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2/20/2023 Reena Bhagat 1
FAMILY PLANNING
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS
Family Planning Methods
2/20/2023 Reena Bhagat 3
Ideal Contraceptives??
• Safe
• Effective
• Acceptable
• Reversible
• Inexpensive
• Long lasting
• Requires little or no medical supervision
2/20/2023 Reena Bhagat 4
Family Planning: Types
1. Natural ( Traditional) Method
2. Temporary( Short/ Long Acting )
Method
3. Permanent Method
2/20/2023 Reena Bhagat 5
Family Planning Method: Types
• Rhythm (Calendar) method
• Basal Body Temperature (BBT) Method
• Ovulation or Cervical Mucus Method
• Symptothermal method
• Coitus Interrupts
• Lactation Amenorrhea Method (LAM)
A. Natural
Method
• Barrier Method
• Hormonal Method
• Intrauterine Devices
• Post-coital Method
B. Temporary
Method
• Male Sterilization
• Female Sterilization
C. Permanent
Method
2/20/2023 Reena Bhagat 6
A. Natural( Traditional) Method
No introduction of chemical of foreign material into the
body.
Practice may be due to religious belief, ―natural‖ way is
best for them.
Effectiveness varies greatly, depends on couple‘s ability
to refrain from having intercourse on fertile days.
Effective in women whose menstrual cycle is regular..
(28-32 days).
2/20/2023 Reena Bhagat 7
1. Rhythm (Calendar) method
• Also called fertility awareness method.
• ―Fertility awareness‖ means that a woman knows how to
tell when the fertile time of her menstrual cycle starts and
ends.
• Sometimes called periodic abstinence or natural family
planning.
• Calendar-based methods involve keeping track of days of
the menstrual cycle to identify the start and end of the
fertile time. – Examples: Standard Days Method, which
avoids unprotected vaginal sex on days 8 through 19 of
the menstrual cycle, and calendar rhythm method.
2/20/2023 Reena Bhagat 8
Fig. Calendar Rhythm Method
2/20/2023 Reena Bhagat 9
How to calculate??
Example: If she has 6 menstrual cycles ranging from 25 to
29 days, fertile period would be from 7th day (25- 18) to the
18thday (29-11). i.e. 7th day- 18th day
• So, to calculate fertility phase:
• Subtract 18 from shortest cycle and 11 from the longest one
• * 25- 18= 7 (infertile phase)
• * 29-11= 18 (post -ovulatory infertile phase)
•
To avoid pregnancy, avoid coitus/use contraceptive
during those days.
2/20/2023 Reena Bhagat 10
2. Basal Body Temperature (BBT)
- Identifying fertile and infertile period of a woman‘s
cycle by daily taking and recording of the rise in body
temperature during and after ovulation.
- At time of ovulation, as a result of increase in her BBT
0.3- 0.60C i.e. ( 0.5-1 0F) rises a full degree (influence
of progesterone).
DISADVATAGES
- NOT reliable method of birth control, especially for
women with irregular cycles.
2/20/2023 Reena Bhagat 11
BBT Method
2/20/2023 Reena Bhagat 12
3. Ovulation or Cervical Mucus Method
- Cervical mucus, is a fluid produced by small glands
near the cervix. This fluid changes throughout her
cycle, from scant and sticky, to cloudy and thick.
• Cervical Mucus/Ovulation
- During the peak of fertility, The consistency of
ovulation mucus is like that of an egg white and it can
be stretched between the fingers.
- After the ovulation, the mucus tends to dry up again.
These are also safe days.
2/20/2023 Reena Bhagat 13
Cervical Mucus Method
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Symtothermal Method
• Combines the cervical mucus and BBT methods.
Watches temp. daily and analyzes cervical mucus
daily.
• Watch for midcycle abdominal pain. Couple must
abstain from intercourse until 3 days after rise in
temp. or 4th day after peak of mucus change.
• More effective than BBT or CM method alone.
- Ideal Failure rate: 2%
2/20/2023 Reena Bhagat 15
Symptothermal Method
2/20/2023 Reena Bhagat 16
5. Coitus Interrupts Method
 One of oldest known
methods of voluntary
contraception.
 Couple proceeds with
coitus until the moment
of ejaculation which
offers little protection, i.e
withdrawal of penis just
before ejaculation.
 Effectivity: 75%
2/20/2023 Reena Bhagat 17
6. LactationAmenorrhea Method(LAM)
LAM: Natural birth control
technique based on the fact that
lactation (breast milk production)
causes amenorrhea (lack of
menstruation).
• How it works:
Breastfeeding interferes with the
release of the hormones needed
to trigger ovulation.
2/20/2023 Reena Bhagat 18
Contd..
• The lactational amenorrhea method (LAM) requires 3
conditions. All 3 must be met:
1. The mother‘s monthly bleeding has not returned.
2. The baby is fully or nearly fully breastfed and is fed
often, day and night.
3. The baby is less than 6 months old.
Works primarily by preventing the release of eggs from
the ovaries (ovulation). Frequent breastfeeding
temporarily prevents the release of the natural hormones
that cause ovulation.
2/20/2023 Reena Bhagat 19
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How Effective?
• Effectiveness depends on the user: Risk of pregnancy is
greatest when a woman cannot fully or nearly fully
breastfeed her infant.
• As commonly used, about 2 pregnancies per 100 women
using LAM in the first 6 months after childbirth.
• When used correctly, less than 1 pregnancy per 100
women using LAM in the first 6 months after childbirth.
