Contra

1. CONTRACEPTIVES

2. Presentation outline
 Definition
 Menstrual cycle overview
 Desired outcomes
 Methods of contraception
 Evaluation of outcomes

3. Definition
 Contraception is generally defined as the
prevention of pregnancy following sexual
intercourse by inhibiting viable sperm from
coming into contact with a mature ovum or
preventing a fertilized ovum from
implanting successfully in the endometrium.

4. overview of menstrual
cycle
Menstrual cycles are counted from the first day
of menstrual bleeding.
Average menstrual cycle is 28 days.
Divided into three phases:
 The follicular phase (pre-ovulatory phase),
 The ovulation phase
 The luteal phase (post-ovulatory phase)

5.  Influenced by the hormonal relationships among the
hypothalamus, anterior pituitary, and ovaries
epinephrine and norepinephrine
gonadotropin-releasing hormone (GnRH)
gonadotropins,
(FSH), and (LH).
Estrogen and progestroneg
At the end, either pregnancy or menstruation
occurs.

6. The Menstrual Cycle
Copyright © Pearson Education 2010

8. Desired outcomes of contraceptives use
 Primary goal
Prevention of pregnancy.
 Secondary goals
prevention of STDs
improvements in menstrual cycle regularity
 prevention of malignancies and other
health conditions
management of perimenopause

9. Methods of contraception
 Barrier methods
 Spermicides
 Sponges
 Condoms
 Diaphrams
 Cervical cap
 Hormonal methods
 Oral pills
 IUD
 Injectables
 Implants and viginal rings
 Skin patches
 Emergence contraception

10. Spermicides
Active ingredient is nonoxynol -9 which is considered
safe and effective by the FDA.
For vaginal use only
They are inserted deep into the vagina shortly before
intercourses.
Dosage forms
Creams, jellies, and gels
Supp & tabs

11. Benefits
• easy to use.
• Cheap
• have no effect on a woman’s natural hormones.
• can be used while pregnancy & breastfeeding
Adverse effects
• Genital Organ Pruritis
• Rectal Irritation,
• Vaginal Burning,
• Vaginal Discharge,
• Vaginal Dryness,
• Vaginal Irritation

12. Cont….
• Risks
 When used alone, spermicides do not protect against
STD infection, including infection with HIV. So, it
should only be used if you are at low risk of HIV
infection

13. Sponges
 a doughnut-shaped device made of soft foam coated
with spermicide.
 The sponge is inserted into the vagina to cover the
cervix.
 It is believed to act as a contraceptive in three ways:
1. mechanically blocking the cervical entrance,
2. absorbing semen
3. providing a spermicide.
 The sponge can be worn for up to 30 hours total.

15. • It can be put in up to 24 hours before sex
• The sponge does not protect against STDs, including
HIV.
• Its effectiveness is higher in women who have never
given birth (Childbirth changes the size and shape of
the cervix, which may affect how the sponge covers the
cervix).
• Can make irritation or allergy from latex.

16. Benefits
 It can be bought over-the-counter.
 It has no effect on a woman’s natural hormones.
 Each sponge contains enough spermicide for repeated
acts of intercourse during a 24-hour period.
 It can be used while breastfeeding beginning 6 weeks
after childbirth.
Risks
 The sponge should not be used if you gave birth less
than 6 weeks ago.
 Do not wear the sponge for more than 30 hours total.
 Frequent use of spermicides can increase the risk of
getting HIV from an infected partner.

17. Condoms
 Can be Latex or polyurethane type
 Available for both sexes
Benefits
Condoms do not cost very much.
They can be bought over-the-counter.
They have no effect on a woman’s natural hormones.
They can be used while breastfeeding.
provide the best available protection against STDs.
The female condom can be inserted up to 8 hours before sex.
Risks
 The only risk related to condom use is when there is tearing.

