Methods of contraception

WALAA MAHMOUD ABDELRAHMAN
By
ASSISTANT LECTURER – FACULTY OF NURSING
CAIRO UNIVERSITY

OBJECTIVES
Define family planning.
Discuss the health benefits of family planning.
Differentiate between different types of family
planning methods.
Identify specific mechanisms, indication,
contraindication, and side effects of those methods.
At the end of the lecture the student will be able to

Family planning: is defined as "educational, comprehensive
medical or social activities and services which enable individuals,
including minors, to determine freely the number and spacing of
their children and to select the means by which this may be
achieved.
Birth control: Birth control is the use of any practices, methods,
or devices to prevent pregnancy from occurring in a sexually active
woman. Also referred to as family planning, pregnancy prevention,
fertility control, or contraception; birth control methods are
designed either to prevent fertilization of an egg or implantation of
a fertilized egg in the uterus. Birth control methods may be
reversible or irreversible.
Contraception: (birth control) prevents pregnancy by interfering
with the normal process of ovulation, fertilization, and
implantation. There are different kinds of birth control that act at
different points in the process.

Women/family
Better health
Less physical/emotional strain
Improved quality of life
Increased educational opportunities
Increased economic opportunities
More energy for household activities
More energy for personal
development and community
activities

For Children:
Better health
More food and other resources
available
Greater opportunity for
emotional support from parents
Better opportunity for education

 husband involvement
 Effectiveness--statistics show two numbers:
 Failure rate: no. of women per 100 who become
pregnant after 1 yr. when using a birth control
consistently & correctly
 Typical use failure rate: takes into account
improper or inconsistent use
 Cost
 Ease of use
 Side effects

Hormonal Contraceptive
Combined (Estrogen/Progestin)
Contraceptives
Combined Injectable Contraceptives
Combined Oral Contraceptives
Progestin-Only Contraceptives
Norplant Implants
Progestin-Only Injectable Contraceptives
Progestin-Only Pills
Intrauterine Devices (IUDs)
Barrier Methods
Male Condoms
Female Condoms
Diaphragms
Spermicides
Natural Methods
Lactational Amenorrhea Method
Withdrawal (Coitus Interruptus)
Standard Days Method Multimedia
Tutorial
Voluntary Sterilization
Female: Tubal Occlusion
Male: Vasectomy

6 types
1) Oral contraceptives (pills)
2) Vaginal ring
3) Transdermal patch
4) Injected hormones
5) Hormonal implants
6) Hormonal IUDs

Types of Contraceptives Pills
 Combined oral contraceptives (COCs)
 Most widely used
 Contain both estrogen & progestagen
 Triphasic pill
 Levels of hormones (estrogen & progestin) fluctuate
during cycle
 Progestin-only pills (POPs)
 Contain only a progestagen, mostly Levonorgestrel (no
estrogen).
 Especially suitable for breastfeeding women.

FSH & LH trigger ovulation
Gonadotropin releasing
hormone (GnRH) triggers
release of gonadotropins FSH
& LH
Estrogen & progesterone in
hormonal contraceptives
inhibit LH, FSH, and GnRH
secretion, preventing ovulation

Progesterone also:
• thickens cervical mucus to prevent
Passage of sperm into the uterus
• changes uterine lining to inhibit implantation


1- COCs
 Initiation:
- In the 1st day of menses
- Sure that the women not pregnant
- After child birth:
* Non-breastfed women: delay until 6 weeks
* Breastfed women: can delay until 6 months in complete, exclusive
breastfeeding.
 Schedule:
- One pill per day until the pack is finished (21 pills).
- 7 days break between packs
- Start another pack in day 7

Missed 1
pill
Missed 2
pills or
more
•Taking missed pill as soon as remembered
•Taking remaining pills on schedule
•No backup method needed
•Taking most recently missed pill
•Discard other missed pills
•Resume daily pill-taking
•For next 7 days, abstain or using backup method
7 or more pills
left in the pack
Fewer than 7
pills left in the
pack
•Finishing pills
•Taking 7-days break before
starting a new pack
•Finishing pills
•Starting a new pack
without taking 7-days break

2- POPs
 Initiation:
- In the 1st day of menses
- Sure that the women not pregnant
- After child birth:
* Non-breastfed women: can start immediately.
* Breastfed women: can delay until 6 weeks
 Schedule:
- One pill per day at the same time daily until the pack is finished (28
pills).
- no breaks between packs

Taking most recent missed pill as soon
as possible.
If not breastfed woman abstain or
backup method used for 48 hrs.
Taking nest pill at regular time.

