METHODS OF CONTRACEPTION

1. METHODS OF
CONTRACEPTION
Aboubakr Elnashar
Benha University Hospital, Egypt

2. I. Hormonal Methods
II. Intrauterine Device
III. Barrier Methods
IV. Natural Methods
V. Sterilization
Outline

3. I. Hormonal Methods

4. Advantages
 Most effective, long-term reversible contraception
available
 Most methods offer complete privacy
 Require no planning before intercourse
Disadvantages
 Require a visit to a healthcare professional
 May cause common hormonal side effects
 Products containing estrogen may be associated with
rare, but serious health risks
 Not effective against STD

5. Daily Use
 Oral Contraceptive Pill
– Combination pill
– Progestin-only pill
Nondaily Use
 Injectable contraceptive
 Contraceptive patch
 Hormone-releasing
intrauterine system
 Emergency Contraception

6. 1. The Combination Pill
 Contain Synthetic Estrogen/Progestin
 Modern E2 Dosage ≤ 50 Mcg
 Despite Diversity, Side Effects and Efficacies
Similar
 Requires Patient Compliance
 May Be Monophasic or Triphasic

7. Estrogens:
 Ethinyl estradiol
 Mestranol
Progestins:
 Ethynodiol diacetate
 Norethindrone acetate
 Norethindrone
 Norgestrel
 Levonorgestrel
 Desogestrel
 Norgestimate
 Drospirenone
2nd Generation
3rd Generation
Spironolactone Derived

9. Advantages:
 Highly effective
 Provides noncontraceptive health benefits
 Private
 Does not require vaginal insertion
 Allows to control cycle
Disadvantages:
 Must be taken daily
 Side effects may lead to discontinuation
 Associated with rare, but serious health risks, such as
blood clots and stroke

10. Non-Contraceptive Benefits of OCPs
Improvement
Dysmenorrhea
Acne
Hirsutism
Anemia
Cycle Regulation
Reduction Risks
Colorectal Cancer (18-40%)
Endometrial Cancer
PID (10 – 70%)
Osteoporosis
Osteopenia
Cleveland Journal of Medicine 2004

11. Mechanism of Action
 Suppresses LH / FSH Release
(E2 FSH, P LH)
 Progestin Thickens Cervical Mucus and Alters
Endometrium
 Major Effect Is Anovulation and Impairment of
Sperm Transport and Oöcyte Implantation

12. Side Effects
 Breakthrough Bleeding (≤ 25%)
 Amenorrhea
 Breast Tenderness, Nausea
 ? HTN
 ? Weight Gain

13. Risks
 Thromboembolism (≥ 35 yo, Smoker)
 MI (Smokers Only):
 < 15 cig/day: 3X Risk
 > 15 cig/day : 21X Risk
 Liver Adenomas (Very Rare)

14. 2. The Contraceptive Patch (Evra Patch)
Advantages:
 Efficacy comparable to OCPs
 Weekly application encourages compliance
 Does not require vaginal insertion
Disadvantages:
 Application site reactions may occur
 May not be as effective in women weighing
more than 198 pounds
 May produce side effects similar to OCPs, with
higher rate of transient breast pain
 Noncontraceptive health benefits theoretically
similar to combination OCPs, but not as well
documented
 May be visible on the skin
OCP = Oral Contraceptive Pill

15. 3. The Progestin-Only Pill
Progestins:
 Norethindrone
 Norgestrel
Advantages:
 Useful for women with
contraindications to estrogen
 Use with postpartum women who are
breastfeeding
 Does not require vaginal insertion
Disadvantages:
 Higher pregnancy rate than
combination OCPs
 More sensitive to missed pills than
combination OCPs
 Associated with abnormal bleeding
and other side effects

16. 4. Injectable Hormonal Contraception
Advantages:
 Highly effective
 Convenient three month administration schedule encourages
adherence
 Private
 Useful when estrogen should be avoided
 Decreases risk of endometrial cancer
Disadvantages:
 Irregular bleeding and amenorrhea frequently occur
 Weight gain, abdominal pain, and depression are common side
effects
 Prolonged use may decrease bone mass

