This document provides information on family planning and contraceptive methods. It defines family planning as individuals and couples attaining their desired number and timing of children through contraceptive use or infertility treatment. The main contraceptive methods discussed are barrier methods, combined hormonal contraception, and progesterone-only hormonal contraception. Combined methods contain estrogen and progesterone while progesterone-only methods only contain progesterone. Barrier methods include condoms and diaphragms while combined options include oral contraceptive pills, transdermal patches, and vaginal rings. Hormonal contraception is typically more effective than barrier methods at preventing pregnancy.

1. Family planning/contraception
methods
What is family planning?
Family planning is "the ability of individuals and couples to anticipate and attain their
desired number of children and the spacing and timing of their births.
It is achieved through use of contraceptive methods and the treatment of involuntary
infertility.
Contraceptive information and services are fundamental to the health and human rights
of all individuals.

2. • The prevention of unintended pregnancies helps to lower maternal ill-
health and the number of pregnancy-related deaths.
• Delaying pregnancies in young girls who are at increased risk of
health problems from early childbearing, and preventing pregnancies
among older women who also face increased risks, are important
health benefits of family planning.
• By reducing rates of unintended pregnancies, contraception also
reduces the need for unsafe abortion and reduces HIV transmissions
from mothers to newborns.
• This can also benefit the education of girls and create opportunities
for women to participate more fully in society, including paid
employment.

3. • According to 2017 estimates, 214 million women of reproductive age in
developing regions have an unmet need for contraception.
• Reasons for this include:
• limited access to contraception
• a limited choice of methods
• a fear or experience of side-effects
• cultural or religious opposition
• poor quality of available services

4. FP methods
1.Barrier contraception
2. Combined Hormonal Contraception.
3. Emergency contraception.
4. Postpartum Contraception.
5. Progesterone Only Hormonal Contraception
• Approach
• Advantages
• Disadvantages
• Indications
• Contraindications

5. 1. Barrier contraception
• prevents pregnancy by stopping the male’s sperm from coming into
contact with the female’s ovum. Depending on the type of
contraception, they may convey a decreased risk of STI transmission.
Types of barrier contraception
• Principally, there are four physical barrier contraceptive types:
1.Male condoms – typically made of latex, male condoms are rolled
down from the tip of the penis to the base. Semen collects in a reservoir
at the tip end of the condom. They are proven to reduce transmission of
many STIs such as chlamydia and gonorrhea.
2. Female condoms – made of polyurethane, these are tubular shaped,
where an inner ring sits deep in the vagina, with an open outer ring
sitting just outside the vulva. The male inserts their penis into the
female condom, preventing contact with the vagina. They are proven to
reduce transmission of many STIs, such as chlamydia and gonorrhoea.

6. Male condom

7. Female condom

8. 3. Diaphragms – these are typically rubber structures with a metal inner
frame that spans the posterior fornix to the anteroinferior wall of the
vagina, covering the cervix and therefore preventing entry of semen.
They are held in place by a combination of vaginal tone, the rigid metal
inner frame and the pubic symphysis. Often combined with spermicide to
increase their efficiency.
• 4. Cervical caps – these sit directly over the cervix, and are held in
place by suction and vaginal tone. They are often combined with
spermicide to increase their efficiency.

10. Advantages
• Male condom
• Not contraindicated by any condition exception latex allergy, in which
other materials (such as polyurethane) can be used, with similar
efficiency rate.
• It is the only contraceptive method mentioned that is controlled by the
male, which may be desirable by the couple.
• Widely available and simple to use, and only need to be used
immediately before intercourse.
• Are protective against many STIs.

11. Female condom
• No contraindications.
• Less likely to tear than the male condom.
• May protect against some STIs.
• Can be inserted up to 8 hours before intercourse.
Diaphragm/cap
• Can be inserted up to 3 hours before intercourse.

12. Disadvantages
• Male condom
• Perfect use is rarely achieved – may tear or couple may lack motivation to
use them every time.
• Can reduce sensitivity and/or arousal.
• Female condom
• Perfect use is rarely achieved – may become dislodged or couple may lack
motivation to use them every time.
• Penis may be inserted between condom and vaginal wall.
• Can be noisy and/or uncomfortable for the woman during intercourse.

13. Diaphragm/cap
• Perfect use is rarely achieved – may tear or couple may lack motivation
to use them every time.
• They require prior planning and careful insertion.
• They require measuring and fitting to find the correct size – any weight
gain or pregnancy mandates a refitting.
• They are associated with a higher risk of urinary tract infections.
• Most likely due to the position of the diaphragm/cap putting pressure on the
urethra.
• STI transmission is not reduced – in fact spermicide may irritate vaginal
mucosa, possibly increasing the rate of transmission.

