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METHODS OF CONTRACEPTION

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METHODS OF CONTRACEPTION

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METHODS OF CONTRACEPTION

  1. 1. METHODS OF CONTRACEPTION Aboubakr Elnashar Benha University Hospital, Egypt
  2. 2. I. Hormonal Methods II. Intrauterine Device III. Barrier Methods IV. Natural Methods V. Sterilization Outline
  3. 3. I. Hormonal Methods
  4. 4. Advantages  Most effective, long-term reversible contraception available  Most methods offer complete privacy  Require no planning before intercourse Disadvantages  Require a visit to a healthcare professional  May cause common hormonal side effects  Products containing estrogen may be associated with rare, but serious health risks  Not effective against STD
  5. 5. Daily Use  Oral Contraceptive Pill – Combination pill – Progestin-only pill Nondaily Use  Injectable contraceptive  Contraceptive patch  Hormone-releasing intrauterine system  Emergency Contraception
  6. 6. 1. The Combination Pill  Contain Synthetic Estrogen/Progestin  Modern E2 Dosage ≤ 50 Mcg  Despite Diversity, Side Effects and Efficacies Similar  Requires Patient Compliance  May Be Monophasic or Triphasic
  7. 7. Estrogens:  Ethinyl estradiol  Mestranol Progestins:  Ethynodiol diacetate  Norethindrone acetate  Norethindrone  Norgestrel  Levonorgestrel  Desogestrel  Norgestimate  Drospirenone 2nd Generation 3rd Generation Spironolactone Derived
  8. 8. Advantages:  Highly effective  Provides noncontraceptive health benefits  Private  Does not require vaginal insertion  Allows to control cycle Disadvantages:  Must be taken daily  Side effects may lead to discontinuation  Associated with rare, but serious health risks, such as blood clots and stroke
  9. 9. Non-Contraceptive Benefits of OCPs Improvement Dysmenorrhea Acne Hirsutism Anemia Cycle Regulation Reduction Risks Colorectal Cancer (18-40%) Endometrial Cancer PID (10 – 70%) Osteoporosis Osteopenia Cleveland Journal of Medicine 2004
  10. 10. Mechanism of Action  Suppresses LH / FSH Release (E2 FSH, P LH)  Progestin Thickens Cervical Mucus and Alters Endometrium  Major Effect Is Anovulation and Impairment of Sperm Transport and Oöcyte Implantation
  11. 11. Side Effects  Breakthrough Bleeding (≤ 25%)  Amenorrhea  Breast Tenderness, Nausea  ? HTN  ? Weight Gain
  12. 12. Risks  Thromboembolism (≥ 35 yo, Smoker)  MI (Smokers Only):  < 15 cig/day: 3X Risk  > 15 cig/day : 21X Risk  Liver Adenomas (Very Rare)
  13. 13. 2. The Contraceptive Patch (Evra Patch) Advantages:  Efficacy comparable to OCPs  Weekly application encourages compliance  Does not require vaginal insertion Disadvantages:  Application site reactions may occur  May not be as effective in women weighing more than 198 pounds  May produce side effects similar to OCPs, with higher rate of transient breast pain  Noncontraceptive health benefits theoretically similar to combination OCPs, but not as well documented  May be visible on the skin OCP = Oral Contraceptive Pill
  14. 14. 3. The Progestin-Only Pill Progestins:  Norethindrone  Norgestrel Advantages:  Useful for women with contraindications to estrogen  Use with postpartum women who are breastfeeding  Does not require vaginal insertion Disadvantages:  Higher pregnancy rate than combination OCPs  More sensitive to missed pills than combination OCPs  Associated with abnormal bleeding and other side effects
  15. 15. 4. Injectable Hormonal Contraception Advantages:  Highly effective  Convenient three month administration schedule encourages adherence  Private  Useful when estrogen should be avoided  Decreases risk of endometrial cancer Disadvantages:  Irregular bleeding and amenorrhea frequently occur  Weight gain, abdominal pain, and depression are common side effects  Prolonged use may decrease bone mass
  16. 16. Depo Provera: -every 3 months -Medroxyprogestin Acetate 150 mg. Types
  17. 17. Main Side-Effects:  Amenorrhea  AUB  Weight Gain  Hair Loss
  18. 18. 5. Emergency Contraception Indications -standard of care for women not protected by efffective contraception. -No contraception was used -Condom broke, slipped, leaked etc…. -Missed more 2 or more days of ocp’s -Highly effective 75% -Effective up to 120 hours after unprotected sex -Will not disrupt or harm developing pregnancy J Adolesc Health. 2004;35:66-70.
