage.
• At any other time- additional
contraception for 7 days.
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26. HOW TO TAKE
POP
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• Daily pill at around the same time.
• No pill-free interval.
COCP
• Daily pill at around the same time.
• 7 days pill free interval.
POIC
• IM injection at upper outer quadrant of
gluteus maximus.
• Alternative site- deltoid.
• Repeat injection every 12 weeks for
DMPA, 8 weeks for NET-EN.
• Up to 2 weeks early or 2 weeks late.

27. WHEN TO START
• IUCD/IUS:
• At any time during menstrual cycle. (for
IUS- if amenorrhoeic or >7days after
menstrual bleeding started, need backup
contraception for 7 days)
• Immediately after 1st or 2nd trimester
abortion or at anytime thereafter.
• From 4 weeks postpartum, irrespective of
mode of delivery.
• Implanon NXT
• At any time during menstrual cycle. (if
amenorrhoeic or >5days menstrual
bleeding started, need backup
contraception for 7 days).
• Inserted subdermally:
• in the groove between biceps and triceps,
• in the non-dominant hand,
• about 8-10cm form medial epicondyle.
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28. 7 DAYS RULE
• 7 consecutive pills are enough to ‘shut the door’ on the ovaries.
• 7 pills can be omitted without ovulation- Pill Free Period (PFI).
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29. MISSED PILL COCP
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30. MISSED PILL COCP
<48Hr
Week 1
Take the missed pill ASAP.
Continue remaning pill at
usual time.
No need backup
contraception/EC.
Week 2 Week 3
30
≥48Hr
Week 1
Take the most
recent missed pill
ASAP.
Continue remaining
pill at usual time.
Back up
contraception for 7
days.
Consider EC
Week 2
Take the most recent
missed pill ASAP.
Continue remaining
pill at usual time.
Backp contraception
for 7 days.
EC not required if
week 1 perfect use.
Week 3
Take the most recent
missed pill ASAP.
Continue remaining
pill at usual time.
Backup contraception
for 7 days.
Skip HFI.
EC not required if
week 1 perfect use.
Faculty od Sexual & Reproductive Healthcare, RCOG

31. WHAT IF VOMITING AND DIARRHOEA?
• If vomiting >2 hours- can safely assumed it has been absorbed.
• If vomiting <2 hours- take another pill immediately.
• Diarrhoea 6-8times/day = missing 1 tablet in 24hours.
• Diarrhoea alone is not a problem (? Having S.I.)
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32. COMBINED TRANSDERMAL PATCH
• Patch Detachment:
32
Week 1
<48Hr
-Reapply new patch.
-Keep same patch
change day.
-No need EC/Backup
contraception for 7days.
≥48Hr
-Reapply new patch.
Keep same patch
change day.
-Backup contraception.
-Consider EC.
Week 2
<48Hr
-Reapply new patch.
-Keep same patch
change day.
-No need Backup
contraception.
-No need EC if week 1
correct use.
≥48Hr
-Reapply new patch.
Keep same patch change
day.
-Backup contraception.
-No need EC of week 1
correct use.
Week 3
<48Hr
-Reapply new patch.
-Keep same patch change
day.
-No need Backup
contraception.
-No need EC if week 1
correct use.
≥48Hr
-Reapply new patch.
Keep same patch change day.
-Backup contraception.
-No need EC of week 1 correct
use.
-Skip HFI.
Faculty od Sexual & Reproductive Healthcare, RCOG

33. COMBINED VAGINAL RING
• Unscheduled ring removal:
33
<48Hr
Reinsert ring ASAP.
Keep ring until
scheduled removal
day.
No need backup
contraception.
EC not required.
≥48Hr
Week 1
Reinsert ring ASAP.
Keep ring until scheduled
removal day.
Backup contraception for 7
days.
Consider EC.
Week 2
Reinsert ring ASAP.
Keep ring until scheduled removal
day.
Backup contraception for 7 days.
EC not required if week 1 perfect
use.
Week 3
Reinsert ring ASAP.
Keep ring until scheduled removal day.
Backup contraception for 7 days.
Skip HFI.
EC not required if week 1 perfect use.

