Familyyyyyyyyyyy

1. 1

2. Oral contraceptives are commonly known as ‘the pill’,
‘combined pill’, ‘birth control’ or ‘mini-pill’.
The pill works mainly by changing the body’s hormone bal
ance so that the woman does not ovulate.
2

3. Con’t…
It is more effective if taken correctly and consis
tently.
 Most women can take the pill with out develop
ing any side-effects.
However, a small number of women develop m
ild side- effects, which usually go away with in d
ays or weeks of starting the pill

4. Classification of Oral contraceptives
Based on their hormone content oral contraceptives a
re divided into two types:
1. combined oral contraceptives (COCs): Which co
ntain the hormones estrogen and progesterone.
2. Oral contraceptives with a single hormone, kno
wn as progestin-only oral contraceptives.
4

5. 5
A. Combined oral contraceptive (COC)

6. Combined oral contraceptive (C
OC)
6
What are COCs?
•Pills that contain low doses of two hormones –
a synthetic progestin and a synthetic estrogen – like t
he natural hormones progesterone and estrogen in a
woman’s body.
•Combined oral contraceptives (COCs) are also calle
d “the Pill,” low-dose combined pills, OCPs, and
OCs

7. Mechanism of action
Work primarily by preventing the release of eggs f
rom the ovaries (ovulation).
COCs prevent synthesis of gonadotropins from the
pituitary.
Hence, ovarian follicles do not mature and ovulati
on does not occur
7

8. 8
3
COCs: Mechanisms of Action
Suppress ovulation
Change endometrium making
implantation less likely
Thicken cervical mucus
(preventing sperm
penetration)
Reduce sperm transport
in upper genital tract
(fallopian tubes)

9. Starting COCs
There are several ways to begin taking the pill.
One common way is to start on the first day of me
nstruation (or period),
6 month after delivery if breast feeding
After 3 weeks if not breast feeding
Immediately or with in 7 days after abortion
9

10. Effectiveness of COC
Effectiveness depends on the user:
As commonly used, about 8 pregnancies occur per 1
00 women using COCs over the first year. This means
that 92 of every 100 women using COCs will not beco
me pregnant.
Consistent and correct use (When women remember
to take all pills on time)), less than1 pregnancy per 10
0 women using COCs over the first year (3 per 1,000
women).
10

11. 11
Rules for missed pills
ALWAYS:
1 Take a pill as soon as you remember.
2 Take the next pill at the usual time.
This may mean taking two pills on the same day or
even at the same time.
3 Continue taking active pills
11

12. 12
Who Can Use COCs Without Restriction
• Adolescents
• Nulliparous women
• Postpartum ( more than 3 weeks, if not BF)
• Immediately post-abortion
• Women with varicose veins
• Any weight (including obese)

13. 13 13
Who Should Not Use COCs
• Women with:
– Pregnancy (but no proven negative effects on fetus if take
n accidentally)
– < 6 weeks post partum if breast feeding
– Age > 35 and smoker
– SBP >160 & DBP >100
– DVT or pulmonary embolism
– Cardio vascular disease or increased risk of CV disease
– Breast cancer
– Liver disease

14. 14 14
Con’t…
• Women with:
– < 3 weeks post partum and not breast feeding
– 6 weeks - 6 months post partum and breast feeding
– SBP 140-159 & DBP 90- 99
– Migraine head ache with aura
– Woman taking rifampicin & anti convulsants

15. Known health benefit of COC
• Help protect against:
 Risks of pregnancy
 Cancer of the lining of the uterus
(endometrial cancer)
 Cancer of the ovary
 Symptomatic pelvic inflammatory disease

16. 16 16
Side effects of COCs
Some users report the following:
• Changes in bleeding patterns including:
– Lighter bleeding and fewer days of bleeding
– Irregular bleeding
– Infrequent bleeding
– No monthly bleeding
• Headaches
• Dizziness
• Nausea
• Breast tenderness

17. What is POP?
 POPs are pills that contain very low doses of a progestin like the nat
ural hormone progesterone in a woman’s body.
 POPs do not contain estrogen, and so can be used throughout breastf
eeding and by women who cannot use methods with estrogen.
Progestin-only pills (POPs) are also called “minipills” and progest
in-only oral contraceptives.
POPs contain 0.025 mg – 0.030 mg progesterone of different chemic
al composition.
 Come in packs of 28 pills and women take one every day.
17
B. Progesterone-only pills (minipills)

18. Mechanism of action
•POPs primarily prevent pregnancy by:
– Thickening cervical mucus. Thick cervical mucus bloc
ks passage of sperm through the cervical canal and meet
ing the ovum (egg).
– Disrupting the menstrual cycle, including preventing th
e release of eggs from the ovaries (ovulation).
18