18. Female condom

19. Male condom

20. Diaphragm
• a reusable dome-shaped rubber cap with a flexible rim
that is inserted vaginally
• fits over the cervix in order to decrease access of sperm
to the ovum
• Its effectiveness depends on its function as a barrier
and on the spermicidal.
• may be inserted up to 6 hours before intercourse and
must be left in place for at least 6 hours afterward

22. Advantages
• Decreased incidence of cervical neoplasia
• low cost
Disadvantages
• High user failure rate
• Decreased efficacy with increased frequency of intercourse
• Increased incidence of vaginal yeast UTIs, TSS
• Cervical irritation

23. Cervical cap
• a soft, deep cup with a firm round rim that is smaller than a
diaphragm and fits over the cervix like a thimble
• can be inserted 6 hours prior to intercourse and remain in place
for multiple episodes of intercourse without adding more
spermicide
• should not be worn for more than 48 hours at a time
• Failure rates are higher than with other methods

25. Advantages Disadvantages
• Low cost
• Latex-free
• Some protection against
STDs
• FemCap reusable for up to 2
years
• Higher failure rate
• Decreased efficacy with
parity
• cannot be used during
menses

26. •
Hormonal method

27. Components
• Progestins
 provide most of the contraceptive effect
 thickening cervical mucus to prevent
sperm penetration,
 slowing tubal motility
 delaying sperm transport,
 inducing endometrial atrophy.
 inhibits ovulation

28. Components cont…
• Estrogens
 The primary role is to stabilize the endometrial
lining and provide cycle control
 Also prevent ovulation
 Mestranol and ethinyl estradiol

29. Points to be considered while using COCs
 A medical history and blood pressure measurement
before use
 The benefits,
 Adverse effects,
 Risks should be considered

30. Adverse effects
• Estrogen excess
 Nausea, breast tenderness, headaches, cyclic weight gain due
to fluid retention
 Dysmenorrhea, menorrhagia, uterine fibroid growth
• Estrogen deficiency
 Vasomotor symptoms, nervousness,
 decreased libido
 Early-cycle (days 1–9) breakthrough bleeding and spotting
Increase

31. • Progestin excess
Increased appetite, weight gain,
bloating, constipation
Acne, oily skin, hirsutism
Depression, fatigue, irritability
• Progestin deficiency
Dysmenorrhea, menorrhagia

32. Safety concern
• WHO precautions in the provision of CHCs
• 4 categories of precautions
 Category I- no contraindication
 Category II- benefits > outweigh risks
 Category III- risk > benefit. Need
monitoring
 Category IV-Absolute contraindication

33. Oral Contraceptives
Combined oral contraceptives (COCs) Vs
progestin only pills (POPs)

34. COCs
 Preparation with the lowest oestrogen & progestogen
which gives good cycle control & minimal side-effects
should be selected.
MOA
 Changing the body's hormone balance so that you do not
ovulate.
 Causing the mucus made by the cervix to thicken and
form a 'mucus plug' in the cervix
 Making the lining of the uterus thinner.

35. Types of cocs
 Mono-phasic
Fixed amount of estrogen and progesterone in 21 pills.
 Bi-pahsic:
Fixed amount of estrogens and changeable levels of
progesterones
 Tri-phasic contraceptives: 3 different strength pills are
available
 Extended cycle pills – 84 days + 7days placebo
 Continuous combined pills- few /no placebo pills
 Third generation pills - newer progs
eg . Desogestrel, norgestimate etc…

36. Advantages
1. Reduced dysmenorrhoea and menorrhagia.
2. Reduced incidence of premenstrual tension.
3. Reduced risk of ovarian and endometrial cancer.
4. Reduced risk of pelvic inflammatory disease, which
may be a risk with intra-uterine devices.

37. Choice of cocs
 are similarly effective in preventing pregnancy,
 the initial choice is based on
• the hormonal content and dose,
• preferred pattern of pill use,
• coexisting medical conditions

38. Pops(minipills)
• The 28 days active hormone per cycle
• less effective than combination OCs
• associated with irregular menstrual bleeding.
• must be taken every day at approximately the same
time.
• the risk of ectopic pregnancy is higher than with other
hormonal contraceptives.