 Safe
 Combined pills are highly effective: when used correctly
and consistently, pregnancy prevention rate is more than
99%
 Reversible, rapid return to fertility
 No action needed at the time of intercourse.
 Serious complications are extremely rare.
 Can have beneficial health effects other than
contraception.
 Use is controlled by the patient.

 Incorrect use and pill missing is common; not as
effective in typical use.
 Require daily pill intake
 Side effects are common
 May pose health risks for small number of
women
 Re-supply required
 Offer no protection against STIs including HIV.

COCs POPs
 Reduce risk of ovarian &
endometrial cancer
 Reduce risk of benign breast
diseases
 Reduce risk of ectopic pregnancy
 Reduce menstrual irregularities
 Reduce risk of anemia
 Reduce symptoms of
dysmenorrhea, endometriosis,
premenstrual syndrome and PID.
 The same as COCs.

COCs POPs
 Nausea
 Dizziness
 Breast tenderness
 Headaches
 Mood changes
 Wt gain (water and salt retention)
 Menstrual irregularities:
- Spotting
- Breakthrough bleeding
- Amenorrhea
 Menstrual irregularities:
- Spotting, breakthrough bleeding (if
not breastfeeding mother)
- Amenorrhea
 Wt gain (↑ appetite)
 Other side effects are similar to
those of COCs, but less common.
 Acne

Absolute Contraindications Relative Contraindications
 Thrombophlebitis or Thromboembolic
diseases
 History of DVT
 Coronary Heart Disease
 Cerebrovascular accident of stroke
 Liver diseases
 Malignancy of female genital system
 Abnormal bleeding from the genital tract
 Benign or malignant liver tumors
 Breast cancer or H/O benign neoplasms
 Pregnancy
 Heavy smokers
 Sever HTN
 Complicated DM
 Epilepsy
 Prolonged immobilization
 Complicated valvular heart diseases
 Superficial Thrombophlebitis
 Mild and moderate HTN
 Varicose veins
 Migraine headache
 Diabetes Mellitus
 H/O liver disease
 Gall bladder stones
 Age > 35 years
 H/O pre-eclampsia, diabetes, or cholestasis
with previous pregnancies.
 Current treatment of antibiotic or
antiepileptic drugs

Rare but serious side effects of OCs

Injected Contraceptives
 Depo-Provera (prog.); Lunelle (prog.+est.)
 Injections: D-P every 12 weeks; Lunelle
monthly
 Cost effective
 Pros: no daily pill; spontaneity
 Cons: no STD protection, weight gain,
bleeding, mood change, frequent clinic visits
 D-P: takes up to 10 months for a woman
to get pregnant after stopping injections

Product Duration of protection
Progestin-only
Injectables
Depo-provera
DMPA 3 months
Norstrat
NET-EN 2 months
Combined
Injectables
Mesygyna
NET-EN + estrogen
Cyclofem
DMPA + estrogen
1 month

 Transdermal patch (Ortho-Evra)
 Patch is placed on buttock, abdomen, outer
upper arm, or upper torso
 Replaced weekly for 3 weeks, then a patch-
free week
 Cost less than Nuvaring
 Cons: no STD protection, skin irritation

 Vaginal ring (Nuvaring)
 Ring inserted into the vagina during period
 Worn for 3 weeks, removed for 1 week, then
replaced with new ring
 Highly Cost
 Cons: no STD protection, not effective for
obese women.

Contraceptive Implants
1.5" rod is inserted under skin of upper arm
 Progestin-only
 Effective for up to 3 years
 Cost not yet known
 Cons: no STD protection, weight gain,
bleeding, mood change, surgical procedure

 Small plastic objects inserted into
uterus
 2 types
 Hormone-releasing (progesterone)
 Copper-releasing
 Have fine plastic threads attached
that hang slightly out of cervix into
vagina for removal
 Very high continuation rate (how
many women are still using it one
year after starting) compared
w/other methods
progesterone

http://www.youtube.com/watch?v=FuPFbgSm0QQ

Levonorgestrel-Releasing IUD
(LNG-IUS, Mirena®)
 Inhibits fertilization
 Thickens cervical mucous
 Inhibits sperm function
 Thins and suppresses the
endometrium
Copper-Releasing IUD
(ParaGard® T380A)
• Inhibits fertilization
• Releases copper ions (Cu2+)
that reduce sperm motility
• May disrupt the normal
division of oocytes and the
formation of fertilizable ova

Advantages Disadvantages
 Very safe and highly effective
(essentially no “user error”)
 Long-term protection
 No interruption of sexual
activity
 Don’t have to remember to use
 Can be used during breast-
feeding
 No systemic side effects
 Complications are rare
 Can cause side effects
 Insertion & removal needs
trained health care provider
 No protection against STIs

Absolute:
 Women who are pregnant.
 Women who have unprotected sex with more than
one partner.
 Women whose partners have other sex partners.
 Women with unexplained vaginal bleeding.
 Women with infections such as gonorrhea,
chlamydia, or cervicitis.
 Women who have an active, recent, or frequent
pelvic infections.