19. Effectiveness
Breastfeeding women:
As commonly used, about 1 pregnancy per 100 women usin
g POPs over the first year. This means that 99 of every 100 wo
men will not become pregnant.
When pills are taken every day at the same hour of the day, l
ess than 1pregnancy per 100 women using POPs over the first
year (3 per 1,000 women).
Women not breastfeeding POPs are less effective:
19

20. Continuing mini-pills
As soon as she finishes one pack the woman has to
begin the next one, and start her next pack even if
she is still bleeding, or has not started her period.
Characteristics:
Contains no estrogen
Doesn't affect breast feeding
Slightly increased incidence of EP
May cause irregular uterine bleeding
Extra contraceptive method required if taken 3 h
rs apart
20

21. When to start
• A woman can start using POPs any time she
wants if it is reasonably certain she is not
pregnant
6 week after delivery if breast feeding
After 3 weeks if not breast feeding
Immediately or with in 7 days after abortion

22. 4.2 Injectable Contraceptives
22

23. Injectable contraceptives are artificial hormo
nal preparations administered by a deep intra
muscular injection into the muscle of the arm
or buttock, to be effective immediately.
From the injection site they are slowly absor
bed into the bloodstream and the body gets s
ufficient levels of hormone to provide contra
ception for one to three months..
23

24. DMPA (Depo-Provera)
DMPA (Depot Medroxy Progesterone Acetate, or
Depo-Provera) is an artificial progestin preparatio
n which resembles the naturally occurring female
hormone progesterone.
It is usually given in doses of 150 mg, which gives t
hree months’ protection following injection.
24
 DMPA has a grace period of 4 weeks and delays fertilit
y for an average of 9 months

25. Mechanism of action of DMPA
Primary Mechanism of Action
 Inhibits Ovulation - After a 150 mg injection of DM
PA, ovulation does not occur for at least 13 to 14 wee
ks. Levels of the follicle stimulating hormone (FSH) a
nd luteinizing hormone (LH) are lowered and a LH su
rge does not occur.
25

26. Mechanism of action Cont.
Secondary Mechanisms of Action
 Thickens the Cervical Mucus - the cervical mucus b
ecomes thick, making sperm penetration difficult.
Thins the Endometrial Lining - because of the high
progestin and low estrogen levels, the endometrium ch
anges, making it unfavorable for implantation.
Slowing of sperm and ovum transport through redu
ced fallopian tube peristalsis (wave like muscular cont
ractions of the fallopian tube by which contents are for
ced onward towards the uterus.
26

27. How effective is DMPA
DMPA is very effective. In the first year of use on
ly about 0.3 pregnancies per
100 women occur, that is, one pregnancy for every
333 clients who do not get px.
27

28. Advantages Disadvantages
Very effective Disturbance of menstrual cycle
Maintains privacy Delayed return of fertility
Reversible No protection against STIs
Suitable for breastfeeding women; n
o
oestrogen side-effects.
Increased appetite causing weight ga
in for some women.
Best choice for those with gastritis o
r
peptic ulcer diseases (ulcer of stoma
ch
or duodenum).
Protects against ectopic pregnancy
Other side-effects include headache
and dizziness, breast tenderness, nau
sea, hair loss, acne and loss of sexual
feeling.
If ovulation occurs, the chance of
ectopic pregnancy increases
28

29. When to start DMPA injections
 In the first seven days after menstrual bleeding starts.
 Six weeks after childbirth, or at any time once menstruat
ion has returned, indicating the woman is not pregnant.
 Immediately, or on the seventh day after childbirth, if yo
ur client is not breastfeeding.
 Immediately, or on the seventh day after a miscarriage o
r abortion.
 Immediately after stopping another method.
29

30. Reinjection schedule
If she comes to you up to two weeks before her appointm
ent, or up to one month after her scheduled appointment,
you can still give her the injection.
 But if she is more than one month late, she can get anoth
er injection that day only if you can be sure that she is not
pregnant.
30
Remember!
 DMPA has a grace period of 4 weeks and delays fertilit
y for an average of 9 months

31. 31
Who should not use DMPA
• Women with:
– Pregnancy
– Breast cancer
– Un explained vaginal bleeding

32. 4.3 Contraceptive implants
2-Rod
Jadelle for 5 year
s
1-Rod
Implanon
for 3 years
32

33. Contraceptive implants
Is a reversible, long-acting progestin which r
esembles the natural hormone progesterone i
n a woman’s body.
It consists of flexible tubes or rods, each abo
ut the size of a match stick, inserted under th
e skin of a woman’s upper arm by a traine
d professional.
33

34. Types
Many types of implants:
• Norplant: 6 capsules, labeled for 5 years of use
• Jadelle: 2 rods, lasts 5 years
– 75 mg of levonorgestrel
• Implanon: 1 rod, lasts 3 years (studies are underway t
o see if it lasts 4 years)
– 68 mg of etonogestrel
• Sinoplant: 2 rods, lasts 4 years
– 75 mg of levonorgestrel
• Trust implants: 2 rods
• JADELLE & IMPLANON are available in Ethiopia.