14. • Failure rates for barrier contraception are much higher than those of long
acting reversible contraception.
• These methods require thought at intercourse hence their typical and
perfect use failure rates vary greatly.
• All values are expressed as the percentage of women who will get
pregnant in one year using this method

15. Points to consider
• All patients should be offered verbal and/or written advice on long
acting reversible contraception, due to their lower failure rates.
• Male condoms protect against STIs (as do female condoms to a lesser
degree) – they are the only type of contraception to offer this
protection.
• Contraception may be provided to under 16s provided they meet the
Fraser criteria.
• Inform all patients of the limited efficacy of barrier methods versus
long acting reversible methods.
• All patients should be aware of the need for emergency contraception
(link) should barrier contraception fail or be omitted.

16. 2. Combined Hormonal Contraception
• Hormonal contraception uses the female steroid
hormones oestrogen and progesterone and is a very effective method of preventing
pregnancy, more so than barrier contraception.
• Hormonal contraception can be effectively split into two categories;
1. …‘combined methods’ which contain both oestrogen
2. ..and progesterone and ‘progesterone-only methods’ which contain
only progesterone.
• Mechanism of Action
• Combined hormonal contraceptives act primarily to inhibit ovulation due to the
negative feedback effect of the oestrogen and progesterone on the hypothalamo-
pituitary axis. This prevents the surge in LH thus preventing ovulation. The
progesterone also acts to inhibit proliferation of the endometrium, creating
unfavourable conditions for implantation and increases the thickness of cervical
mucus, preventing passage of sperm.
• The period free of hormones, (pill-free break or taking placebos) causes a fall in
hormonal concentration which leads to degeneration of the endometrium and
menstrual bleeding.

17. i. Combined Oral Contraceptive Pill
• The COCP is commonly called ‘the pill’ and contains both oestrogen and
progesterone.
There are two types of combined oral contraceptive pills:
• Monophasic pills: every pill contains the same levels of oestrogen and
progesterone.
• This is the most common type of pill.
• Examples include:
• Microgynon®30 – 30µg ethinylestradiol (oestrogen) and 150µg
levonorgestrel (progesterone). Microgynon®30 is the most common
monophasic pill used and is taken once daily for 21 days with a 7 day
break between packs.
• Brevinor® – 35µg ethinylestradiol and 0.5mg norethisterone. Brevinor® is
taken once daily for 21 days with a 7 day break between packs.

18. • Phasic pills:
• Phasic oral contraceptives contain a varying amount of oestrogen and
progesterone across the cycle and can be biphasic, triphasic or
quadraphasic depending on the number of different active tablets.
• It is very important for the patient to take the pills in the correct order
due to the varying levels of hormones through the cycle. Examples
include:
• Qlaira® – This is a quadraphasic combined oral contraceptive containing
estradiol valerate and dienogest at varying levels through the cycle.
Qlaira® is taken every day for 28 days without a break between packs, it
contains 26 active pills and 2 inactive pills.
• BiNovum® – This is a biphasic pill containing 35µg of ethinylestradiol
and varying levels of norethisterone. BiNovum® is taken for 21 days
with a 7 day break between packets.

19. • The Contraceptive Transdermal Patch
• The contraceptive patch is a small 5cmx5cm patch that can be stuck
onto the upper arm, abdomen, buttock or back to prevent
pregnancy. ..hormones work in the same way as the COCP by
preventing ovulation, thinning the endometrial lining and thickening
cervical mucus.
• The patch is applied and changed every 7 days over a period of 3
weeks (21 days in total) and then the patch is removed for 7 patch-
free days where the individual will usually experience a withdrawal
bleed.
• The patch is extremely sticky and can be used whilst bathing and
swimming.

20. Contraceptive Transdermal Patch

21. • The Contraceptive Vaginal Ring
• The vaginal ring (NuvaRing®) is a combined hormonal contraceptive
method. The plastic ring is inserted into the vagina and delivers 120µg
etonogestrel and 15µg ethinyl estradiol per day. These hormones work
in the same way as the COCP by preventing ovulation, thinning the
endometrial lining and thickening cervical mucus.
• Once inserted the ring sits in the vagina for 21 days. It is then
removed for 7 days before inserting the new ring.
• Some women however may feel uncomfortable inserting or removing
the ring.