• Return of fertility after LAM is stopped: Depends on
how much the woman continues to breastfeed
• Protection against sexually transmitted infections: None
2/20/2023 Reena Bhagat 21
B. TEMPORARY METHODS
2/20/2023 Reena Bhagat 22
1. Barrier Methods
A. Mechanical
Condoms (male and female)
Diaphragm
Cervical cap
B. Chemical
Spermicidal
Sponge
2/20/2023 Reena Bhagat 23
A. Mechanical Methods
Work by forming a barrier that keeps sperm out of
the vagina, preventing pregnancy.
Condoms( both male and female) are the only
contraceptive method that can protect against both
pregnancy and sexually transmitted infections.
2/20/2023 Reena Bhagat 24
Condoms
2/20/2023 Reena Bhagat 25
1.Condoms( Male)
Sheaths, or coverings, that fit over a man‘s erect penis.
Also called rubbers, ―raincoats,‖ ―umbrellas,‖ skins,
prophylactics; known by many different brand names.
Most are made of thin latex rubber. Male condoms also
are made from other materials, including polyurethane,
polyisoprene, lambskin, and nitrile.
Work by forming a barrier that keeps sperm out of the
vagina, preventing pregnancy.
Also keep infections in semen, on the penis, or in the
vagina from infecting the other partner.
2/20/2023 Reena Bhagat 26
 Male condoms help
protect against
sexually transmitted
infections, including
HIV.
 Condoms are the
only contraceptive
method that can
protect against both
pregnancy and
sexually transmitted
infections.
2/20/2023 Reena Bhagat 27
How Effective??
Effectiveness depends on the user: Risk of pregnancy or
sexually transmitted infection (STI) is greatest when
condoms are not used with every act of sex.
As commonly used, about 13 pregnancies per 100
women whose partners use male condoms over the first
year.
When used correctly with every act of sex, about 2
pregnancies per 100 women whose partners use male
condoms over the first year.
Return of fertility after use of condoms is stopped: No
delay
2/20/2023 Reena Bhagat 28
Contd..
Protection against HIV and other STIs:
Male condoms significantly reduce the risk of
becoming infected with HIV when used correctly with
every act of vaginal or anal sex.
When used consistently and correctly, condom use
prevents 80% to 95% of HIV transmission that would
have occurred without condoms.
Protect best against STIs spread by discharge, such as
HIV, gonorrhea, and chlamydia. – Also protect against
STIs spread by skin-to-skin contact, such as herpes and
human papillomavirus.
2/20/2023 Reena Bhagat 29
Side effects: None
Known Health Benefits
Help protect against:
Risks of pregnancy
STIs, including HIV May
help protect against:
Conditions caused by STIs:
Recurring pelvic
inflammatory disease and
chronic pelvic pain
Cervical cancer
Infertility (male and female)
Known Health Risks
Extremely rare:
• Severe allergic reaction
(among people with
latex allergy)
2/20/2023 Reena Bhagat 30
Condoms( Female)
Sheaths, or linings, that fit loosely inside a woman‘s
vagina, made of thin, transparent, soft film.
Have flexible rings at both ends
– One ring at the closed end helps to insert the condom
– The ring at the open end holds part of the condom outside
the vagina
Female condoms are made of various materials, such as
latex, polyurethane, and nitrile.
Work by forming a barrier that keeps sperm out of the
vagina, preventing pregnancy. Also helps to keep infections
in semen, on the penis, or in the vagina from infecting the
other partner.
2/20/2023 Reena Bhagat 31
Female Condom
2/20/2023 Reena Bhagat 32
How Effective??
Effectiveness depends on the user: Risk of pregnancy or
sexually transmitted infection (STI) is greatest when
female condoms are not used with every act of sex. Few
pregnancies or infections occur due to incorrect use,
slips, or breaks.
Protection against pregnancy:
As commonly used, about 21 pregnancies per 100 women
using female condoms over the first year.
When used correctly with every act of sex, about 5
pregnancies per 100 women using female condoms over
the first year.
2/20/2023 Reena Bhagat 33
Contd..
 Return of fertility after use of female condom is stopped: No
delay
 Protection against HIV and other STIs:
Female condoms reduce the risk of infection with STIs,
including HIV, when used correctly with every act of sex.
 Side effects: None
 Known Health Benefits Help protect against:
 Risks of pregnancy
 STIs, including HIV
 Known Health Risks: None
2/20/2023 Reena Bhagat 34
2. Diaphragms
oA soft latex cup that covers the cervix. Plastic and
silicone diaphragms may also be available.
oThe rim contains a firm, flexible spring that keeps the
diaphragm in place.
oUsed with spermicidal cream, jelly, or foam to improve
effectiveness.
oMost diaphragms come in different sizes and require
fitting by a specifically trained provider.
oWorks by blocking sperm from entering the cervix;
spermicide kills or disables sperm. Both keep sperm
from meeting an egg.
2/20/2023 Reena Bhagat 35
How Effective??
Effectiveness depends on the user: Risk of pregnancy is
greatest when the diaphragm with spermicide is not used
with every act of sex.
As commonly used, about 17 pregnancies per 100
women using the diaphragm with spermicide over the
first year.
When used correctly with every act of sex, about 16
pregnancies per 100 women using the diaphragm with
spermicide over the first year.
Return of fertility after use of the diaphragm is
stopped: No delay
2/20/2023 Reena Bhagat 36
2/20/2023 Reena Bhagat 37
Diaphragms
 Protection against STIs:
May provide some
protection against
certain STIs but should
not be relied on for STI
prevention
 Side Effects: Some users
report the following:
 Irritation in or around
the vagina or penis
 Other possible physical
changes: Vaginal lesions
2/20/2023 Reena Bhagat 38
Contd..
