Contraceptives summary

1. Dr. Priya Bagade

2. Issues
 Decision made by individual or by couple
 Many factors influence decision:
 Advantages & disadvantages of various methods
 Side effects & contraindications
 Effectivenes
 Expense
 Spiritual/cultural beliefs
 Practicality of method

3. Some facts
 Correct & consistent use of contraceptives results in lower risk of pregn
ancy
 Using more than one method together dramatically lowers risk of preg
nancy
 Emergency contraception offers last chance to prevent pregnancy after
unprotected intercourse or when extent of protection isn’t clear
 Most contraceptives pose little risk to most users’ health
 Half of all pregnancies are unintended (3.1 million/yr)
 More than 4/10 unintended pregnancies end in elective abortion
 Half of unintended pregnancies result from contraceptive failure
 1/3 of all births are unintended
Source: Contraceptive Technology (19th ed)

4.  Defination:
 CONTRACETION: All measures , temporary or permanent
, designed to prevent pregnancy due to coital act.
 IDEAL CONTRACEPTION: Fulfill following criteria
 Widely accetable
 Inexpensive
 Simple to use
 Safe
 Highly effective
 Require minimal motivation, maintainence, and supervision

5.  Benefits of fertility control:
 Improved quality of life
 Better health
 Less physical & emotional stress of life
 Better education, job & economic opportunities
 Fertility Control: Includes
Fertility Inhibition(Contraception)
 Fertility Stimulation.

6. Basic types of contraception
 Fertility awareness methods
 Barrier methods
 Situational methods
 Spermicides
 IUDs
 Hormonal contraception
 Operative sterilization

7. Fertility Awareness Methods
 Natural Family Planning methods
 Based on understanding ovulatory cycle
 Require periods of abstinence & careful recording of events throughout
cycle
 Cooperation very important
 Free, safe, and acceptable to all spiritual beliefs
 Require extensive initial counseling
 25% of women will experience unintended pregnancy in first year
 Some women combine barrier methods (use during fertile periods) an
d/or combine types of FAM
 More difficult when breastfeeding (masks some signs)

8. Fertility Awareness Methods
 Basal body temperature (BBT)
 Woman takes temp early morning
 Must be before any activity
 Uses BBT thermometer and same method
 Chart for 3-4 months to determine normal pattern
 Temp sometimes drops just before ovulation
 Almost always rises by 0.5 degrees & remains elevated fo
r several days after
 Abstain from intercourse several days before and 3 days
after anticipated ovulation

9. Fertility Awareness Methods
 Calendar method
 Also known as rhythm method
 Assumes ovulation takes place 14 days before start of me
nstrual period
 Sperm viable for 48-72 hours, ovum for 24 hours
 Record menstrual cycles for 6-8 months to determine sh
ortest & longest cycles
 Use record to identify fertile & infertile periods
 Least reliable of FAM

10. Fertility Awareness Methods
 Cervical mucus method
 Also known as Billings or ovulation method
 Involves careful assessment of cervical mucus changes throughout c
ycle
 Ovulation mucus clearer, more stretchable (spinnbarkeit), more per
meable to sperm
 Also ferns when dried on glass slide
 Luteal phase mucus thick, sticky, traps sperm (progesterone influen
ce)
 Woman abstains from intercourse for one cycle & assesses mucus st
atus
 Peak day of wetness & clear, stretchable mucus is assumed day of ov
ulation
 Can be used by women with irregular cycles

11. Fertility Awareness Methods
 Symptothermal method
 Multiple assessments made & recorded
 Cycle days, coitus, cervical mucus changes, BBT, & secon
dary changes (increased libido, bloating, mittelschmerz)
 Combined approach is more effective

12. Situational contraceptives
 Abstinence
 Coitus interruptus (withdrawal)
 Very unreliable
 Demands great self-control
 Pre-ejaculate may contain sperm, esp. after a recent ejaculation
 Douching after intercourse
 Not recommended; may facilitate conception
 Lactational amenorrhea method (LAM)
 Lactation depresses ovarian function
 Exclusive breastfeeding, from the breast (no pumping), in first s
ix months following birth without PP menses is 98% effective
 Even more effective if used with other method of contracep.