22. Advantages
• Non invasive
• More effective than barrier methods if taken correctly
• Sex doesn’t need to be interrupted to use contraception
• Menses tends to become regular, lighter and less painful, also
allowing for control over timing of menses
• Reduced risk of cancer of the ovary, uterus and colon
• Reduced risk of functional ovarian cysts
• Normal fertility returns immediately after stopping usage

23. Disadvantages
• User dependent
• Some temporary adverse effects such as headaches, breast
tenderness and mood changes can be experienced by some women
• Blood pressure may increase
• Women may experience breakthrough bleeding and spotting for the
first few months
• Increased risk of venous thromboembolism
• Small increase in risk of myocardial infarctions and strokes
• Small increase risk of breast and cervical cancer

24. Contraindications
• BMI greater than 35
• Breast feeding
• Smoking over the age of 35
• Hypertension
• History of or family history of venous thromboembolisms
• Prolonged immobility due to surgery or disability
• Diabetes mellitus with complications e.g. retinopathy
• History of migraines with aura
• Breast cancer or primary liver tumours

25. • Failure rates of combined hormonal contraceptive methods are lower
than those for barrier contraception. Values are expressed as the
percentage of women who will get pregnant in one year using the
particular method.

26. 3. Emergency contraception
• Emergency contraception is used to prevent
pregnancy following sexual intercourse (in contrast to other forms of
contraception, which are used either before or during sex).
• indications
There are two key indications for emergency contraception:
i.Sexual intercourse without contraception, or
ii. Contraceptive method has failed (e.g. a condom has torn).
• For women using either the combined or progesterone only OCP,
there may be a requirement for emergency contraception depending
on how many pills have been missed.

27. • Types of Emergency Contraception
two forms of emergency contraception are the ‘morning after pill’ and the
intrauterine device (IUD).
• Emergency Hormonal Contraception (‘Morning After Pill’)
• There are two types of emergency hormonal contraception currently available :
• Levonorgestrel (1.5mg tablet) – Synthetic progesterone (marketed as Levonelle
One Step, amongst others).
• Current evidence indicates that it can delay ovulation for 5 to 7 days, after which any
sperm will have become non-viable. Licensed for use within 72 hours of unprotected sex.
• Ulipristal acetate (30mg tablet) – Progesterone receptor modulator (marketed
as EllaOne).
• Current evidence indicates that it can delay ovulation for 5 to 7 days, after which any
sperm will have become non-viable. Licensed for use within 120 hours of unprotected
sex.
• Both contraceptive pills have no known effect on disruption/inhibition of
implantation. Their principle effect is due to inhibition of ovulation.

28. The Intrauterine Device
• The copper intrauterine device (commonly abbreviated to Cu-IUD) is
usually used a method of long term non-hormonal contraception, but
when it is inserted within 5 days of unprotected sex, it may be used as
emergency contraception.
• The copper within the coil is toxic to sperm, and it may induce a sterile
inflammatory response within the uterus that makes implantation
impossible.
• It remains in situ and provides contraceptive cover for five to ten years,
depending on the type. Due to this, it is the only method of emergency
contraception that provides protection past the initial administration.
• This method is over 99% effective and should be offered to all women
presenting for emergency contraception.

30. • Contraindications
• Levonorgestrel
• There are no absolute contraindications to the use of levonorgestrel, however efficacy may be reduced by:
• Diseases of malabsorption e.g. Crohn’s
• Enzyme inducing drugs e.g. rifampicin
• If patient refuses IUD, then double dose i.e. 3mg at once may be taken
• Ulipristal Acetate
• Diseases of malabsorption e.g. Crohn’s
• Hypersensitivity to Ulipristal Acetate
• Severe hepatic dysfunction
• Enzyme inducing drugs e.g. rifampicin
• Give 3mg levonorgestrel if the patient refuses an IUD, ulipristal acetate is absolutely contraindicated here
• Breast feeding – avoid breastfeeding for 7 days after taking UPA
• Asthma insufficiently controlled by corticosteroids
• Drugs increasing gastric pH e.g. omeprazole, ranitidine
• Copper IUD
• Uterine fibroids with distortion of the uterine cavity
• Documented or suspected pelvic inflammatory disease (PID)
• Documented or suspected STI (especially chlamydia or gonorrhoea)

31. Follow Up/Adverse Effects
• Emergency Hormonal Contraception
• As always, follow up advice should be provided in both verbal and
written forms. Advise patient to seek help if vomiting occurs within 2
hours of taking levonorgestrel or 3 hours of taking ulipristal as the
medication may not have been absorbed adequately.
• Also advise that only the IUD affords protection for the rest of the
cycle (and onwards).
• Adverse effects of emergency hormonal contraception include
nausea, dizziness, menstrual disturbance and abdominal
pain. Consider a pregnancy test no sooner than 3 weeks after
unprotected intercourse to exclude pregnancy.

