Based on the graph, rear entry coital position is associated with the highest risk of preterm delivery with PROM. The graph shows that rear entry position has the highest percentage of preterm deliveries with PROM compared to female superior, male superior and side by side positions.

1. CONTRACEPTIVE
FACTS AND FAMILY
PLANNING
RONALDO R. SANTOS, MD, FPOGS
Departments of Obstetrics and Gynecology,
FEU-NRMF and JRRMMC
MODULE 3 Updates on Family Planning Methods

2. Is sex important?
 WHO reports: 42 B coitus/year
 115 million/day: 250,000/day
 4.8 million/hr: 10,000/day
 1,331 ejaculations / sec: 2.8


3. Contraceptive Prevalence Rate in the
Phil. (2000 - 2008)
60
49.8 49.4 49.3 50.6 50.7
50 47
40 35.1 36 35.9
32.3 33 34
30
20 16.8 14.8 16.7
14.7 14.2 13.2
10
0
2000 2001 2004 2005 2006 2008
Total Modern Trad

4. Contraceptive Use according to
methods in the Phil among women
15 - 45 years

5. Effectiveness

6. Outline of Presentation
1. Understand the new methods of
contraception
 New generation progestogens
 Combined injectable contraception
 Extended and continuous use oral contraceptives
 Levonorgestrel intrauterine system
 Single rod implant
 Essure
 Frameless IUD
 Female condom
 Emergency contraception

7. Outline of Presentation
2. Understand the mechanism of action of the
IUD
3. Define the following relationships:
 IUD and PID, Ectopic pregnancy
 Hormonal contraception and breast, cervical and
ovarian cancers
 DMPA and breast cancer
 LAM and breast cancer
 Calendar method and abortion
4. Apply the WHO Medical Eligibility Criteria

8. References:
 Vern L. Katz, MD, Gretchen M. Lentz, MD, Rogerio A. Lobo, MD
and David M. Gershenson, MD, Comprehensive Gynecology 5th ed,
Mosby, an affiliate of Elsevier Inc., Philadelphia, PA, 2007
 Berek, Jonathan S. Berek & Novak's Gynecology, 14th Edition,
Lippincott Williams & Wilkins, 2007
 John O. Schorge, MD, Joseph I. Schaffer, MD, Lisa M. Halvorson,
MD, Barbara L. Hoffman, MD, Karen D. Bradshaw, MD, F. Gary
Cunningham, MD, Editors, Williams Gynecology, Williams
Gynecology, The McGraw-Hill Companies, Inc, 2008
 Family Planning: A global Handbook for Providers, WHO
Department of Reproductive Health and Research, Johns Hopkins
Bloomberg School of Public Health/Center for Communication
Programs, 2007
 WHO Medical Eligibility Criteria for contraception, 4th ed, 2009
 Cunningham, Leveno, Bloom, Hauth, Rouse, Spong, eds, Williams
Obstetrics 23rd ed, McGraw-Hill Companies, USA, 2010
 The Philippine Clinical Standards Manual on Family Planning, Dept
of Health, 2006

9. New Progestins:
Notable characteristics
 Dienogest: antiandrogenic
 Drospirenone: antimineralocorticoid
 Trimegestone: highly progestational
 Nestorone: highly progestational and
antigonadotrophic
 Nomogestrol acetate: highly
antigonadotrophic

10. Classification
PROGESTERONE DERIVATED TESTOSTERONE DERIVATED
17-OH PROG 19-NORPROG ESTRANE GONANES
PREGNANE NON-PREGNANE
OHprogesterone Nomegestrol Lynestrenol Norgestrel
caproate acetate
OHprogesterone Demegestone Levonorgestrel Desogestrel
heptanoate
Gestonorone Promegestone Norethisterone Gestodene
caproate
Chlormadinone Nestorone Norethisterone Norgestimate
acetate acetate
Medrogestone Trimegestone Ethinodiol
diacetate
MPA Norgestrienone
CPA Dienogest

11. Dienogest
 Anti-androgenic: 40%
potency of cyproterone
acetate
 As OCP with EE 30 ug:
Pearl index of 0.2
 Also used for HRT in
combination with
estradiol valerate

12. Drospirenone
 Derived from spirolactone
 Antimineralocorticoid
 Competes with aldosterone
receptors
 30% potency of cyproterone
acetate
 Available as
 Yasmin: 30 ug EE
 Yasminelle: 20 ug EE
 Yas: 20 ug EE x 24 days (2008)
Indicated for PMDD

13. Trimegestone (TMG)
 High progesterone
receptor affinity
 30x more potent than
MPA
 Used for HRT

14. Nomegestrol Acetate
 20% potency of CPA
 Component of HRT
 Highly
antigonadotrophic:
can be use for
inhibition of ovulation

15. Nestorone
 Not active orally but in
target tissues only
 Used in sustained
release implants,
vaginal rings or
transdermal systems
 Highly
antigonadotrophic

16. Progestogens: Relative potencies
MPA
Progestational activity Norgestimate
TMG DSG NOMAc NET
Drospirenone
McPhail NES 100 > LNG 10 > Progesterone 1
index
Ovulation NES 30 > LNG 10 > Progesterone 1
inhibition
DSG MPA NET
Drospirenone
Norgestimate
CPA
Sitruk-Ware R. Menopause 9:6, 2002 Dienogest

17. Antiandrogenic potency
CMA  Highest
antiandrogen
DRSP ic potency of
CPA vs.
DNG other
progestagen
CPA s
0 20 40 60 80 100
Relative antiandrogenic potency (Hershberger test)
Muhn P. et al. Drospirenone: a novel progestogen with antimineralocorticoid and antiandrogenic activity. Contraception 1995; 51: 99-110
Stölzer W. et al. Tierexperimentelle Charakterisierung des Gestagens Dienogest (STS 557). II. Antigonadotrope, gestagene, estrogene und
antiandrogene Wirkungen. III Jenaer Symposium zur hormonalen Kontrazeption, 1985

18. Continuous-Use Oral
Contraceptives
Seasonale
 150 µg levonorgestrel
and 30 µg ethinyl
estradiol.
 a pill every day for 84
days (12 weeks) and
then take hormone-
free pills for 7 days.

