2. IDEAL CONTRACEPTIVE
ď§ Inexpensive
ď§ Easy and simple to use with minimum side effects
ď§ Rapidly reversible
ď§ Readily available
ď§ Highly effective.?
ď§ Can be administered by non-healthcare personnel.
3. Contraceptive effectiveness
⢠Difficult to determine :
1. Perfect VS typical use (method failure and patient
failure)
2. Correct VS incorrect use
3. long term VS short term
4. Pearl index
⢠Method used for determination of pregnancy failure
rate:
Pregnancy rate = no. of pregnancies x100women/12
months of use
5. classifications
A. Natural Methods
⢠Periodic abstinence
⢠Withdrawal
⢠Lactational Amenorrhea Method
⢠Standard days method
⢠Calender rhythm method
B. Barrier Methods
C. Hormonal
D Intrauterine Devices
E.. Sterilization
11. POP: Suitable for -
⢠Older women,
⢠Heavy smokers,
⢠Hx/Predisposition to VTE,
⢠Pts with HTN,Valvular heart ds., DM, or Migraine,
⢠Breastfeeding women < 6mo postpartum (delay
until =/> 3w postpartum to avoid risk of heavy
bleeding).
12. Starting the POP
⢠No previous contraception= start on day 1,
⢠Changing from COC= start the day following last pill (
no pill-free period),
⢠After childbirth= start anytime > 3w,
⢠If weight > 70 kg= Consider Desogestrel or 2 tabs/d
of any other POP( unlicensed)
13. Mechanism of action
⢠Combined :
most effective method because they inhibit midcycle gonadotropin surge
and prevent ovulation
⢠Progestin only pills:
donât mainly not inhibit ovulation
Both types act by -altering cervical mucus making it thick viscid and scanty
-alter endometrium so not fit for implantation
- alter ovarian responsiveness to gonadotropin stimulation
14. How to prevent ovulation?
⢠Interfere with the release of GnRH from
hypothalamus so it will suppress LH & FSH
⢠In high concentration they will inhibit pituitary gland
directly
⢠Progestin only pills don't inhibit ovulation mainly
because a lower dose of progestin is used in
preparations less than combine forms it is important
to be taken at the same time of the day to ensure that
blood level do not fall below the effective levels
15. Short-term side-effects
⢠OESTROGENIC EFFECTS ⢠PROGESTOGENIC EFFECTS
⢠Breast tenderness (3.6%), ⢠Depression(3.9%),
⢠Nausea ( 1.5%), ⢠Premenstrual tension
⢠Dizziness ⢠Dry Vagina
⢠Cyclical wt. gain ⢠Sustained wt. gain
⢠Bloating ⢠Decreased libido
⢠Vaginal discharge without ⢠Lassitude
infection ⢠Acne
⢠use a more progestogen- ⢠Use a more oestrogen-dominant
dominant pill pill
16. ⢠Estrogen cause pigmentation and high level of
estrogen may accelerate the development of
gallbladder disease in young female but not increase
the risk of acute cholelithiasis
⢠Progestin : because they are structural related to
testosterone they produce androgenic effects like
increase weight and acnes
18. NONCONTRACEPTIVE BENEFITS
⢠BENEFITS FROM ANTIESTROGENIC EFFECTS
OF PROGESTERON:
1-decrease menses blood loss & improve anemia
2- risk of adeno CA of uterus
3- estrogen receptors in breast so risk
begnin breast disease ?
⢠BENEFITS FROM INHIBITION OF OVULATION
(dysmenorrhea )
use as therapy of severe dysmenorrhea
⢠OTHER BENEFITS: risk (PID,Rhumatoid a, bone
loss)
20. Neoplastic effects
⢠Breast CA
⢠Endometrial CA : protection related to duration of use
⢠Ovarian CA : decrease risk duration related
⢠Liver adenoma and CA?
