Contraception Update April 2019

2.  Epidemiology and statistics
 Types of contraception
 UKMEC criteria for contraception usage
 Disease-specific contraception
 Issues pertaining to contraception

3.  The 2013 National Survey of Sexual Attitudes and Lifestyles
(NATSAL) research project showed that 1 in 5 pregnancies
conceived when the mother is aged 40 years or older are
unplanned and 28% of these pregnancies end in termination
 A significant number of pregnancies in the UK are unplanned, with
data suggesting that up to one-third of term pregnancies are
unintended at conception
 A study showed that 1 in 13 women presenting for abortion or
childbirth in a UK health board had conceived within a year of a
previous childbirth

4. Source: MPFS-5 (2014),
LPPKN, Malaysia

5. Source: MPFS-5 (2014),
LPPKN, Malaysia

8.  WHO definition: The voluntary avoidance of intercourse by a couple
during the fertile phase of the menstrual cycle in order to avoid a
pregnancy
 Cycle length is recorded for the minimum of 12 cycles
 Likely fertile days are then calculated allowing for the survival of sperm
and ova
 First fertile day : shortest cycle – 20
 Last fertile day : longest cycle – 10
 Example:
 For cycles of 26-32 days, abstinence should be practiced from day 6 to day 22
 Failure rate: 20%

9. • Require long periods of
sexual abstinence
• Provide low & varying
levels of efficacy
• Do not provide any
protections against STIs
Not suitable for:
 Cycle length <23 days or
>35 days
 PCOS
 Breastfeeding
 Menopausal symptoms
 Women taking hormonal
medication

10.  Criteria:
Fully breastfeeding day and night
Amenorrhoeic
Less than 6 months’ postpartum
 Failure rate: <2%

11.  Failure rates:
 Perfect use: 2%
 Typical use: 18%
REASONS FOR CONDOM FAILURE
• Condom put on after genital contact
• Condom not completely unrolled onto the penis
• Condom slippage when penis withdrawn from the
vagina, or during sexual intercourse
• Condom breakage
• Use of oil-based lubricants (including lipsticks) which
cause latex condom to break
• Mechanical damage (e.g. from fingernails)
• Concurrent use of some vaginal preparations of drugs
(may damage latex condom)

12. Mechanism of action:
 Suppression of ovulation
 By prevention of ovarian follicular maturation
 By interrupting the oestrogen-mediated positive
feedback on the hypothalamic-pituitary axis thus
preventing LH surge
 Thicken the cervical mucus, thus reducing sperm
penetrability
 Alteration of the endometrium
 Thin endometrium prevents implantation

13. Examples of COCP available in Malaysia:
•Regulon
•Rigevidon
•Microgynon
•Mercilon
•Marvelon
•Yazmin/Yaz
•Liza/Liz
•Qlaira

14. • 2 different packaging : 28 days (1 week of placebo) or 21 days (7 days pill-free period)
• 7 days of pill-free period/placebo - women will have a ‘withdrawal bleed’
• Best to be taken at same time every day
• Contraception is immediate if start the pills on D1-5 menses (EE containing COCP)
• If 1st pill after D5 , other contraception needed for 7 days
• If vomiting or diarrhoea: extra contraception
• Postpartum (not BF) : start D21 after delivery
• Post-termination/ERPOC : within 5 days of termination (anytime after: need
additional contraception)
• If taking antibiotics:
No need extra contraception (if non-enzyme inducers).
If enzyme-inducers: Ideally switch to intrauterine or progestogen-only injectable. If only for
short term, may consider using COC with 30mcg EE during and for 28 days after stopping
the enzyme-inducing drug.
Very potent enzyme inducers (rifampicin, rifabutin): consider switching to another method

15. • For COCP containing 20 mcg/30mcg EE:
If 1 pill is missed at anytime, take the
pill ASAP (NO NEED EXTRA COVER,
DO NOT STOP)
If 2 or more pills are missed in the:
1st week: need emergency
contraception if unprotected sex and
use condoms for 7 days
2nd week: use condom for 7 days
3rd week: use condom for 7 days and
continue with next packet without a
break (omit pill-free interval)
 Failure rates:
 Perfect use: 0.3%
 Typical use: 9%

16. RIGHT PATIENT SELECTION…
• Grandmultipara
• Desires long term
contraception
• Previous history of failed
COCP
• Intolerable side effects
• Poor education/social
background
• Compliance is an issue
• Risks outweigh benefits