19. Lybrel: no menstruation pill
 90 ug
Levonorgestrel
 20 ug ethinyl
estradiol
 365 days
without pill-
free interval

20. Extended use OCP
 Goal: to prevent menstruation
 Rationale: Amenorrhea leads to
a reduction in:
Premenstrual
syndrome
Dysmenorrhea

21. Combined Injectables
 Monthly injection of Estrogen/Progestin:
 less bleeding problems, better compliance
 Earlier return to fertility
 Cyclofem/Cyclo-Provera
Feminena/Lunelle/Lunella: 5 mg estradiol and
25 mg MPA
 Mesigyna/Norigynon: 5 mg estradiol and 50 mg
Norethisterone enanthate
 Norifam

22. rationale
Negative effects in progestin injectables
bleeding pattern disruption (Goldberg, 2007)
return to fertility: 9 – 10 months (Schwallie 1974;
Pardthaisong 1980; Kaunitz 2000)
Regular cyclic endometrial shedding for
combined estrogen – progesterone prep. (Kaunitz,
2000).

23. Composition: Norifam
Estradiol valerate 5
mg
Natural
Less potent than
ethinyl estradiol
Norethisterone
enanthate 50 mg
o Available as Noristerat
Indication:
Contraception

24. Mechanism of Action:
How does it prevent pregnancy
 Inhibition of ovulation
 Motility of the
endometrium and
fallopian tube is
altered
 Cervical mucus
thickens preventing
entry of sperms

25. Pharmacokinetics
 Injected intramuscularly every month
 Elevated estradiol levels for 7 – 11 days
 Predominance of progesterone in the 2nd half
of the cycle
 Inhibits follicle maturation for 30 days
 Inhibit ovulation and corpus luteum formation
for 60 days
Sang, Contraception, 1994 Apr;49(4):361-85.

26. Monthly Injectable (Lunelle)
 MPA/E2C injection: 25 mg of
medroxyprogesterone acetate and 5 mg of
estradiol cypionate
 Monthly intramuscular injection
 Contraindications the same as oral
contraceptive pills
Kaunitz AM., Obstet Gynecol Clin North Am. 2000 Dec;27(4):741-80.

27. DMPA-SC
 Lower dose: 104 mg
 Subcutaneous injection
every 3 months
 Pre-filled Uniject syringe
 Self administered

28. The NuvaRing
 releases 120 µg of
etonogestrel and 15 µg of
ethinyl estradiol per day
 1 ring every 3 weeks, 13 rings
in a year
 Pearl index of 0.65 (95%
confidence interval 0.24-1.41)
 32-40 US$
 Nestorone 150 ug in one ring,
x 3 wks, remove, reinserted,
cycle repeated.
 Can be removed for 3 hrs if
bothersome during sex

29. Otho-Evra Patch
 150 µg of the progestin
norelgestromin and 20 µg of the
estrogen ethinyl estradiol per day.
 Weekly patch x 3 followed by
patchless week
 square patch, each side about 4.45
centimeters (1.75 inches) long,
resembling a light brown bandage

30. Spray-On Contraceptives
 Nestorone Metered Dose
Transdermal System, a daily
progestin-only spray-on
contraceptive, began in
Australia in 2004.
 In a clinical trial a Nestorone
gel applied to the skin daily
for three months
suppressed ovulation in
83% of participants applying
1.2 mg per day
 Phase II studies

31. Implants
 Levonorgestrel: Jadelle, 2 rods of 140 mg, 5
years effectiveness
 Etonogestrel: Implanon, 1 rod, 3 years
effectiveness
 Nestorone: ST 1435, 1 rod, 2 years

32. Levonorgestrel - IUS
 Levonorgestrel: 20 ug/day
 5 years effective
 Indicated for DUB
 Some bleeding problems
 Mirena, Femilis

33. Standard Days Method
 Natural FP method
 Color-coded beads:
Cycle beads
 Fertile period: 8 to 19
days
 For women with cycles
26-32 days only
 12/100 pregnancies

34. How to Use
Day 1
Pre-
ovulation
(infertile)
Post-ovulation
(infertile)
Fertile days
(D8 –D19)

35. TwoDay method
 Based on cervical secretions
 Q1) “Did I notice secretions today?” and Q(2)
“Did I notice secretions yesterday?
 14/100 pregnancies

36. Emergency Contraception
 Taken within 72 hours after unprotected
intercourse
 Plan B: 0.75 mg of levonorgestrel (postinor)
 Yuzpe: 100 ug of EE and 1 mg norgestrel or
0.5 levonorgestrel taken 12 hours apart
 IUD insertion
 MOA: inhibition or delay of ovulation, alteration
of the endometrium, sperm penetration, and
tubal motility
 Established pregnancies are not harmed.

