Contraception

 CONTRACEPTION is defined as the intentional
prevention of conception through the use of various
devices , sexual practices , chemicals , drugs or
surgical procedures .
 Thus , any device or act whose purpose is to prevent a
women from becoming pregnant can be considered as
a contraceptive.
 CONTRACEPTION ( birth control) prevents pregnancy
by interference with the normal process of ovulation ,
fertilization and implantation .

METHODS OF CONTRACEPTION
TEMPORARY PERMANENT
- Natural contraception
- Barrier methods
- Intrauterine contraceptive Female Male
devices (IUDs) -Tubal -VASECTOMY
- Steroidal contraception occlusion

 Contraceptive methods which do not requires
any medication or appliances are Natural
Family Planning Methods .

 Menstrual cycles begins on the first day of the period
and ends when the next period begins. Usual duration
of cycle is 28 days.
 Ovulation takes place 13 – 14 days prior to next
menstrual period in a regularly menstruating woman.
 Few days prior to ovulation there is excessive secretion
of cervical mucous which is thinner , profuse and
having a spinnbarkait more than 10 cms. This is
preovulatory high levels of oestrogen . Such mucous is
having very good sperm penetration quality

 After the ovulation , the mucous becomes scanty ,
thick and the spinnbarkait less than 4 cms . Such
mucous is having poor sperm penetration .
 Soon after ovulation , basal body temperature rises
about 0.6 to 0.8 degree F and remains elevated
until few days prior to the onset of next
menstruation .
Based on these physiological principles , the
woman identifies her own fertile period during which
she avoids intercourse or uses barrier methods .

 The method is based on identification of the
fertile period of a cycle and to abstain from
sexual intercourse during that period.
 This requires partner’s cooperation.
 The methods to determine the approximate time
of ovulation and the fertile period include —
(a) recording of previous menstrual cycles
(calendar rhythm)
(b) noting the basal body temperature chart
(temperature rhythm) and
(c) noting excessive mucoid vaginal discharge
(mucus rhythm).

 The users of the calendar method obtain the
period of abstinence from calculations based on
the previous twelve menstrual cycle records.
 The first unsafe day is obtained by subtracting
20 days from the length of the shortest cycle
and last unsafe day by deducting 10 days from
the longest cycle.
 Users of temperature rhythm require
abstinence until the third day of the rise of
temperature.
 Users of mucus rhythm require abstinence on
all days of noticeable mucus and for 3 days
thereafters .

Advantages Disadvantages
• No cost •Difficult to calculate the safe period
reliably
• Lack of side effects •Needs several months training to
use these methods
•Compulsory abstinence from sexual
act during certain periods
•Not applicable during lactational
amenorrhea or when the periods are
irregular

 is the oldest and probably the most widely
accepted contraceptive method used by man.
 It necessitates withdrawal of penis shortly
before ejaculation.
 It requires sufficient self-control by the man so
that withdrawal of penis precedes ejaculation.

• No appliance is required • Requires sufficient self-control by
the man
• No cost • The woman may develop anxiety
neurosis, vaginismus or pelvic
congestion
• Chance of pregnancy is more :
(a) Precoital secretion may contain
sperm
(b) Accidental chance of sperm
deposition into the vagina

 Prolonged and sustained breastfeeding offers a natural
protection of pregnancy.
 This is more effective in women who are amenorrheic than those
who are menstruating.
 The risk of pregnancy to a woman who is fully breastfeeding
and amenorrheic is less than 2 percent in the first 6 months.
 Otherwise, the failure rate is high (1–10%).
 Thus during breastfeeding, additional contraceptive support
should be given by condom, IUCD or injectable steroids where
available to provide complete contraception .

 When the women is full breastfeeding, a
contraceptive method should be used in the
3rd postpartum month .
 and with partial or no breastfeeding, she
should use it in the 3rd postpartum week.

 These methods prevent sperm deposition in the
vagina or prevent sperm penetration through
the cervical canal.
 The objective is achieved by mechanical
devices or by chemical means which produce
sperm immobilization, or by combined means.

The following are used
 Mechanical
 Male — condom
 female — condom, diaphragm, cervical cap
 Chemical (Vaginal contraceptives)
 creams — delfen (nonoxynol-9, 12.5 %)
 Jelly — Koromex, Volpar paste
 Foam tablets— Aerosol foams, chlorimin t or
contab, sponge (today)
 Combination
 combined use of mechanical and chemical

 Condoms are made of polyurethane or latex.
 Polyurethane condoms are thinner and
suitable to those who are sensitive to latex
rubber.
 It is the most widely practiced method used by
the male.
 In India, one particular brand (latex) is widely
marketed as ‘Nirodh’.
 The efficacy of condoms can be augmented by
improving the quality of the products and by
adding spermicidal agents during its use.

 Protection against sexually transmitted disease
is an additional advantage.
 Occasionally, the partner may be allergic to
latex.
 The method is suitable for couples who want to
space their families and who have
contraindications to the use of oral
contraceptive or IUD.

1. Cheaper with no contraindications 1. May accidentally break or slip off
during coitus
2. No side effects 2. Inadequate sexual pleasure
3. Easy to carry, simple to use and
disposable
3. Allergic reaction (Latex)
4. Protection against sexually
transmitted diseases, e.g. gonorrhea,
chlamydia, HPV and HIV
4. To discard after one coital act
5. Protection against pelvic
inflammatory diseases
5. Failure rate — 15 (HWY)
6. Reduces the incidence of tubal
infertility and ectopic pregnancy
7. Protection against cervical cell
abnormalities
8. Useful where the coital act is
infrequent and irregular

 It is an intravaginal device made of latex with
flexible metal or spring ring at the margin.
 Its diameter varies from 5–10 cm.
 It requires a medical or paramedical personnel to
measure the size of the device.
 The distance between the tip of the middle finger
placed in the posterior fornix and the point over the
finger below the symphysis pubis gives the
approximate diameter of the diaphragm.