17.  Reduced risk of ovarian (25%) and endometrial cancer
(50%) that continues for several decades after stopping
COCP
 Reduced risk of colorectal cancer
 May help improve acne
 May help reduce menstrual pain and bleeding and regulate
menstrual cycle
 May reduce menopausal symptoms

18. • Postpartum <6 weeks (BF)
• Postpartum <3 weeks (non-BF,
with other risk factors for VTE)
• Smoker, age≥ 35 (≥ 15
cigarettes/day)
• Uncontrolled hypertension
• Vascular disease
• Ischemic heart disease, stroke
• VTE
• Major surgery with prolonged
immobilisation
• Thrombogenic mutations
• Complicated
valvular/congenital heart
disease
• Decompensated
cardiomyopathy
• Atrial fibrillation
• Migraine with aura
• Current breast cancer
• Decompensated liver cirrhosis
• Benign hepatocellular
adenoma
• Positive APL antibodies

19.  Main effect: thickens cervical mucus thus decreasing
sperm penetrability of cervix
 Reduces receptivity of endometrium to implantation
 Reduction in ovulation
 Suppress ovulation in ~60%, this is unpredictable and varies between cycles
resulting in irregular menstruation
 50% have regular ovulatory cycles with normal luteal phase and a normal
menstrual cycle
 10-15% of women have complete inhibition of ovarian activity and are
amenorrhoeic
 New: Cerazette inhibits ovulation 97%
 Reduces Fallopian tube motility
Failure Rates:
• LNG: 1.55 per 100
woman-years
• DSG: 0.41 per 100
woman-years

21. • One pill daily taken continuously without a break
• Best to be taken at same hour every day (within 3 hours at the most)
• Contraception is immediate if start the pills on D1-5 of menses
• If 1st pill after D5, extra contraception needed for 2 days
• If taking antibiotics : do not effect the efficacy of POP
• If taking rifampicin (or other enzyme inducers): reduction of efficacy due to
increased metabolism of POP
• Postpartum: start day 21 after delivery (regardless BF). But if not EBF, then will
need extra contraception for 2 days
• Post-termination/ERPOC : within D1-5; if later – will need extra contraception
for 2 days

22. •If ˃3 hours late or 27 hours since last pill:
Take missed pill ASAP
Take subsequent pill at the usual time (2 pills may
be taken on same day)
Use extra contraception for the next 2 days
•If vomit within 2 hours of ingestion:
Take another pill immediately
If the subsequent pill is taken >3 hours later,
missed pills as above should be followed
Same rules apply if woman were to continue
vomiting or have severe watery diarrhea
An estimated 48 hours of
POP use is deemed
necessary to achieve the
contraceptive effects on
cervical mucus

23. • Strict adherence to the rules of pill taking is essential
• Pattern of bleeding is unpredictable
• Associated with increased incidence of ovarian follicular
cysts

24. • Released in 2003
• Contains 3rd generation of progestogen –
desogestrel
• Inhibits ovulation – 97%
• Window period of 12 hours instead of 3 hours
• Taken every day with no break
• Useful for younger women who cannot or do
not wish to take oestrogen containing
products or women who cannot tolerate other
POPs.

26.  Preparations
 DMPA : Depo-Provera (Depot Medroxyprogesterone Acetate) (IM DMPA
150mg every 3 months +/- 2 weeks)
 NET-EN : Norethisterone Enantate (IM NET-EN 200mg every 2 months +/- 2
weeks)
 MOA – similar to POP
 When to start – can be started up to D5 without additional
contraception. May start beyond D5 if reasonably certain
pregnancy has been excluded (with additional
contraception or abstinence for the next 7 days)
Failure Rates:
• Perfect use: 0.2%
• Typical use: 6%

27. • Who forget to take pills, particularly travelers,
due to frequent changes in time zones
(missed pills are likely or where suboptimal
compliance is expected)
• Who wish for a secret or ‘private’ method
• In whom oestrogen is contraindicated