13. Barrier Methods
 Male condom
 Female condom
 Diaphragm
 Cervical cap
 Vaginal sponge
 Usually used with spermicides
 All vaginal barriers may cause increased risk of tox
ic shock syndrome if used longer than recommend
ed

14. Spermicides
 Available as creams, jellies, foams, film, suppositories
 May require up to 30 minutes to become effective
 Minimally effective if used alone
 May cause skin/mucus membrane irritation, allergic re
action

15. Barrier methods
 Male condom
 Must be used correctly to be effective
 No side effects
 Inexpensive and easily available
 Usually latex, but other types available for allergic
 Offers protection from pregnancy and STIs
 May also be used for STI protection in oral and anal inte
rcourse

16. Barrier Methods
 Female condoms
 Thin sheath with flexible ring at each end
 May be inserted up to 8 hrs before intercourse
 Internal ring functions like diaphragm to cover cervix
 External ring covers portion of perineum
 Cannot be used with male condom
 Slightly less reliable than other barrier methods
 More expensive than male condom
 Noisy and cumbersome

17. Barrier methods
 Diaphragm
 Must be used with spermicide
 Requires prescription and fitting by HCP
 Fits over cervix between pubic symphysis and posterior fornix
 Must be inserted before and remain in place at least six hours after i
ntercourse; additional spermicide must be inserted for additional ac
ts of coitus
 No hormones involved; may help protect cervix against HPV
 Requires comfort with insertion and checking placement
 Not recommended for those with hx of recurrent UTI

18. Barrier methods
 Cervical cap
 Fits over cervix by suction (smaller than diaphragm)
 Also used with spermicide
 May be left in place 24- 48 hrs
 May be more difficult to fit than diaphragm
 Requires more comfort with body to place correctly

19. Barrier methods
 Lea’s shield
 Similar to cervical cap, but with valve for passage of secr
etions & air
 One size fits all, but only available by rx in US
 Contraceptive sponge
 Available OTC, one size (expensive)
 Contains nonoxynol-9
 No additional spermicide needed for additional coitus w
ithin 24 hrs sponge may be in place
 Less effective in parous women

20. Intrauterine contraception
 Two forms available
 Paragard (copper T)
 Mirena (releases levonogestrel)
 Trigger spermicidal reaction in body, preventing fe
rtilization
 Provide long-term, highly effective contraception
 Risks include PID, perforation, dysmenorrhea, exp
ulsion
 Also may be used as emergency contraception (Par
agard only)

21. Intrauterine contraception
 Used in parous women in stable, long-term, monogamous re
lationships
 Inserted into uterus by practitioner.
 Nursing action: premedicate with ibuprofen to decrease cra
mping with procedure
 Usually inserted immidiately after menses or during first six
weeks postpartum (may be inserted any time as long as not p
regnant)
 String protrudes through cervix into vagina (path for ascendi
ng infection if exposed to STI)
 Women should check string after each menses
 Warning signs: late period, abnormal bleeding (may happen
with Mirena), abnormal discharge, s/sx of infection

22. Intrauterine contraception
Copper T
 Works by impairing fertilization
 May stay in place up to ten years
 May cause increased bleeding/cramping with periods
 No hormones
 Contraindicated in copper allergy
 Low daily cost
 High user compliance, continuation, & satisfaction
 May help prevent endometrial cancer

23. Intrauterine contraception
 Mirena
 Releases small amount of progesterone (10% of oral cont
raceptives)
 May remain in place for up to 5 yrs
 Decreased bleeding, cramping compared to copper T
 May be recommended to women with menorrhagia
 Some women stop ovulating while it’s in place
 May cease bleeding altogether
 May have irregular bleeding, esp. in first few months

24. Hormonal contraception
 Combined oral contraceptives
 Progesterone-only oral contraceptives
 Implanted contraceptives
 Injected contraceptives
 Other hormonal contraceptives
 Vaginal ring
 Contraceptive patch

25. Hormonal contraception
 Combined oral contraceptives (COCs)
 Birth control pills with both estrogen & progesterone
 Most taken daily for 21 days, with 7 days of placebo or no
pill (exceptions: Seasonale,Seasonique, Yaz)
 Many formulations--monophasic, multiphasic, different
strengths, different progesterones
 Side effects differ somewhat based on formulations
 Very effective if used correctly
 No protection against STI

26. Hormonal contraception
 COCs
 Action:
 Suppress ovulation through negative feedback to hypothalami
c-pituitary axis
 Thickening of cervical mucus to prevent sperm entry
 May also slow tubal motility, disrupt transport of ova, change f
unction of endometrial vessels, cause endometrial atrophy, an
d inhibit implantation (not proven)

27. Hormonal contraception
 COCs
 Contraindications
 Pregnancy
 Hx of thrombophlebitis/thromboembolic disease
 Acute or chronic liver disease or gallbladder disease
 Estrogen-depended carcinoma
 Undiagnosed menorrhagia
 Smoking (esp. if over 35)
 Diabetes
 HTN
 Hyperlipidemia