40. What if dose missed????

41. Transdermal patch
• includes 0.75 mg of EE and 6 mg of norelgestromin,
• abdomen, buttocks, upper torso, or upper arm
• Applied at the beginning of the menstrual cycle
• Replaced every week for 3 weeks
• compliance > ocs
• risk of increased estrogen exposure

42. Vaginal Rings
 It is a 54-mm flexible ring, 4 mm in thickness
 contains EE and etonogestrel (NuvaRing)
 It stays there for 21 days, then remove the ring for 7 days.
 The ring can be used as a continuous-dose form of birth control.
 To use it this way, a new ring is inserted every 3 weeks with no
ring-free week in between
 precise placement is not an issue

43. Implant
 Etonogestrel-releasing (Implanon®)
• Consisting of a single flexible rod; the rod is inserted
subdermally into the lower surface of the upper arm and it
provides effective contraception for up to 3 years.
• If a women wish to become pregnant, the implant can be
removed by health care provider, and fertility returns without
delay
• The implant can be used by women who are breastfeeding.

45. Injectable Progestins.
DMPA 150 mg (Depo-Provera)
• administered by deep intramuscular injection
• in the gluteal or deltoid muscle
• within 5 days of onset of menstrual bleeding
• inhibits ovulation for more than 3 months
DMPA (Depo-SubQ Provera 104)
• a new formulation approved by the FDA contains 104 mg of
DMPA
• injected subcutaneously
• into the abdomen or thigh
• Reduces BMD (need monotoring)

46. Intrauterine Devices
small, "T-shaped" devices made of flexible
plastic that inserted into a woman's uterus.
 It is one of the most effective reversible forms
of birth control available.

48. Types
IUD that slowly releases
progesterone
(hormonal)
Copper containing IUD
(non-hormonal)
The hormonal IUD works for up
to 5 years
The copper IUD works for up to
10 years.

49. Mirena
• Prevent egg from passing by blocking fallopian tube
• Prevent ovulation (but less than combined pills)
• prevents pregnancy by thickening a woman's cervical
mucus & prevents sperm penetration

50. Para gard
• Copper T380, Multiload 375 ® (polyethylene
loop), Nova-T®
• MOA:
 Block fallopian tube
 Release of leukocytes and prostaglandins by the
endometrium
 These substances are hostile to both sperm and
eggs

51. Benefits OF IUD
No need to remember it every day.
The hormonal IUD may help decrease and, in some cases, treat
menstrual pain .
If a woman wishes to become pregnant, she can have the IUD
removed.
It can be used by women who are breastfeeding.
The copper IUD has no effect on a woman’s natural hormones.

52. RISK OF IUD
 There is an increased risk that the pregnancy will be ectopic.
 The IUD should be removed from pregnant women when
possible.
 The woman having STD or at risk to have, she’s at risk of
Pelvic inflammatory disease (PID) is an infection of the uterus
and fallopian tubes specially in the first 3 weeks after insertion
of an IUD.

53. Emergency Contraception
 Is used to prevent unwanted pregnancy after unprotected sexual
intercourse
 It is effective if taken within 3-5 days of unprotected intercourse.
 Hormonal emergency contraception involves the use of
levonorgestrel
 Currently plan B is FDA approved
 Post coital insertion of IUD also method of emergency
contraception.
 Also 4 pills of COCs & then 2 pills after 12 hrs

54. EVALUATION OF OUTCOMES
• At least annual blood pressure monitoring is recommended for
all users of CHC
• history of glucose intolerance or overt diabetes mellitus begins
or discontinues the use of CHC, glucose levels
• at least annual (more frequent if they are at risk for STDs)
cytologic screening

55.  Women using Implant should be monitored annually for
 menstrual cycle disturbances,
weight gain,
local inflammation or infection at the implant site, acne,
breast tenderness, headaches, and hair loss.
 Women using DMPA should be asked at 3-month follow up visits
about
 weight gain,
menstrual cycle disturbances, and
STD risks.

56. Thank you !!!