lecture for medical students

1. Dr.Tarig Mahmoud Ahmed
MD SUDAN
HAIL UNIVERSITY KSA

2. the practice of controlling the number of children one
has and the intervals between their births,
particularly by means of contraception or voluntary
sterilization.

3.  Combined hormonal contraceptio
The pill
Patches
The vaginal ring
 Progestogen-only preparations
Progestogen-only pills
Injectables
Subdermal implants
 Hormonal emergency contraception

4.  Intrauterine contraception
Copper intrauterine device (IUD)
Hormone-releasing intrauterine system (IUS)
 Barrier methods
Condoms
Female barriers
Coitus interruptus
Natural family planning
 Sterilization
Female sterilization
Vasectomy

5. The effectiveness of a method depends on two
factors:
1 )how it works;
2) how easy it is to use.
failure caused mainly due to poor use (user failure)
rather than an intrinsic failure of the method
itself.

6. Method of contraception Failure rate per 100
woman years
Combined oral contraceptive pill 0.1–1
Progestogen-only pill 1–3
Depo-Provera® 0.1–2
Implanon® 0.1
Copper IUD 1–2

7. Method of contraception Failure rate per 100
woman years
Mirena® 0.5
Male condom 2–5
Diaphragm 1–15
Natural family planning 2–3
Vasectomy 0.02
Female sterilization 0.13

8. Studies looking at pill use report nearly
half of all women missing at least one pill per packet and a
quarter missing two pills.
Women are often quick to stop contraception because of
perceived side effects, such as weight gain or mood change.

10. It contains a combination of two hormones:
synthetic oestrogen and a progestogen.
Most brands contain 21 pills; one pill to be taken
daily, followed by a 7-day pill-free interval (the
traditional 21/7 model). There are also some
everyday (ED) preparations that include seven
placebo pills that are taken instead of having a
pill-free interval.

11. Mode of action
 Inhibition of ovulation :
Both oestrogen and progestogen suppress the release
of (FSH) &(LH),which prevents follicular
development within the ovary and therefore
ovulation.
 Peripheral effects :
making the endometrium atrophic and hostile to
implantation and altering cervical mucus to prevent
sperm ascending into the uterine cavity.

12. absolute contraindications:
1-Breastfeeding <6 weeks postpartum
2-Smoking ≥15 cigarettes/day and age ≥35
3-Multiple risk factors for cardiovascular disease
4-Hypertension: systolic pressure ≥160 or diastolic ≥100
mmHg
5-Hypertension with vascular disease

13. 6-Current or history of deep-vein thrombosis/pulmonary
embolism
7-Major surgery with prolonged immobilization
8-Known thrombogenic mutations
9-Current or history of ischaemic heart disease
10-Current or history of stroke
11-Complicated valvular heart disease

14. 12-Migraine with aura
13-Migraine without aura and age ≥35 (continuation)
14-Current breast cancer
15-Diabetes for ≥20 years or with severe vascular disease or
with severe nephropathy,retinopathy or neuropathy
16-Active viral hepatitis
17-Severe cirrhosis
18-Benign or malignant liver

15. relative contraindications:
1-Multiple risk factors for arterial disease
2-Hypertension: systolic blood pressure 140–159 or diastolic
pressure 90–99 mmHg,
or adequately treated to below 140/90 mmHg
3-Some known hyperlipidaemias
4-Diabetes mellitus with vascular disease
5-Smoking (<15 cigarettes/day) and age ≥35 years
6-Obesity
7-Migraine, even without aura, and age ≥35 years

16. 8-Breast cancer with >5 years without recurrence
9-Breastfeeding until six months postpartum
10-Postpartum and not breastfeeding until 21 days after
childbirth
11-Current or medically treated gallbladder disease
12-History of cholestasis related to combined oral
contraceptives
13-Mild cirrhosis
14-Taking rifampicin (rifampin) or certain anticonvulsants

17.  CNS: Depressed mood, Mood swings, Headache
Loss of libido.
 GIT: Nausea, weight gain & Bloatedness.
 Reproductive system : Breakthrough bleeding
&Increased vaginal discharge
 Breasts :Breast pain & enlarged breasts.
 Miscellaneous :Chloasma (facial
pigmentation),Fluid retention & Change in
contact lens.

18.  • 5 per 100 000 for normal population;
 • 15 per 100 000 for users of second-generation
COC
 • 30 per 100 000 for users of third-generation
COC
 • 60 per 100 000 for pregnant women.

19. This can occur with enzyme-inducing agents, such as
some anti-epileptic drugs. Higher dose estrogen may
need to be prescribed.
Some broad-spectrum antibiotics can alter
intestinal absorption of COC and reduce its efficacy.
Additional contraceptive measures should therefore be
recommended during antibiotic therapy and for 1
week thereafter.