• Insert the diaphragm less than 6 hours before having
sex
• Leave the diaphragm in place at least 6 hours after
having sex but no longer than 24 hours.
• Leaving the diaphragm in place for more than one day
may increase the risk of toxic shock syndrome. It can
also cause a bad odor and vaginal discharge. (Odor and
discharge go away on their own after the diaphragm is
removed.
2/20/2023 Reena Bhagat 39
Contd..
Known Health Benefits
Help protect against:
 Risks of pregnancy
 May help protect against:
Certain STIs (chlamydia,
gonorrhea, pelvic
inflammatory disease,
trichomoniasis)
Cervical precancer and
cancer
Known Health Risks
Common to uncommon:
Urinary tract infection
Uncommon:
Bacterial vaginosis
Candidiasis
Rare:
Frequent use of nonoxynol-9
may increase risk of HIV
infection
Extremely rare: Toxic shock
syndrome
2/20/2023 Reena Bhagat 40
3. Cervical Cap
• A soft, deep, latex or
plastic rubber cup that
snugly covers the cervix.
• Comes in different sizes;
requires fitting by a
specifically trained
provider.
2/20/2023 Reena Bhagat 41
How effective?
Effectiveness depends on the user: Risk of pregnancy is
greatest when the cervical cap with spermicide is not
used with every act of sex.
Women who have given birth: One of the least
effective methods, as commonly used.
As commonly used, about 32 pregnancies per 100
women using the cervical cap with spermicide over the
first year.
When used correctly with every act of sex, about 26
pregnancies per 100 women using the cervical cap over
the first year.
2/20/2023 Reena Bhagat 42
Contd..
More effective among women who have not given
birth:
As commonly used, about 16 pregnancies per 100
women using the cervical cap with spermicide over the
first year.
When used correctly with every act of sex, about 9
pregnancies per 100 women using the cervical cap over
the first year.
Return of fertility after use of cervical cap is stopped:
No delay
Protection against sexually transmitted infections: None
2/20/2023 Reena Bhagat 43
Contd..
• Insert the cervical cap any time up to 42 hours before
having sex.
Removing
• Leave the cervical cap in for at least 6 hours after her
partner‘s last ejaculation, but not more than 48 hours
from the time it was put in.
• Leaving the cap in place for more than 48 hours may
increase the risk of toxic shock syndrome and can
cause a bad odor and vaginal discharge.
2/20/2023 Reena Bhagat 44
Barrier Methods: Mechanical
Advantages:
o Comparatively Inexpensive
oDo not require medical consultation
Disadvantages:
oDemonstration by trained person needed for proper
use.
oFailure most common- due to displacement of device
oCervicitis( inflammation of cervix) & local irritation
2/20/2023 Reena Bhagat 45
B. Chemical: Spermicides
2/20/2023 Reena Bhagat 46
Spermicides
• Sperm-killing substances inserted deep in the vagina,
near the cervix, before sex.
• Nonoxynol-9 is most widely used. Others include
benzalkonium chloride, chlorhexidine, menfegol,
octoxynol-9, and sodium docusate.
• Available in foaming tablets, melting or foaming
suppositories, cans of pressurized foam, melting film,
jelly, and cream.
• Work by causing the membrane of sperm cells to break,
killing them or slowing their movement. This keeps
sperm from meeting an egg.
2/20/2023 Reena Bhagat 47
How Effective?
• Effectiveness depends on the user: Risk of pregnancy is
greatest when spermicides are not used with every act
of sex.
• One of the least effective family planning methods.
• As commonly used, about 21 pregnancies per 100
women using spermicides over the first year.
• When used correctly with every act of sex, about 16
pregnancies per 100 women using spermicides over the
first year.
• Return of fertility after spermicides are stopped:
No delay
2/20/2023 Reena Bhagat 48
Contd…
• Protection against sexually transmitted infections
(STIs): None. Frequent use of nonoxynol-9 may
increase risk of HIV infection.
• All women can safely use spermicides except those
who:
Are at high risk for HIV infection
Have HIV infection
• Side Effects: Some users report the following:
Irritation in or around the vagina or penis
Other possible physical changes: Vaginal lesions
2/20/2023 Reena Bhagat 49
Contd..
Known Health Benefits
Help protect against:
Risks of pregnancy
Known Health Risks
Uncommon:
Urinary tract infection,
especially when using
spermicides 2 or more
times a day
Rare:
Frequent use of
nonoxynol-9 may increase
risk of HIV infection
2/20/2023 Reena Bhagat 50
Vaginal contraceptive sponge (widely
available as Today)
 The sponge is a doughnut-
shaped device
 Made of soft foam coated with
spermicide, (polyurethane with
1gm of nonoxynol-9) as a
spermicide.
 It releases spermicide during
coitus, absorbs ejaculate and
blocks the entrance of cervical
canal.
2/20/2023 Reena Bhagat 51
Chemical Methods
Advantages:
 Comparatively Inexpensive
Well tolerated
Good protection
Disadvantages
Local irritation & burning sensation
2/20/2023 Reena Bhagat 52
2. Hormonal Contraceptives
2/20/2023 Reena Bhagat 53
a. Combined Oral Contraceptives( COCs)
• Pills that contain low doses of 2 hormones—a
progestin and an estrogen—like the natural hormones
progesterone and estrogen in a woman‘s body.
• Combined oral contraceptives (COCs) are also called
―the Pill,‖ low-dose combined pills, OCPs, and OCs.
• Work primarily by preventing the release of eggs from
the ovaries (ovulation).
2/20/2023 Reena Bhagat 54
Contd..