37. Essure – Microcoil

40. FEMALE CONDOM

42. New Methods
 Lower doses of Ethinyl Estradiol: safer
 Newer Progestins: other non-contraceptive
benefits
 New routes of administration: compliance
 New technology: effectiveness

43. ASSOCIATIONS AND
RELATIONSHIPS

44. Mechanics:
 5 groups of 5 members each
 Identify your team with a innovative name for a
new contraceptive
 Objective: to earn points
 Group earn points if they answer the questions
correctly
 The group with the highest points wins
 Each member of the team can only answer a
maximum of 2 questions
 Decision of the judge is final
 I am the judge

45. Relationships, Associations
 IUD and:
 Abortion
 PID
 Ectopic pregnancy
 COC and:
 VTE, MI and CVA
 Breast, cervical and ovarian cancer
 DMPA and Breast cancer
 Calendar method and abortion

46. GROUPINGS

47. PRACTICE: HOW MANY DAYS
BEFORE OVULATION CAN
SEXUAL ABSTINENCE
PREVENT PREGNANCY?
A. 2
B. 3
C. 5
D. 7

48. Contraception: General
 Because sperm may survive 5 to 7 days in
the female genital tract, even a week's
abstinence around the time of actual
ovulation offers no guarantee against
pregnancy
 Ovulation can occur even in the absence of
menstruation.
 Pregnancies have occurred after a single
act of coitus 7 days before apparent
ovulation indicated by basal body
temperature.

49. GRAPH, WHICH OF THE
FOLLOWING COITAL POSITION IS
ASSOCIATED WITH PRETERM
DELIVER WITH PROM?
A. FEMALE SUPERIOR
B. MALE SUPERIOR
C. SIDE BY SIDE
D. REAR ENTRY

50. Risk of Preterm Delivery with PROM as to Coital
Position
ODD’S RATIO ACCORDING TO COITAL POSITION
4
3
2
1
0
FEMALE MALE SIDE BY SIDE REAR ENTRY ORGASM
SUPERIOR SUPERIOR
51
Ekwo et al, ACOG 168:1, 1993

51. Clinical vs. Statistical
Significance
 STATISTICAL SIGNIFICANCE
◦ Hypothesis testing: expressed as probabilities
or P value
◦ Confidence interval: expressed as a range of
values
 CLINICAL SIGNIFICANCE
◦ If RR = 1: no association
◦ If RR > 1: harm
◦ If RR < 1: protection

52. Relationship of Coitus to Pregnancy
Outcome
SEXUAL PRETERM TERM WITH PRETERM
ACTIVITY DELIVERY WITH PROM DELIVERY
PROM WITHOUT PROM
FEMALE 1.50 (0.80-2.82) 0.88 (0.41-1.67) 1.08 (0.51-2.29)
SUPERIOR
MALE SUPERIOR 1.84 (1.05-3.22) 1.59 (0.93-2.71) 2.05 (1.20-3.50)
SIDE BY SIDE 1.19 (0.71-1.98) 0.84 (0.48-1.36) 1.19 (0.71-2.01)
REAR ENTRY 1.40 (0.72-2.72) 0.88 (0.43-1.79) 1.06 (0.55-2.01)
ORGASM 1.91 (1.12-3.23) 1.12 (0.70-1.79) 0.93 (0.60-1.41)
Ekwo et al, ACOG 168:1, 1993

53. IUD
 It is approved for up to 10 years
of continuous use.
 The levonorgestrel T is approved
in the United States for 5 years
of use, although studies through
7 years of use show no loss of
efficacy
Sivin I, Stern J. Health during prolonged use of levonorgestrel 20
micrograms/d and the copper TCu 380A intrauterine contraceptive
devices: a multicenter study. Fertil Steril 1994;61:70–77.)

54. 1. WHAT IS THE MAIN
MECHANISM OF ACTION OF IUD
AS A CONTRACEPTIVE METHOD?
A.Prevents implantation
B.Inhibits ovulation
C.Impairs sperm and egg
motility
D.Thickens cervical mucus

55. Mechanism of Action:
 Intrauterine devices cause the formation of biologic foam within the
uterine cavity that contains strands of fibrin, phagocytic cells, and
proteolytic enzymes.
 Copper IUDs continuously release a small amount of the
metal, producing an even greater inflammatory response.
 All IUDs stimulate the formation of prostaglandins within the
uterus, consistent with both smooth muscle contraction and
inflammation.
 Scanning electron microscopy studies of the endometrium of women
wearing IUDs show alterations in the surface morphology of
cells, especially of the microvilli of ciliated cells
 There are major alterations in the composition of proteins within the
uterine cavity, and new proteins and proteinase inhibitors are found in
washings from the uterus
 The altered intrauterine environment interferes with sperm passage

56. IUD and MOA
 Sperm can be obtained by laparoscopy in washings from the fallopian tubes of
control women at midcycle; fewer sperm are present in the tubal washings from
women wearing IUDs (57Stanford JB, Mikolajczyk RT. Mechanism of action of the intrauterine
device: update and estimation of post fertilization effect. Am J Obstet Gynecol 2002;187:1699-
1708).
 Ova flushed from the tubes at tubal sterilization showed no evidence of fertilization
in women wearing IUDs (58Alvarez F, Guiloff E, Brache V, et al. New insights on the mode of
action of intrauterine devices in women. Fertil Steril 1989;49:768-773.
 studies of serum β-human chorionic gonadotropin levels in women wearing IUDs
do not indicate pregnancy (59Segal S, Alvarez-Sanchez F, Adejeuwon CA, et al.
Absence of chorionic gonadotropin in sera of women who use intrauterine devices.
Fertil Steril 1985;44:214-218).
 The contraceptive effectiveness does not depend on interference with
implantation, although this phenomenon also occurs and is the basis for using
copper IUDs for emergency contraception.
 The IUD is not an abortifacient.

57. New Insights on MOA of IUD
No IUD IUD  115 women using no
60
contraception vs. 56
50 with IUDs for
40 surgical sterilization
30  Tubal flushings 48
20
and 120 hrs after
midcycle LH peak
10
0
Ova Fertilized
Alvarez F, et al, Fertil Steril. 1988 May;49(5):768-73.