28. • **Menstrual disturbances
(amenorrhea, spotting, infrequent
bleeding or prolonged bleeding)
 Amenorrhoea becomes more
likely with increased duration of
use
 10% after 3rd month of use
 47% after 1st year of use
• **Weight gain (probably due to
progestogen effect, which increases
appetite and may also cause fluid
rentention)
• Headaches and mood changes
• **Diffuse hair loss (alopecia)
• Delay in return to normal fertility
 Following a final injection of
DMPA, ovulation returns after 6-
12 months
 Following discontinuation:
 78% conceive by 12 months,
92% conceive by 24 months
 Thought to be due to slow
metabolism of the drug from the
microcrystalline deposits in
muscle tissue
• Small loss of BMD (which is usually
recovered after discontinuation)

30. IMPLANON
 68mg etonogestrel
 Biodegradable single rod implant
 Initial release rate of 60-70µg/day and
reduces to 25-30µg at the end of 3 years
 MOA – similar to POP
 Currently Implanon has been replaced by
Nexplanon
 Addition of barium sulphate for detection under X-
ray
 Modified applicator to reduce risk of deep insertion
and facilitate one-handed insertion

31.  The implant should be inserted at the
inner side of the upper arm to avoid the
large blood vessels and nerves that lie
deeper in the connective tissue
between the bicep and tricep muscles
 Can be administered up to day 5 of
menses without the need for additional
contraception
• License for 3 years – efficacy may be
lower during the 3rd year in overweight
women

32. Independent of user compliance
Rapid return to fertility
90% of women ovulate within 30 days
Efficacy not being affected by broad-spectrum
antibiotics
Failure rate : 0.05%

33. Menstrual disturbances
 1/3 have infrequent bleeding, 1/4 have prolonged or frequent
bleeding, 1/5 have no bleeding
 Improves over 3-5 months
 NSAIDs and low dose COCP are generally effective treatment
strategies for Implanon-related bleeding

35. COPPER IUD
 1st generation
Copper seven
Copper T 200
 2nd generation
Multiload 250
Nova T
 3rd generation
Copper T380A
Multiload 375

36.  MOA
 Toxic effect of copper on ovum and
sperm
 Alteration in copper content of
cervical mucus inhibits sperm
penetration
 Endometrial inflammatory reaction
has an anti-implantation effect
 Licensed for 5 years
 Low expulsion rate
 8/100 women over 5 years
 Low failure rate
 0.1-1%

37. • Can be inserted at any period of the
menstrual cycle as long as reasonably
certain pregnancy has been excluded
• Effective immediately after insertion
• Can be used as EC provided it is inserted
before implantation occurs (within first 120
hours of UPSI in a cycle) or up to 5 days
after the earliest estimated day of
ovulation
• When to insert postpartum?
 Within 48 hours postpartum OR after 4
weeks postpartum (as long as
reasonably certain pregnancy has been
excluded)

38. • Expulsion
Most common in 1st 3
months after insertion and
often during menses (1:20)
• Perforation
Risk 2:1000 insertions, 6 fold
higher in breastfeeding
women
• Pelvic infection
Although 6 fold increase in
risk of developing PID in the
first 20 days, the overall risk
is low unless there’s
exposure to STIs
• Bleeding pattern and pain
 Irregular, prolonged or frequent
bleeding in 3-6 months after IUD
insertion but bleeding patterns
tend to improve over time
• Pregnancy
 Exclude ectopic pregnancy ( risk
1:1000 with IUD)
 If threads are visible, IUCD should
be removed (up to 12 weeks)
 With IUCD left in situ : 2nd TS
abortion, PTL, infection
 Removal associated with small risk
of abortion

39.  Long-acting, rapidly reversible
 52mg levonorgestrel released at the rate
of 20µg/day
 Frame is rendered radio-opaque by
impregnation with barium sulphate
 Licensed for contraception for 5 years
 Also licensed for management of HMB
and endometrial protection during ERT
 May reduce pain associated with
dysmenorrhoea, endometriosis or
adenomyosis
Failure rate of 0.06/100
women years

40. • The contraceptive effect is achieved by:
 Works primarily by its effect on endometrium
preventing implantation
 Endometrial glandular and stromal atrophy
 Changes in the cervical mucus which prevent
ascent of spermatozoa
• May be fitted up to day 7 of menstrual cycle without
need of additional contraception OR at any time in
the menstrual cycle with additional contraceptives
for the next 7 days (exclude pregnancy first)