• Commonly available as
‗Nilocon White’ or
‗Gulaf’.
• Its one cycle contains 21
hormonal tablets and 7
Iron tablets.
• The composition of each
white colored tablet
contains Levonorgestrel
0.15 mg, Eithinyl Estradiol
0.03 mg and each brown
tablet contains Ferrous
Fumarate 75 mg.
2/20/2023 Reena Bhagat 55
How Effective?
• Effectiveness depends on the user: Risk of pregnancy is
greatest when a woman starts a new pill pack 3 or more
days late, or misses 3 or more pills near the beginning or
end of a pill pack.
• As commonly used, about 7 pregnancies per 100 women
using COCs over the first year.
• When no pill-taking mistakes are made, less than 1
pregnancy per 100 women using COCs over the first
year (3 per 1,000 women).
• Return of fertility after COCs are stopped: No delay
• Protection against sexually transmitted infections (STIs):
None
2/20/2023 Reena Bhagat 56
Contd..
 Side Effects: Some users report the following:
• Changes in bleeding patterns, including:
Lighter bleeding and fewer days of bleeding – Irregular
bleeding – Infrequent bleeding – No monthly bleeding
• Headaches
• Dizziness
• Nausea
• Breast tenderness
• Weight changes
• Mood changes
2/20/2023 Reena Bhagat 57
Contd..
• Acne (can improve or worsen, but usually improves)
• Other possible physical changes: Blood pressure
increases a few points (mm Hg). When increase is due to
COCs, blood pressure declines quickly after use of
COCs stops.
 Known Health Benefits
• Help protect against:
oRisks of pregnancy
oCancer of the lining of the uterus (endometrial cancer)
oCancer of the ovary
oSymptomatic pelvic inflammatory disease
2/20/2023 Reena Bhagat 58
Contd..
• May help protect against:
oOvarian cysts
oIron-deficiency anemia
• Reduce:
oMenstrual cramps
oMenstrual bleeding problems
oOvulation pain
oExcess hair on face or body
oSymptoms of polycystic ovarian syndrome (irregular
bleeding, acne, excess hair on face or body)
oSymptoms of endometriosis (pelvic pain, irregular
bleeding)
2/20/2023 Reena Bhagat 59
Contd..
Known Health Risks
Very rare:
• Blood clot in deep veins of legs or lungs (deep vein
thrombosis or pulmonary embolism)
Extremely rare:
• Stroke
• Heart attack
2/20/2023 Reena Bhagat 60
b. Progestin Only Pills(POPs)
 Pills that contain very low doses of a progestin like the
natural hormone progesterone in a woman‘s body.
 Do not contain estrogen, and so can be used throughout
breastfeeding and by women who cannot use methods with
estrogen.
 Progestin-only pills (POPs) are also called ―minipills‖ and
progestin-only oral contraceptives.
 Work primarily by:
Thickening cervical mucus (this blocks sperm from meeting
an egg)
Disrupting the menstrual cycle, including preventing the
release of eggs from the ovaries (ovulation)
2/20/2023 Reena Bhagat 61
How Effective?
Effectiveness depends on the user: For women who have
monthly bleeding, risk of pregnancy is greatest if pills
are taken late or missed completely.
Breastfeeding women:
As commonly used, about 1 pregnancy per 100 women
using POPs over the first year.
When pills are taken every day, less than 1 pregnancy
per 100 women using POPs over the first year (3 per
1,000 women).
2/20/2023 Reena Bhagat 62
Contd..
Less effective for women not breastfeeding:
As commonly used, about 7 pregnancies per 100 women
using POPs over the first year.
When pills are taken every day at the same time, less
than 1 pregnancy per 100 women using POPs over the
first year (3 per 1,000 women).
• Return of fertility after POPs are stopped: No delay
• Protection against sexually transmitted infections
(STIs): None
2/20/2023 Reena Bhagat 63
Contd..
Side Effects: Some users report the following:
• Changes in bleeding patterns, including:
For breastfeeding women, longer delay in return of
monthly bleeding after childbirth (lengthened
postpartum amenorrhea) – Frequent bleeding – Irregular
bleeding – Infrequent bleeding – Prolonged bleeding –
No monthly bleeding.
 Breastfeeding also affects a woman‘s bleeding patterns.
• Headaches
• Dizziness
• Mood changes
2/20/2023 Reena Bhagat 64
Contd..
• Breast tenderness
• Abdominal pain
• Nausea
• Other possible physical changes: For women not
breastfeeding, enlarged ovarian follicles
• Known Health Benefits: Help protect against: Risks
of pregnancy
• Known Health Risks: None
2/20/2023 Reena Bhagat 65
Progestin-Only Injectables( Depo Provera)
oThe injectable contraceptives depot medroxyprogesterone
acetate (DMPA) and norethisterone enanthate (NET-EN)
each contain a progestin like the natural hormone
progesterone in a woman‘s body.
oDo not contain estrogen, and so can be used throughout
breastfeeding, starting 6 weeks after giving birth, and by
women who cannot use methods with estrogen.
oGiven by injection into the muscle (intramuscular
injection). The hormone is then released slowly into the
bloodstream.
oWork primarily by preventing the release of eggs from the
ovaries (ovulation).
2/20/2023 Reena Bhagat 66
Dose: 150 mg IM
Provide protection for 3
months.
2/20/2023 Reena Bhagat 67
How Effective?
• Effectiveness depends on getting injections regularly: Risk
of pregnancy is greatest when a woman misses an
injection.
• As commonly used, about 4 pregnancies per 100 women
using progestin-only injectables over the first year.