 Women who have uterine problems such as
fibroids that can change the uterus.
 Women who have an impaired immune response,
such as a disease that lowers the body’s method to
fight infection.
 Women with a recent abnormal pap-smar test.
 Women with cancer of the uterus or cervix.
Relative:
 Anemia
 Diabetic woman.

 Bleeding (Menorrhagia)
 Pelvic inflammatory disease (PID)
 Perforation
 Ectopic pregnancy or pregnancy on IUD
 Expulsion

 Interval insertion
during menstruation (at the end of it usually at the 5th
day)
 Postpartum insertion:
4-6 weeks after delivery (some specialists prefer to
insert it 10 minutes after delivery)
 Post-abortive insertion:
2-3 weeks after abortion (some prefer to insert
immediately after abortion if there is no infection)

 4 to 6 weeks after the IUD
insertion, to make sure it is in
place.
 The women have to check the
string of the IUD after every
period.
 checkup must be done once a year
for:
 The copper IUD is approved for
use for up to 10 years.
 The LNg IUD is approved for
use for up to 5 years.

P – Period late, abnormal spotting or bleeding
A – Abdominal pain, pain with intercourse
I – Infection exposure (any STD), abnormal discharge
N – Not feeling well, unexplained fever or chills
S – String missing, shorter, or longer

Include:
 Condoms (male & female)
 Spermicides (foam, sponge)
 Cervical barriers (diaphragm & cervical
cap)
Work by preventing sperm from reaching an
egg
Only condoms provide protection against
STIs

 Sheath that fits over the erect penis
 The only temporary method of birth control for men
 Only form of contraception that effectively reduces STI
transmission
 Made of thin latex, polyurethane, or natural membrane
 Natural membrane (from sheep intestines) condoms can permit passage
of viruses (AIDS, herpes, hepatitis, HPV)
 Many varieties
 Different features, shapes, textures, colors, flavors
 Some “extended pleasure” types have a desensitizing agent on the
inside to delay ejaculation
 Lubricated or nonlubricated
 Note: average shelf life of condoms is 5 years; not to be
stored in hot places (heat can deteriorate the latex)

Consists of two flexible polyurethane rings
and a soft, loose-fitting polyurethane sheath
 One ring at closed end fits loosely against
cervix; other ring at open end encircles the
labial area
Can be inserted before sexual activity; don’t
need to remove it immediately following
ejaculation

Costs
Advantages
 STI protection!
 Available without prescription or medical
intervention
Disadvantages
 Can reduce sensation
 Polyurethane transmits heat well, so some say that the
female condom has less reduction in sensation
 Interruption of sexual experience

 Include: foam, sponge, suppositories, creams, film
 Spermicide: chemical that kills sperm
(nonoxynol-9)
 Cost
 Advantage: no prescription necessary
 Disadvantages:
 Interruption of sexual experience (except for the
sponge)
 Skin irritation (which can increase susceptibility
to STI infection)
 No protection from STIs
 Not effective enough to be used without a
condom or other method

 Covering the cervix is one of the oldest
methods in contraceptive history
 Casanova (18th century Europe) promoted using
squeezed-out lemon half; European women
shaped beeswax to cover cervix
 Cervical cap: covers cervix only
 Diaphragm: covers upper vaginal wall
behind cervix underneath pubic bone
 FemCap & Lea’s shield have removal straps
 Lea’s Shield allows a one-way flow of fluid
from cervix to vagina
 Method is usually combined with spermicide

Diaphragm & cervical cap: need to be fitted
(may need to be refitted with weight gain or
loss >10 lbs.)
FemCap & Lea’s Shield do not have to be
fitted, but still require a prescription
Use diaphragm & cervical cap only with water-
based lubricants b/c they are latex (FemCap &
L.S. are silicone)
Can insert up to 6-8 hr. before intercourse;
should leave in at least 8 hr after

 Works mainly by preventing ovulation or fertilization
 In theory, can also interfere with implantation
 Evidence suggests this is not primary mechanism of action
 If it was, efficacy should not decrease with short-term delay, as long
as EC was administered some time before implantation
 However, EC is increasingly less effective with delay
 Oral contraceptive pills
 95% effective within 24 hrs; 75% effective within 72 hrs
 Prevention: 2 doses of combined estrogen & progesterone
 Plan B: 2 doses of progesterone
 Other combinations of oral contraceptives can substitute for these
 Copper-T IUD
 99% effective if inserted within 5 days