58. STATEMENTS BEST DESCRIBE THE
ASSOCIATION OF IUD AND PID?
A. CURRENT IUD USE IS A RISK
FACTOR FOR PID
B. PID IS ASSOCIATED WITH IUD
INSERTION
C. IUD IS THE CAUSE FOR CHRONIC
PID
D. INCIDENCE OF PID IS DIRECTLY
PROPORTIONAL TO DURATION OF IUD
USE

59. IUD
 Increased risk was detectable only within 4 months
of insertion of the IUD.
 A still larger, prospective World Health Organization
study revealed that PID increased only during the
first 20 days after insertion.
 Thereafter, the rate of diagnosis of PID was about 1.6
cases per 1,000 women per year, the same as in the
general population
Farley TMM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and
pelvic inflammatory disease: an international perspective. Lancet
1992;339:785-788.

60. 3. IS IUD A RISK FACTOR FOR
ECTOPIC PREGNANCY?
A. No
B. Yes, only if compared to other
contraceptive methods
C.Yes, only if compared to non-
contraceptive user
D.Yes, compared to other
contraceptive methods and to non-
contraceptive users

61. IUD
 Ectopic Pregnancy: If pregnancy occurs in an
IUD wearer, it will be ectopic in about 5% of
cases. This is because the fallopian tubes are
less well protected against pregnancy than is
the uterus.
 Compared with women using no
contraception, however, women wearing either
the copper T380A or the levonorgestrel T have
an 80% to 90% reduction in the risk of ectopic
pregnancy (53), which is a greater reduction
than that seen for users of barrier methods.
 Both the copper T 380A and the levonorgestrel
T protect against ectopic pregnancy.

62. IUD and pregnancy
 In case of pregnancy and the strings of the IUD are
not visible, an ultrasound examination should be
performed to localize the IUD and determine whether
expulsion has occurred.
 If the IUD is present, there are three options for
management:
 Therapeutic abortion
 Ultrasound-guided intrauterine removal of the IUD
 Continuation of the pregnancy with the device left in
place
 No recommendation on the time of insertion

63. Combined Oral Contraception
 Typically, they are administered for 21 days
beginning on the Sunday after a menstrual
period, then discontinued for 7 days to
allow for withdrawal bleeding that mimics
the normal menstrual cycle.
 Alternatively, OCs can be started on the
first day of menstruation.
 The 28-day version provides placebo
tablets for the last 7 days of the cycle so
the user simply takes one pill a day and
starts a new pack as soon as the first pack
is completed.

64. COC
 Ovulation can be inhibited by estrogen or by progestin
alone.
 Pharmacologic synergism is exhibited when the two
hormones are combined and ovulation is suppressed at
a much lower dose of each agent.
 Combination OCs, patches, and the NuvaRing suppress
basal follicle-stimulating hormone FSH and LH. They
diminish the ability of the pituitary gland to synthesize
gonadotropins when it is stimulated by the hypothalamic
GnRH (89).
 Ovarian follicles do not mature, little estradiol is
produced, and there is no midcycle LH surge. Ovulation
does not occur, the corpus luteum does not form, and
progesterone is not produced.
 This blockade of ovulation is dose related.

65. 4. HOW CAN THE RISK OF VTE
AMONG USERS OF COC BEST
DESCRIBED?
A. No clinical nor statistical risk
B. Both Clinical and statistical risk
C. Clinically significant risk only
D. Statistically significant risk only

66. COC and thrombosis
 The absolute risk of thrombosis in COC users taking pills
containing 30 to 35 µg EE is 3 per 10,000 per year, compared
with 1 per 10,000 reproductive-aged women not using OCs
and 6 per 10,000 in pregnancy (106 Farmer RDT, Preston TD. The risk of
venous thromboembolism associated with low oestrogen oral contraceptives. J Obstet
Gynaecol 1995;15:195-200).
 Thrombosis risk is apparent by 4 months after starting
estrogen-containing OCs and does not increase further with
continued use.
 Risk is highest during the first year of use (107Sazelenko JK, Nace
MC, Alving B. Women with thrombophilia: assessing the risks for thrombosis with
oral contraceptives or hormone replacement therapy. Semin Thromb Hemost
1998;24(suppl 1):33–39.
 ).

67. Hormonal Contraception and
VTE
 National Cohort Study in Denmark: 1995-2005
 Full article available

68. Hormonal contraception and risk of venous
thromboembolism: national follow-up study.
Stud Healthy Danish women 15-49 years, from 1995-2005, 10.4 M woman –
y years
7 VTE RISK RATIO / 10,000 WOMEN-YEARS
6.29
6
5
4
3.01
3
2
1
0
NON USERS OC USERS
Lidegaard Ø, Løkkegaard E, Svendsen AL, Agger C., BMJ. 2009 Aug
13;339:b2890. doi: 10.1136/bmj.b2890. 71

69. Hormonal contraception and risk of venous
thromboembolism: national follow-up study.
Study Healthy Danish women 15-49 years, from 1995-2005, 10.4 M woman –
years
VTE RATE RATIO ACCDG TO DURATION OF USE IN YEARS
5
4
3
2
1
0
NON USER <1 1-4 >4
Lidegaard Ø, Løkkegaard E, Svendsen AL, Agger C., BMJ. 2009 Aug 13;339
72

70. Hormonal contraception and risk of venous
thromboembolism: national follow-up study.
Stud Healthy Danish women 15-49 years, from 1995-2005, 10.4 M woman –
y years
VTE RATE RATIO ACCDG TO TYPE OF PROGESTINS
3
2
1
0
LEVO NORETH NORGE DESO GST DRSP CPA
Lidegaard Ø, Løkkegaard E, Svendsen AL, Agger C., BMJ. 2009 Aug 13;339
73