 Diaphragm should completely cover the
cervix.
 As it cannot effectively prevent ascent of the
sperms alongside the margin of the device,
additional chemical spermicidal agent should
be placed on the superior surface of the device
during insertion, so that it remains in contact
with the cervix.
 The device is introduced up to 3 hours before
intercourse and is to be kept for at least 6 hours
after the last coital act.
 ill fitting and accidental displacement during
intercourse increase the failure rate.

• Cheap • Requires help of a doctor or
paramedical person to measure the
size required
• Can be used repeatedly for a long
time
• Risk of vaginal irritation, abrasion
and urinary tract infection are there
• Reduces PID/STIs to some extent • Not suitable for women with
uterine prolapse
• Protects against cervical precancer
and cancer
•Failure rate—16 (HWY)

 Spermicides:
 Spermicides are available as vaginal foams,
gels, creams, tablets and suppositories.
 Usually, they contain surfactants like
nonoxynol–9, octoxynol or benzalkonium
chloride.
 These agents mostly cause sperm
immobilization.
 The cream or jelly is introduced high in the
vagina with the help of the applicator soon
before coitus.

 Foam tablets (1–2) are to be introduced high in
the vagina at least 5 minutes prior to
intercourse.
 In isolation, it is not effective (18–29 HWY), but
enhances the efficacy of condom or diaphragm
when used along with it.
 There may be occasional local allergic
manifestations either in the vagina or vulva.

 It is made of polyurethane impregnated with
1 g of nonoxynol-9 as a spermicide.
 Nonoxynol-9 acts as a surfactant which either
immobilizes or kills sperm.
 It releases spermicide during coitus, absorbs
ejaculate and blocks the entrance to the cervical
canal.
 The sponge should not be removed for 6 hours
after intercourse. Its failure rate (HWY) is
about — Parous women: 32-20, Nulliparous
16-9.

 Currently it is observed that nonoxynol–9 is
not effective in preventing cervical gonorrhea,
chlamydia or HIV infection.
 Moreover, it produces lesions in the genital
tract when used frequently.
 Those lesions are associated with increased risk
of HIV transmission.

 The intrauterine device have been used
throughout the world.
 There has been a significant improvement in its
design and content.
 The idea is to obtain maximum efficacy
without increasing the adverse effects.
 The device may be non- medicated as Lippes
loop or medicated (bioactive) by incorporating
a metal copper, in devices like Cu T-200,
Cu T-380A, Multiload-250, Multiload-375

 Hormone containing IUD either releasing
progesterone (progestasert) or levonorgestrel
(LNG- IUS) has also been introduced.
 Nowadays the following medicated intra
uterine contraceptive devices are in use :
• Cu T 200 • Multiload 250
• Multiload 375 • Cu T 380A
• LNG – IUS ( levonorgestrel – releasing
intrauterine system)

 Copper T 200 —
 It carries 215 sq mm surface area of fine copper
wire wounded round the vertical stem of the
device.
 Stem of the T-shaped device is made of a
polyethylene frame.
 It has a polyethylene monofilament tied at the
end of the vertical stem.
 These two threads are used for detection and
removal. In spite of the copper being
radiopaque, additional barium sulfate is
incorporated in the device.

 The device contains 124 mg of copper.
 The copper is lost at the rate of about 50 µg per
24 hours during a period of one year.
 It is supplied inside a sterilized sealed packet.
 The device is to be removed after 4 years.
 Cu T 200 carries 200 sq mm surface area of wire
containing 120 mg of copper and is removed
after 3 years.

 Cu T 380A carries total 380 mm2 surface area
of copper wire wound around the stem (314
mm2) and each copper sleeve on the
horizontal arms (33 mm2).
 The frame contains barium sulfate and is
radiopaque.
 Replacement is every 10 years.

 The device emits 60–100 µg of copper per day
during a period of one year.
 The device is to be replaced every 3 years.

 The device is available in a sterilized sealed
packet with an applicator.
 There is no introducer and no plunger.
 It has 375 mm2 surface area of copper wire
wound around its vertical stem.
 Replacement is every 5 years

 This is a T-shaped device, with
polydimethylsiloxane membrane around the stem
which acts as a steroid reservoir.
 Total amount of levonorgestrel is 52 mg and is
released at the rate 20 µg/day.
 This device is to be replaced every 7 years.
 Its efficacy is comparable to sterilization.
 It has many non-contraceptive benefits also

 Mechanism of antifertility effect of all the IUDs is
not yet clear.
 They act predominantly in the uterine cavity and do
not inhibit ovulation. Probable factors are:
 Biochemical and histological changes in the
endometrium —
 There is a nonspecific inflammatory reaction along
with biochemical changes in the endometrium
which have got gametotoxic and spermicidal
property.

 Lysosomal disintegration from the macrophages
attached to the device liberates prostaglandins,
which are toxic to spermatozoa. Macrophages cause
phagocytosis of spermatozoa.
 There may be increased tubal motility which
prevent fertilization of the ovum.
 Endometrial inflammatory response decreases
sperm transport and impedes the ability of sperm to
fertilize the ovum.
 Copper devices — Ionized copper has got an
additional local antifertility effect by preventing
blastocyst implantation through enzymatic
interference

 Copper initiates the release of cytokines which
are cytotoxic.
 Serum copper level is not increased.
 It seems that the progressive calcium
deposition in the device prevents copper
diffusion, if kept for longer period.

