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an overview of contraception

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  1. 1. CONTRACEPTION Associate Professor Dr Hanifullah Khan
  2. 2. Objectives1. Understand the definition, classification & terminology2. Understand the reason for contraception3. Know the advantages & side-effects4. Know the proper use of each method5. To be able to advise on the use
  3. 3. Introduction• Definition – any • Allows to choose method used to whether & when to prevent pregnancy have a child19 May 07 3
  4. 4. Reproduction• Ovulation• Fertile period• Fertilisation19 May 07 4
  5. 5. Consequences of unintended pregnancies - fetus • Late booking or no booking. • Fetus more likely to be exposed to harmful sub- stances (smoking tobacco and drinking alcohol). • The child is at greater risk of – weighing < 2.5kg at birth – of dying in its first year of life – of being abused – of not receiving sufficient resources for healthy development.Cleland NEJM 2011 5
  6. 6. Consequences of unintended pregnancies - mother • Late booking or no booking – increased antenatal risks • The mother may be at greater risk of physical abuse • Her relationship with her partner is at greater risk of dissolution. • Both mother and father may suffer economic hardship and fail to achieve their educational and career goals.Cleland 2003October NEJM 2011 6
  7. 7. Reproductive age • The typical woman - capacity to bear children for an 39 years of her life • Different contraceptive methods required for each life stage – to accommodate the complex factors accompanying each stage • Without contraception - 85% of couples conceive within 1 year.Trussell J. Contraception 2010
  8. 8. Female Contraception Reversible Non-Reversible Hormonal Non-Hormonal Tubal ligation COC IUD POP Barriers POP Spermicides Injectables Implants Emergency Mirena7 June 2006 8
  10. 10. Combined Oral Contraception I• Large number of users• Prompt return of ovulation – 70% in 1st cycle , 98% by 3rd cycle*• No permanent loss of fertility• Beneficial effects on future fertility – ↓ ascending infection & PID (progestogenic effect) – ↓ risk of EP – ↑ ferritin levels & Hb*Rice-Wray E et al. Return of ovulation after discontinuation of oralcontraception. Fertil Steril 1967;18:212-8.
  11. 11. Combined Oral Contraception II• Women who conceive after discontinuation of COC: – No ↑ risk of pregnancy loss or EP – No alteration in sex ratio• No ↑ miscarriage rate or chromosomal abnormalities in women who continue COC during early pregnancy*• No risk of masculinization *Huggins GR. Fertility after contraception or abortion. Fertil Steril 1990;54:559-73.
  12. 12. Patch• Transdermal supply of 750 µg ethinyl estradiol (an estrogen) and 6000 µg norelgestromin (a progestin)• Side effects similar to COC• ? Slightly increased risk of TED
  14. 14. Progestogen-only Methods● POP● Subdermal implants● Injectables● Combined injectables● Emergency contraception● Mirena
  15. 15. Progestogen-only Methods Of Contraception*Route of Very low dose Low dose High doseadministrationOral Progestogen-only pillSubdermal Etonogestrel-releasing implant (Implanon®) Levonorgesterel- releasing implant (Norplant®)Intrauterine Levonorgesterel- releasing intrauterine system (Mirena®)Vaginal Vaginal rings (under development)Intramuscular Depo-injection Provera®
  16. 16. POP - Effects• Local effect on cervical mucous & endometrium – inhibits gamete transport & implantation• No effect on future fertility• Does not offer same protection against EP as COC
  17. 17. Subdermal Implants• Implanon – single rod. Between biceps & triceps of non-dominant arm. – 3 year efficacy. – Inhibits LH surge – ovulation inhibition – Oestradiol levels unchanged – The only contraceptive method to have a Pearl Index of 0.* – Prompt return of fertility*• Norplant – older. 6 rods. *Croxatto HB. The pharmacodynamics and efficacy of Implanon. An overview of the data. Contraception 1998;58:91S-97S.