17. Depo Provera:
-every 3 months
-Medroxyprogestin
Acetate 150 mg.
Types

18. Main Side-Effects:
 Amenorrhea
 AUB
 Weight Gain
 Hair Loss

20. 5. Emergency Contraception
Indications
-standard of care for women not protected by
efffective contraception.
-No contraception was used
-Condom broke, slipped, leaked etc….
-Missed more 2 or more days of ocp’s
-Highly effective 75%
-Effective up to 120 hours after unprotected sex
-Will not disrupt or harm developing pregnancy
J Adolesc Health. 2004;35:66-70.

21. FDA Approved Emergency Contraceptive Kits
PREVEN KIT
- Contains 4 pills
- EE 50 ug.
- Levonorgestril
0.25 mg.
- 2 pills 12 hourly
for 2 doses
Plan B Kit
- contains 2 pills
- Levonorgestril
0.75 mg
- 1 pill 12 hourly for
2 doses

22. The Yuzpe Regimen:
 Two Doses of:
 EE 0.1 mg with
dl-norgestrel 1.0 mg
 Administered 12
hours apart
 First dose taken within 120
hours of unprotected
intercourse
The Combination Pill
Advantages:
 Prevents approximately 75% of
unintended pregnancies
Disadvantages:
 Increased incidence of side
effects due to high estrogen
component
 High rate of nausea (50%) and
vomiting (20%) may limit
adherence
EE = Ethinyl Estradiol

23. The Progestin-Only Pill
Advantages:
 More effective than Yuzpe regimen
 Better tolerated than Yuzpe regimen
 May be taken as a single dose
 May be preferable for women with history
of idiopathic thrombosis
Disadvantages:
 Associated with a moderate degree of side
effects including nausea, vomiting,
dizziness, and fatigue
Plan B
(levonorgestrel 0.75 mg)
Levonorgestrel:
 Single dose of 1.5 mg or two
doses of 0.75 mg taken 12
hours apart
 First dose administered within
120 hours

24. ACOG GUIDELINES (Emergency Contraception)
-Should be offered or made available for (UPSI)
- Levonorgestril only regime is more effective &
less side effects than combined regime
- 1.5 mg Levonorgestril can be taken single dose
or 2 divided doses (0.75 mg) 12-24 hrs. apart
- An anti-emetic can be taken 1 hr before 1st dose
- Prescription of EC in advance can increase
availability and use.

25. II. IUD

26.  ParaGard (CuT380A),
 Very Effective (~ TL), Reversible
 Risks OVERBLOWN
 Does Not Protect Against STD’s
 Can Remain for ≤ 10 Years

28. Mechanisms of Action
 NOT ABORTIFACIENT!!!!!!!!
 Prevents Conception:
– Sperm Transport Inhibited
– Sperm Survival / Capacitation
Diminished
 Prevents Implantation: hCG Levels = 0

29. Work-up
 History: STD’s, Sexual History, Ectopic
 PEx: Size / Configuration of Uterus
 Cervical Cultures, Pap
 Counseling

30. Contraindications
 High Risk for STD’s
 Abnormal Uterine Bleeding
 Current Pelvic Infection (GC, Chl)
 Actinomyces on Pap
 ???Nulliparity
 Pregnancy
 Wilson’s Dz, Cu Allergy (both rare)

31. Complications
 PID: Usually 20 Insertional Contamination
– Unproven Role for Prophylactic ABx
 Hypermenorrhea
 Expulsion
 Perforation (< 0.1%)
 Failure: IUD Should be Removed
 ??Ectopic

32. 1. The Copper Intrauterine Device (IUD)
Advantages:
 Highly effective
 May be efficacious if inserted up to 7
days after intercourse
 Generally well tolerated
Disadvantages:
 Not cost effective for short-term use
 Not recommended for women with a
sexually transmitted disease