71. MEGA: Venous thromboembolism increased with
OC use irrespective of progestin type
Study 1524 Premenopausal women <50 years old vs 1760 controls
Risk (OR, 95% CI) of VTE associated with type of progestogen
in combined OCs
25
20
15
10
5
3.6 5.6 7.3 5.6 3.9 6.8 5.9 6.3
0
Levonorgestrel Gestodene Desogestrel Lynestrenol Norethisterone Cyproterone Norgestimate Drospirenone
MEGA study: multiple environmental and genetic assessment of risk factors for venous thrombosis-study.
van Hylckama Vlieg A, et al. BMJ. 2009 Aug 13;339:b2921. doi:0.1136/bmj.b2921.
74

72. Risk of venous thromboembolism* by
population characteristics
Non-OC users 8
OC users 35
Pregnant women 60
OC users with
Factor V Leiden 230
0 50 100 150 200 250 300 350 400
Estimated average risk/100,000 women/year
*Cases of non-fatal venous thromboembolism.
FDA. FDA Talk Paper. 1995. Ridker PM, et al. JAMA. 1997 Apr 23-30;277(16):1305-7.
75

73. Prevalence in Asian women of Factor
V Leiden mutation is low
Study of the ethnic distribution of Factor V Leiden mutation in
4047 men and women
Prevalence of Factor V Leiden mutation, %
Native Americans 1.25
Hispanics 2.21
Asians 0.45
Blacks 1.23
White 4.85
0 1 2 3 4 5 6
Ridker PM, et al. J Am Med Assoc 1997;277:1305–7.
76

74. 4. WHICH OF THE FOLLOWING
CONDITIONS HAS THE GREATEST
ATTRIBUTABLE RISK TO AN ISCHEMIC
CARDIOVASCULAR EVENT AMONG
OCP USERS?
A. Age > 35 but < 50
B. Controlled hypertension
C. BMI > 30
D. 25 sticks of cigarettes/day

75. COC and Vascular events
 Past use of OCs does not increase risk for subsequent
myocardial infarction (123Stampfer MJ, Willett WC, Colditz GA, et al. A
prospective study of past use of oral contraceptive agents and risk of cardiovascular
diseases. N Engl J Med 1988;319:1313-1317.
 Smokers taking OCs had seven times the risk of ischemic
(thrombotic) stroke when compared with smokers who did not
use OCs, and hypertensive women had 10-fold increased risk
if they took OCs, but a fivefold risk if they did not (129World
Health Organization Collaborative Study of Cardiovascular Disease and Steroid
Hormone Contraception. Ischaemic stroke and combined oral contraceptives:
results of an international, multicenter, case control study. Lancet 1996;348:505-
510).

76. COC and MI
 After adjusting for age, illness, smoking, ethnicity, and body
mass index, risk for myocardial infarction was not increased
by OC use (OR, 1.14; CI 95%, 0.27 to 4.72).
 Of heart attack victims, 61% smoked; only 7.7% were current
users of OCs.
 In a later study, the same investigators pooled results from the
California study with a similar study from Washington State.
 The results were the same. Current users of low-dose OCs had
no increased risk for myocardial infarction after adjustment
for major risk factors and sociodemographic factors (122Sidney
S, Siscovick DS, Petitti DB, et al. Myocardial infarction and use of low dose oral
contraceptives: a pooled analysis of 2 U.S. studies. Circulation 1998;98:1058-
1063).

77. Ischemic Stroke Risk With Oral Contraceptives:
A meta-analysis
Study 73 Studies published from January 1960 through November 1999
RISK RATIO OF OC USERS
7
6
5
4
3
2
1
0
HPN NO HPN Hx OF HPN NO HX of HPN
Leslie Allison Gillum, BA, JAMA, July 5, 2000—Vol 284, No. 1
81

78. Risk of Myocardial Infarction among
women < 50 years old: effect of
smoking
Never smoked Past smoker Current smoker
30
Relative
Risks
20
10
0
Non smoker1-24 sticks +25
sticks/day

79. COC and stroke
 Similarly, a study from Denmark found that women
with diabetes had a fivefold increase risk for
stroke, which increased to 10-fold if they took OCs
(132 Lidegaard O. Oral contraceptives, pregnancy and the risk of cerebral
thromboembolism: the influence of diabetes, hypertension, migraine and previous
thromboembolic disease. BJOG 1995;102:153-159).
 Unfortunately, these data were not limited to low-
estrogen OCs.
 Oral estrogen alone has no adverse effect on glucose
metabolism, but progestins exhibit insulin
antagonism .

80. Risk of myocardial infarction in current
OC users by smoking status
Risk (RR, 95% CI) of MI with OC use and smoking status
301
251
201
151
101 87
51 20.8 30
4 11.1 0.9 3.3 8.7
1
-49
Current Never Current Current Never Current Never Current
user, nonsmoker user, heavy user, heavy user, nonsmoker user, heavy user, heavy user, heavy user, heavy
smoker smoker smoker smoker smoker smoker
WHO (Europe). 1997* Croft P (RCGP). 1989** Rosenberg L. 1990***
Heavy smokers defined as: *10 cigarettes/day; **15 cigarettes/day; ***25 cigarettes/day.
WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet 1997 Apr
26;349(9060):1202-9. Croft P, Hannaford P. BMJ. 1989 Jan;298(6667):165-8. Rosenberg L, et al. Am J
Epidemiol 1990 Jun;131(6):1009-16.
84

