Gyna

1. Methods of contraception
Amr Othman Abdelkareem
Assisstant lecturer at OB/GYN
department
Sohag Faculty of Medicine

2. Introduction
• Definitions:
– Fecundability: ability of a couple to achieve
pregnancy during one menstrual cycle. About 25%
– Fecundity: ability of a couple to have a live birth
during one menstrual cycle.

3. Pearl index
• Unit is : /HWY (hundred women per year)
• PI / 1200 = # un desired preg./ total # of months of use

4. Types of Contraceptive methods

5. Types of Contraceptive methods

6. Types of Contraceptive methods
• 1- Natural ( physiological).
• 2- Mechanical.
• 3- Chemical.
• 4- Hormonal.
• 5- Surgical (sterilization).
Barrier
Except IUD

7. 1-Natural methods
• Abstinence.
• Coitus interruptus (withdrawal).
• Periodic abstinence ( fertility awareness based
methods, safe period).
• Lactational amenorrhea ( LAM ).

8. 2-Mechanical methods
A- The intrauterine device ( IUD )
“ Intrauterine contraceptive device (IUCD)”

9. Historical background

10. Types of IUDs
1. Inert devices (non medicated) lippes loop
2. Medicated devices:
– Copper devices. e.g.Cu T 380A , Multiload ,
NovaT .
– Hormone releasing devices. e.g. Progestasert &
Mirena.
– Frameless IUD.

11. Indications ???
• Contraception
• Asherman’s syndrome

12. Method(s) of application
• Withdrawal technique.
• Pushing out technique.
Post insertion precautions

14. Complications and side effects
1. pain and shock during insertion.
2. post insertion bleeding.
3. perforation.
4. expulsion.
5. Vaginal discharge.
6. pain.
7. bleeding.
8. Pelvic infection.
9. Pregnancy ( contraceptive failure)
10. Ectopic pregnancy.
11. Difficult removal.
12. Discomfort to the husband.
13. Infertility.

15. Contraindications
• Pregnancy
• Congenitally malformed uterus
• Uterine fibroid encroaching on the cavity
• Abnormal uterine bleeding
• Current or history of PID
• Women at risk for STDs
• History of ectopic pregnancy
• Patient with valvular heart lesions
• Nulligravid women
• Allergy to copper

16. Missed threads (missed IUD)

17. Investigations
Speculum examination &
Pelvic ultrasonography
Intrauterine
1-detached threads
2-threads cut too short
3-threads adherent to
cervical mucousa
Extrauterine
1- perforation
2-expulsion
Plain X-ray

19. B-Barrier methods
• Types:
1. Male condom
2. Female condom
3. Vaginal diaphragm
4. Cervical cap
5. Vaginal sponge

20. 1- Male condom

21. • Male condoms can be made of latex,
polyurethane or rubber.
• They can be lubricated with a spermicidal to
improve its effectiveness.
• Advantages:
– prevents STDs
– No systemic side effects
– Simple

22. • Disadvantages:
1. Failure rate is 3-6/ HWY
2. Allergy to latex or spermicidal may occur
3. Interferes with skin to skin contact→ less
pleasure during coitus.

23. 2-Female condom

24. • Advantages: as male condom but with better
protection against STDs.
• Disadvantages: as male condom except for
there’s no known allergy to polyurethane.

26. 3-Vaginal diaphragm

27. • Made of rubber or latex with flexible metal
rim.
• A spermicidal cream must be used, placed in
the dome of the cap and around the edges.
• Must left in place after intercourse for at least
6 hours and not more than 24 hrs. so that all
spermatozoa will be killed.
• Washed, dried and powdered and kept for
more times to be used.

29. • Disadvantages:
1. Failure rate 3-15 preg./HWY
2. Difficult applications
3. Can’t be used genital organs displacements.
4. Recurrent cystitis due to compression of the
urethra which forces the bacteria into the
bladder.
5. Allergic reactions to latex or spermicidal.
6. If left in place for long period can lead to
Toxic shock syndrome.

30. 4- Cervical cap

31. • It is cup shaped, made of rubber and fits
directly over the cervix where it is retained in
its place by suction and its flexible rim.
• Spermicidal cream must be used
concomitantly.
• Difficult application and removal.
• Can be displaced during coitus.
• Must be removed not before 6 hrs. postcoital.
• High failure rate( 10-20 preg./HWY)

32. 5- Vaginal sponge

33. • Polyurethane sponge containing spermicidal.
• Fits to the cervix and act mechanically and
chemically.
• Not to be removed before 6 hrs. post coital

34. 3-Chemical methods
( spermicidals)

36. • Comes in the form of tablets, creams, jellies,
foaming tablets, aerosol foam or soluble film.
• Contains a spermicidal agent like nonoxynol-9.
• Applied 15-30 min before intercourse and not
washed before 6 hrs. postcoital.
• Can be used alone or with other barrier
methods to enhance their effectiveness.

37. • Advantages:
1. No systemic side effects
2. Enhances effectiveness of other barrier
methods.
3. Helps in prevention of STDs.
• Disadvantages:
1. Failure: 20-25/HWY
2. Promote growth of E.coli in the vagina and
predisposes to UTI.
3. May cause irritation and allergic reaction.
4. They are messy.