  19. 19. FDA Approved Emergency Contraceptive Kits PREVEN KIT - Contains 4 pills - EE 50 ug. - Levonorgestril 0.25 mg. - 2 pills 12 hourly for 2 doses Plan B Kit - contains 2 pills - Levonorgestril 0.75 mg - 1 pill 12 hourly for 2 doses
  20. 20. The Yuzpe Regimen:  Two Doses of:  EE 0.1 mg with dl-norgestrel 1.0 mg  Administered 12 hours apart  First dose taken within 120 hours of unprotected intercourse The Combination Pill Advantages:  Prevents approximately 75% of unintended pregnancies Disadvantages:  Increased incidence of side effects due to high estrogen component  High rate of nausea (50%) and vomiting (20%) may limit adherence EE = Ethinyl Estradiol
  21. 21. The Progestin-Only Pill Advantages:  More effective than Yuzpe regimen  Better tolerated than Yuzpe regimen  May be taken as a single dose  May be preferable for women with history of idiopathic thrombosis Disadvantages:  Associated with a moderate degree of side effects including nausea, vomiting, dizziness, and fatigue Plan B (levonorgestrel 0.75 mg) Levonorgestrel:  Single dose of 1.5 mg or two doses of 0.75 mg taken 12 hours apart  First dose administered within 120 hours
  22. 22. ACOG GUIDELINES (Emergency Contraception) -Should be offered or made available for (UPSI) - Levonorgestril only regime is more effective & less side effects than combined regime - 1.5 mg Levonorgestril can be taken single dose or 2 divided doses (0.75 mg) 12-24 hrs. apart - An anti-emetic can be taken 1 hr before 1st dose - Prescription of EC in advance can increase availability and use.
  23. 23. II. IUD
  24. 24.  ParaGard (CuT380A),  Very Effective (~ TL), Reversible  Risks OVERBLOWN  Does Not Protect Against STD’s  Can Remain for ≤ 10 Years
  25. 25. Mechanisms of Action  NOT ABORTIFACIENT!!!!!!!!  Prevents Conception: – Sperm Transport Inhibited – Sperm Survival / Capacitation Diminished  Prevents Implantation: hCG Levels = 0
  26. 26. Work-up  History: STD’s, Sexual History, Ectopic  PEx: Size / Configuration of Uterus  Cervical Cultures, Pap  Counseling
  27. 27. Contraindications  High Risk for STD’s  Abnormal Uterine Bleeding  Current Pelvic Infection (GC, Chl)  Actinomyces on Pap  ???Nulliparity  Pregnancy  Wilson’s Dz, Cu Allergy (both rare)
  28. 28. Complications  PID: Usually 20 Insertional Contamination – Unproven Role for Prophylactic ABx  Hypermenorrhea  Expulsion  Perforation (< 0.1%)  Failure: IUD Should be Removed  ??Ectopic
  29. 29. 1. The Copper Intrauterine Device (IUD) Advantages:  Highly effective  May be efficacious if inserted up to 7 days after intercourse  Generally well tolerated Disadvantages:  Not cost effective for short-term use  Not recommended for women with a sexually transmitted disease
  30. 30. 2. Multi load with IUCD inserter
  31. 31. 3. Levonorgestrel Intrauterine System Advantages:  Highly effective  Stays in place for up to five years, limiting adherence concerns  Private  Decreases menstrual blood loss Disadvantages:  Requires professional insertion and removal  Abnormal bleeding, dysmenorrhea, and pelvic, abdominal and back pain  May not be appropriate for women with increase STD risk
  32. 32. III. Barrier Methods
  33. 33. Advantages - Preferred by many who have occasional intercourse - Useful alternatives for those who want to avoid hormonal side effects - Some methods available without prescription - Some methods offer limited protection against sexually transmitted disease