  18. 18. Implanon
  19. 19. Injectables• DMPA• Inhibition of ovulation caused by Gn suppression• Ovulation returns after 4-5 months & median conception time of 5-7 months*• No permanent effect on fertility. However, may take 2 years to return.**• Delay may be due to slow drug metabolism (microcrystalline deposits in muscle)****Kaunitz AM. Ob/Gyn 1993** Kaunitz AM. Int J Fertil Womens Med 1998***Hickey M. Clin Obstet Gynecol 1995
  20. 20. Emergency contraception I• ECP/ "morning-after pills• a short course – either a high-dose combination of estrogen & progestin or – progestin-only – used within 72 hours of unprotected intercourse to prevent pregnancy• taken after SI but before implantation• more effective the sooner they are initiated after SI.• estrogen-progestin combinations (commonly known as the Yuzpe regimen) – may reduce the risk of pregnancy by 75% and the progestin- only formulation by 88%
  21. 21. EC IUCD• copper-containing intrauterine device (IUD) inserted within 120 hours of unprotected intercourse to prevent pregnancy• work by the same mechanisms of action as OC - inhibit ovulation, fertilization, or implantation.• They will not terminate an existing pregnancy
  22. 22. Emergency Contraception IIILevonorgestrel Nordette 4 tablets/dose 2 doses0.15 mg +ethinyl (light orangeestradiol 30 mcg tablets)Levonorgestrel Plan B 1 tablet/dose 2 doses First dose within 72 hours of0.75 mg unprotected intercourse; second dose 12 hours later(no anti-emetic required)
  23. 23. NATURAL METHODWednesday 15 23
  24. 24. Body changes during menstruation • Likelihood of pregnancy high if SI just before or after ovulation • During the menstrual cycle, a number of changes occur in a womans body – By keeping track of these changes, couples can plan when to have intercourse and when to avoid intercourse, depending on whether they are trying to achieve or avoid pregnancy.Wednesday 15 24
  25. 25. What is natural family planning? • A way to help decide when SI can or cannot result in pregnancy • Learn to recognise the changes in a woman’s body that shows when she is fertile each month • Avoid sex at the fertile times, or use condoms or a diaphragm.Wednesday 15 25
  26. 26. Advantages: • Acceptable to most faiths and cultures • No need to take any hormones • No side effects • Gives a greater awareness of fertility • Can be used to plan pregnancy as well as avoid itWednesday 15 26
  27. 27. Disadvantages• No protection against STIs• Takes a long time to learn (3 to 6 months)• Daily tests and records need to be made• Illness, stress and travel can affect fertility indicators• Both partners need to be committed to using the method• Unsuitable for: – Women who cant check their temperature and cervix every day – Couples who are even slightly disorganised – Women with very irregular periodsWednesday 15 27
  28. 28. Methods • Coitus Interruptus • Rhythm Method – Calendar – BBT – Cervical Mucous (Ovulation) – Symptothermal – Ovulation Predictor Kits • Abstinence • Lactational Amenorrhoea MethodWednesday 15 28
  29. 29. Coitus InterruptusWednesday 15 29
  30. 30. Coitus Interruptus (Withdrawal) • The penis is withdrawn from the vagina prior to ejaculation • When done correctly - failure rate of 6.7% (6.7 out of every 100 women) • Advantages - immediately available and it is free • Disadvantages – unsure able to withdraw before ejaculating – preejaculatory fluids may contain viable spermWednesday 15 30
  31. 31. Effectiveness Among typical couples - 19 in 100 will experience an accidental pregnancy in the first yearo Some men cannot tell when they are going to ejaculate. o Some men ejaculate very quickly, before they realize it. o Before ejaculation, almost all penises leak fluid that contains sperm that can cause pregnancy. o Some men lack the experience and self-control to pull out in time. o Some men are unreliable o It offers no protection against STDs and infections. o Its freeWednesday 15 31
  32. 32. Rhythm MethodWednesday 15 32
  33. 33. What is it? • Also known as "fertility awareness" • Uses the menstrual cycle to predict the most fertile time of the month . • Once the fertile time has been identified - dont have sex or use a barrier method during that period.Wednesday 15 33