⢠Pituitary adenoma : mask symptoms produced by
prolactinoma amenorrhea and galactorrhea
⢠colorectal CA: protection
⢠Liver cyst and adenoma
21. Contraindications
⢠Absolutes
⢠Histoy of vascular disease (thromboembolism)
⢠Systemic diseases (affect vascular system) SLE , DM
with retinopathy or nephropathy
⢠Undiagnosed uterine bleeding
⢠Increase serum TGs
⢠Heart failure rare because incidence of heart diseases
are mostly after menopause
⢠Smoking in female more than 35y
23. VAGINAL RING
⢠Steroids absorbed though vaginal epithelium directly
into circulation
⢠Contain ethniyl estradiol and etonogestreland
⢠Place in vagina for 21 days and remove 7 days to
allow withdrawal bleedings
24.
25. TRANSDERMAL PATCH
⢠It releases norelgestromin & ethinyl estradiol
⢠Weekly applied, for 3 weeks, and the last week of the
cycle is a patch-free week
⢠Normal activities can be done while using the patch
27. ⢠Sub dermal implants:
⢠Need trained personal for insertion and
removal.
⢠Out patients procedure.
⢠99.5% effectiveness rate.
⢠Requires no user motivation so compliance
not problem.
⢠Amennorhoea is common
28. ⢠Subdermal implantation for continuous release
⢠Effective for up to 3 years
⢠Rapid return of fertility
⢠Problems
⢠Menstrual irregularity
⢠Weight gain
⢠Surgical implantation & removal
31. IUD
-IUD is the world's most widely used method of
reversible birth control
3 TYPES:
1- Inert ( no longer recommended because of
painful and heavy periods).
2-Copper Releasing (paragard).
3-Progesterone Releasing (IUS):
A-Progestasert (progesterone T) 1976 - 2001.
B-Mirena (levonorgestrel).
32. ď˘Intrauterine Contraception Devices:
1. Most commonly used reversible
- Method of Contraception
worldwide
- effective > 97%.
- The newer devices have failure
rate < 0.5%
33. 2. Copper bearing IUCD
- Consist of a plastic frame with copper wire
around the stem.
- Surface of the copper determine the
effectiveness and active life of the device.
- Most IUCD licensed for use over 5-10 years
and because of gradual absoption of
copper, these IUCD renewed after 3-5 years.
ď Copper Salt give some protection against bacterial
infection.
34. Mechanism of Action:
- All IUCD cause a foreign body reaction in the
endometrium with increased prostaglandin
production and Leucocyte infeltration. This reaction
enhanced by copper which effect endometrial
enzymes and oestrogen uptake and also inhibit
sperm transport.
- Alteration of uterine and tubal fluid impairs the
viability of the gametes.
- The progesterone IUCD (LNG.IUS) cause endometrial
suppression and change in the cervical mucus and
utro tubal fluid impair sperm migration.
35. Clinical uses
⢠Long-term contraception
⢠Women with contraindications to COC
⢠Emergency contraceptive (1:1000 )
⢠menorrhagia , endometriosis, chronic
pelvic pain, dysmenorrhea , anemia.
37. EMERGENCY CONTRACEPTION
⢠After intercourse and before implantation
⢠Indication: failure of condoms
⢠Unprotected intercourse
⢠Within 72 hours after unprotected intercourse
⢠Levonorgestrel Combined
Prescription
⢠Single dose, the earlier the better
⢠Prevented 75% of unplanned pregnancies
⢠IUD Emergency Contraception
⢠Within 5 days after unprotected intercourse
⢠Copper IUD
41. Barrier methods of contraception
Two types :
1. Physical barrier methods, such as
condoms, diaphragm, and cervical caps, that prevent
pregnancy by blocking the entry of sperm into the
upper genital tract;
2. Chemical barrier methods (spermicides) that kill
or inactivate sperm on contact. ( less effective , used
in combination , no STDs protection )
42. Barrier methods of contraception
⢠easily available, reversible, and have fewer side
effects than hormonal methods.
⢠effective and acceptable if used consistently and
correctly.
⢠Protect against STD
43. Natural Methods:
1.) Calendar Method (Safe period)
- relies upon the fact that there are certain days during
the menstrual cycle when conception can occur
following ovulation, the ovum is viable within
reproductive tract for a maximum of 24 hrs.