 Levonorgestrel-IUS (Mirena)
 It induces strong and uniform suppression of
endometrium.
 Cervical mucus becomes very scanty.
 Anovulation and insufficient luteal phase
activity has also been mentioned.
 Serum progesterone level is not increased.

(1) Presence of pelvic infection current or within 3
months;
(2) Undiagnosed genital tract bleeding;
(3) Suspected pregnancy;
(4) Distortion of the shape of the uterine cavity as
in fibroid or congenital uterine-malformation;
(5) Severe dysmenorrhea;
(6) Past history of ectopic pregnancy;
(7) Within 6 weeks following cesarean section;

(8) STIs — Current or within 3 months;
(9) Trophoblastic disease;
(10) Significant immunosuppression.

(a) Interval — It is preferable to insert 2–3 days
after the period is over. But it can be inserted any
time during the cycle even during menstrual
phase which has certain advantages (open
cervical canal, distended uterine cavity, less
cramp). However, during lactational
amenorrhea, it can be inserted at any time.

(b) Postabortal — Immediately following termination of
pregnancy by suction evacuation or D and E, or following
spontaneous abortion, the device may be inserted. The
additional advantage of preventing uterine synechia can
help in motivation for insertion.
(c) Postpartum Insertion of the device can be done before
the patients are discharged from the hospital. Because of
high rate of expulsion, it is preferable to withhold
insertion for 6 weeks when the uterus will be involuted to
near normal size.

(d) Postplacental delivery — Insertion
immediately following delivery of the placenta
could be done. But the expulsion rate is high.

 Cu T 200
 Cu T 380A
(A) Preliminaries
(1) History taking and examinations (general and
pelvic) to exclude any contraindication of
insertion.
(2) Patient is informed about the various
problems, the device is shown to her and
consent is obtained.
(3) The insertion is done in the outpatient
department, taking aseptic precautions

without sedation or anesthesia. To reduce
cramping pain Ibuprofen (NSAID) may be given
(200–400 mg) 30 minutes before insertion.
(4) Placement of the device inside the inserter —
The device is taken out from the sealed packet.
The thread, the vertical stem and then the
horizontal stem folded to the vertical stem are
introduced through the distal end of the inserter.
The device is now ready for introduction. “No
touch” insertion method is also preferred .

(B) Actual steps
(1) The patient empties her bladder and is placed in
lithotomy position. Uterine size and position are
ascertained by pelvic examination.
(2) Posterior vaginal speculum is introduced and the
vagina and cervix are cleansed by antiseptic lotion.
(3) The anterior lip of the cervix is grasped
by Allis forceps. A sound is passed through the cervical
canal to note the position of the uterus and the length of
the uterine cavity. The appropriate length of the inserter is
adjusted depending on the length of the uterine cavity.

(4) The inserter with the device placed inside is then
introduced through the cervical canal right up to the
fundus and after positioning it by the guard, the
inserter is withdrawn keeping the plunger in position.
Thus, the device is not pushed out of the tube but
held in place by the plunger while the inserter is
withdrawn
(5) The excess of the nylon thread beyond 2–3 cm from
the external os is cut. Then the Allis forceps and the
posterior vaginal speculum are taken off.

 “No-touch” insertion technique includes:
(i) Loading the IUD in the inserter without
opening the sterile package. The loaded
inserter is now taken out of the package
without touching the distal end.
(ii) Not to touch the vaginal wall and the
speculum while introducing the loaded IUD
inserter through the cervical canal.

Multiload Cu 250: Multiload 375
The applicator with the device is just to be taken
out of the sealed packet in a ‘no-touch’ method
and the same is pushed through the cervical canal
up to the fundus of the uterus. The applicator is
then withdrawn .

LNG-IUS:
The arms of the device are released in the uterine
cavity about 2 cm below the fundus. The details
of insertion is to be followed as in the instruction
package .

The possible symptoms of pain and slight vaginal
bleeding should be explained. The patient should
be advised to feel the thread periodically by the
finger.
The patient is checked after 1 month and then
annually

Immediate:
 Cramp like pain — It is transient but at times, severe and
usually lasts for 1/2 to 1 hour. It is relieved by analgesic or
antispasmodic drugs.
 Syncopal attack—Pain and syncopal attack are more often
found in nulliparous or when the device is large enough to
distend the uterine cavity.
 Partial or complete perforation — It is due to faulty technique
of insertion but liable to be met with in lactational period
when the uterus remains small and soft.

Remote :
 Pain — The pain is more or less proportionate to the degree
of myometrial distension. A proper size of the device may
minimize the pain.
 Abnormal menstrual bleeding — The excessive bleeding
involves increased menstrual blood loss, prolongation of
duration of period and intermenstrual bleeding. The patient
may become anemic and is of concern in one who is already
anemic. Iron supplement is advocated. Tranexamic acid may
be given for short-term relief. Menstrual loss is much less
with the use of third generation IUDs

 Pelvic infection (PID) — The risk of developing
PID is 2–10 times greater amongst IUD users. The
risk is more in the first 3 weeks. Infection with
chlamydia and rarely with actinomyces are seen.
Newer IUDs reduce the risk.
 Pain, abnormal uterine bleeding and PID are the
principal factors related to its discontinuation (10–
15%).

 Perforation of the uterus—The incidence of
uterine perforation is about 1 in 1000 insertions.
Most perforations occur at the time of insertion
but the migration may also occur following
initial partial perforation with subsequent
myometrial contraction. It is however less
common when the device is introduced by the
withdrawal technique.