• When women have injections on time, less than 1
pregnancy per 100 women using progestin-only injectables
over the first year (2 per 1,000 women).
• Return of fertility after injections are stopped: An average
of about 4 months longer for DMPA and 1 month longer
for NET-EN than with most other methods
• Protection against sexually transmitted infections (STIs):
None
2/20/2023 Reena Bhagat 68
Contd..
Side Effects: Most users report some changes in monthly
bleeding.
• Typically, these include, with DMPA: First 3 months: –
Irregular bleeding – Prolonged bleeding At one year: –
No monthly bleeding – Infrequent bleeding – Irregular
bleeding
• Some users report the following:
Weight gain
Headaches
Dizziness
Abdominal bloating and discomfort
2/20/2023 Reena Bhagat 69
Contd..
Known Health Benefits: DMPA Helps protect against:
• Risks of pregnancy
• Cancer of the lining of the uterus (endometrial cancer)
• Uterine fibroids
• May help protect against:
• Symptomatic pelvic inflammatory disease
• Iron-deficiency anemia
• Reduces:
• Sickle cell crises among women with sickle cell anemia
• Symptoms of endometriosis (pelvic pain, irregular bleeding)
Known Health Risks: None
2/20/2023 Reena Bhagat 70
Implants( Jadelle)
• Small plastic rods, each about the size of a
matchstick, that release a progestin like the
natural hormone progesterone in a woman‘s
body.
• A specifically trained provider performs a minor
surgical procedure to place one or 2 rods under
the skin on the inside of a woman‘s upper arm.
• Do not contain estrogen, and so can be used
throughout breastfeeding and by women who
cannot use methods with estrogen.
2/20/2023 Reena Bhagat 71
Contd..
Types of implants:
Jadelle: 2 rods containing levonorgestrel, highly
effective for 5 years
Implanon NXT (Nexplanon): 1 rod containing
etonogestrel, labeled for up to 3 years of use (a recent
study shows it may be highly effective for 5 years).
Implants are small flexible rods that are placed just
under the skin of the upper arm.
Provide long-term pregnancy protection. Very effective
for 3 to 5 years, depending on the type of implant.
Immediately reversible.
2/20/2023 Reena Bhagat 72
Work primarily by:
- Preventing the release of eggs from the ovaries (ovulation)
- Thickening cervical mucus (this blocks sperm from reaching
an egg)
2/20/2023 Reena Bhagat 73
How Effective?
 One of the most effective and long-lasting methods:
Far less than 1 pregnancy per 100 women using implants
over the first year (1 per 1,000 women).
Less than 1 pregnancy per 100 women over the duration
of use.
Return of fertility after implants are removed: No delay
Protection against sexually transmitted infections (STIs):
None
2/20/2023 Reena Bhagat 74
Contd..
• Side Effects : Some users report the following:
• Changes in bleeding patterns, including: First several
months to a year: – Lighter bleeding and fewer days of
bleeding – Prolonged bleeding – Irregular bleeding –
Infrequent bleeding – No monthly bleeding
• After about one year: – Lighter bleeding and fewer days
of bleeding – Irregular bleeding – Infrequent bleeding –
No monthly bleeding
• Headaches
• Abdominal pain
• Acne (can improve or worsen)
2/20/2023 Reena Bhagat 75
Contd...
• Weight change
• Breast tenderness
• Dizziness
• Mood changes
• Nausea
• Other possible physical changes: Enlarged ovarian
follicles
2/20/2023 Reena Bhagat 76
Contd..
Known Health Benefits
Help protect against:
• Risks of pregnancy, including ectopic pregnancy
• Symptomatic pelvic inflammatory disease
May help protect against:
• Iron-deficiency anemia
• Reduces: Risk of ectopic pregnancy
• Known Health Risks: None
2/20/2023 Reena Bhagat 77
Contd..
• Complications
Uncommon:
 Infection at insertion site (most infections occur within the
first 2 months after insertion)
 Difficult removal (rare if properly inserted and the provider is
skilled at removal)
Rare:
Expulsion of implant (expulsions most often occur within the
first 4 months after insertion)
Extremely rare:
There are a few reports of implants found in another place in
the body due to improper insertion, for example, in a blood
vessel.
2/20/2023 Reena Bhagat 78
Combined Patch( EVRA)
• A small, thin, square of flexible plastic worn on the body.
• Continuously releases 2 hormones—a progestin and an
estrogen, like the natural hormones progesterone and
estrogen in a woman‘s body— directly through the skin
into the bloodstream.
• The woman puts on a new patch every week for 3 weeks,
then no patch for the fourth week. During this fourth week
the woman will have monthly bleeding.
• Also called Ortho Evra and Evra.
• Works primarily by preventing the release of eggs from the
ovaries (ovulation)
2/20/2023 Reena Bhagat 79
Patch- EVRA
2/20/2023 Reena Bhagat 80
How Effective?
• Effectiveness depends on the user: Risk of pregnancy is
greatest when a woman is late to change the patch.
• As commonly used, about 7 pregnancies per 100 women
using the combined patch over the first year.
• When no mistakes are made with use of the patch, less
than 1 pregnancy per 100 women using a patch over the
first year (3 per 1,000 women).
• A woman wears a small adhesive patch on her body at all
times, day and night. A new patch is put on each week
for 3 weeks, and then no patch for the fourth week.
2/20/2023 Reena Bhagat 81
Contd..
• Bleeding changes are common but not harmful.
Typically, irregular bleeding for the first few months
and then lighter and more regular bleeding.
• Pregnancy rates may be slightly higher among women
weighing 90 kg or more.