32. • The Intrauterine Device
• Patients should be advised of the increased relative risk of ectopic
pregnancy following insertion of an IUD and to be alert if her next period
is >5 days late with reduced bleeding, especially coupled with severe
lower abdominal pain.
• If a pregnancy test is positive, an urgent ultrasound scan is required to
locate the pregnancy.
• Adverse effects of the IUD include pelvic infections, expulsion (of the
IUD), bleeding and pelvic pain.

33. 4. Postpartum Contraception
• Women can become fertile from 21 days after delivery so contraception
is an important discussion for healthcare providers to have before a
woman is discharged from maternity services.
• This is important for two reasons; firstly women are often so busy with
their newborn to seek contraception advice after discharge, and a
birth-to-conception time of less than 12 months leads to increased risk
of premature delivery, low birth weight, small-for-gestational age
babies and fetal mortality.

34. Term delivery
• Long-acting reversible contraceptives (LARCs) are particularly
recommended by guidelines as they can be inserted
immediately after birth and are effective for years.

35. Type of contraception Safe to start Other notes
Lactational amenorrhoea Immediately after delivery
Requires >85% feeds being breastfeeding,
amenorrhea and within 6 months of
delivery
Intrauterine (IUD and IUS)
Post-placental – within 10 minutes of
delivery of the placentaPost-partum –
within 48h of delivery
Delayed – over 4 weeks after delivery
Contraindicated if risk of pelvic infection

36. Progesterone-only pill Immediately after delivery Safe in breastfeeding
Progesterone implant Immediately after delivery Safe in breastfeeding
Combined hormonal
contraception
Breastfeeding – 6 weeks after delivery
Non-breastfeeding – 3 weeks after delivery
Pregnancy-related considerations
Barrier contraception
Condoms immediately
Diaphragm – wait 6 weeks
Delay in diaphragm due to changing
uterine size

37. Female sterilisation Delay advised
Delay advised due to increased risk of
regret if done immediately
If a woman has requested sterilisation
during an elective C-section ensure
consent is taken at least 2 weeks
before
Male sterilisation Immediately after delivery
Much safer and lower failure rates
than female sterilisation
Fertility awareness method Immediately after delivery
Hormonal changes due to pregnancy
and lactation can make it harder to
identify ovulation

38. • If contraception is started before the 21-day mark then no additional
precautions are required, whereas if it has been longer than this the
standard precautions for each contraceptive method are needed.
Women are advised to take a pregnancy test before starting
contraception if it is over 3 weeks since delivery.
• If a woman is not on contraception and has unprotected sex over 3
weeks she can safely be given ulipristal acetate or levonorgestrel as
emergency contraception.
• The IUD is safe from 4 weeks after delivery. However, breastfeeding
women should be advised to avoid feeding for one week if they take
ulipristal acetate and should instead express and discard the milk.

39. • Key points
• Women become fertile 21 days after delivery
• Progesterone-only methods and the copper coil are all safe immediately
after delivery and during breastfeeding
• Women who are not breastfeeding should wait 3 weeks to start
combined hormonal contraception, those who are breastfeeding should
wait 6 weeks
• Lactational amenorrhoea is 98% effective for the first 6 months if the
woman is fully breastfeeding and amenorrhoeic
• Contraception is needed from 5 days of ectopic pregnancy management,
miscarriage or abortion

40. 5. Progesterone Only Hormonal Contraception
• Progesterone only hormonal contraception uses the female steroid
hormone progesterone and is a very effective method of preventing
pregnancy, more so than barrier contraception.
• The progesterone only contraceptive pill (POCP) doesn’t contain any oestrogen
and has a different mechanism of action to the combined oral contraceptive.
The POCP is especially used for women when the combined pill is
contraindicated – e.g. in breast feeding mothers and patients with
hypertension.
• Examples.. Femulen® – etynodiol diacetate 500µg.
• Norgeston® – levonorgestrel 30µg.
• Noriday® – norethisterone 350µg.
• Micronor® – norethisterone 350µg.
• Cerazette® – desogestrel 75µg.

41. Mechanism of Action
• The primary method of action in POCP’s is to thicken the cervical
mucus due to the high levels of progesterone. This prevents the entry
of sperm and thereby fertilisation of the oocyte.
• It also suppresses ovulation to varying degrees. It inhibits ovulation in
about 60% of cycles with pills containing levonorgestrel whereas POCP’s
containing desogestrel suppresses ovulation in 97% of cycles.
• The increased levels of progesterone also cause thinning of the
endometrium which inhibits implantation.