 Non-visibility of the thread through the external os
and the appearance of pelvic symptoms after a long
asymptomatic period are suspicious. Negative findings
on exploration of the uterine cavity by a probe is
suggestive.
 Ultrasonography can detect the IUD in abdominal
cavity and is better than radiography.
 Straight X-ray, anteroposterior and lateral view,
following introduction of a radiopaque probe (uterine
sound) into the uterine cavity is conclusive. The device
is found away from the opaque shadow placed in the
uterine cavity, if it has perforated the uterine wall .

 Lippes loop — As it is an open device made of
inert material, it will cause no harm if left in the
peritoneal cavity. Adhesions and intestinal injury
are unlikely. But for psychological reason or
otherwise, it is better to remove it by laparoscopy
or by laparotomy.
 Copper device — A copper bearing device
induces an intense local inflammatory reaction
with adhesions with the surrounding structures.
Thus, as soon as the diagnosis is made, it is to be
removed by laparoscopy or laparotomy.

 Pregnancy —
 The pregnancy rate with the device in situ is about 2
per 100 women years of use.
 Lowest pregnancy rates are observed with Cu T 380A
(0.8–HWY) and LNG-IUS (0.2–HWY).
 Should pregnancy occur with a device in situ, there is
risk of ectopic pregnancy (0.02percent).
 IUD can thus prevent an uterine but not an ectopic
pregnancy.
 Third generation of IUDs like Cu T 380 A and LNG-
IUS give some amount of protection against an ectopic
pregnancy.

 If the thread is visible through the cervix it is
best to remove the device. This will minimize
such complications as abortion, preterm labor
sepsis and low birth weight baby.
 However, if the thread is not visible it is better
to leave it alone after counseling with the
patient about the risks involved in continuing
pregnancy.

 The device is expected to be expelled
spontaneously with the delivery of the after-
births. There is no conclusive evidence of
increased risk of fetal anomalies with copper
devices.

(1) Persistent excessive regular or irregular
uterine bleeding
(2) Flaring up of salpingitis
(3) Perforation of the uterus
(4) IUD has come out of place (partial expulsion)
(5) Pregnancy occurring with the device in situ
(6) Woman desirous of a baby
(7) Missing thread
(8) One year after menopause
(9) When effective lifespan of the device is over.

IUD removal is simple and can be done at any
time. It is done by pulling the strings gently and
slowly with a forceps.

The thread may not be visible through the
cervical os due to —
(a) Thread coiled inside;
(b) Thread torn through;
(c) Device expelled outside unnoticed by the
patient;
(d) Device perforated the uterine wall and is lying
in the peritoneal cavity;
(e) Device pulled up by the growing uterus in
pregnancy.

Pregnancy is to be excluded first —
1. Ultrasonography can detect the IUD either within
the uterine cavity or in the peritoneal cavity
2. Hysteroscopy can be used for direct visualization
of the uterine cavity and it could be removed
simultaneously .
3. Sounding the uterine cavity by a probe
4. If negative, straight X-ray after introducing
radiopaque probe (uterine sound) into the uterine
cavity. This will not only reveal the presence or
absence of the device but also its existence outside
the uterine cavity

A. Device inside the uterine cavity:
It can be removed by any of the following
methods mentioned below :
(i) Especially designed blunt hook
(ii) Artery forceps
(iii) Uterine curette
(iv) Hysteroscopically under direct vision
B. Outside the uterus but inside the abdominal
cavity:
(i) Laparoscopy (ii) Laparotomy (rarely).

1. Inexpensive : cu t-distributed free
of cost through Government channel
1. require motivation
2. simplicity in techniques of insertion
and most cost effective of all methods
2. Limitation in its use
3. prolonged contraceptive protection
after insertion (5–10 years) and
suitable for the rural population of
developing countries
3. Adverse local reactions manifested
by menstrual abnormalities, PID,
pelvic pain and heavy periods. Beside
effects are less with third generation of
IUDs
4. systemic side effects are nil.
suitable for hypertensives,
breastfeeding women and epileptics
4. Risk of ectopic pregnancy
5. reversibility to fertility is prompt
after removal
Failure rate – 0.1 – 2 (HWY)

COMBINED ORAL CONTRACEPTIVES (PILLS)
 The combined oral steroidal contraceptives is the most
effective reversible method of contraception.
 In the combination pill, the commonly used progestins are
either levonorgestrel or norethisterone or desogestrel
and the estrogens are principally confined to either
ethinyl-estradiol or menstranol (3 methyl ether of
ethinyl-estradiol).
 Currently ‘lipid friendly’, third generation progestins, namely
desogestrel, gestodene, norgestimate are available.

 Only Mala-N is distributed through government
channel free of cost.
4th generation:
 Drospirenone which is an analogue of spironolactone is
used as progestin.
 It has antiandrogenic and antimineralocorticoid action.
 It causes retention of K+.

 The probable mechanism of contraception are:
Inhibition of ovulation —
 Both the hormones synergistically act on the
hypothalamopituitary axis.
 The release of gonadotropin releasing hormones from
the hypothalamus is prevented through a negative
feedback mechanism.
 There is thus no peak release of FSH and LH from the
anterior pituitary. So follicular growth is either not
initiated or if initiated, recruitment does not occur.

 Producing static endometrial hypoplasia—
There is stromal edema, decidual reaction and
regression of the glands making endometrium
nonreceptive to the embryo.
 Alteration of the character of the cervical
mucus (thick, viscid and scanty) so as to prevent
sperm penetration.

