Gynecology Medical Student notes describing use of contraceptives and application in the medical field. A guide on the criteria use of oral contraceptives and their indications for use.

1. Contraception
Dr Bellington Vwalika
Obstetrician and
Gynaecologist-UTH
Honorary Lecturer -UNZA

2. 2
Definition
 The prevention of an unwanted pregnancy
using a contraceptive which acts by
preventing fertilization of the ovum by
spermatozoa

3. 3
Measurement of Contraception
 Pearl Index
 Life table Analysis

4. 4
Methods available
 Oral contraception
 Injectables
 Intrauterine devices
 Implants
 Barrier
 Withdrawal
 Natural
 Sterilization

5. 5
Factors affecting choice of method
Whether or not a
method:
 is permanent or
reversible
 is effective
 is inexpensive
 is perceived to be safe
 is easy to obtain
 is easy to use and
discontinue
 has frequent or
undesirable side effects

6. 6
Factors affecting choice cont’d
 can be used while
b/feeding
 protects against STIs
 requires partner
cooperation
 must be used each time
the couple have sexual
intercourse

7. 7
‘Contraceptive Method Mix’
 Refers to the variety of contraceptives
available to clients through a family planning
programme

8. 8
Combined oral contraceptives
(COCs)
 Consists of oestrogen (E) and progestin (P)
 Monophasic pills - same dose of E/P all through the
course
 Biphasic pills - fixed dose or E/P & more P in the last
14/7
 Triphasic pills - variable dose of E/P
 Sequential pills - fixed dose of E, No P for first 7/7
then P for 14/7

9. 9
Mechanism of action
- COCs
 Prevents ovulation by inhibiting
gonadotrophin secretion via an effect on both
pituitary and hypothalamic centres
 The progestin suppresses LH secretion (&
thus prevents ovulation, while the
oestrogenic agent suppresses FSH secretion
(& thus prevents the selection and
emergence of a dominant follicle

10. 10
Efficacy of COC
 Typical usage is associated with a 3.0%
failure rate during the first year of use
 Efficacy decreases significantly when the
oestrogen component is removed

11. 11
Absolute contraindications to COC
use
 thrombophlebitis,
thromboembolic
disorders, CVA,
coronary occlusion
 markedly impaired liver
function
 known or suspected
breast cancer
 undiagnosed abnormal
vaginal bleeding
 known or suspected
pregnancy
 smokers over the age
of 35 years

12. 12
Relative contraindications to COC
use
 Migraine headaches
 Hypertension
 H/O gestational
diabetes
 Elective surgery
 Epilepsy
 H/O obstructive
jaundice in pregn
 Sickle cell disease or
sickle C disease
 Diabetes mellitus
 Gall bladder disease

13. 13
Clinical problems associated with
COCs
 Breakthrough bleeding
 Amenorrhoea
 weight gain
 Acne
 Ovarian cysts
 Drugs that affect
efficacy
 Migraine headaches

14. 14
Non-Contraceptive Benefits of
OCs
These can broadly be grouped into two main
categories:
 Benefits that incidentally accrue when OC is
specifically utilized for contraception &;
 Benefits that result from the use of OCs to
treat problems or disorders

15. 15
Non contraceptive incidental
benefits of OCs
 effective contraception
 less endometrial cancer
 less ovarian cancer
 fewer ectopic pregns.
 more regular menses
 less PID
 less rheumatoid arthritis
 increased bone density
 ~ less endometriosis
 ~ less benign breast disease
 ~ fewer ovarian cysts

16. 16
OC as treatment
 DUB
 dysmenorrhoea
 mittelschmerz
 endometriosis
prophylaxis
 acne & hirsutism
 hormone therapy for
hypothalamic
amenorrhoea
 control of bleeding
 ~ functional ovarian
cysts
 ~ premenstrual
syndrome

17. 17
Pill taking
 Effective contraception is present during the
first cycle of pill use, provided the pills are
started no later than the 5th day of the cycle
and no pills are missed

18. 18
Missed Pills
 If a woman misses 1 pill, she should take that
pill as soon as she remembers and take the
next pill as usual. No back-up is needed.
 If she misses 2 pills in the first two weeks,
she should take two pills on each of the next
two days, and back-up for the next 7 days

19. 19
Missed pills cont’d
 If 2 pills are missed in the third week, or if
more than 2 active pills are missed at any
time, another form of contraception should
be used as back-up immediately and for 7
days or start a new pack with back-up for 7
days