  34. 34. How does it work? • Based on the fact that: – The fertile period lasts about 4 days following ovulation, when the mature ovum travels through the fallopian tubes to the uterus and can be fertilized • Sperm may live in the female reproductive tract for up to 7 days • The female egg lives for only a day • fertilization may occur even days after intercourse • "safe days" occur 2 days after ovulation and continue until the next periodWednesday 15 34
  35. 35. How effective is it? • Choose a fertility awareness method only if: – There is a cooperative partner – A regular, steady monthly cycle – Willing to invest time and effort required to learn about fertility awareness methods – accept the fact that protection against pregnancy is not perfect • There are no side effectsWednesday 15 35
  36. 36. Several Methods • Several methods of determining which are the most fertile days of the cycle: – Calendar Rhythm Method – Basal Body Temperature Method – Ovulation Method – Symptothermal Method – Ovulation Predictor KitsWednesday 15 36
  37. 37. Calendar Rhythm Method • Requires keeping track of the cycle for 6 to 12 months to determine the pattern of ovulation -will determine when it is most "dangerous" to have sexual intercourse. • Estimate the first and last days of the fertile period – subtract 18 from the length of the shortest cycle and 11 from the length of the longest cycle – if the shortest cycle is 28 days and her longest cycle is 32 days, the first and last days of the fertile period should be days 10 and 21 – should abstain from SI for 12 days, starting on the 10th day after the beginning of the menstrual cycle • The failure rate for this method is 40% (40 out of 100 women).Wednesday 15 37
  38. 38. Shortest cycle (S) minus 18 = Last infertile day of the pre-ovulatory phaseLongest cycle (L) minus 11 = Last fertile day For example:- Length of cycles during last six months = 28, 29, 28, 27, 30, 28 (S = 27) S - 18 = Last infertile day 27 - 18 = 9 (L = 30) L - 11 = Last fertile day 30 - 11 = 19Wednesday 15 38
  39. 39. Basal Body Temperature Method• Keeping track of body temperature• Body temperature rises two days prior to ovulation.Wednesday 15 39
  40. 40. RECORDING & CHARTING THE BBT• The temperature should be taken immediately on waking before getting out of bed, drinking tea or any other activity, and at about the same time each morningWednesday 15 40
  41. 41. THERMOMETERS• Two types of thermometer – Glass / mercury fertility thermometer – Digital thermometer• covers only the range from 35-39 deg. CWednesday 15 41
  42. 42. Ovulation (Billing) Method • Requires feeling and observing the cervical mucus to determine the time of ovulation. • Note the production of clear, watery mucus in the days immediately before ovulation • To avoid pregnancy, intercourse is avoided for several days following change in the color and consistency of cervical mucus.Wednesday 15 42
  43. 43. Changes in the Cervix - in Relation to Ovulation Cervical changes take place over an interval of around 10 days. Approximately 6/7 before the shift in temperature the cervix will begin to show fertile characteristics. Following ovulation, the cervix returns to its infertile state within 24- 48 hoursWednesday 15 43
  44. 44. RECOGNISING THE CHANGES IN CERVICAL MUCUS • Sensation - at the vulva :the sensation may be a distinct feeling of dryness, of dampness or moistness, stickiness, wetness, slipperiness or lubrication. • Appearance – use toilet tissue to blot or wipe the vulva - white, creamy, opaque, or transparent (clear). – Mucus is often noticed on underclothing, where it will have dried slightly causing some alteration in its characteristics • Finger Testing - finger-tip applied to the mucus on the tissue and then pulled gently away to test its capacity to stretch – It may feel sticky and break easily – or it may feel smoother and slippery like raw egg white and stretch between the thumb and first finger, from a little up to several inches before it breaks. This stretchiness is described as the Spinnbarkeit or Spinn effect, and shows that the mucus is highly fertile.Wednesday 15 44
  45. 45. Sensation Finger Test Appearance at Vulva Early Mucus Scanty Moist Thick or White Sticky Sticky Holds its shape Transitional Mucus Increasing Amounts Wetter Thinner Cloudy Slightly Stretchy Highly Fertile Mucus Profuse Thin Slippery Transparent Stretchy (like raw egg white)Wednesday 15 45
  46. 46. Mucus changes throughout the cycle Complete cycle showing typical pattern of menstruation, pre- ovulatory dry days, mucus days with increasingly fertile characteristics approaching peak day, the abrupt change back to less fertile characteristics, the count of four after peak day and post-ovulatory dry daysWednesday 15 46