 Probably interferes with tubal motility and
alters tubal transport. Thus, even though
accidental breakthrough ovulation occurs, the
other mechanisms prevent conception.
 Estrogen inhibits FSH rise and prevents
follicular growth. It is also useful for better
cycle control and to prevent breakthrough
bleeding.

 Progestin
 Anovulatory effect is primarily by inhibiting
LH surge.
 It is also helpful to counteract the adverse
effects of estrogen on the endometrium
(endometrial hyperplasia and heavy
withdrawal bleeding).
 It is also responsible for changes in the
cervical mucus (vide supra).

Commercial names Composition No. of tablets
Progestins (mg) Estrogen (μg)
1. Mala N (Govt of India) Levonorgestrel
0.15
Ethinyl
estradiol 30
21 + 7 iron
tablets
2. Mala-D Levonorgestrel
0.15
Ethinyl
estradiol 30
21 + 7 iron
tablets
3. Loette (Wyeth) Desogestrel 0.15 Ethinyl
estradiol 20
21
4. Yasmin (Schering) Drospirenone
3 mg
Ethinyl
estradiol 30
21

 History and general examination should be thorough,
taking special care to screen cases for contraindications
(headache, migraine).
 Examination of the breasts for any nodules, weight and
blood pressure are to be noted.
 Pelvic examination to exclude cervical pathology, is
mandatory.
 Pregnancy must be excluded.
 Cervical cytology to exclude abnormal cells, is to be
done.

 Thus, any woman of reproductive age group
without any systemic disease and
contraindications listed, is a suitable candidate
for combined pill therapy.
 Growth and development of the pubertal and
sexually active girls are not affected by the use
of “pill”.

 Instruction:
 New users should normally start their pill packet on day
one of their cycle.
 One tablet is to be taken daily preferably at bed time for
consecutive 21 days.
 It is continued for 21 days and then have a 7 days break,
with this routine there is contraceptive protection from the
first pill.
 Next pack should be started on the eighth day, irrespective
of bleeding (same day of the
week, the pill finished).

 Thus, a simple regime of “3 weeks on and 1
week off ” is to be followed.
 Packing of 28 tablets, there should be no break
between packs.
 Seven of the pills are dummies and contain
either iron or vitamin preparations.
 However, a woman can start the pill up to day 5
of the bleeding.

 In that case she is advised to use a condom for
the next 7 days.
 The pill should be started on the day after
abortion.
 Following childbirth in non-lactating woman,
it is started after 3 weeks and in
lactating woman it is to be withheld for
6 months

 The patient should be examined after 3 months, then
after 6 months and then yearly.
 The patient above the age 35 should be checked more
frequently.
 At each visit, any adverse symptoms are
to be noted.
 Examination of the breasts, weight and
blood pressure recording and pelvic examination
including cervical cytology, are to be done and
compared with the previous records.

 Missed pills:
 Normally there is return of pituitary
and ovarian follicular activity during the pill-free
interval (PFI) of 7 days.
 Breakthrough ovulation may occur in about 20
percent cases during the time.
 Lengthening of PFI due to omissions,
malabsorption, or vomiting either at the start or at
the end of a packet, increases the risk of
breakthrough ovulation and therefore pregnancy.

 When a woman forgets to take one pill (late up to 24
hours), she should take the missed pill at once and
continue the rest as schedule.
 When she misses two pills in the first week (days 1–7),
she should take 2 pills on each of the next 2 days and
then continue the rest as schedule.
 Extra precaution has to be taken for next 7 days either
by using a condom or by avoiding sex.

 If 2 pills are missed in the third week (days 15–21)
or if more than two active pills are missed at any
time, another form of contraception should be
used as back up for next 7 days as mentioned
above.
 She should start the next pack without a break.
 If she misses any of the 7 inactive pills (in a 28-day
pack only) she should throw away the missed pills.
 She should take the remaining pills one a day and
start the new pack as usual.

 Effectiveness of some drugs (Aspirin, oral
anticoagulants, oral hypoglycemics)
are decreased and
 that for some other drugs (beta blockers,
corticosteroids, diazepam, aminophylline)
are increased by oral contraceptives.

 To ensure cent percent efficacy, additional
mechanical contraceptives (usually condom) are
to be used in the following circumstances :
(1) When broad spectrum antibiotics like
ampicillin, amoxicillin, tetracycline, doxycycline
are used — as they impair the absorption of
ethinyl estradiol.

(2) When enzyme inducing drugs are
used, e.g.
(a) barbiturates
(b) all antiepileptic drugs except
sodium valproate and clonazepam
(c) rifampicin
(d) ketoconazole

(e) griseofulvin
(f) ritonavir
(g) nevirapine—under such circumstances high
dose preparations (ethinyl estradiol of 50 μg
or more) are to be used to counter balance the
increased liver metabolism.

 The indications for withdrawal of the pill are—
(1) Severe migraine;
(2) Visual or speech disturbances;
(3) Sudden chest pain;
(4) Unexplained fainting attack or acute vertigo;
(5) Severe cramps and pains in legs;

(6)Excessive weight gain;
(7) Severe depression;
(8) Prior to surgery (it should be withheld for at
least 6 weeks to minimize postoperative vascular
complications) and
(9)Patient wanting pregnancy.

 It can be used by women who prefer to bleed at
an interval of 60–80 days (3–4 times a year).
 For extended use of pills, the woman should
take the active pills from pill pack and
immediately start the next pack of active pills.
 The pills should be continued for 60–80 days,

 then a withdrawal bleed is allowed.
 Formulations with 84 active pills followed by 7
placebo pills are being made.
 This results in a “seasonal” withdrawal bleed
 at an interval of 4 months. Any monophasic pill
may be used in this manner.