38. 4- HORMONAL CONTRACEPTION

39. Main forms
• Pills
• Injectables
• Implants
• Vaginal rings
• Skin patches
• IUDs ( Mirena & progestasert)

40. Contraceptive pills
• 1- combined oral contraceptive pills.
(COCs)
• 2- progestogen only pills.
(POPs)

41. 1- COCs
• Composition :
1. Estrogen :
• Ethinyl estradiol (20 times more active)
100µg
50 µg
35 µg
30 µg
20 µg
• Mestranol (3-ethyl ester of ethinyl estradiol)
low dose pills

42. Composition:
2. Progestogen:
• 19-Nortestosterone derivatives:
– Norethinderone “norethisterone”.
– Levonorgestrel (microcept) 150 µg
– Gestodene (gynera) 75 µg
– Desogestrel ( marvelon)150 µg
– Norgestimate ( cilest )250 µg
• 17-α spironolactone derivatives:
– Drospirenone (yasmin) 3mg

43. Types of COCs
1. Monophasic pills.
– E.g. Microcept, Gynera, Cilest, Marvelon and Yasmin.
2. Biphasic pills.
– Estrogen fixed dose throughout the cycle with
doubled dose of progestin in the 2nd. Half of the
cycle.
3. Triphasic pills.
– 1st. 6days : 30 µg EE + 50 µg LNG
– 2nd. 5days: 40 µg EE + 75 µg LNG
– 3rd. 10days: 30 µg EE + 125 µg LNG

44. Types of COCs
• 1st. Generation: EE > 50 µg
• 2nd.Generation: EE<50 µg + any progestin
except( Gestodine, Desogestrel, Norgestimate
or Drospirenone)
• 3rd. Generation: EE<50 µg + Gestodine,
Desogestrel or Norgestimate.
• 4th. Generation: EE<50 µg + Drospirenone.

47. Advantages of COCs
1. Highly effective if used correctly.
2. Rapid return of fertility after stoppage.
3. Suitable for nulligravid women and newly
married couples.
4. Completely controlled by the woman and can be
stopped at any time unlike other methods (IUD
& Implants).
5. No need to do any thing at the time of
intercourse.
6. Increased sexual enjoyment as there’s no worry
about getting pregnant.

48. Non contraceptive benefits of COCs
7. Regulation of the cycle with ↓ amount &
duration.
8. So it helps in prevention & ttt of Fe def.
anemia.
9. ↓risk of epithelial ovarian tumors.
10.↓Inc. of functional ovarian cysts.
11.↓ risk of ectopic pregnancy.
12.↓risk of developing PID.
13.↓risk of endometrial cancer.
14.↓spasmodic dysmenorrhea and PMS.

49. Cont.” Non contraceptive benefits of
COCs”
15.↓risk of benign breast lesions.
16.May protect from colorectal cancer.
17.May ↓ Inc. of fibroid.
18.May ↓ Inc. of rhumatoid arthritis.

50. Non contraceptive uses of COCs
1. Ttt of Dysfunctional uterine bleeding.
2. Ttt of Endometriosis.
3. Ttt of PMS.
4. Ttt of spasmodic dysmenorrhea.
5. Postponing of menstruation for social or
religious causes.
6. Ttt of hirsutism: “ Yasmin” contains
antiandrogenic progestin Drosprirenone.

51. How and when to use it???
Start on the 1st 5 days of the cycle
regularly every day : 21 days 0n, 7
days off.

52. Disadvantages & Side effects
• 1- The need for daily use.
• 2- GIT:
– Nausea and vomiting.
– Increased incidence of gall bladder stones).
– Women with active hepatitis will have a deterioration
in liver functions.
– ↑inc. of hepatocellular adenoma ( rare).
• 3-central nervous system:
– Headache and migraine.
– Mood changes: depression, irritabilty, ↑or↓ libido.

53. • 4-Breast
– Not suitable with breast feeding.
– Mild breast tenderness may occur.
– May increase the risk for developing breast cancer
• 5-Genital tract.
A. Menstrual irrigularities:
– BTB
– Hypomenorrhea
– Missed period
– Hypomenorrhea.

54. B. Cervix:
– Cervical erosion is a common finding
– Increased risk for CIN and invasive cervical
carcinoma ???confounding effects can’t be
eliminatd.
C. Vagina:
– Increased normal vaginal disharge.
– Vaginal candidiasis.
• 6-CVS:
– Increased risk of venous thromboembolism.

55. – Increased risk of MI & Hgic stroke in elderly
patients with hypertension and smokers.
– Slightly Increased risk of ischemic stroke in elderly
nonsmokers non hypertensive.
• 7-Metabolic :
– Increased body wt.
– In diabetic patients: leads to hyperglycemia and
increased risk of vascular complications.
– Dyslipidemia:↑cholesterol, ↑triglycrides, ↑LDL&
↓HDL.