20. 20
The Progestin-Only Pill (POP)
Minipill
 The minipill contains a small dose of
progestational agent (25% of that in COC)
and must be taken daily, in a continuous
fashion

21. 21
Mechanism of Action - POP
The contraceptive effect is more dependent
upon endometrial and cervical mucus effects,
since the gonadotrophins are not consistently
suppressed
 The endometrium involutes and becomes
hostile to implantation and the cervical
mucus becomes thick and impermeable

22. 22
POP cont’d
 There are no significant metabolic effects
(lipid levels, CHO metabolism and
coagulation factors remain unchanged)
 There is an immediate return to fertility upon
discontinuation
 Failure rates range form 1.1 to 9.6% per 100
women in the first year of use

23. 23
POP cont’d
Pill taking
 The minipill should be started on the first day
of menses and a back-up method must be
used for the first 7 days
 The pill should be taken at the same time of
the day
 If more than 3 hours late in taking a pill, a
back-up method should be used for 48 hours

24. 24
Problems associated with POP
POP have unpredictable
effect on ovulation
 40% of patients can
expect to have normal
ovulatory cycles
 40% short irregular
cycles
 20% total lack of cycles
ranging from irregular
bleeding to spotting and
amenorrhoea
 development of
functional cysts
 levonorgestrel minipill
may be associated with
acne

25. 25
POP
There are two situations where excellent
efficacy is achieved:
 In lactating women, the contribution of the
minipill is combined with prolactin-induced
suppression of ovulation adding up to very
effective protection
 In women over age 40, reduced fecundity
adds to the minipill’s effects.

26. 26
Implant contraception -
NORPLANT
 Progestin circulating at levels 1/4 to 1/10th of
those in COC, prevents conception by
suppressing ovulation and thickening cervical
mucus to inhibit sperm penetration
 Side effects include changes in menstrual
pattern, weight gain, headache, and effects
on mood

27. 27
NORPLANT
 consists of 6 capsules
34mm in length, 2.4
mm outer diameter,
containing 36 mg
crystalline
levonorgestrel.
 the 6 capsules contain
a total of 216 mg of
levonorgestrel which is
very stable
 the capsules release ~
80 micro grams of
levonorgestrel per 24
hours during the first 6-
12 months of use
 once inserted have an
effective life of 5 years

28. 28
The mechanism of action
 Suppression at both the hypothalamic and
pituiatry LH surge necessary for ovulation
 The constant level of progestin has a marked
effect on the cervical mucus
 Suppression of the estradiol-induced cyclic
maturation of the endometrium and
eventually causes atrophy

29. 29
Disadvantages of NORPLANT
 disruption of bleeding
patterns in up to 80% of
users
 implants must be
inserted and removed
in a surgical procedure
by trained personnel
 implants can be visible
under the naked eye
 does not protect
against STI/HIV
 acne
 30% of pregnancies are
ectopic

30. 30
Absolute contraindications
 active thrombophlebitis
or thromboemboilc
phenomena
 undiagnosed genital
bleeding
 acute liver disease
 benign or malignant
liver tumours
 known or suspected
breast cancer

31. 31
IMPLANON
 A single implant 4 cm long contains 60 mg of
3-keto desogestrel
 The hormone is released at a rate of about
60 micro grams per day
 Is designed to provide contraception for 2-3
years
 Efficacy and side effects are similar to those
or NORPLANT

32. 32
Jadelle
 Two rods containing 75mg LNG crystals embedded
in a coplolymer and encased in silastic tubing
 Rods are 43mm long and 2.5mm wide
 Lasts for 5 years
 Rods are easier and more convenient to insert and
remove
 Norplant and Jadelle are bioequivalent over 5 years
of use

33. 33
Injectable Contraception:
Depo-Provera
 Comes as microcrystals, suspended in an
aqueous solution
 Correct dose is150 mg IM (gluteal or deltoid)
every 3 months
 Relies on higher peaks of progestin to inhibit
ovulation and thicken cervical mucus. The
progestin level is high enough to block the
LH surge

34. 34
Depo-Provera
cont’d
 The injection should be given within the first
5 days of the current menstrual cycle,
otherwise a back-up method is necessary for
2 weeks
 The injection must be given deeply in muscle
by the Z-track technique and not massaged

35. 35
Depo-Provera
Advantages
 easy to use, no daily or
coital acton required
 safe no serious health
effects
 effective as sterilization,
IUCD & implant
contraception
 free from eostrogen
related problems
 private use not
detectable
 enhances lactation
 has noncontraceptive
benefits