• Return of fertility after patch use is stopped: No delay
• Protection against sexually transmitted infections:
None
2/20/2023 Reena Bhagat 82
Contd..
Side Effects : Some users report the following:
• Skin irritation or rash where the patch is applied
• Changes in bleeding patterns: – Lighter bleeding and
fewer days of bleeding – Irregular bleeding – Prolonged
bleeding – No monthly bleeding
• Headaches
• Nausea
• Vomiting
• Breast tenderness and pain
• Abdominal pain
• Flu symptoms/upper respiratory infection
2/20/2023 Reena Bhagat 83
3. Intrauterine Devices(IUDs)
IUD( a LARC) is a small, T-shaped, plastic device that is
inserted and left inside the uterus to prevent pregnancy.
After insertion, the effective contraceptive action lasts at
least 12 years.
The usual timings are:
Immediate Postpartum:
Post-placental: Insertion within 10 minutes after expulsion
of the placenta following a vaginal delivery on the same
delivery table.
Intracesarean: Insertion that takes place during a cesarean
delivery, after removal of the placenta and before closure
of the uterine incision.
2/20/2023 Reena Bhagat 84
contd..
Within 48 hours after delivery: Insertion within 48
hours of delivery and prior to discharge from the
postnatal ward.
Postabortion: Insertion following an abortion, if there
is no infection, Mending or any other
contraindications.
Extended Postpartum/Interval: Insertion any time after
6 weeks postpartum.
2/20/2023 Reena Bhagat 85
Contd..
Mode of Action
• The IUD interferes with the ability of sperm to
survive and to ascend the fallopian tubes where
fertilization occurs. It alters or inhibits sperm
migration, ovum transport and fertilization. It
stimulates a sterile foreign body reaction in
endometrium potentiated by copper.
•
2/20/2023 Reena Bhagat 86
Contd..
• Ideal candidates for IUD
oHas born one child
oNormal menstrual cycle
oNo pelvic inflammation
oReady to check the device
2/20/2023 Reena Bhagat 87
IUD Classification
First generation Second generation Third generation
 Non-medicated
made up of
polyethylene.
 LIPPE’S LOOP
 Double ‗s‘ shaped
device, made up of
polyethylene
material.
 Non- toxic, non-
tissue reactive and
extremely durable.
 Made up of metal
Copper
Copper-T(Cu-T)
• Most commonly
used
• Made of Cu
• T-shaped attatched
with a nylon thread(
tail).
 Hormones releasing
IUD
PROGESTASTERT
 Most commonly used
T shaped device filled
with 38 mg
progesterone
 Effective for 1 year
 LNG- mirena
 Mirena
(levonorgestrel-
releasing intrauterine
device) and Releases
20 µg of
levonorgestrel.
Effective for 5 years.
2/20/2023 Reena Bhagat 88
How Effective??
One of the most effective and long-lasting methods:
Less than 1 pregnancy per 100 women using an IUD
over the first year (6 per 1,000 women who use the IUD
perfectly, and 8 per 1,000 women as commonly used).
• Return of fertility after IUD is removed: No delay
• Protection against sexually transmitted infections
(STIs): None
2/20/2023 Reena Bhagat 89
Contd..
Side Effects: Some users report the following:
• Changes in bleeding patterns (especially in the first 3 to 6
months), including:
– Prolonged and heavy monthly bleeding – Irregular
bleeding – More cramps and pain during monthly bleeding
Known Health Benefits:
Helps protect against: Risks of pregnancy
May help protect against:
Cancer of the lining of the uterus (endometrial cancer)
Cervical cancer
Reduces: Risk of ectopic pregnancy
2/20/2023 Reena Bhagat 90
Contd..
Complications: Rare:
Puncturing (perforation) of the wall of the uterus by
the IUD or an instrument used for insertion. Usually
heals without treatment.
Miscarriage, preterm birth, or infection in the rare case
that the woman becomes pregnant with the IUD in
place.
2/20/2023 Reena Bhagat 91
Contd..
Known Health Risks:
Uncommon:
• May contribute to anemia if a woman already has low
iron blood stores before insertion and the IUD causes
heavier monthly bleeding
Rare:
• Pelvic inflammatory disease (PID) may occur if the
woman has chlamydia or gonorrhea at the time of IUD
insertion
2/20/2023 Reena Bhagat 92
Contd..
Contraindications for Insertion of IUCD:
1. Presence of pelvic infection current or within 3
months;
2. Undiagnosed genital tract bleeding;
3. Suspected pregnancy;
4. Distortion of the shape of the uterine cavity as in
fibroid or congenital uterine-malformation;
5. Severe dysmenorrhea;
6. Past history of ectopic pregnancy;
7. Within 6 weeks following cesarean section;
2/20/2023 Reena Bhagat 93
Contd..
8. STIs: Current or within 3 months;
9. Significant immunosuppression.
Additionally for CuT are:
11. Wilson disease and
12. Copper allergy.
For LNG-IUS are:
13. Hepatic tumor or hepatocellular disease (active);
14. Current breast cancer and
15. Severe arterial disease
2/20/2023 Reena Bhagat 94
Post coital method: Emergency contraceptives
Emergency contraception is contraception provided to
women to prevent unwanted pregnancy following an
unprotected sexual intercourse.
ECPs are sometimes called ―morning after‖ pills or
postcoital contraceptives.
ECPs may include
Special ECP product with levonorgestrel only
Progestin-only pills with levonorgestrel or norgestrel
Combined oral contraceptives with estrogen and a
progestin— levonorgestrel, norgestrel, or norethindrone
(also called norethisterone)
The copper-bearing IUD
2/20/2023 Reena Bhagat 95
Contd..