81. Low-dose OC use not associated with
increased myocardial infarction risk
Study 48,321 Swedish women, aged 30–49 years, followed for
mean of 11 years
Most current users were taking low-dose estrogen and
second- or third-generation progestins
Results Risk (RR, 95% CI) of fatal and nonfatal MI in OC
users vs non-users
1.4
1
1
0.6 0.7
0.2
Former users Current users
Margolis KL,et al. Fertil Steril 2007 Aug;88(2):310-6.
85

82. 5. WHICH OF THE FOLLOWING
THYROID CONDITIONS IS COC
CONTRAINDICATED?
A. HYPERTHYROIDISM
B. HYPOTHYROIDISM
C. BOTH
D. NEITHER

83. COC and thyroid function tests
 The estrogen in OCs increases circulating
thyroid-binding globulin, thereby affecting
tests of thyroid function that are based on
binding, increasing total thyroxine (T4)
levels, and decreasing triiodothyronine (T3)
resin uptake.
 The results of actual thyroid function
tests, as measured by free T4 and
radioiodine tests, are normal (138Mishell DR Jr, Colodyn
SZ, Swanson LA. The effect of an oral contraceptive on tests of thyroid function.
Fertil Steril 1969;20:335-339).

84. 6. IN WHICH GROUP OF COC USERS
HAS THE GREATEST RELATIVE RISK
OF BREAST CANCER ?
A. Positive family history of breast
cancer
B. > 4 year use prior to FFTP (first full
term pregnancy)
C. 35-40 years of age
D. Caucasian pill users

85. COC and breast cancer
 A meta-analysis of 54 studies of breast cancer and hormonal
contraceptive use reanalyzed data on 53,297 women with
breast cancer and 100,239 controls from 25
countries, representing about 90% of the epidemiologic data
available worldwide at that time Collaborative Group on Hormonal
Factors in Breast Cancer. Breast cancer and hormonal contraceptives:
collaborative reanalysis of individual data on 53,297 women with breast cancer
and 100,239 women without breast cancer from 54 epidemiologic studies. Lancet
1996;347:1713-1727.
 Current use of OCs was associated with a very small but
statistically stable 24% increased risk (RR, 1.24; 95%
CI, 1.15-1.33).

86. COC and breast cancer
 The risk fell rapidly after discontinuation, to 16% 1
to 4 years after stopping and to 7% 5 to 9 years after
stopping.
 Risk disappeared 10 years after cessation (RR, 1.01;
95% CI, 0.96-1.05).
 Results did not differ in any important way by ethnic
group, reproductive history, or family history.
 Since the meta-analysis was published, subsequent
studies have found no increased risk. Marchbanks
PA, McDonald JA, Wilson HG, et al. Oral contraceptives and risk of breast cancer.
N Engl J Med 2002;346:2025-2032

87. Use of oral contraceptive pills does not
lead to an increased risk of breast
cancer
OCP None
4000
number of cases
3000
2000
OR = 0.91 (95%CI 0.90-0.91)
1000
0
Breast Cancer Normal
Marchbanks, PA, et al. Oral contraceptive and the risk of breast cancer. NEJM
2002 June, 346(26):2025-2032

88. Odd’s Ratio for invasive Breast cancer for OCP
user accdg to duration of use
Study 907 cases with incident invasive breast cancer and 1,711 controls
from 1993 to 2007
ODD.’S RATIO ACCDG TO DURATION OF USE
3.5
3
2.5
2
1.5
1
0.5
0
NON USER 1-4 5-9 10-14 >15
Lynn Rosenberg, et al, Amer J Epid Vol 169, No. 4, Dec 2008
92

89. Odd’s Ratio for Premenopausal invasive Breast
cancer among OCP user
Study Meta-Analysis: 34 studies after 1980, < 50 years old
ODD.’S RATIO
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
NON USER OVERALL B4FFTP AFFTP
CHRIS KAHLENBORN, MD; et al, Mayo Clin Proc. 2006;81(10):1290-1302
93

90. 7. WHICH OF THE FOLLOWING
RELATIONSHIP BETWEEN HORMONAL
CONTRACEPTION AND CERVICAL
CANCER HAS NO EVIDENCE?
A. OCP has a causal relationship to
cervical cancer
B. Increasing risk of cervical cancer
according to duration of use of OCP
among HPV positive women
C. HPV maybe a confounder

91. COC and other genital cancer
 Combination OCs reduce the risk of subsequent
endometrial cancer and ovarian cancer (139,140).
 Two-year use of OCs reduces the risk of endometrial
cancer by 40%, and 4 or more years of use reduces
the risk by 60%.
 Another study found a 50% reduction in ovarian
cancer risk for women who took OCs for 3 to 4 years
and an 80% reduction with 10 or more years of use
(141).
 There was some benefit from as little as 3 to 11
months of use. Benefit continues for at least 15 years
from last use (125,127,142).

92. COC and cervical cancer
 A systematic review of 28 epidemiologic studies of cervical
cancer in OC users compared with those who never used OCs
reported summary relative risks of 1.1 (95% CI 1.1-1.2) at less
than 5 years of pill use, 1.6 (1.4-1.7) at 5 to 9 years, and 2.2
(1.9-2.4) at 10 or more years (146 Smith JS, Green J, Berrington de
Gonzales A, et al. Cervical cancer and use of hormonal contraceptives: a
systematic review. Lancet 2003;363:1159-1167).
 A critique of this study argued that causation is not proved
because few of the studies cited adequately control for the key
behavioral factors of partners, use of barrier
contraception, and adequacy of cervical cancer screening (147
Miller K, Blumenthal P, Blanchard K. Oral contraceptives and cervical cancer:
critique of a recent review. Contraception 2004;69:347-351).