35. Norplant vs Jadelle/Trust Implant vs Implanon
Norplant (6 capsules)
216 mg LNG
Jadelle/Trust Implant
(2 rods)
150 mg LNG
Implanon (one rod)
68 g Etonogestrel (ENG)
(ENG, 3-ketodesogestrel)
34
mm
Jadelle
43
mm
40
mm
Silastic medical a
dhesive
Silastic tubing
Levonorgestrel
36 mg
free
crystals
75 mg
crystals
in silicone
copolymer
2.4 mm
2.4 mm
2 mm
EVA copolymer rod
covered by a thin
EVA membrane
68 mg ENG
embedded in EVA c
opolymer
35
Trust
Implant
=
44
mm

36. 36
Comparison
of Jadelle®, Trust Implant® and Implanon®
Jadelle ®
• 2 rods
• Effective for 5 years
• Failure rate
– 1st -yr : 0.05%
– Over 5-yrs : 1%
• Available in Ethiopi
a
• Short insertion and r
emoval time
• Cost: $29
Implanon®
• 1 rod
• Effective for 3 yrs
• Failure rate
–1st -yr : 0.05%
–Over 3- yrs: 0.1 %
• Available in Ethiopi
a
• Very short insertion
and removal time
• Cost: comparable;
Jadelle ®
• 2 rods
• Effective for 4 yrs
• Failure rate
1st -yr : 0.05%
Over 4-yrs : <1 %
• Available in Ethiopi
a
• Short insertion and r
emoval time
• Cost: 50% lower tha
n other implants
3

37. Mechanism of action
• Implants continually release a small amount of pro
gestin steadily into the blood.
• The primary mechanisms are:
– Increased viscosity of the cervical mucus making it har
der for sperm to swim through (within 48-72 hours aft
er insertion).
– Inhibition of ovulation- in about 50% of menstrual cyc
les.
– Alters endometrium, making it less conducive for impl
antation
37

38. Safety and effectiveness of IMPLANTS
• Are one of the most effective and long-lasting meth
ods
• <1 preg. per 100 women over the first year (5 per 1
0,000 women).
A small risk of pregnancy remains beyond the first year
.
Start to lose effectiveness sooner for heavier women
• No delay in return of fertility after removal
• No protection against sexually transmitted infectio
ns
• Do not increase frequency of ectopic pregnancy.
38

39.  Implants are very effective Once the implant is in pl
ace, the client does not have to think about contraceptio
n for the period of the implant.
 It is also a good choice of method for women who c
an’t use any contraceptive that contains oestrogen, an
d for women who find it difficult to regularly take a pill
at the same time every day.
39
Advantages

40. Disadvantages
Require a trained provider
 Amenorrhoea),weight gain, nervousness, anxiety,
nausea, vomiting
 dizziness, dermatitis/rashes, abnormal or heavy gr
owth of hair over the body hair loss,
headaches, depression and acne.
 Sometimes pain, itching, or infection at the site of
the implant will
40

41. Who Can Use Implants?
• Suitable for nearly all women; including women
who:
– Prefers a long-acting method
– Cannot remember to take a pill every day.
– Is breastfeeding (starting 6 wks after childbirth)
– Cannot take estrogen-containing contraceptives
– Is post-abortal
– Has moderate to severe menstrual cramping
– Smokers
41

42. WHO Medical Eligibility Criteria Classific
ation Categories
Classification
With clinical
judgment
With limited
clinical judgment
1
Use method in any circumsta
nces
Yes
Use the method
2
Generally use:
advantages outweigh risks
3
Generally do not use:
risks outweigh advantages
No
Do not use the meth
od
4 Method not to be used
42

43. 43
When implants should not be given
Implants should not be given to women who
have:
Serious Liver Disease
 Problems Of Blood Clots
 Unexplained Vaginal Bleeding
Breast Cancer.
43