36. 36
Depo-Provera
Disadvantages
 irregular menstrual
bleeding
 breast tenderness
 weight gain
 depression
 can’t be removed
 return to fertility is
delayed
 regular injections
required
 no STI/HIV protection

37. 37
Depo-Provera
Absolute contraindications
 Pregnancy
 Unexplained genital bleeding

38. 38
Intrauterine Contraception
Types of IUDS
 Unmedicated IUDs -Lippes Loop
 Copper IUDs - TCu-380A, Tcu-220C, Nova
T, Mulitload-375
 Hormone-releasing IUDs - Progestasert

39. 39
IUDS
Mechanism of Action
 The mechanism of action is the production of
an intrauterine environment that is
spermicidal
 Ovulation is not affected nor is the IUD an
abortifacient

40. 40
Efficacy of IUDS
 The actual failure rate in the first year is
approximately 3%, with a 10% expulsion
rate, and a 15% rate of removal, mainly for
bleeding and pain.
 The non medicated IUDs never have to be
replaced

41. 41
Timing of IUD insertion
 An IUD can be safely inserted at any time
after delivery, abortion or during the
menstrual cycle
 The IUD can also be inserted at Caesarean
section

42. 42
IUD Use
and Medical conditions
 a woman with a H/O
ectopic pregn can use a
copper IUD or the
Levonorgestrel IUD
 a progestin releasing
IUD should be
considered for women
with bleeding disorder
 women at risk of
bacterial endocarditis
should receive
prophylactic antibiotics
at insertion & removal
 current, recent, or
recurrent PID is a
contraindication for IUD
use

43. 43
Pregnancy with IUD in situ
 Spontaneous abortion - 40-50%, IUDs
should be removed if pregnancy is
diagnosed and the strings are visible
 Septic abortion - there is no evidence that
there is an increased risk of septic abortion if
pregn occurs, other than with the Dalkon
Shield
 Pre-term labour and birth - incidence is
increased 4-fold

44. 44
Barrier methods
Have been the most widely used contraceptive
technique throughout recorded history.
 Spermicides - 21% failure rate
 Cervical cap - 18-28%
 Sponge - 18%
 Diaphragm - 18%
 Condom - 12%

45. 45
Periodic abstinence
 Is keyed to the observation of naturally
occurring signs and symptoms of the fertile
phase of the menstrual cycle.
 It takes into account the viability of sperm in
the female reproductive tract and the life
span of the ovum

46. 46
Methods of Periodic abstinence
 Rhythm of Calender method
 Cervical Mucus method
 Symptothermal method

47. 47
Periodic abstinence
Periodic abstinence is associated with good
efficacy when used correctly and consistently
and the following rules are observed:
 No intercourse during mucus days
 No intercourse within 3days after peak
fecundity
 No intercourse during times of stress

48. 48
Withdrawal
 Involves removal of the penis from the
vagina before ejaculation takes place
 1st year failure rate - 18%
 Some sperm may be released before
ejaculation
 Is a better method than using no method at
all

49. 49
Lactational Amennorrhoea Method
(LAM)
 High concentrations of prolactin work at both
central and ovarian sites to produce
lactational amenorrhoea and anovulation
 Elevated levels of prolactin inhibit the
pulsatile secretion of GnRH

50. 50
LAM
 Only amenorrhoeic women who
exclusively breastfeed at regular intervals,
including at nighttime, during the first 6
months have the contraceptive protection
equivalent to that provided by oral
contraception

51. 51
LAM
 With menstruation or after 6 months, the risk
of ovulation increases
 Supplemental feeding increases the risk of
ovulation (and pregnancy) even in
amenorrheic women
 Total protection against pregnancy is
achieved by exclusively b/feeding for 10
weeks

52. 52
B/feeding and Contraception
The rule of 3s
 In the presence of FULL b/feeding, a
contraceptive method should be used
beginning in the 3rd postpartum month
 With PARTIAL b/feeding or NO b/feeding, a
contraceptive method should begin during
the 3rd postpartum week

53. 53
B/feeding and Contraception
 Oral contraception even in low doses
diminishes the quantity and quality of breast
milk
 Depo-provera does not affect breast feeding

54. 54
B/feeding and Contraception
cont’d
 Periodic abstinence cannot be used with a
great deal of confidence
 Barrier methods are an excellent choice for
motivated couples
 IUDs can be inserted after vaginal or C/S