Work by:
preventing fertilization by affecting the cervical
mucus
Preventing implantation by hypermotility of
fallopian tubes and uterus.
delaying the release of eggs from the ovaries
(ovulation).
2/20/2023 Reena Bhagat 96
Contd..
Indications of emergency contraception:
 Sexual assault
 Any unprotected sex
 Mistakes using contraception such as:
Condom was used incorrectly, slipped, or broke
Couple incorrectly used fertility awareness method (for
example, failed to abstain or to use another method during
the fertile days)
Failure to withdraw, as intended, before ejaculation
Woman has had unprotected sex after she has missed 3 or
more combined oral contraceptive pills or has started a new
pack 3 or more days late
2/20/2023 Reena Bhagat 97
Contd..
IUCD has come out of place.
Woman has had unprotected sex when she is more
than 4 weeks late for her repeat injection of DMPA.
• If a woman is breastfeeding but not using: Post-partum
Contraception and LAM) and thinks she might be at
risk of pregnancy, emergency contraception may be
used (except Estrogen containing).
2/20/2023 Reena Bhagat 98
Most commonly used ECP is
the POP, which contains 1.5mg
levonorgestrel. The pill is
available as either a single
dose containing dthe full
1.5mg or two doses of 0.75mg
taken 12-24 hours apart.
When to Take Them?
 The sooner ECPs are taken
after unprotected sex, the
better they prevent pregnancy.
 Within 120 hours or 5 days
after unprotected sex.
2/20/2023 Reena Bhagat 99
How Effective??
• If all 100 women used ulipristal acetate ECPs, fewer
than one woman would likely become pregnant.
• If all 100 women used progestin-only ECPs, one woman
would likely become pregnant.
• Return of fertility after taking ECPs: No delay. A woman
can become pregnant immediately after taking ECPs.
Taking ECPs prevents pregnancy only from acts of sex
that took place in the 5 days before. They will not protect
a woman from pregnancy from acts of sex more than 24
hours after she takes ECPs.
• Protection against sexually transmitted infections (STIs):
None
2/20/2023 Reena Bhagat 100
Contd..
Side Effects: Some users report the following:
• Changes in bleeding patterns, including:
– Slight irregular bleeding for 1–2 days after taking ECPs
– Monthly bleeding that starts earlier or later than expected
In the first several days after taking ECPs:
• Nausea
• Abdominal pain
• Fatigue
• Headaches
• Breast tenderness
• Dizziness
• Vomiting
2/20/2023 Reena Bhagat 101
Contd..
• Contraindication: There are no known
contraindications to the use of hormonal emergency
contraception. The dose of hormones used in
emergency contraception is small and the pills are
given for a short time, so the contraindications
associated with continuous use of combined hormonal
contraception do not apply.
• Known Health Benefits:
Help protect against: Risks of pregnancy
• Known Health Risks : None
2/20/2023 Reena Bhagat 102
3. Permanent Sterilization
STERILIZATION
• It is most effective method its failure rate is 1/2000 so
in this there is permanent termination.
•
 VASECTOMY( Male Sterilization)
 TUBECTOMY( Female Sterilization)
2/20/2023 Reena Bhagat 103
a. Female Sterilization
Permanent surgical contraception for women who will
not want more children.
The 2 surgical approaches most often used:
Minilaparotomy involves making a small incision in
the abdomen. The fallopian tubes are brought to the
incision to be cut or blocked.
Laparoscopy involves inserting a long, thin tube
containing lenses into the abdomen through a small
incision. This laparoscope enables the doctor to reach
and block or cut the fallopian tubes in the abdomen.
2/20/2023 Reena Bhagat 104
2/20/2023 Reena Bhagat 105
Contd..
Also called tubal sterilization, tubal ligation, voluntary
surgical contraception, tubectomy, bi-tubal ligation,
tying the tubes, minilap, and ―the operation.‖
Works because the fallopian tubes are blocked or cut.
Eggs released from the ovaries cannot move down the
tubes, and so they do not meet sperm.
2/20/2023 Reena Bhagat 106
Contd..
Indications:
• Family planning purposes.
• Socioeconomic: An individual is adopted to accept the
method after having the desired number of children.
• Medico-surgical indications (therapeutic): Medical
diseases such as heart disease, diabetes, chronic renal
disease, hypertension are likely to worsen, if repeated
pregnancies occur and hence sterilization is advisable.
During third time repeat cesarean section or repair of
prolapse operation, to avoid the risks involved in the
future childbirth process, sterilization operation should
be seriously considered.
2/20/2023 Reena Bhagat 107
Contd..
Time of Operation:
(1) During puerperium (puerperal):If the patient is
otherwise healthy, the operation can be done 24–48
hours following delivery.
(2) Interval: The operation is done beyond 3 months
following delivery or abortion. The ideal time of
operation is following the menstrual period in the
proliferative phase.
(3) Concurrent with MTP: Sterilization is performed
along with termination of pregnancy. This is mostly
done especially in the urban centers.
2/20/2023 Reena Bhagat 108
How Effective?
One of the most effective contraceptive methods but
carries a small risk of failure:
• Less than 1 pregnancy per 100 women over the first year
after having the sterilization procedure (5 per 1,000).
• Effectiveness varies slightly depending on how the tubes
are blocked, but pregnancy rates are low with all
techniques. One of the most effective techniques is
cutting and tying the cut ends of the fallopian tubes after
childbirth (postpartum female sterilization).
• Protection against sexually transmitted infections ( STIs):
None
2/20/2023 Reena Bhagat 109
Contd..