93. OCP use and Cervical Cancer
Study Meta-Analysis: 28 studies, 12531 cases
RELATIVE RISKS ACCDG TO DURATION OF USE
3
2.5
2
1.5
1
0.5
0
NON USER <5 5-9 >10
Smith JS, et al,, Lancet. 2003 Apr 5;361(9364):1159-67.
97

94. OCP use and Cervical Cancer: HPV POSITIVE
Study Meta-Analysis: 28 studies, 12531 cases
RELATIVE RISKS ACCDG TO DURATION OF USE
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
NON USER <5 5-9 >10
Smith JS, et al,, Lancet. 2003 Apr 5;361(9364):1159-67.
98

95. COC and Cervical Cancer
 Individual data for 16,573 women with cervical
cancer and 35,509 without cervical cancer
were reanalysed centrally
 The relative risk of cervical cancer is increased
in current users of oral contraceptives and
declines after use ceases

96. Cancer and COC
 No additional cancer risk in a cohort of UK
women
 oral contraception was not associated with an
overall increased risk of cancer

97. COC and Liver Cancer
 There are case reports of hepatocellular
carcinoma in young women with no risk
factors other than long-term OC use
(157).
 However, a large study from six
countries in Europe found no
association between use of OCs and
subsequent liver cancer (158Oral contraceptives and
liver cancer: results from the Multicentre International Liver Tumor Study
(MILTS). Contraception 1997;56:275–284.).

98. 8. WHO WILL BENEFIT MOST FROM
LACTATION AMENORRHEA METHOD
IN THE PREVENTION OF BREAST
CANCER?
A. Positive history of breast
cancer
B. Asians
C. Obese women
D. Breast feeding for 24 months

99. Lactation Amenorrhea:
 Ovulation is suppressed during lactation.
 The suckling of the infant elevates prolactin levels and reduces
gonadotropin-releasing hormone (GnRH) from the
hypothalamus, reducing luteinizing hormone (LH) release and thus
inhibiting follicular maturation (10 Knobil E, Neil JD, Ewing LI, et al (eds).
The physiology of reproduction. New York, NY: Raven Press, 1988:2323-2349.
 Breastfeeding reduces the mother's lifetime risk of breast cancer.
 In a very large study in Korea, 13 to 24 months of lactation reduced the
risk of breast cancer by 30%, and there was a clear trend of decreasing
breast cancer risk with increasing duration of lactation (14 Lee SY, Kim
MT, Kim SW, et al. Effect of lifetime lactation on breast cancer risk: a Korean women's
cohort study. Int J Cancer 2003;105:390-393).

100. Lactational Amenorrhea Method and Reduction in
Breast Cancer Risk
Study Cohort Study: 110,604 premenopausal Korean Women, 57,440 breast
fed, 4,584 breast fed > 24 months, 6 years follow-up
RELATIVE RISKS ACCDG TO DURATION OF USE
1.2
1
0.8
0.6
0.4
0.2
0
NON USER 1-2 years > 2 years
Lee SY,, et al, Int J Cancer. 2003 Jun 20;105(3):390-3.
111

101. LAM and Breast Cancer
 Risk of breast cancer is reduced only in
patients with family history of breast cancer
 No reduction in the general population

102. Lactational Amenorrhea Method and Reduction in
Breast Cancer Risk
Study Cohort Study: 60,075 women, 608 incident cases, 357,556 person-
years of follow-up
HAZARD RATIO
1.2
1
0.8
0.6
0.4
0.2
0
NON USER BREASTFED 1ST DEGREE
Stuebe AM, Arch Intern Med. 2009 Aug 10;169(15):1364-71.
113

103. 9. IS THERE A RELATIONSHIP
BETWEEN THE CALENDAR
METHOD AND ABORTION?
A. Of course NOT!
B. Yes, it is directly proportional to the
remoteness of coitus to ovulation day
C. Yes, it is highest when sex is
consummated 3 days after ovulation day
D. Yes, the fear of pregnancy creates a
hostile intra-uterine environment

104. Timing of intercourse and
Abortion
 Conceptions resulting from
intercourse remote from the time of
ovulation more often lead to
spontaneous abortion than
conceptions from midcycle
intercourse However, malformations
are not more common
Guerrero R, Rojas OI. Spontaneous abortion and aging of human ova
and spermatozoa. N Engl J Med 1975;293

105. INJECTABLE HORMONAL
CONTRACEPTION
 Depomedroxyprogesterone acetate (DMPA), a suspension of
micro crystals of a synthetic progestin, was approved for
contraception in 1992. A single 150-mg intramuscular dose
will suppress ovulation in most women for 14 weeks or longer
(188).
 Persistent irregular bleeding can be treated by adding low-
dose estrogen temporarily; for example, conjugated
estrogens, 1.25 mg per day, can be given for 10 to 21 days at a
time.
 Irregular bleeding with DMPA may be related to the down
regulation of endometrial estrogen receptors it produces.

106.  The FDA has issued a black box
warning proposing that DMPA
treatment be limited to 2 years
at a time unless the patient
has no other good options for
contraception.

107. 10. IS DMPA CARCINOGENIC?
A. No, it is not carcinogenic
B. It can cause breast cancer
C. It can cause ovarian cancer
D. It can cause both breast and
ovarian cancer

108. DMPA and Breast Cancer
 The risk of breast cancer during the first 4
years of use appears to be slightly
increased, but there is no relation to long-
term use and no overall increase in breast
cancer risk; hence, any causal relationship
between DMPA and breast cancer is
unlikely
Chilvers C. Breast cancer and depot-medroxyprogesterone acetate: a
review. Contraception 1994;49:211-222).
Breast cancer and depot-medroxyprogesterone acetate: a
multinational study. WHO Collaborative Study of Neoplasia and
Steroid Contraceptives. Lancet. 1991 Oct 5;338(8771):833-8.