55. 55
Female Sterilization
 Unipolar coagulation
 Postpartum tubal excision
 Silastic (Falope or Yoon) ring
 Interval tubal excision
 Bipolar coagulation
 Hulka-Clemens clip/Filshie clip

56. 56
Advantages of female sterilization
 Very effective-failure one in 200
 Permanent
 Nothing to remember
 No interference with sex
 Increased enjoyment-no worries
 No effect on milk
 No health reisks
 Can be done soon after birth

57. 57
Disadvantages
 Painful for few days
 Uncommon complications of surgery
– Infection
– Internal infection and bleeding
– anaesthetic risks
– Death
– Ectopic
– Requires trained staff
– Reversal difficult and expensive
– No protection against STI
– No method of proving effectiveness

58. 58
Male Sterilization
 Standard vasectomy
 “No scalpel” technique

59. 59
Advantages of vasectomy
 Very effective-failure 1/700
 Permanent
 Nothing to remember after 20 ejaculations or
3 months
 No interference with sex
 Increased enjoyment
 No apparent longterm health risks

60. 60
 Easier to perform,less expensive
 Able to test for efectiveness at any time

61. 61
disadvantages
 Complications of surgery
– Discomfort for 2-3 days
– Pain in scrotum
– Brief feeling of faintness
– Bleeding
– Blood clots in scrotum
 Requires someone trained
 Not immediately effective-unless after 20
ejaculations or 3/12

62. 62
 Reversal expensive
 No STI protection

63. 63
Reversal of Sterilization
 Pregnancy rates correlate with the length of
remaining tube, a length of 4 cm or more is
optimal
 Pregnancy rates are lowest with
electrocoagulation, and reach 70-80% with
clips, rings and surgical methods such as the
Pomeroy
 About 2 per 1000 women will eventually
undergo tubal anastomosis

64. 64
counselling
 Consider reason for request
 Age
 Permanet
 Irreversible
 Explain procedure
 Failure rate

65. 65
Medical methods for the Male
 Hormonal contraception is inherently a
difficult physiological problem, because
unlike cyclic ovulation in the female,
spermatogenesis is continuous

66. 66
Medical methods for the Male
 Sex steroids reduce testosterone synthesis
which leads to loss of libido and development
of female 2o sexual characteristics. Sperm
counts are not reduced adequately
 GnRH analogues also decrease endogenous
synthesis of testosterone, and supplemental
testosterone must be provided

67. 67
Medical methods for the Male
 Gossypol a derivative of cotton seed oil,
effectively decreases sperm counts to
contraceptive levels, by incapacitating the
sperm producing cells
 The pills are taken daily for 2 months until
sperm are no longer observed in the
ejaculate, and then weekly
 Fertility returns to normal 3 months after
discontinuation

68. 68
Emergency Contraception
 Emergency contraception methods can
prevent pregnancy after unprotected
intercourse, method failure or incorrect
method use
 Can help reduce unplanned pregnancies,
many of which result in unsafe abortion

69. 69
Emergency contraception
methods
 Combined oral contraceptive pills
 Progestin only pills
 Intra uterine contraceptive device

70. 70
Oral contraceptive pills
 Emergency contraceptive pills use the same
ingredients as regular contraceptives
 Should be initiated ideally within 3 days (72
hours) of unprotected intercourse
 Should be taken in two doses 12 hours apart

71. 71
COC
 Each of the two doses of COC should
contain at least 100 ug (0.10 mg) Ethinyl
Estradiol (EE) and 500 ug (0.50 mg)
Levonorgestrel

72. 72
COC
PC-4, Eugoynon 50, Neogynon, Noral, Nordiol,
Ovidon, Ovral, Ovran
 Two tablets per dose: each tablet contains
50 ug EE & either 0.25mg or 0.50 mg
levonorgestrel

73. 73
COC
LoFemenal, Microgynon 30, Nordette, Ovral L,
Rigevidon
 Four tablets per dose: each tablet contains
30 ug EE & either 0.15 mg or 0.30 mg
Levonorgestrel

74. 74
POP
 Each of the two doses of POP contraceptives
should contain at least 0.75 mg
Levonorgestrel

75. 75
POP
 Ovrette - 20 tablets per dose, each tablet
contains 0.0375 mg Levonorgestrel
 Microlut, Microval, Norgestron - 25 tablets
per dose, each tablet contains 0.03mg
Levonorgestrel

76. 76
IUCDs
 Copper T and others
 Insertion within 120 hours (five days) of
unprotected intercourse