 Pill regimen with 24 active pills followed by 4
placebo pills results in menses at a 28 days
interval with lesser bleeding both in amount and
days.
 Failure rate is also less.

 Potential benefits of pills are greater when compared to
risks, in a wellselected individual.
 A woman who does not smoke and has no other risk
factor for cardiovascular disease, may continue the pill
(with careful monitoring)until the age of fifty years .
 This offers the dual advantages of effective
contraception and hormone replacement therapy.
 However, for spacing of births, use of 3 to 5
years is considered enough and safe.

 The combined preparations containing estrogen and
progestin have got a wide range of metabolic activities
which affect almost all the systems of the body.
 The changes are almost similar to those of pregnancy
and almost completely revert back to normal after the
drug is withdrawn.
 The effects are related either to the
estrogen (OGN) or to the progestin (PGN) or to
both (OGN + PGN) of the compounds.

(a) Contraceptive benefits:
(i) Protection against unwanted pregnancy (failure
rate – 0.1 per 100women year)
(ii) Convenient to use
(iii) Not intercourse related
(iv) Reversibility
(v) Improving maternal and child health care

(b) Non-contraceptive benefits:
Improvement of menstrual abnormalities—
(1) Regulation of menstrual cycle
(2) Reduction of dysmenorrhea (40%)
(3) Reduction of menorrhagia (50%)
(4) Reduction of premenstrual tension syndrome
(PMS)
(5) Reduction of Mittelschmerz’s syndrome
(6) Protection against iron-deficiency anemia.

Protection against health disorders —
(7) Pelvic inflammatory disease (thick cervical mucus)
(8) Ectopic pregnancy
(9) Endometriosis
(10) Fibroid uterus
(11) Hirsutism and acne
(12) Functional ovarian cysts
(13) Benign breast disease
(14) Osteopenia and postmenopausal
osteoporotic fractures
(15) Autoimmune disorders of thyroid
(16) Rheumatoid arthritis.

 Prevention of malignancies—
(17) Endometrial cancer (50%)
(18) Epithelial ovarian cancer (50%)
(19) Colorectal cancer (40%).

 The minor complications or ailments are —
 Nausea, vomiting, headache (OGN) and leg
cramps (PGN) — These are transient and often
subside following continuous use for 2–3 cycles.
 Mastalgia (OGN + PGN) — Heaviness or even
tenderness in the breast is often transient.

 Weight gain (PGN) — Though progestins have
got an anabolic effect due to its chemical relation
to testosterone, use of low dose COCs does not
cause any increase in weight.

 Chloasma (OGN) and acne (PGN) are
annoying for cosmetic reasons. Low dose oral
contraceptives improves acne as levonorgestrel
preparations are less androgenic.

Menstrual abnormalities —
(a) Breakthrough bleeding (BTB) is commonly due
to subthreshold blood level of hormones. Other
causes of breakthrough bleeding in pill takers are -
i. Disturbance of drug absorption — diarrhea,
vomiting
ii. use of enzyme inducing drugs (mentioned
earlier), missing pills, use of low dose pills
iii. Pregnancy complications (miscarriage)

(iv) diseases— cervicalectopy or carcinoma. Usually, it settles
after 3–4 cycles when there is no other specific cause for BTB.
 Exogenous estrogen (conjugated estrogen 1.25 mg or
estradiol 2 mg) given daily for 7 days can control the
bleeding.
 Doubling up the active pills for 2–3 days, or until bleeding
stops, is helpful.
 A pill containing higher dose of estrogen, with different
progestin could be helpful. BTB is not associated with any
increased failure rate.

(b) Hypomenorrhea (PGN) — It is of little significance
although disturbing to the
patient. It is due to the local endometrial changes.
(c) Menorrhagia (OGN) — It is usually preexisting and
use of compounds with progestin preponderance is
helpful.
(d) Amenorrhea (OGN or PGN) — Post pill amenorrhea
of more than 6 months duration occurs in less than 1
percent cases. The association is casual not causal. It is
usually more in women with pre-existing functional
menstrual disorders.

 Spontaneous resumption of menstruation
occurs in majority of cases.
 A refractory case (> 12 months) should be
investigated as a case of secondary amenorrhea.
Libido: Libido may be diminished (PGN)
probably due to dryness of the vagina.
More often, it may either remain static or at times,
may even increase due to loss of fear of
pregnancy.

 Leucorrhea: It may be due to excessive cervical
mucus secretion (OGN) or due to increased
preponderance of monilial infection (OGN + PGN).

 Depression: Low dose estrogen preparations
are not associated with depression
 Hypertension (OGN): Current low dose COCS
rarely cause significant hypertension.
 Pre-existing hypertension is likely to be
aggravated.
 Changes are seen only in systolic but not in
diastolic blood pressure.

 The effect on blood pressure is thought to involve the renin-
angiotensin system.
 There is marked increase in plasma angiotensinogen.
 The changes however reverse back to normal
3–6months after stoppage of pill
 Vascular complications (OGN) –
(a) Venous thromboembolism (VTE) — The overall risk is to the extent
of 3–4 times more than the non-users.
(b) Pre-existing hypertension, diabetes, obesity
thrombophilias (inherited or acquired) and elderly
patient (over 35 especially with smoking habits)
are some of the important risk factors.