41. • Difficult insertion especially in
nulliparous woman
• Bleeding pattern
Irregular bleeding &
spotting common during 1st
6-8mths
By 1 year amenorrhoea or
infrequent bleeding ensues
• Amenorrhoea
Some women may regard
this as abnormal –
counseling important
• Increased incidence of
functional ovarian cysts
compared to copper IUD users
• Progestogenic SE – oedema/
headache/ breast tenderness/
acne – subsides after a few
months
• Expulsion – commonly occurs
during first 3 months
following insertion

42. • Female
 Mini Laparotomy
 The Pomeroy method
 The Parkland technique
 The Ushida method
 The Irving method
 Fimbriectomy
 Laparoscopic
 Filshie clip
 Hulka clip
 Falope ring
 Hysteroscopic
 Chemical method: quinacrine
 Mechanical method
 Ovabloc®
 Essure® device

43.  A permanent and usually irreversible method
 Counseling, written information, its risks, benefits &
failure rates should be provided
 Discussion & information should be given regarding
other methods of contraception.
 Both men and women should be informed that reversal
is rarely provided

44. ADVANTAGES
 99% effective in the
first year following the
procedure
DISADVANTAGES
 Difficult to reverse (meant to
be PERMANENT)
 If pregnancy does occur, it
carries a 33% chance of it
being an ectopic pregnancy
 Expose to risk of anaesthetic /
surgical complication
 More difficult than vasectomy
(complication: 1-4% with
BTL)

47. Contraception use amongst the youth
Sex education – need or not?
Fear of the unknown
Amenorrhea – can start contraception?

48.  Contraception use amongst the youth remains at an all
time low
 Teenage pregnancies – 18000 per year in Malaysia, out of
which 25% are pregnancies out of wedlock
 2016 data on Sarawak
2nd highest number of teenage pregnancies after Sabah
(2481 versus 2564)
Highest percentage of teenage pregnancies compared to
Malaysia as a whole (6.4% versus 2.7%)
54.1 were unmarried, 90-95% not schooling
56.7% between ages of 10-17
Source: Sarawak State Health Department

49.  Lack of sexual education and contraceptive knowledge
 Poor availability of contraceptive service
Contraception is not available for those unmarried - true?
 Cultural and religious taboo
 Legal and ethical considerations, including confidentiality

50.  Weight gain
Reassure that COCP does not cause weight gain
Depot medroxyprogesterone acetate can cause weight gain
 Acne
COCP improves acne
 Bleeding patterns and dysmenorrhea
Hormonal contraceptive use can alter bleeding pattern
Primary dysmenorrhea improves with COCP use

51.  Bone health
Progestogen only injectable is associated with a small loss of
bone mineral density which recovers after discontinuation
Women on DMPA should be reviewed every 2 years to assess
the benefit and risk of continuing
 Thrombosis
Small risk of thrombosis with COCP

52.  Future fertility
No delay in returning of fertility with COCP, IUD, implants
There can be delay of up to 1 year in the return of fertility
after discontinuation of DMPA
 Sexual transmitted infections (STIs)
Correct and consistent use of condoms can reduce the risk of
STIs

53.  Amenorrhea – can you start contraception?
Confusion regarding starting contraception in certain cases,
such as postpartum mothers who are breastfeeding and
appear to be amenorrheic.
Things to consider – exclusively breastfeeding? Is she within
6 months postpartum?
In cases of women with history of oligomenorrhea (such as in
PCOS) – can contraception be given?

54. COCP POP Progestin-only
injectables
Implants LNG IUD Copper IUD
1 1 2 1 2 2

55. COCP POP Progestin-only
injectables
Implants LNG IUD Copper IUD
2/3 1 1 1 1 1

56. COCP POP Progestin-only
injectables
Implants LNG IUD Copper IUD
2/3 1 1 1 1 1

57. COCP POP Progestin-only
injectables
Implants LNG IUD Copper IUD
2 1 2 1 1 1

58. COCP POP Progestin-only
injectables
Implant LNG IUD Copper IUD
1 1 1 1 4(I) 2(C) 4(I) 2(C)

59. Medical
Conditions
COCP POP Progestin-
only
injectables
Implant
s
Levonogestrel
IUD
Copper
IUD
HPT <160/100 3 1 2 1 1 1
>160/100 4 2 3 3 2 1

60. COCP POP Progestin-only
injectables
Implants Levonogestrel IUD Copper IUD
2 2 2 2 2 1

61. COCP POP Progestin-only
injectables
Implants Levonogestrel IUD Copper IUD
3 1 1 1 1 1