109. BONUS: WHAT IS MAIN
DRAWBACK OF A MALE
HORMONAL CONTRACEPTIVE?
A. Negative feedback is not
complete
B. Poor metabolic results
C. Risk of liver cancer
D. All of the above

110. MALE HORMONAL
CONTRACEPTION
 The same negative feedback of sex steroids that can block ovulation in
women will also suppress spermatogenesis in men, but it will produce
loss of libido and potentially extinguish sexual performance
 Asian men virtually always achieve azospermia or oligospermia when
treated with testosterone undecanoate, 500 to 1,000 mg
monthly, whereas only 86% of white men achieved oligospermia or
azospermia with similar testosterone regimens (218Wang C, Swerdloff RS.
Male hormonal contraception. Am J Obstet Gynecol 2004;190:S60-S68.
 However, pregnancy has occurred in partners of androgen-treated
oligospermic men with sperm counts as low as 3 million/mL (219
Wallace EM, Aitken RJ, Wu FC. Residual sperm function in oligozoospermia
induced by testosterone enanthate administered as a potential steroid male
contraceptive. Int J Androl 1992;15:416-424.

111. Male Hormonal Contraception
 Combining testosterone with a progestin allows a lower dose
of the androgen with efficacy comparable to use of
testosterone alone.
 One promising regimen combined injections of testosterone
undecanoate with norethindrone enanthate given at 6-week
intervals.
 This regimen produced azospermia in 90% of subjects (220).
Adverse lipid changes have been noted with DMPA and
androgen combinations, raising concern about vascular
disease with prolonged use.
 Liver cancer is also a concern with long-term androgen
therapy (221).

112. WHO MEC 2009

113. WHO Categories for Temporary
Methods
WHO 1 Can use the method. No restriction on
use
WHO 2 Can use the method. Advantages
outweigh theoretical or proven harm
WHO 3 Should not use the method unless a
doctor or nurse makes a clinical
judgement that the client can safely
use it
WHO 4 Should not use the method. Condition
represents an unacceptable health
risk.

114. Simplified 2-Category System
WHO With Clinical Judgement With Limited
Category Clinical Judgement
1 Use the method in any Use the
circumstances
method
2 Generally use the method
3 Use of the method not Do not use
usually recommended unless
other, more appropriate the method
methods are not available or
acceptable
4 Method not to be used

115. Importance of Selected Procedures for
Providing Family Planning Methods
A. Essential and mandatory
B. Contributes substantially to safe and effective
use, but implementation maybe considered within
the public health and / or service context
C.Does not contribute substantially to safe and
effective use
D.No materially related to either good routine
preventive health or to the safe and effective use
of the method

116. Procedures before COC use
PELVIC EXAM C
BLOOD PRESSURE READING 2
BREAST EXAM BY PROVIDER C
HEMOGLOBIN TEST C
STD risk assessment C
STD screening by lab test C
CERVICAL CANCER SCREENING C
Routine, mandatory lab tests (eg. Cholesterol, FBS, LFT) C
Proper infection-prevention procedures C
Specific COUNSELLING points for FP methods A
COUNSELLING about change in menses A

117. CASES

118. Case 1:
 32 year old G1P1 sought consult for
contraception. Her mother is a breast cancer
survivor. Menses are irregular but no
dysmenorrhea. BP 120/80, Uterus is slightly
enlarged due to 3x3 cms myoma found on
ultrasound. What can be given to address her
concerns?

119. Case 2:
 V.N. is 42 years old, G5P4 with on and off BP
elevations. No antihypertensive drugs taken.
Non –smoker. Her blood sugar is controlled
with regular medications. Menstruation is
regular at 28-30 days cycle. She wants to take
the pills. What is your advise?

120. Case 3:
 24 year old, G2P2, DMPA user for 1 year
before her husband left abroad for work sough
consult for contraceptive advise. She used to
have vaginal spotting while on DMPA. Her
husband would be coming home for just 2
months. What is your recommendation?

121. Case 4
 19 year old, nulligravida, with an OFW partner,
comes come for 2 weeks. She, however, has
vaginal discharge. What is her recommended
method of contraception?

122. Case 5
 42 years old, G3P3 is on COC for the past 4
years. Her vital signs are normal. She is
concerned about VTE because of her varicose
veins. Can she continue the COC? If
not, what method is recommended?

123. Case 6
 38 years old, G5P5, had just delivered by
forceps delivery under epidural anesthesia.
She had requested for BTL during the prenatal
check-up. Her pregnancies were complicated
by pre-eclampsia, severe. What will be your
course of action?

124. Case 7
 32 year old, G1P1, s/p partum 2 weeks, asks
for contraceptive advise. She wants to go
back to work but would want to continue breast
feeding. What would be your advise?

125. Case 8
 21 years old, nulligravida, had an unprotected
intercourse 2 days ago. She requested for
emergency contraception. She had tried EC
2x. What will be your advise?

126. Case 9
 24 year old, G1P1, sought consult in a health
center, manned by a midwife. She had
controlled hypertension. Can she take the
pills? If NO, what would you recommend?

127. Case 10
 34 year old, G1P1, is diagnosed case of
mental retardation. Her parents requested that
she be ligated. She would usually leaves the
house for days without information on her
whereabouts. She does not remember the
father of her child. What is your
recommendation?

128. Learning Objectives: Strategies
 Learning objective 1: Lecture – 1 hr
 Learning objective 2 & 3: Interactive lecturettes
– 1 hr
 Learning objective 4: Problem solving, Case
discussion – 2 hours
 Learning objective 5: small group
 Writeshop: course content of a FP method class