 Ethinyl estradiol used with a dose of 20 μg in the
pill markedly reduce the incidence.
 Cholestatic jaundice—Susceptibility is increased in
women with previous history of idiopathic
recurrent jaundice in pregnancy or hepatitis.
 Neoplasia (OGN) — Combined oral contraceptives
(COCs) reduce the risk of epithelial ovarian (50%
↓) and endometrial (50% ↓) carcinoma.
This protective effect persists for 10–15 years even
after stopping the method following a use
of 6 months to 1 year.

 Hypothalamopituitary axis: Both FSH and LH
levels remain low as found in early proliferative
phase and remain throughout the cycle at such
static low level.
 Ovary:
 Ovarian function remains quiescent with
occasional evidence of breakthrough ovulation.
 There is evidence of fibrosis, progressive wastage
of unripe ova with advancing age without
evidence of corpus luteum.

 Endometrium (PGN) — Stromal edema,
decidual reaction and glandular exhaustion out
of depletion of glycogen are more or less
constant findings
 Cervix (PGN + OGN)—
 Increased glandular hyperplasia and
downgrowth of the endocervical epithelium
beyond the squamocolumnar junction gives the
appearance of an ectopy.
 Relative risk of cervical cancer with COC use is
1.1.

 Uterus (OGN)—
 Uterus may be slightly enlarged.
 Low dose COCs do not usually increase the
size of a pre-existing fibroid. COCs can reduce
the amount of menstrual bleeding.
 Vagina (PGN)—
 Cytohormonal study reflects the picture of
early luteal phase.

 Other organs:
(i) Liver — The liver functions are depressed.
(ii) Gastrointestinal tract — There is increased
incidence of mesenteric vein thrombosis.
(iii) Urinary— There is increased incidence of
urinary tract infection but is probably related to
increase in sexual activity.

 Ovulation returns within 3 months of
withdrawal of the drug in 90 percent cases.
 Risk to fetus: When COC is taken during
early pregnancy inadvertently there is no
greater risk of significant congenital anomaly.
Risk of congenital abnormality in general is 2–3
percent.

 Lactation (OGN + PGN):
 Lactation is probably affected by a reduction in the
milk production and also by alteration of the
quality of the milk (reduction of protein and fat
content).
 Moreover, significant amount of the steroids are
ingested by the infant, the effects are as yet
unknown.
 Mini-pill is a better alternative for the
breastfeeders.

 POP is devoid of any estrogen compound. It
contains very low dose of a progestin in any one of
the following form —
 Levonorgestrel 75 μg, norethisterone 350 μg,
desogestrel 75 μg, lynestrenol 500 μg or norgestrel
30 μg.
 It has to be taken daily from the first day
of the cycle.

 It works mainly by making cervical mucus thick
and viscous, thereby prevents sperm
penetration.
 Endometrium becomes atrophic, so blastocyst
implantation is also hindered.
 In about 2 percent of cases ovulation is inhibited
and 50 percent women ovulate normally.

 The first pill has to be taken on the first day of the
cycle and then continuously.
 It has to be taken regularly and at the same time of
the day.
 There must be no break between the packs.
 Delay in intake for more than 3 hours, the woman.
 should have missed pill immediately and the next
one as schedule.

(1) Side effects attributed to estrogen in the
combined pill are totally eliminated
(2) No adverse effect on lactation and hence can be
suitably prescribed in lactating women and as
such it is often called “Lactation Pill”
(3) Easy to take as there is no “On and Off” regime
(4) It may be prescribed in patient having (medical
disorders) hypertension, fibroid, diabetes,
epilepsy, smoking and history of
thromboembolism
(5) Reduces the risk of PID and endometrial cancer.

(1) There may be acne, mastalgia, headache,
breakthrough bleeding, or at times amenorrhea in
about 20–30 percent cases
(2) All the side effects, attributed to progestins may be
evident
(3) Simple cysts of the ovary may be seen, but they
do not require any surgery
(4) Failure rate is about 0.5–2 per 100 women years of
use.

 Failure is more in young compared to women
over 40.
 Women using drugs that induce liver
microsomal enzymes to alter a metabolism
should avoid this method of contraception.

(i) Pregnancy
(ii) unexplained vaginal bleeding
(iii) recent breast cancer
(iv) arterial disease.
(v) thromboembolic disease.

 The preparations commonly used are
depomedroxy progesterone acetate (DMPA)
and norethisterone enanthate (NET-EN).
 Both are administered intramuscularly (deltoid
or gluteus muscle) within 5 days of the cycle.
 The injection should be deep, Z-tract
technique and the site not to be messaged.
 DMPA in a dose of 150 mg every three months
(WHO 4 months) or 300 mg every six months;
 NET-EN in a dose of 200 mg given at two-
monthly intervals.

 Depo-Sub Q provera 104, contains 104 mg of
DMPA.
 It is given subcutaneously over the anterior
thigh or abdomen.
 It suppresses ovulation for 3 months as it is
absorbed more slowly.

(1) Inhibition of ovulation — by suppressing the
mid cycle LH peak
(2) cervical mucus becomes thick and viscid
thereby prevents sperm penetration
(3) Endometrium is atrophic
preventing blastocyst implantation

(1) It eliminates regular medication as
imposed by oral pill
(2) It can be used safely during lactation. It
probably increases the milk secretion without
altering its composition
(3) No estrogen related side effects
(4) Menstrual symptoms, e.g. menorrhagia,
dysmenorrhea are reduced

(5) Protective against endometrial cancer
(6) Can be used as an interim contraception before
vasectomy becomes effective
(7) Reduction in PID, endometriosis, ectopic
pregnancy and ovarian cancer.
The non-contraceptive benefits:
 DMPA reduces the risk of— salpingitis,
endometrial cancer, iron deficiency anemia,
sickle cell problems and endometriosis.