- The life spam of sperm is longer 3 days.
- During 28 day menstrual cycle, ovulation occur around
day 14. This means that coitus must be avoided from
8th to 17th day.
- Failure rate is high so many couples find it difficult to
adher to this method.
44. 2.) Ovulation method (The billingâs method)
- Ovulation prediction can be enhaced by several
complementary methods including *Basal body
temperature (BBT) rise in progesterone following
ovulates â rise temp. BBT 0.2-0.4 C, until the onset of
menstruation .
* Cervical mucus â several days before ovulation
mucus appearance of raw egg white, clear, slippery
and stretchy (spinnbarkeit). The final day of fertile
mucus is considered to be the day when ovulation is
most likely to occur and abstinence must be
maintained from first day of fertile mucus until 3 days
after the peak day. The end of the fertile period is
characterized by appearance of (infertile mucus)
which is scanty and viscous.
45. *Failure rate of natural method mucus and BBT and
Calendar method 2.8 %.
3-personal fertility monitors: small devices able to
detect urine concentration of oestrone and LH
indicate start and end of fertile period.
- Failure rate 6.2%.
- Disadvantage â provide no protection from STD .
46. How to use Standard Days
Method
ď Every morning move
the rubber ring to the
next bead.
ď THE RED BEAD
is day 1 of cycle. Always move the ring in
On the first day of your the direction of the
period, move the rubber arrow.
ring onto the red bead. ď WHITE BEAD
Each bead DAYS
Mark a calendar to help
represents a day are days when
remember.
of your you CAN get
menstrual cycle pregnant.
ď BROWN BEAD Use a condom or
DAYS do NOT have
are days when sex on these
pregnancy days to prevent
is unlikely. pregnancy.
You can have sex on these days.
No condom needed. Are you ready to
When your next period choose this
starts, move the ring to the red method?
bead again. Skip over any
47. What to remember
⢠Move the rubber ring one bead forward every
day
⢠Always use condoms or avoid sex on
fertile âwhite beadâ days
Come back if:
⢠You get your period early Dark brown
(it starts before you put the ring on bead
the dark brown bead)
⢠You get your period late Last brown
bead
(it does NOT start by the day after
you put the ring on the last brown
bead)
⢠You have unprotected sex Anything else I can
repeat or explain?
on a fertile âwhite beadâ day Any other
questions?
48. Male condoms
⢠It is one of the most popular mechanical barriers.
Among all of the barrier methods, the condom
provides the most effective protection of the genital
tract from STDs. Its usage has increass because of the
concern regarding the acquisition of HIV and STDs.
49. Male condoms
⢠Increasing the efficacy :
⢠reservoir tip
⢠The addition of spermicidal
lubricant to the condom. (water-based not oil-based)
⢠the addition of an intravaginal spermicidal agent
50. Female condoms
⢠It contains 2 flexible rings. The ring at the closed end
of the sheath serves as an insertion mechanism and
internal anchor that is placed inside the vaginal canal.
The other ring forms the external patent edge of the
device and remains outside of the canal after
insertion.
51. Female condoms
- Mechanism of action :
⢠Prevents passage of sperm
and infections into the vagina
( protection against STDs )
⢠Can be inserted up to 8 hours
prior to intercourse; can remain in
place up to 8 hours
52. Female condoms
- Efficacy
⢠Pregnancy rates for the female condom range
between 5 and 21 per 100 women per year.
(higher than male condoms)
⢠To increase efficacy Simultaneous use of both the
female and male condom is not recommended
⢠Re-use is not recommended .
53. Diaphragm
⢠The diaphragm is a shallow latex cup
with a spring mechanism in its rim to hold it
in place in the vagina
⢠It is inserted before intercourse so that the
posterior rim fits into the posterior fornix and
the anterior rim is placed behind the pubic bone.
⢠Spermicidal cream is applied to the inside of the
dome, which fits against the vaginal wall.
54. Diaphragm
⢠It prevents pregnancy by acting as a barrier to the passage of
semen into the cervix
⢠provides effective contraception for 6 hours.