  47. 47. Symptothermal Method • A combination of the calendar and cervical mucus methods and the womans basal body temperature (BBT) • The first day is estimated by subracting 21 from the shortest menstrual cycle (the calendar method) or noting the first day of cervical mucus associated with ovulation (the cervical mucus method), whichever comes first • BBT is used to predict the end of the fertile period. The woman takes her temperature every morning and notes when body temperature rises, indicating that the corpus luteum is producing progesterone and ovulation has occurred • She can resume sexual intercourse 3 days after this so-called thermal shiftWednesday 15 47
  48. 48. Interpretation of the Sympto-Thermal Chart This sympto-thermal chart shows the correlation between all indicators of fertilityWednesday 15 48
  49. 49. Fertility ChartWednesday 15 49
  50. 50. Ovulation Predictor Kits• used to test urine to identify hormones that indicate ovulation is about to occur• electronic fertility computer tells a woman which days she is fertile• Persona: fertile days are indicated with a red light and infertile days with a green light• failure rate as low as 6% among women who abstain on fertile days as indicated by the deviceWednesday 15 50
  51. 51. Anovulation• A monophasic chart indicates that there has been no ovulation in this cycle.• The temperature remains on one level.• The bleed, not a true period, is often lighter than usual.Wednesday 15 51
  52. 52. Faulty technique• Erratic temperature chart - result of poor technique.• Implications of disturbances, such as illness, alcohol, medication, or disturbed sleep patterns and note their occurrence.• A temperature chart showing erratic and abnormally low readings usually indicates faulty technique.Wednesday 15 52
  53. 53. AbstinenceWednesday 15 53
  54. 54. Easily stated, not always easily done • takes commitment from both partners • Abstinence is the most effective method of preventing pregnancy and transmitting sexual disease • Not having traditional sexual intercourse, so the penis does not enter the vagina, at all • Become familiar with the fertility patterns - abstain from vaginal intercourse on the days pregnancy can occcur • Effectiveness - If practiced perfectly, there should not be any pregnancy.Wednesday 15 54
  55. 55. Pros and Cons • The Pros – 1) Anyone can do it, with commitment. – 2) Its free. – 3) Encourages the building of a relationship. Trust. – 4) No supplies – 5) No infections or STIs – 6) Endorsed by some religions. – 7) No hormonal side effects. • The Cons – 1) It can be frustrating for some couples. – 2) If not used properly, infections can be acquired. i.e. oral sex transmission.Wednesday 15 55
  56. 56. Lactational Amenorrhea MethodWednesday 15 56
  57. 57. LAM • Average Failure Rate: 6% • Most BF women do not ovulate for 4-24 months postpartum – whereas non-breastfeeding women can ovulate as early as 1-2 months • Conditions to be fulfilled – Fully BF – No periods – Recommended up to 6 months - the longer LAM is used, the more likely it is that ovulation will precede the first menses • Cervical mucus changes herald the first ovulation – should start checking daily at six weeks postpartum • Women with no periods who BF without practicing LAM - pregnancy rate of 6% over a year. Perfect users can expect a failure rate of only 0.5%.Wednesday 15 57
  58. 58. What are the advantages of natural family planning? • Does not involve the use of medicines, mechanical devices or chemicals. – Side effects or risks that may occur with the use of such medicines or devices will not occur • Inexpensive • Require partners to share the responsibility for planning or avoiding pregnancy – Typically, couples who use these methods notice an increase in communication and in cooperation.Wednesday 15 58
  60. 60. Introduction a small device made of plastic or copper that is placed into the uterus as an effective method of contraception6019 May 07
  61. 61. Types Levonorgestrel- Copper-releasing releasing device device19 May 07 61
  62. 62. Copper IUDs: Mechanisms of Action Interfere withInterfere with reproductiveability of sperm to process before ovapass through reach uterine cavityuterine cavity Change Thicken cervical endometrial mucus lining