 Failure rate for DMPA – (0–0.3) (HWY).
There is chance of irregular bleeding and occasional
phase of amenorrhea.
 Return of fertility after their discontinuation is
usually delayed for several months (4–8 months).
 However, with NET-EN the return of fertility is
quicker.
 Loss of bone mineral density (reversible) has been
observed with long-term use of depot provera.
Overweight, insulin resistant women may develop
diabetes.
 Other side effects are: weight gain and headache

 Women with high risk factors for osteoporosis
and the others are same as in POP

 Implanon is a progestin only delivery system
containing 3 Ketodesogestrel (etonorgestrel).
 It is a long-term (up to 3 years) reversible
contraception.
 It consists of a single closed capsule (made of
polydimethyl siloxane 40 mm × 2 mm) and contains
68 mg of etonorgestrel (ENG).
 It releases the hormone about 60 mcg, gradually
reduced to 30 mcg per day over 3 years.
 Implanon does not cause decrease in bone mineral
density

Single implant rod — Implanon

 It inhibits ovulation in 90 percent of the cycles
for the first year.
 It has got its supplementary effect on
endometrium (atrophy) and cervical mucus
(thick) as well.

 The capsule is inserted subdermally, in the inner
aspect of the nondominant arm, 6–8 cm
above the elbow fold.
 It is inserted between biceps and triceps muscles.
 Preloaded sterile applicator is available
No incision is required.
 Removal is done by making a 2 mm incision at the
tip of the implant and pushing the rod until it pops
out

 It is done under local anesthetic. It is ideally
inserted within D 5 of a menstrual cycle,
immediately after abortion and 3 weeks after
postpartum.

 Implanon should be removed within 3
years of insertion.
 Loss of contraceptive action is immediate.

 Advantages are the same as with DMPA.
Others are -
(i) Highly effective for long-term use and rapidly
reversible.
(ii) Suited for women who have completed
their family but do not desire permanent sterilization.
(iii) Efficacy of implanon is extremely high with Pearl
indices of 0.01.
(iv) This safe and effective method is
considered as ‘reversible sterilization’

 Drawbacks
Frequent irregular menstrual bleeding, spotting and
amenorrhea are common. Difficulty in removal is
felt occasionally.
 Contraindications are similar to POP

 Two rods of 4 cm long with diameter of 2.5 mm
is used.
 Each rod contains 75 mg of levonorgesterel.
 It releases 50 mcg of levonorgestrel per day.
Contraceptive efficacy is similar to combined
pills.
 Failure rate is 0.06 per 100 women years.
 It is used for 3 years.
 The rods are easier to insert and remove.

 Hormones
 IUD
 Anti-progesterone
 Others

 Indications of emergency contraception:
 Unprotected intercourse, condom rupture,
missed pill, delay in taking POP for more than 3
hours, sexual assault or rape and first
time intercourse, as known to be always
unplanned.
 Risk of pregnancy following a single act of
unprotected coitus around the time of ovulation
is 8 percent.

 Morning-after Pill: This is not true contraception,
but has rightly been called interception, preventing
conception in case of accidental unprotected
exposure around the time of ovulation.
 Drugs commonly used: levonorgestrel ethinyl-
estradiol 2.5 mg.
 The drug is taken orally twice daily for 5 days,
beginning soon after the exposure but not later than
72 hours.

 0.75 mg, two doses given at 12
hours interval, is very successful and without any side effects.
 The two tablets (1.50 mg) can be taken as a single dose also.
 The first dose should be taken within 72 hours
 No fetal adverse effects has been observed when there
is failure of emergency contraception.
 However, induced abortion should be offered to the patient,
if the method fails.

Mode of action:
The exact mechanism of action remains
unclear. The following are the possibilities:
 Ovulation is either prevented or delayed when the
drug is taken in the beginning of the cycle.
 Fertilization is interfered.
 Implantation is prevented (except E. Pills) as the
endometrium is rendered unfavorable.
 Interferes with the function of corpus luteum or
may cause luteolysis.

Drawbacks:
 Nausea and vomiting are much more
intense with estrogen use. Antiemetic (meclizine)
should be prescribed.

 Introduction of a copper IUD within a maximum period
of 5 days can prevent conception following accidental
unprotected exposure.
 This prevents implantation.
 Failure rate is about 0–1 percent.
 It is the gold standard method to be opened to all
women for EC.
 Postcoital contraception is only employed as an
emergency measure and is not effective if used as a regular
method of contraception.

 is equally effective.
 Two tablets of Ovral (0.25 mg levonorgestrel
and 50 μg ethinyl estradiol) should be taken as
early as possible
 after coitus (< 72 hours) and two more tablets
are to be taken 12 hours later.

 Oral antiemetic (10 mg metoclopramide) may
be taken 1 hour before each dose to reduce the
problem of nausea and vomiting.

 Anti-progesterone (RU 486- Mifepristone)
binds competitively to progesterone receptors
and nullifies the effect of endogenous progesterone.
 Dose: A single dose of 100 mg is to be taken within
17 days of intercourse. Implantation is prevented
due to its anti-progesterone effect.
 Pregnancy rate is 0–0.6 percent.

 as an EC is as effective as levonorgestrel.
 A single dose 30 mg, to be taken orally as soon as
possible or within 120 hours of coitus.
 It acts by suppressing follicular and endometrial
growth.
 It delays ovulation and inhibits implantation.
 It should not be prescribed in women with
severe hepatic dysfunction nor with severe asthma.

Contraception

More Related Content

What's hot

Similar to Contraception

More from SupriyaMahind

Recently uploaded

Contraception

Editor's Notes