33. 2. Multi load with IUCD inserter

34. 3. Levonorgestrel Intrauterine System
Advantages:
 Highly effective
 Stays in place for up to five years, limiting
adherence concerns
 Private
 Decreases menstrual blood loss
Disadvantages:
 Requires professional insertion and removal
 Abnormal bleeding, dysmenorrhea, and
pelvic, abdominal and back pain
 May not be appropriate for women with
increase STD risk

35. III. Barrier Methods

36. Advantages
- Preferred by many who have occasional
intercourse
- Useful alternatives for those who want to avoid
hormonal side effects
- Some methods available without prescription
- Some methods offer limited protection against
sexually transmitted disease

37. Disadvantages
-Not as effective as hormonal methods
-Efficacy is highly dependent on consistent and correct
use
-Require fitting by healthcare provider
-Require vaginal insertion and removal by the patient
that may be difficult or unacceptable
-Require concomitant use of spermicide
-Associated with an increased risk of urinary tract
infection and toxic shock syndrome

38.  Diaphragm
 Cervical Cap
Types
 Male Condom
 Spermicide

39. Advantages:
 Can be inserted hours before
intercourse
 Does not require removal
between
acts of intercourse
1. Diaphragm

40. Disadvantages:
-Should not be used with suspected or confirmed latex
allergy
-Requires prescription and fitting by healthcare provider
-Requires insertion and removal
-Spermicide must be applied before each use
-Must stay in place for at least six hours after last intercourse
-May increase risk of urinary tract infections and toxic shock
syndrome

41. 2. Male Condom
Advantages:
 Provides greater protection against STDs
than any other method of contraception
 Provides substantial protection against
pregnancy when used with a spermicide
 Does not require a prescription
 Can be used with other methods
 Inexpensive and widely available

42. Disadvantages:
 Can only be used for one act of intercourse
 Can break or slip during use
 May decrease sexual pleasure
 May interfere with spontaneity
 Requires cooperation of male partner

43. IV. Natural Methods

44. 1-Natural family planning techniques
(Fertility Awareness Methods)
2-Contraceptive effect of breast feeding
(Lactational Amenorrhea Method)
3- Withdrawal

45. 1. Rhythm-standard days method (SDM)
 For women with menstrual
cycles between 26 & 32 days.
 Avoid unprotected IC day #9-
19
 70-80% effective
 Assumes ovulation about day
#14

46. 2. Withdrawal Method
 80-90% effective
 Always available
 Requires motivation,
sense of timing
 Some sperm present in
pre-ejaculatory fluid
 Psychological issues

47. V. Sterilization

48.  Surgical sterilization
 Permanent, irreversible
 >99% effective

49. METHODS OF TUBAL LIGATION
Procedure Timing Technique
Minilaparotomy •Post Partum
•Post Abortion
•Interval
•Mechanical Devices
(Clips, Rings)
•Tubal Ligation or Excision
Laparoscopy •Interval Only •Electrocoagulation
(Unipolar, Bipolar)
•Mechanical Devices
(Clips, Rings)
Laparotomy In conjunction with other
surgery (cesarean section,
salpingectomy, ovarian
cystectomy etc.)
•Mechanical Devices
(Clips, Rings)
•Tubal Ligation or ExcisionFemale Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-160

50. Pomeroy Procedure
Tied
Cut
Final result

51. Filshie Clip

52. Hulka Clip

53. Monopolar Coagulation
Laparoscopic
•Proposed in 1937 by Anderson
•Complications
•Bowel Burn
•Longer portion of
tube is damaged
•Failures and ectopic
pregnancy
1. Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8
Failure Rate:7.5/1000

54. Bipolar Coagulation
Laparoscopic
Introduced in 1973 by Jacques Rioux
Benefits
•Most Common method
of Laparoscopic
sterilization Complications
•Formation of
uteroperitoneal fistulas
•High rate of Ectopic
Pregnancy
•Potential for Bowel Burns
•Reversals are potentially
more difficult due to the
extent of tube damage
1. Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170
Failure Rate:24.8/10001