  63. 63. IUDs: Contraceptive Benefits • Highly effective • Effective immediately • Long-term method (up to 10 years protection with Copper T 380A) • Do not interfere with intercourse • Immediate return to fertility upon removal • Do not affect breastfeeding 1 Trussell et al 1998.19 May 07 63
  64. 64. IUDs: Contraceptive Benefits continued • Few side effects • After followup visit, client needs to return to clinic only if problems • No supplies needed by client • Can be provided by trained nonphysician • Inexpensive (Copper T 380A)19 May 07 64
  65. 65. IUDs: Noncontraceptive Benefits • Decrease menstrual cramps (progestin-releasing only) • Decrease menstrual bleeding (progestin- releasing only)19 May 07 65
  66. 66. Who Can Use IUDs Women of any reproductive age or parity who: – Want highly-effective, long-term contraception – Are breastfeeding – Are postpartum and not breastfeeding – Are postabortion – Are at low risk for STDs – Cannot remember to take a pill every day – Prefer not to use hormonal methods or should not use them – Are in need of emergency contraception19 May 07 66
  67. 67. IUDs: Who Should Not Use (WHO Class 4) IUDs should not be used if woman: – Is pregnant (known or suspected) – Has unexplained vaginal bleeding until the cause is determined and any serious problems are treated – Has current, recent PID – Has acute purulent (pus-like) discharge – Has distorted uterine cavity – Has malignant trophoblast disease – Has genital tract cancer – Has an active genital tract infection (e.g., vaginitis, cervicitis) Source: WHO 1996.19 May 07 67
  68. 68. IUDs: Common Side Effects Copper-releasing: – Heavier menstrual bleeding – Irregular or heavy vaginal bleeding – Intermenstrual cramps – Increased menstrual cramping or pain – Vaginal discharge Progestin-releasing: – Amenorrhea or very light menstrual bleeding/spotting19 May 07 68
  69. 69. IUDs: Possible Other Problems • Missing strings • Slight increased risk of pelvic infection (up to 20 days after insertion) • Perforation of the uterus (rare) • Spontaneous expulsion • Ectopic pregnancy • Spontaneous abortion • Partner complains about feeling strings19 May 07 69
  70. 70. IUD Insertion: Withdrawal Method (2) Withdraw inserter tube (1) Hold plungerSource: PATH and Population Council 1989. 19 May 07 70
  71. 71. Postpartum insertion • Delayed (4-6 weeks) or immediate postpartum insertion • safe and effective • Expulsion - more common for immediate than with interval insertions19 May 07 71
  72. 72. Postabortal insertion • Safe and practical • Convenient • Avoid some discomfort from the procedure • Expulsion of the device is marginally increased19 May 07 72
  73. 73. Benefits of IUDs • Long-acting reversible contraceptives • Require no adherence on the part of the user – leaving virtually no scope for user error • More than 99% effective • Once they’ve been inserted, users need not take any action to continue using them – Reduce the number of unintended pregnancies that are due to user error or contraceptive failure. • Exceptionally cost-effective.Trussell J. Contraception 2010
  75. 75. Guidelines Regarding the Use of Combination Estrogen-Progestin Contraceptives in Women >=35 Years of Age, According to Risk Factors Kaunitz A. N Engl J Med 2008;358:1262-1270
  76. 76. Breast feeding • Previously, progestin-only • Low dose COC still possible19 May 07 76
  77. 77. Cancer risk• If used for more than a • Long term – year – protect against Ca protect against Ca endometrium ovary • Those with Ca • Ca breast? - breast should not uncertain take pill
  78. 78. Failure Rates User Failure Method Failure19 May 07 78
  79. 79. Failure rates • Implants, IUDs and LNG-IUS - <1% • Contraceptive pills - 5% • Male condoms - 14% • Diaphragm with spermicide - 20% • Cap with spermicide - 20-40% • Natural methods - 35% • Withdrawal - 19%19 May 07 79
  80. 80. 1. Contraception provides an effective means to plan a family2. Many methods are available - suitability has to be decided based on a proper history & examination3. Pregnancy should be ruled out first4. You should know the advantages & side effects5. Contraception also provides non-contraceptive benefitsKEY POINTS
  81. 81. Further reading• Cleland et al. Family Planning as a cost saving preventive health service. NEJM April 20, 2011.• Trussell J. Update on the cost effectiveness of contraceptives in the United States. Contraception 2010;82:391.