The lecture has been given on Nov. 10th & 22nd, 2010 by Dr. Muhabat Salih Saeid.

1. Contraception
Dr.Muhabat Salih Saeid MRCOG

2. Learning Objectives
 Recognize common adverse effects
of estrogen and progestin
 In a patient case be able to provide
a recommendation for symptom
management
 Identify contraindications to
contraceptive options

3. Contraception Definition
 Contraception generally implies the
prevention of pregnancy following
sexual intercourse by
 inhibiting viable sperm from coming
into contact with a mature ovum
 by preventing a fertilized ovum from
successfully implanting in the
endometrium.

4. Commonly used methods
 Reversible contraception
 Oral contraceptives
 Long acting injectable or implantable
progestins
 Combined estrogen patch
 Condoms, spermicides, diaphragms,
withdrawal, periodic abstinence, and
IUD’s

5. Properties of Contraceptive
Desired by Patients
 Highly effective
 Prolonged duration of action
 Rapidly reversible
 Privacy of Use
 Protection against STD’s
 Easily accessible

6. Oral Contraceptives
 Introduced to the US in 1960
 Works through the manipulation of
normal physiologic feedback
mechanisms of the menstrual cycle
by varying amounts of estrogen
and/or progestin.
 Proven to be a very effective and
popular method of birth control.

7. The Pill
Advantages
 Easy to use
 Dependable
 No additional appliances
 Can regulate menstrual flow and
decrease cramps and other symptoms
of menses

8. Missed pills
 Missed 1 day:ASAP and next pill
at regular time
 Missed 2 days: 2 when she
remembers, 2 the next day, use
back up until her next period
 More than 2 days: Restart and
use a back up method

9. Contraindications
 History of cerebrovascular disease
 Uncontrolled hypertension
 DVT or PE
 Migraines worsened by estrogen
 Estrogen dependent neoplasm
 Ischemic heart disease
 IDDM w/ complications
 Breast Cancer
 Impaired liver function
 Smokers>35y/o

10. Estrogen
 Inhibits ovulation by suppressing of
pituitary release of FSH/LH (negative
feedback)
 Inhibits implantation by altering
secretions within the uterus
 Accelerates ovum transport
 Induction of luteolysis: degeneration of
corpus luteum prevents normal
implantation and placental attachment

11. Estrogenic Side Effects
 Nausea
 Weight gain
 Fluid retention
 Pulmonary emboli
 Hypertension
 Thromboembolic complications
 Stroke
 Increase in bile cholesterol

12. Progesterone
 Inhibits ovulation by disruption of
HPO function and by modification of
mid-cycle FSH/LH surge
 Inhibits implantation by suppressing
the endometrium
 Production of thick cervical mucus
 Prevention of sperm penetration
 Slows ovum transport

13. Progestin Side Effects
 Increased appetite
 Depression, fatigue, lethargy
 Acne, oily skin
 Hirsutism
 Headache
 Weight gain
 Decreased libido
 Increased LDL, decreased HDL
 Hypertension

14. Noncontraceptive benefits
 Relief from
menstruation-
related problems
 Decreased cramps
 Decreased
ovulatory pain
 Decreased
menstrual blood
loss
 Disease prevention
 Ovarian and
endometrial cancer
 Ovarian cysts
 Ectopic pregnancy
 Pelvic inflammatory
disease
 Benign breast
disease

15. Contraindications
 History of cerebrovascular disease
 Uncontrolled hypertension
 DVT or PE
 Migraines worsened by estrogen
 Estrogen dependent neoplasm
 Ischemic heart disease
 IDDM w/ complications
 Breast Cancer
 Impaired liver function
 Smokers>35y/o

16. Transdermal Contraception
 Ortho Evra
 Norelgestromin and Ethinyl
Estradiol
 Similar to OC’s
 Not recommended in patients
>198lbs, less effective
 Applied every 7 days for 3
weeks followed by patch free
week
 Convenience, increased
compliance

17. Ortho Evra
 If a patch comes
off????
 <24 hours
 Reapply
 use a new patch
 >24 hours
 apply a new patch
 use this day as the new
patch change day
 use a back up method
until 7 consecutive
days
 Patient Education
 Similar side effects to
OC’s
 Same incidence of
drug interactions
 Apply to abdomen,
buttock, upper outer
arm, and upper torso
 Back up method
should be used until
after the first 7 days
of consecutive
administration