42. Advantages
• More effective than barrier methods when taken correctly.
• Sex doesn’t need to be interrupted to use contraception.
• Can be used in many patients for whom the combined oral contraceptive is
contraindicated.
• May reduce risk of endometrial cancer.
• Disadvantages
• User dependent and has to be taken at the same time each day.
• Can produce irregular menstruation (4 in 10 women) or amenorrhoea (2 in
10 women).
• Some adverse affects, such as headaches, breast tenderness and skin
changes, may be experienced when POCP’s are first started.
• 30% increased risk of ovarian cysts.
• Small increased risk of breast cancer.

43. Contraindications
• Current or past history of breast cancer.
• Liver cirrhosis or tumours.
• Lower efficacy in women over the weight of 70kg.
• Stroke or coronary heart disease.

44. • Progesterone Only Implant
• There is only one progesterone implant is a small flexible tube about
40mm long which is inserted into the upper arm. The implant contains
68mg of etonogestrel (steroidal progestin) which is released into the
systemic circulation for three years.
• Mechanism of Action
• The main mechanism of action of Nexplanon® is to inhibit ovulation.
The increased levels of progesterone also cause thickening of cervical
mucus which inhibits the passage of sperm. In addition, the high
progesterone levels cause thinning of the endometrium which would
prevent implantation if an egg were to be fertilised.

45. • Advantages
• Extremely effective.
• Can be used in women for whom the combined oral contraceptive pill is
contraindicated.
• Users don’t have to think about contraception for 3 years.
• Can be used when breastfeeding.
• Normal fertility returns as soon as implant is removed.
• Effective in women of all body mass (although earlier replacement
recommended in women with high BMI).
• May reduce the risk of endometrial cancer.

46. • Disadvantages
• About 50% of women experience changes in menstrual bleeding and
bleeding patterns are likely to remain irregular.
• Fitting and removing the implant may cause some pain, bruising and
irritation.
• Small increased risk of breast cancer.
• The implant can sometimes bend or break in situ.
• Contraindications
• Pregnancy
• Unexplained vaginal bleeding
• Liver cirrhosis or tumours
• History of breast cancer
• Stroke or transient ischaemic attacks whilst using the implant

47. Progesterone Only Injectable Contraception
• The progesterone only injectable contraceptive is a long lasting
contraception where synthetic progesterone is slowly released into
systemic circulation following intramuscular (IM) or subcutaneous
injection. There are currently three available:
• Depo-Provera®– 150mg medroxyprogesterone acetate. This is the most
commonly used progesterone only injectable and is licensed for long term
use. It is given every 12 weeks by deep IM injection.
• SAYANA PRESS®– 104mg medroxyprogesterone acetate. This is also
licensed for long term usage and is given every 13 weeks.
• Noristerat®– 200mg Norethisterone enantate. This is rarely used and is
only licensed for short term use (two sets of injections). It’s given every 8
weeks by deep IM injection.

48. Mechanism of Action
• Progesterone only injectables prevent pregnancy by the inhibition of
ovulation and the thickening of cervical mucus. The high progesterone also
causes thinning of the endometrium making it unfavourable for implantation
if fertilisation was to occur.
• Advantages
• A very effective form of contraception.
• Users don’t have to think about contraception for as long as the injection
lasts.
• No known interactions with any drugs.
• It can be used when combined hormonal contraceptives are not
recommended such as in women with migraine and who are breast feeding.
• Can be used in women with a BMI < 35.
• May reduce the risk of endometrial cancer.

49. Disadvantages
• Not rapidly reversible – can take up to a year to return to normal fertility and
menstruation can take several months to return to normal.
• Up to 50% of women stop usage within a year due to altered bleeding
patterns including persistent bleeding.
• Increase in body weight, up to 2-3kg over a year.
• May be a slightly increased risk of breast cancer.
• Loss of bone mineral density with long term use (over a year of use), although
there is no evidence that it increases the risk of fracture.
Contraindications
• Current Breast cancer (within 5 years)
• History of severe arterial disease or very high risk factors
• Pregnancy
• Diabetes with any vascular disease e.g. retinopathy
• People who will want to return to fertility in the near future

50. • Key Points to Consider
• Although hormonal contraception is extremely effective at preventing
pregnancy it doesn’t protect against sexually transmitted infections so
it’s important to counsel patients on safe sexual practices.
• With the progesterone only pill, it is important to explain to the
patient what to do if they miss a pill and this can vary depending on
the brand of POP.