21.  A contraceptive transdermal patch containing
oestrogen and progestogen and releases
norelgestromin 150 mg and ethinylestradiol 20 mg
per 24 hours.
 Patches are applied weekly for 3 weeks, after
which there is a patch-free week.

22.  Contraceptive patches have the same risks and
benefits as COC and, although they are relatively
more expensive, may have better compliance.

24. It is made of latex-free plastic and has a
diameter of 54 mm. It releases a daily dose
of ethinyl estradiol 15 μg and etonorgestrel
120 μg.
The ring is worn for 21 days and removed for
7 days, during which time a withdrawal
bleed occurs.

25. Insertion and removal of the ring is easy and it
does not need to fit in any special place in the
vagina.
The cycle control is excellent and probably
better than with COC.
As with combined patches, the vaginal ring has
the same risks and benefits as COC but is
more expensive.

26.  All progestogen-only methods work by a local
effect on cervical mucus (making it hostile
toascending sperm) and on the endometrium
(making it thin and atrophic), thereby preventing
implantation and sperm transport.
The higher dose progestogen only methods will also
act centrally and inhibit ovulation, making them
highly effective.

27. The common side effects of progestogen-only
methods include:
erratic or absent menstrual bleeding;
simple, functional ovarian cysts;
breast tenderness;
acne.

29. they contain the second-generation
progestogen norethisterone or norgestrel (or
their derivatives) and the third-generation
progestogen desogestrel.
It is taken every day without a break.
If the POP fails, there is a slightly higher risk
of ectopic pregnancy.

30. Particular indications for the POP include:
• breastfeeding;
• older age;
• cardiovascular risk factors, for example
high blood pressure, smoking or diabetes.

32. Two injectable progestogens are marketed :
(1) depot medroxyprogesterone acetate 150 mg (Depo
Provera/DMPA);
(2) norethisterone enanthate 200 mg (Noristerat).

33.  Depo-Provera is highly effective and it is given by
deep intramuscular injection.
 Most women choose Depo-Provera and each
injection lasts for 12 weeks with a 2-week grace
period thereafter.

34.  weight gain of around 2–3 kg in the first year of
use;
 delay in return of fertility – it may take around six
months longer to conceive compared to a
womanwho stops COC;
 persistently irregular periods; most women
become amenorrhoeic.

36.  Implanon consists of a single silastic rod that is
inserted subdermally under local anaesthetic into
the upper arm .
 It releases the progestogen etonogestrel 25–70 mg
daily.
 It lasts for three years and thereafter can be easily
removed and a further implant inserted if
requested.
 Implanon is useful for women who have difficulty
remembering to take a pill

37. There is a rapid return of fertility when it is
removed.
 Irregular bleeding is very common with Implanon
and is the major reason for early discontinuation.
 Healthcare professionals need special training for
Implanon insertion and removal.

39.  Most copper IUDs are licensed for ten years of
use, although the small devices may only be for
five years.
 The modern ‘banded’ device has copper on the
stem and copper sleeves on the arms.
 They cause much less menstrual disruption.

40.  A copper IUD can be inserted for emergency
contraception and is highly effective up to 5 days
after the episode of unprotected intercourse.

41.  Mirena licensed for five years.
 The Mirena has a capsule containing
levonorgestrel around its stem which releases
adaily dose of 20 μg of hormone.
 It is associated with a dramatic reduction in
menstrual blood loss and is licensed for
contraception.

42.  current STI or PID, including post-abortion and
following childbirth;
 malignant trophoblastic disease;
 unexplained vaginal bleeding (before assessment);
 endometrial and cervical cancer (until assessed
and treated);
 known malformation of the uterus or distortion of
the cavity , eg (fibroids);
 copper allergy (but could use a Mirena).

44. Male condoms are usually made of latex rubber
varying sizes and shapes.
They have been heavily promoted to prevent the
spread of STIs , particularly HIV.

45.  The diaphragm iscommon female barrier used.
 They should be used in conjunction with a
spermicidal cream or gel.
 Diaphragms are inserted immediately prior to
intercourse and should be removed no earlier than
6 hours later.

46.  Although not strictly speaking a barrier
method,withdrawal, or coitus interruptus, is a
widespread practice and obviously does not require
any medical advice or supplies.
The penis is removed from the vagina immediately
before ejaculation takes place.

47. It abstaining from intercourse during the fertile
period of the month.
The fertile period is calculated by various
techniques, such as:
(1)changes in basal body temperature;
(2) changes in cervical mucus;
(3) tracking cycle days;
(4)combined approaches.

48. The lactational amenorrhoea method (LAM) is used
by fully breastfeeding mothers. During the first six
months of infant life, full breastfeeding gives more
than 98 per cent contraceptive protection.

50. Female sterilization and male vasectomy are
permanent methods of contraception and are
highly effective.
Vasectomy is easier, cheaper and slightly more
effective than female sterilization.
Technically, both female sterilization and vasectomy
can be reversed, with subsequent pregnancy rates
of about 25 per cent.