34. MISSED PILL POP
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Faculty od Sexual & Reproductive Healthcare, RCOG

35. PREGNANT WITH IUD
35
ACOG

36. EMERGENCY CONTRACEPTION
“MOST ACCIDENTS ARE CAUSED BY HUMANS &
MOST HUMANS ARE CAUSED BY ACCIDENTS”
36

37. EMERGENCY CONTRACEPTION
• A method of preventing unintended pregnancy following unprotected sexual intercourse
(UPSI).
• Terms: EC, Post-coital contraception, the morning after pill.
• Unprotected Sexual Intercourse (UPSI):
• Any situation when a woman has not used contraception or has not used a method correctly
or consistently.
37

38. OPTIONS OF EC
• Levonorgestrel 1.5mg.
• Ulipristal acetate 30mg.
• Copper IUCD.
38

39. MECHANISM OF ACTION
Levonorgestrel Inhibits ovulation.
Delaying or preventing follicular rupture.
Causing luteal dysfunction.
Ulipristal
Acetate
Inhibition or delay of ovulation.
Delay maturation of endometrium.
Copper IUCD Inhibit fertilisation by toxic effect on sperm and ova; effective
immediately after insertion.
Copper affect motility and viability of sperm & viability and transport of
ova.
If fertilisation occurred, there is anti-implantation effect by local
inflammatory reaction.
But if implantation occurred, does not cause abortion. 39

40. HOW SOON?
40
Levonorgest
rel
Up to 72 hours after UPSI.
Ineffective after 72 hours.
Failure rate: 1-2%.
Ulipristal
Acetate
Up to 120 hours after UPSI.
The only oral EC licensed to be used between 72
and 120 hours.
Failure rate: 1-2%
Copper
IUCD
Up to 120 hours after the first episode of UPSI, or
Within 5 days of the earliest expected date of
ovulation
Failure rate: <1%
Can continue as
regular contraception

41. SIDE EFFECTS
EC SIDE EFFECTS REMARKS
LNG
Headache, nausea, dysmenorrhoea, altered bleeding
pattern.
Does not effect woman’s long term fertility
If pregnancy does occur, no adverse reaction.
If nausea and vomiting within 3
hours of taking, repeat dose
should be given.
Pregnancy test should be
carried out if menses are
delayed by >7days after EC.
UPA
Cu-
IUCD
Pain on insertion. Give analgesics- Non-steroidal
Anti-inflammatory Drugs
(NSAIDs)
41

42. CONTRAINDICATIONS
Levonorgestrel No contraindications including breastfeeding.
Ulipristal
acetate
Hypersensitivity to UPA.
Severe asthma insufficiently controlled by glucocorticoids.
Hepatic dysfunction.
Hereditary problems of galactose intolerance, lactase deficiency and glucose-
galactose malabsorption.
Breastfeeding not recommended for up to 36 hours.
Copper IUCD Sexually transmitted infections.
Pelvic inflammatory disease.
Distorted uterine cavity.
Allergic to copper.
Wilson’s disease.
Age and nulliparity are not contraindications. 42

43. REPEAT EC IN THE SAME CYCLE
• Cu-IUCD: not applicable.
• Levonorgestrel & Ulipristal acetate:
• Can be used more than once in a cycle; even if there is an earlier episode of UPSI outside of
treatment window (>120Hr).
• Woman who has already taken LNG, UPA will be less effective if taken in the following 7 days.
• Woman who has already taken UPA, should not be given LNG in the following 5 days.
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44. FATWA
44

45. THANK YOU
45

46. REFERENCE
• Clinical Protocols in Obstetric & Gynaecology for Malaysian Hospitals. Prof Dato’ Dr
Sivalingam Nalliah, Prof Dato’ Dr Sachchithanantham.
• Faculty of Sexual and Reproductive Health, Royal College of Obstetric and
Gynaecology.
• WHO Medical Eligibility Criteria for Contraceptive Use 2015.
• US Medical Eligibility Criteria for Contraceptive Use 2016.
• MyHealth Kementerian Kesihatan Malaysia Portal.
http://www.myhealth.gov.my/en/contraception/
• Centers for Disease Control and Prevention.
https://www.cdc.gov/reproductivehealth/contraception/index.htm
• MIMS Obstetric and Gynaecology.
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