⢠After intercourse, the diaphragm must be left in place for at
least 6 hours.
⢠Effectiveness depends on the age of the user, continuity of
use, and the use of spermicide along with the diaphragm.
Failure rate is estimated to be 20% .
56. Diaphragm
⢠Disadvantages :
- Prolonged use increase the risk of UTI
- More than 24 hours use is not recommended
due to the possible risk of TSS.
- Might cause vaginal erosions if not placed properly .
- Requires a professional fitting (trained provider is needed) .
57. Cervical cap
⢠a cup-shaped latex device that fits over the base of the
cervix.
⢠The cap must be filled one third full with spermicide
prior to insertion
⢠Inserted 8 hours before coitus and can be left in place
for as long as 48 hours.
58. Cervical cap
⢠Acts as both mechanical barrier to sperm and as a chemical agent
with the use of spermicide .
⢠Pregnancy rates range between 4 and 36 per 100 women per year.
⢠Effectiveness depends on the parity of women due to the shape of
the cervical os.
⢠Disadvantages : cervical erosions and vaginal spotting , risk for TSS
, requires professional fitting and training for use , high failure rate
, and candidates must have a history of normal results of pap smears.
59.
60. Spermicides
⢠consist of a base combined with either nonoxynol-9
or octoxynol
⢠Surfactant that destroys the sperm cell membrane
⢠Forms available : vaginal
foams, suppositories, jellies, films, foaming
tablets, and creams.
61. Spermicides
⢠Failure rate is about 26% within the 1st year of use.
⢠Advantages : ease of application , available over the
counter , inexpensive and it augments the
contraceptive efficacy of the cervical cap and
diaphragm .
⢠Disadvantages : minimal protection against STDs
, risk of vaginal irritation and allergic reaction.
62. Sterilization
⢠Sterilization :female sterilization and male vasectomy are permenant
metod of contaception and highly effective
⢠They are generally chosen by relatively older couple who are sure
that they copleted their family.
⢠Also individual who carry a genetic disorder may choose to be
strlizer.
⢠28% of reproductive age women undergo tubal ligation and 10% of
men undergo vasectomy.
⢠Sterilization methods include:
1- Vasectomy in males.
2- Tubal Ligation in females .
63. Tubal Ligation
⢠This involve mechanically blockage of
both fallopian tube to prevent the
sperm reaching and fertilizing the
oocyte
⢠sterilization performed by
laparoscopically(under GA) or through
a suprapubic âmini-laparotomyâ
⢠Failure rate: 0.5%
64.
65. Tubal Ligation
Advantages:
⢠intended to be permanent
⢠highly effective
⢠safe
⢠quick recovery
⢠lack of significant long-term side effects
⢠cost effective
66. Tubal Ligation
Disadvantage:
⢠possibility of patient regret
⢠difficult to reverse
⢠future pregnancy could require assisted reproductive
technology (such as IVF)
⢠more expensive than vasectomy
67. Cont.
Complication:
A women may experienced anasthetic problem or may be
damage to intra-abdominal during the procedure.
NOTE:
ectopic pregnancy can be a late complications
and any sterilized women who misses her period and has
symptom of pregnancy should seek
medical advice.
68. Vasectomy
Mechanism of action:
Vasectomy involve division of the vas deferens on each
side to prevent the release of sperm during
ejaculation.
Easier than tubal ligation.
Usually done under local anesthesia.
⢠Failure rate: 0.1%.
69.
70. Vasectomy
Advantages:
⢠permanent
⢠highly effective
⢠safe
⢠quick recovery
⢠lack of significant long-term side effects
⢠cost effective; less expensive than tubal ligation
71. Vasectomy
Disadvantages:
⢠reversal is difficult, expensive, often unsuccessful
⢠not effective until all sperm cleared from the
reproductive tract (may take up to 12 w)
⢠no protection from STDs
72. Cont.
Complication of vasectomy:
Immediately bleeding, wound infection and hematoma
may occur.
At the cut of vas deferns small lump will apear as a
result of a local inflammation response this is called
sperm granuloma it needs surgica excision.