 Standard days method
 For women with cycles between 26 & 32 days (28 days)
 Couples avoid unprotected intercourse between days 8-19 of each
menstrual cycle
 Highest rate of effectiveness of natural family planning methods
 Mucus method: based on cyclical changes
 Vaginal secretions change throughout cycle; woman learns to
“read” these changes and keeps a daily chart
 Calendar method: self- knowledge of fertility
 After charting cycles for some time (preferably 1 year), a woman
estimates the time she is ovulating based on the calendar
 Basal body-temperature
 Based on changes in body temperature around ovulation
 Often, some combination of these methods will be used

On WHITE bead days
you can get pregnant.
Avoid unprotected
intercourse to prevent
a pregnancy.
On the day you start your
your period, move the
ring to the RED bead.
Every morning
move the ring
to the next
bead.
Always move
the ring from
the narrow to
the wide end.
1
2
Also, mark this date
on your calendar
When you start your
next period, move the
ring directly to red
bead and begin again.
On BROWN bead
days you can
have intercourse
with very low
probability of
pregnancy.
If you have not started
your period by the day
after you put the ring on
the last brown bread,
contact your provider.
If you start
your period
before you put
the ring on the
darker brown
bead, contact
your provider.
(may not be a good
method for you)

• Slight amount
• Thick
• White
• Sticky
• Holds its shape
• Increasing
amounts
• Thinner
• Cloudy
• Slightly stretchy
• Profuse
• Thin
• Transparent
• Stretchy
Early
Mucus
Transitional
Mucus
Highly Fertile
Mucus

Low-risk Days
Egg may still
be present Ovulation
These days may be
unsafe if 28-day cycle
varies as much as 8-9
days between shortest
and longest cycles.
Intercourse on these days
may leave live sperm to
fertilize egg.
8

 BBT=body temp in resting state on waking
 Slight drop immediately before ovulation
 After ovulation, release of progesterone causes slight
increase in temperature

 Pros:
 Essentially free
 No medical side effects
 Does not interrupt sexual activity
 Woman gains awareness about her body and natural cycles,
which can increase comfort w/sexuality
 Acceptable to Catholic Church
 Cons:
 No STI protection
 Requires some degree of discipline in order to keep track of
calendar/charts, etc.
 Need to abstain from intercourse or use a backup method during
fertile days

 Essentially permanent, although vasectomies are
sometimes reversible
 Does not affect hormones, desire, sexual functioning
 Female sterilization
 Tubal sterilization: fallopian tubes are severed to block
passage of sperm & eggs
 Transcervical sterilization: tiny coil inserted through cervix
into fallopian tubes
 Coil promotes tissue growth that, after 3 months, blocks fallopian
tubes
 Male sterilization (vasectomy)
 Safer, less expensive, fewer complications than female
sterilization
 Cutting and closing vas deferens (ducts that carry sperm)

 Laparoscope: narrow, lighted viewing instrument that is
inserted into abdomen to locate the fallopian tubes

Vas deferens
on each side is
cut; small
section is
removed, and
the ends are
tied off or
cauterized

 Nursing
 amenorrhea is common for a brief period after birth
while breastfeeding
 80% of women ovulate before first period (and so do not
know that they are fertile)
 Withdrawal before ejaculation
 difficult to judge when to withdraw
 anxiety may lower pleasure for both partners
 Cowper's gland fluid may carry sperm
 any sperm on vulva may travel into vagina/uterus
 Douching
 sperm reach uterus in 1-2 minutes
 douching may speed sperm along
 irritates vaginal tissue

 Backup methods: contraceptive methods used
simultaneously with another method to support it
 When a backup method might be a good idea:
 If on the pill:
 During first cycle of the pill
 After forgetting 2 or more pills, or after several days of
diarrhea or vomiting when on the pill
 First month after switching pill type
 When taking medications that can reduce effectiveness of
the pill
 During first 1-3 months after IUD insertion
 When first learning how to use a new method
 To increase overall effectiveness of contraception

The “male pill”: Testosterone & progestin
may lower sperm count
New forms of reversible vasectomy
 Injection of a blocking gel into vas
deferens; gel is dissolved to reverse the
procedure
 Insertion of two plugs into each vas
deferens--can be removed later

Most new developments are improvements on
existing contraception for females
 Variations on methods of delivery,
formulation of hormones
 New designs of IUDs, female condoms
 spermicides with microbicides (to kill
microbes that cause STIs)

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