44. Client Assessment
• Assess the client by taking history that:-
– Identifies the client’s reproductive goals
– Screens for precautions to the use of implants
• Depending on the client’s history, perform P/E.
– Pelvic exam is not required for beginning Implant
• Pregnancy testing is unnecessary except in case w
here it is difficult to rule out pregnancy
44

45. Client Assessment…
• How could one be certain that the client is not pre
gnant?
Early in her menstrual cycle (days 1-7 of the menstrual
cycle for Jadelle; days 1-5 for Implanon).
No intercourse since LNMP
Post partum and on LAM - 6 months
Within 4 wks for post partum & non lactating
Immediately or within the 1st 7 days post abortion
Has been correctly / consistently using a reliable F/P m
ethods.
45

46. Client Assessment…
• If pregnancy is not ruled out,
Counsel the client to use a temporary contracept
ive method or
Abstain from intercourse until her menses occur
or the possibility of pregnancy is confirmed.
46

47. Timing of insertion …
• A woman can start using implants any time she w
ants if it is reasonably certain she is not pregnant.
• Recommended times for insertion when changing
from another contraceptive
– Natural FP or barrier method: before day 7 of cycle
– COC: within 7 days of last active pill
– Implant: when Implant is removed
– Progestogen-only pill: on the day the last pill is taken
– Injectable hormones: any time before next injection
– IUD: any time
47

48. 48
Timing of implant removal
• At anytime during the menstrual cycle.
• At 5 years of use for Jadelle, 4 years for Trust Im
plant and 3 years for Implanon.
• Anytime client requests removal, after adequate c
ounseling.
48

49. Characteristics of Implants
• Are safe
• Easy to use
• Highly effective
• Not motivation dependent
• Discreet, virtually invisible
• Rapidly reversible
• Require minor surgical procedure for insertion /
removal
49

50. Characteristics of Implants Cont.
• Stable hormone levels
• Contain no estrogen
• Safe for Breast feeding mother (after 6 wks PP)
,
• No need for user compliance , Convenient
• Can cause irregular bleeding
• Does not protect from STIs
• High initial cost
50

51. 51
4.3.1 IMPLANON®
51

52. Implanon cont…
Implanon is a single-rod contraceptive implant pr
epared from another type of progestin, which give
s effective protection for three years.
 It looks like a small flexible plastic matchstick.
 It can be inserted into the arm following a simple
procedure, similar to an injection, and you do not
need to make an incision as with other implants.
52

53. Emergency contraceptive
A. Emergency contraceptive pills (ECPs)
B.Intrauterine devices (IUDs)
53

54. Introduction
Emergency contraception (EC) is a method used to
prevent unwanted pregnancy, and is usually effective
up to five days following unprotected sexual intercou
rse.
 Unprotected sexual intercourse means that either t
he woman did not use any contraceptive method t
o prevent pregnancy, or the birth control method
failed.
54

55. Situations when emergency contraception is
appropriate
Emergency contraception can be appropriate:
in cases where the woman has not use contracepti
on
in cases where sex has been forced or coerced, or t
he woman has been raped.
when a woman must deal with a contraceptive mis
take, such as a condom breaking or used incorrectly,
an IUCD dislodging, a diaphragm removed too earl
y, or the man failing to withdraw before ejaculation.
55

56. Types of EC
There are two major types of emergency contraceptive meth
ods available:
A. Emergency contraceptive pills (ECPs)
COC
POP
B. Copper-bearing IUDs.
56

57. A. Emergency contraceptive pills
Are hormonal methods of contraception that can be used
to prevent pregnancy following unprotected sexual intercou
rse.
Some women call this method ‘morning-after pills’ or
‘post coital pills’.
57

58. M e c h a n i s m o f a c t i o n o f e m e r g e n c y
contraceptive pills.
If the ovaries have not yet released an egg (ovulation), t
hey can stop or slow down this process (called the suppres
sion of ovulation
If an egg has already been released, they can stop sperm
from fertilizing it by thickening the cervical mucus to ma
ke it difficult for sperm penetration.
 If an egg has already been released and been fertilized,
they can prevent it from implanting in the uterus wall by t
hinning the endometrial lining of the uterus.
58

59. 59
ECP regimen
1. Progesterone only pills
– Pills containing 0.75mg levonorgestrel such as postino
r-2, Optinor.
• 1 pill as soon as possible after unprotected intercourse follo
wed by a same dose taken 12 hours later.
– Pill containing 1.5mg levonorgestrel:
• 1 pill only as soon as possible after unprotected intercourse
– Pills containing 0.03mg levonorgestrel (microlute, nor
geston, ovrette)
• 20 pills for the 1st & 2nd dose