28. Hormonal contraception
 COCs
 Caution/relative contraindications
 Hx of migraine headaches
 Seizure disorder
 Depression
 Oligomenorrhea
 Amenorrhea
 Often safer than pregnancy

29. Hormonal contraception
 COCs
 Noncontraceptive benefits:
 Decreased risk of ovarian and endometrial cancer
 Relief of menstrual symptoms (e.g. fewer/less painful cramps
, lighter flow)
 Regulation of irregular menses
 Reduced risk of ovarian cysts
 Improvement in menstrual migraines
 Decreased incidence of ectopic pregnancy
 Decreased incidence of benign breast disease & iron deficien
cy anemia
 Some pills decrease PMS symptoms (Yasmin & Yaz)
 Reduced symptoms of endometriosis, acne, hirsutism

30. Hormonal contraception
 Other combined methods
 NuvaRing vaginal ring (must be comfortable inserting)
 Ortho Evra contraceptive patch
 Similar effectiveness, non-contraceptive benefits, contraindications,
and side effects as COCs
 Patch dispenses higher dose of hormones than COCs, with possible
higher risk of venous thromboemobolic conditions
 Ring uses progesterone formulation that may increase risk of VTC a
s well
 Neither require daily use
 Patch replaced weekly for three weeks, then one week without
 Ring left in for three weeks, then one week without

31. Hormonal contraception
 Progesterone only pills (mini-pill)
 Do not suppress ovulation
 Do not affect breast milk supply (good for nursing mom
s)
 Must be taken at same time every day to be effective
 Often causes irregular bleeding
 Not as effective as combined methods
 No risk of venous thromboembolic events

32. Hormonal contraception
 Injectable contraception
 Formulations use progesterone only
 Depo-Provera (DMPA-IM 150 mg/1 ml) most commonly
used
 Given IM every 12 weeks
 NET-EN (Norethisterone enanthate)
 Given 200 mg every 2 monthly.

33. Hormonal contraception
 DMPA actions & advantages
 Works by inhibiting ovulation (suppresses FSH & LH), t
hickening cervical mucus
 Safe for those who can’t take estrogen (e.g. hx of DVT)
 Highly effective
 Very light to no menstrual periods (but can have irregul
ar bleeding)
 New SC formulation less painful, may be self-administer
ed

34. Hormonal contraception
 DMPA disadvantages
 Most women have irregular bleeding/spotting
 Most women gain weight
 May increase risk of depression
 May decrease bone density
 May take up to one year to reverse effects/regain fertility
 Must return for injectionsf every 3 monthly
 No protection from STI

35. Hormonal contraception
 Implanted contraception
 Implanon
 Single rod implanted under skin of upper arm
 Provides contraception for 3 years
 Releases progestin continuously
 Extremely effective
 Like all progestin-only methods, causes irregular bleeding in ma
ny women
 Must be inserted by HCP & removed later

36. Emergency contraception
 Used after unprotected sex, contraceptive failure, or unsure
protection
 Should be taken as soon as possible after incident
 No medical contraindications except established pregnanc
y
 Most effective in first 72 hours, but still somewhat effective
up to 5 days after coitus
 Providing EC is the standard of care for women who requ
est it

37. Emergency contraception
 Methods
 Combined hormonal ( estrogen & progestin)
 Progestin-only (Plan B, available OTC for those >/= 18, rx for those <
18, more effective & better tolerated )
 Copper IUD insertion (99% effective; can insert up to 7 days after co
itus)
 Not the same as abortion pill (RU486/mifepristone)!

38. Operative sterilization
 Surgical procedures that permanently prevent pregnan
cy
 Very difficult to reverse
 Vasectomy and tubal ligation
 Extremely effective and cost-effective
 Does not protect against STI

39. Operative sterilization
 Vasectomy
 Relatively minor procedure (safer and less expensive tha
n female sterilization)
 Surgical severing of vas deferens
 Takes 4-6 weeks/6-36 ejaculations to clear remaining act
ive sperm from vas
 Couple needs to use alternate method and bring in seme
n samples to verify (and recheck at 6-12 months)
 SE include pain, infection, hematoma, sperm granuloma
s, spontaneous reanastomosis

40. Operative sterilization
 Female sterilization
 May be done with repeat cesarean section or postpartum
from vaginal birth
 More serious surgery than vasectomy
 Complications include injury to bowel, bladder & adjace
nt structures, pain, infection, hemorrhage, adverse effec
ts of anesthesia
 New transcervical method (Essure) does not require ope
ning abdominal cavity, can be done under local anesthes
ia in physician’s office

41. Thank you