18. Implants
 Progestin only (Norplant)
 Prevents ovulation
 More effective than the Pill

19. Implant
 Advantages
 Convenience
 Eliminate user error
 No menses or very light
 Decreased cramping

20. Implant
 Problems
• Difficulty in
removing
 Side effects
•Similar to the
pill
•Changes in
menstrual
bleeding
•Headaches
 Side effects
•wt. gain
•Acne
•breast
tenderness
•hair growth
•ovarian cysts

21. Implant
 Contraindications
 Liver disease
 Breast cancer
 Cardiovascular disease
 Unexplained vaginal bleeding
 Pregnant
 Smokers

22. Injectable Contraceptives
 Depo-Provera
 Medroxyprogesterone acetate
 150mg/ml
 Progestin only
 Inhibits ovulation for 3
months
 IM injection 5 days w/in
onset of menstrual bleeding
and Q12 weeks

23. Depo-Provera
 Advantages
 Highly effective
99.7%
 Increased compliance
 Amennorrhea
 Reduced risk of anemia
 Decreased menstrual
cramps/pain
 No drug interactions
w/ anticonvulsants
 Disadvantages
 Break through
bleeding
 Weight gain
 Headache
 Depression
 Decreased HDL
 Risk of ectopic
pregnancy
 Contraception
reversible in 4-
13months

24. Barrier Methods
 The condom
 Female condom
 Diaphragm
 Cervical cap
 Sponge

25. IUD
 Intrauterine device
 Copper and plastic (Copper T-380A)
10 years
 Plastic and Progesterone
(progestasert IUD) 1 year
 90-96 % effective in use
 Increased risk of PID

26. Spermicides
 Nonoxynol-9
 Use in combination with barrier
methods of contraception
 Foam
 gel
 Film
 Creams, jellies and suppositories

27. Fertility Awareness Methods
 Calendar or rhythm method
 Midway in cycle
 Basal body temperature (BBT)
method
 Increase in body temperature
 Cervical Mucous Method
 Clear slippery mucous
 Symptothermal method
 Combination of BBT and Cervical
Mucous methods

28. Sterilization
 For Women
 Tubal ligations
• Cut and seal the fallopian tubes
 Hysterectomy
• Removal of the uterus
 For Men
 Vasectomy
 Vas deferens are cut and sealed

29. Emergency Contraception
 Emergency Contraception Pill (ECP)
 Copper IUD

30. Emergency Contraception
 Indications:
 Unprotected
intercourse
 Condom
slipped/broke
 Missed pills
 Sexual assault
 Preven
 50µg EE and
0.25mg
levonorgestrel
 Plan B
 0.75mg
levonorgestrel

31. Patient Education
 Prescribing Info.
 First dose must be
taken within 72 hours
of unprotected
intercourse
 Second dose is 12
hours later
 Side Effects
 Nausea
 Vomiting
 Breast Tenderness
 Reglan(metoclopramide)
1 hour prior can
reduce n/v
 Repeat dose if
vomiting occurs w/in
1 hr of admin.

32. Abortion
 Spontaneous abortion
(miscarriages)
 Induced abortion

33. Injectable Contraceptives
 Depo-Provera
 Medroxyprogesterone acetate
 150mg/ml
 Progestin only
 Inhibits ovulation for 3
months
 IM injection 5 days w/in
onset of menstrual bleeding
and Q12 weeks

34. Depo-Provera
 Advantages
 Highly effective
99.7%
 Increased compliance
 Amennorrhea
 Reduced risk of anemia
 Decreased menstrual
cramps/pain
 No drug interactions
w/ anticonvulsants
 Disadvantages
 Break through
bleeding
 Weight gain
 Headache
 Depression
 Decreased HDL
 Risk of ectopic
pregnancy
 Contraception
reversible in 4-
13months

35. Implantable Contraception
 Norplant
 Subdermal progestin implant
 6 implantable capsules filled
w/ levonorgestrol
 Requires physician
administration
 Effective for 5 years
 Every 3 yrs for women
weighing >154lbs

36. Norplant
 Advantages
 Convenience
 Highly effective
 Decreased
menstrual cramps
 Fertility rapidly
returns
 Disadvantages
 Irregular period
 Headache
 Depression
 Weight gain
 Pain/itching @ site
 Site infection
 Ectopic pregnancy
 Removal
difficulties

37. TTTTT