60. 60
ECP regimen …
2. Combined OCP/ Yuzpe's method
– High dose pills containing 50 µg of ethinyl oestradiol
& 0.25mg levonorgestrel (neogenon, ovran, eugynon)
• 1st dose: 2 pills as soon as possible after unprotected with i
n 5 days
• 2nd dose: 2 pills 12 hours later
This is a total of four pills within a 12-hour period.
– Low dose pills containing 30 µg ethinyl oestradiol &
0.15 mg of levonorgestrel (microgynon, nordate, lo/fe
menal)
• 4 pills for the 1st & 2nd dose
This is a total of eight pills within a 12 hour interval

61. 61
Safety and effectiveness
• Safety
– ECP are considered very safe
– In > 20 yrs no death or serious complication reported
– ECP is not associated with fetal malformation/ congen
ital defect
– ECP do not increase the possibility of ectopic pregnan
cy
• Effectiveness
– ECP reduce probability of becoming pregnant
• By 75% in case of COC &
• By 85% in case of POP
– Most effective if taken within 3 days (or 72 hours).

62. Disadvantages of emergency Contraception
 It does not work if women are already pregnant.
 It has a limited timeframe of 5 days following un
protected intercourse.
Women still have a small chance of getting pregn
ant.
IUCD insertion requires a trained professional.
Neither method provides protection from sexually
transmitted infections.
62

63. 63
Side effects
• Nausea
–Most common
–More in COC user than POP users
• In about 50% of clients using combined ECPs and in
20% of women using progestogen-only ECPs
–Usually does not last > 24 hrs
–Management:
• Take the pill with food/ at bed time
• Prophylactic anti -emetic may be considered in women who
had nausea in previous ECP use

64. 64
Side effects …
• Vomiting
– In 20% of women using COC &
– In 5% of women using pops as ECP
– Management- if vomiting occurs with in 2 hours, the
dose should be repeated
• Irregular vaginal bleeding or spotting
– Inform that ECP do not bring menses immediately
– If the menstrual period is delayed for >1 week from th
e expected date, consider the possibility of pregnancy
• Breast tenderness, headache, dizziness & fatigue
– Management: pain reliever

65. 65
Follow-up care
• If the client adopted a method of contraception for regul
ar use no follow-up should be required in relation to the use of E
C
• During the follow-up contact discuss suitable contracepti
ve options
• Oral contraception can be started the day after ECP is ta
ken.
• Injectables, implants and IUCD can be given within 7 da
ys of the beginning of the next menstrual cycle.
• In case of failure of ECP
– If the client decides to continue the pregnancy, reassure her tha
t there is no risk of teratogenic effect following ECP.

66. B. Intrauterine contraceptive devices (IUC
Ds)
 A copper-bearing IUCD can be used within five days of unprote
cted sexual intercourse as an emergency contraceptive.
 so an IUCD can be inserted within five days of unprotected sex
ual intercourse, provided it is after the earliest calculated day of
ovulation.
 Implantation may occur 6–12 days after ovulation.
 Therefore, inserting an IUCD would be effective in making imp
lantation difficult, but would not cause the abortion of an existin
g implanted fetus. 66

67. Mechanism of action of copper-bearing IUCD
For emergency contraception Based on evidence from a num
ber of studies, copper-bearing IUCDs prevent pregnancy by:
interfering with fertilization, by stopping the sperm from fe
rtilizing the egg.
decreasing the number of sperm reaching the uterine tube a
nd interfering with their motility.
preventing the fertilized egg from implanting in the uterus.
67

68. Con..
When to use an IUCD
When would you advise using an IUCD as an emergency
contraception?
You can use an IUCD as an emergency contraception:
Five days after unprotected sexual intercourse but not m
ore than five days after ovulation.
If the client also wants to use an IUCD for continuous l
ong-term contraception.
68

69. Advantages of emergency contraception
Emergency contraception is very effective when us
ed early, with only 3% of women becoming preg
nant if used within 24 hours unprotected sexual in
tercourse.
Its use can also provide an appropriate opportunity f
or a client to start an ongoing family planning me
thod, such as an IUCD.
69

70. Disadvantages of emergency contraception
It does not work if women are already pregnant.
It has a limited time frame of 5 days following unp
rotected intercourse.
Women still have a small chance of getting pregna
nt.
IUCD insertion requires a trained professional.
Neither method provides protection from sexually t
ransmitted infections.
70

71. SUMMARY
• Discuss hormonal methods in detail
• Mention the disadvantage of COC
• Describe implants
• List the complications of COC with their mana
gement
• Mention an indication of IUCD insertion
71

72. Thank You!
72