  34. 34. Disadvantages -Not as effective as hormonal methods -Efficacy is highly dependent on consistent and correct use -Require fitting by healthcare provider -Require vaginal insertion and removal by the patient that may be difficult or unacceptable -Require concomitant use of spermicide -Associated with an increased risk of urinary tract infection and toxic shock syndrome
  35. 35.  Diaphragm  Cervical Cap Types  Male Condom  Spermicide
  36. 36. Advantages:  Can be inserted hours before intercourse  Does not require removal between acts of intercourse 1. Diaphragm
  37. 37. Disadvantages: -Should not be used with suspected or confirmed latex allergy -Requires prescription and fitting by healthcare provider -Requires insertion and removal -Spermicide must be applied before each use -Must stay in place for at least six hours after last intercourse -May increase risk of urinary tract infections and toxic shock syndrome
  38. 38. 2. Male Condom Advantages:  Provides greater protection against STDs than any other method of contraception  Provides substantial protection against pregnancy when used with a spermicide  Does not require a prescription  Can be used with other methods  Inexpensive and widely available
  39. 39. Disadvantages:  Can only be used for one act of intercourse  Can break or slip during use  May decrease sexual pleasure  May interfere with spontaneity  Requires cooperation of male partner
  40. 40. IV. Natural Methods
  41. 41. 1-Natural family planning techniques (Fertility Awareness Methods) 2-Contraceptive effect of breast feeding (Lactational Amenorrhea Method) 3- Withdrawal
  42. 42. 1. Rhythm-standard days method (SDM)  For women with menstrual cycles between 26 & 32 days.  Avoid unprotected IC day #9- 19  70-80% effective  Assumes ovulation about day #14
  43. 43. 2. Withdrawal Method  80-90% effective  Always available  Requires motivation, sense of timing  Some sperm present in pre-ejaculatory fluid  Psychological issues
  44. 44. V. Sterilization
  45. 45.  Surgical sterilization  Permanent, irreversible  >99% effective
  46. 46. METHODS OF TUBAL LIGATION Procedure Timing Technique Minilaparotomy •Post Partum •Post Abortion •Interval •Mechanical Devices (Clips, Rings) •Tubal Ligation or Excision Laparoscopy •Interval Only •Electrocoagulation (Unipolar, Bipolar) •Mechanical Devices (Clips, Rings) Laparotomy In conjunction with other surgery (cesarean section, salpingectomy, ovarian cystectomy etc.) •Mechanical Devices (Clips, Rings) •Tubal Ligation or ExcisionFemale Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-160
  47. 47. Pomeroy Procedure Tied Cut Final result
  48. 48. Filshie Clip
  49. 49. Hulka Clip
  50. 50. Monopolar Coagulation Laparoscopic •Proposed in 1937 by Anderson •Complications •Bowel Burn •Longer portion of tube is damaged •Failures and ectopic pregnancy 1. Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8 Failure Rate:7.5/1000
  51. 51. Bipolar Coagulation Laparoscopic Introduced in 1973 by Jacques Rioux Benefits •Most Common method of Laparoscopic sterilization Complications •Formation of uteroperitoneal fistulas •High rate of Ectopic Pregnancy •Potential for Bowel Burns •Reversals are potentially more difficult due to the extent of tube damage 1. Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170 Failure Rate:24.8/10001

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