56. • 8-skin changes:
– Acne may be accentuated by the pills ( now use
Yasmin).
– Rare: dark pigmentation and hair loss.

57. Progestogen only pills ( POPs)
• Types:
1. Levonorgestrel 30µg ( microlut)
2. Lynestrenol 500µg (exluton)

59. How to use????
• Start on the 1st 5 days of the cycle or after 6
weeks postpartum.
• Daily tablet at the same time every day
without discontinuation.
• Woman consider her self fertile for the first
week of use.
Missed pill??

60. Better not to be used in:
• Active hepatitis
• Ischemic heart diseases.
• Breast cancer
• History of ectopic
• With other drugs as: rifampicin,
phenytoin,carbamazipine,
barbiturates,grisefulvin…..

61. Advantages
• Suitable when breast feeding
• Suitable when EE is contraindicated
• Immediate return of fertility
• Less likely to cause metabolic disturbances

62. Disadvantages
• Must be taken daily at the same time
• Less effective than COCs
• More likely to cause menstrual irregularities
• Headache, nausea, breast tenderness, mood
changes, depression and ↓libido.
• Less effective in preventing ectopic pregnancy.

63. POIs
• Types:
1. DMPA 150 mg ( depoprovera)
2. Norethinderone enanthate 200mg
(noristerat)

65. How and when to use it??
• Start on the 1st week of the cycle or
after 6 weeks postpartum.
• Injection every 2 or 3 months
according to type of injection.
• Grace period: 2 weeks for
depoprovera and 1 week for noristrat

66. Side effects
1. Menstrual irregularities. How to treat???
2. Delay in return of fertility.
3. Weight gain
4. Headache and dizziness
5. Effect on lipid metabolism ( no strong evidence
of increased C.V.S. diseases.
6. Reduced bone density. Due to prolonged
hypoesrtogenemia.
7. Slight increase of cancer risk in young age during
the 1st 5yrs. Of use

67. Disadvantages
• Common side effects
• Delayed return of fertility
• Repeated injections
• May lead to transmission of blood born
diseases
• No protection against STDs

68. Advantages
1. High effectiveness.
2. Long term effect.
3. No need for daily use.
4. No need to do any thing at the time of
intercourse.
5. Less likely to have failures due to incorrect
use.
6. Presence of grace period.
7. Doesn’t affect breast milk.

69. 8. Decreased risk of estrogen related
complications; stroke, MI, thromboembolism,
safe for smokers over 35 yrs. Of age.
9. Prevent ectopic pregnancy.
10.Prevent Fe def. anaemia.
11.May reduce PID
12.Decrease endometrial cancer risk
13.May reduce incidence of endometriosis and
decreases the symptoms.
14.May check the development of existing
fibroids.

70. Eligibility
A. Can be used when other alternatives are
unavailable in:
1. Severe hypertension
2. Complicated diabetes.
3. Liver cirrhosis
4. Young patients younger than 20 yrs.

71. B- contraindications:
1. Suspected pregnancy
2. Breast feeding less than 6 ws.
3. Current and history of ischemic Ht. Dis.
4. History of stroke.
5. Severe headache and migraine
6. Current or history of breast cancer
7. Benign and malignant liver tumors.
8. Active hepatitis
9. Using anticonvulsants
10.Undiagnosed vaginal bleeding

72. Combined injectable
contraceptives

73. Types
1. Mesigyna
Norethinderone enanthate 50 mg + estradiol
valerate 5 mg.
2. Cycloprovera & Cyclofem
DMPA 25 mg + estradiol cypionate 5 mg

75. How to use it ?
• Start on the 1st 5 days of the cycle.
• Taken regularly every month with grace period
of 3 days.
• Menses is expected to occur 15 days after
each injection due to drop in estrogen level.

76. • Mechanism of action, eligibility criteria and
side effects are the same as for COCs.
• However, because that the estrogen used in
the CICs has shorter duration of action and is
more physiological and less potent compared
to estrogen in COCs, the estrogen related side
effects and metabolic effect is expected to be
reduced with this type of combined
contraception.

77. Subdermal contraceptive
implants

78. Types
1. Norplant system
2. The 2 rod system ( javelle)
3. Implanon
4. Nestrone

79. 1- Norplant system
• Composed of 6 silastic capsules.
• Each containing 36mg levonorgestrel.
– Release rate is : 80µg/day for the 1st year.
– 30µg/day for next 4yrs.
• Implanted subcutaneously in the inner side of
the left arm under local anasthesia.
• Duration of action 5yrs. Then removed but can
be removed at any time with immediate
return of fertility.

81. Other contraceptive implants
2. Norplant 2 (javelle):
– 2 silastic rods each containing 75 mg LNG
– Duration of action 5yrs.
3. Implanon:
– One rod system containing 68mg etonogestrel
released at a rate of 40µg/day.
– Duration of action 3 yrs.
4. Nestrone:
– One rod system, duration of action 2 yrs.

83. Other contraceptive implants
5. Uniplant:
– One capsule containing nomegestrol acetate.
– Duration of action one year.
6. Capronor:
– Biodegradable capsule containing LNG.
– Duration of action one year.

85. Thank you