• Side Effects: None
• Known Health Benefits
Helps protect against: Risks of pregnancy
Pelvic inflammatory disease ( PID)
Reduces: Risk of ectopic pregnancy
• Known Health Risks
• Uncommon to extremely rare: Complications of
surgery and anesthesia
2/20/2023 Reena Bhagat 110
Contd..
Complications of Surgery: Uncommon to extremely
rare:
• Female sterilization is a safe method of contraception.
It requires surgery and anesthesia, however. Like other
minor surgeries, female sterilization carries some risks,
such as infection or abscess of the wound. Serious
complications are uncommon.
• Death, due to the procedure or anesthesia, is extremely
rare.
• Complications can be kept to a minimum if appropriate
techniques are used and if the procedure is performed
in an appropriate setting by a skilled provider.
2/20/2023 Reena Bhagat 111
b. Male Sterilization( Vasectomy)
 Permanent contraception for men who will not want more
children.
 Also called male sterilization and male surgical contraception.
 Non-scalpel vasectomy(NSV) is done under local anesthesia
making a tiny puncture over the stretched skin of the vasa.
Through a puncture or small incision in the scrotum, the
provider locates each of the 2 tubes that carries sperm to the
penis (vas deferens) and cuts or blocks them by cutting and
tying them closed or by applying heat or electricity (cautery).
 Works by closing off each vas deferens, keeping sperm out of
semen. Semen is ejaculated, but it cannot cause pregnancy
2/20/2023 Reena Bhagat 112
How Effective?
• One of the most effective methods but carries a small
risk of failure: less than 2 women in every 1,000 will
become pregnant.
• Permanent. Intended to provide life-long, permanent, and
very effective protection against pregnancy. Reversal is
usually not possible.
• Involves a safe, simple surgical procedure. 3-month
delay in taking effect. The man or couple must use
condoms or another contraceptive method for 3 months
after the vasectomy.
• Does not affect male sexual performance.
2/20/2023 Reena Bhagat 113
Contd..
• If the partner of a man who has had a vasectomy
becomes pregnant, it may be because:
The couple did not always use another method during
the first 3 months after the procedure
The provider made a mistake
The cut ends of the vas deferens grew back together
The procedure is intended to be permanent. Reversal
surgery is difficult, expensive, and not available in most
areas. When performed, reversal surgery often does not
lead to pregnancy.
Protection against sexually transmitted infections (STIs):
None
2/20/2023 Reena Bhagat 114
2/20/2023 Reena Bhagat 115
Contd..
Advantages:
(1) The operative technique is simple and can be
performed by one with minimal training
(2) The operation can be done as an outdoor procedure or
in a mass camp even in remote villages
(3) Complications—immediate or late are few
(4) Failure rate is minimal—0.15 percent and there is a
fair chance of success of reversal anastomosis
operation (70–80 percent)
(5) The overall expenditure is minimal in terms of
equipment, hospital stay and doctor‘s training.
2/20/2023 Reena Bhagat 116
Contd..
Drawbacks:
(1) Additional contraceptive protection is needed for
about 2–3 months following operations, i.e. till the
semen becomes free of sperm.
(2) Frigidity or impotency when occurs is mostly
psychological.
(3) Selection of candidates: Sexually active and
psychologically adjusted husband having the desired
number of children is an ideal one.
2/20/2023 Reena Bhagat 117
Contd..
• Side Effects None
• Complications: Uncommon to rare:
• Severe scrotal or testicular pain that lasts for months or
years.
Uncommon to very rare:
Infection at the incision site or inside the incision
(uncommon with conventional incision technique; very
rare with no-scalpel technique;
Rare: Bleeding under the skin that may cause swelling
or bruising (hematoma).
2/20/2023 Reena Bhagat 118
2/20/2023 Reena Bhagat 119
Benefits of Family Planning
Family Planning has multiple benefits for men, women,
children, community and nation.
For saving women’s lives:
Reduce maternal mortality and morbidity by reducing
the number of pregnancies, the number of abortion and
the proportion of the births at high risk.
It has been estimated that meeting women‘s need for
modern contraceptives would prevent about one quarter
to one third of maternal deaths.
2/20/2023 Reena Bhagat 120
Contd..
Family Planning saves women‘s lives by:
1. Avoiding unsafe abortion.
2. Limiting risks of pregnancy and child birth
3. Limiting pregnancy to the healthiest ages, frequency
and interval
4. Improve health status of adolescents
For families:
• Health birth spacing and smaller families which
improve women‘s health.
• Improved education and status for women
2/20/2023 Reena Bhagat 121
Contd..
• Health birth spacing and smaller families which improve
women‘s health.
• Improved education and status for women
• Improved well being of families because of mothers survival
• Better nutrition and education for children specially girls
For Children
• Family Planning is an important part of effort to improve
infant and child survival. Family Planning saves the lives of
children by:
1. Spacing Birth
2. Limiting child bearing to the healthiest age
3. Spacing births helps assure that babies are adequately
breastfed.
2/20/2023 Reena Bhagat 122
Contraception forAdolescent
• World Health Organization definition of adolescence as
the period between 10-19 years of age. Adolescence is a
period of transition from childhood to adulthood and this
is not only period of growth, exploration and
opportunities, but also a time of risk taking,
experimentation, and vulnerability.
• While adolescence generally is a healthy period of life,
adolescents are often not well-informed about how to
protect their sexual and reproductive health, thus are at
potential risk of unwanted pregnancies, unsafe abortion,
STIs, and HIV.
2/20/2023 Reena Bhagat 123
Contd..
• They are less informed, less experienced, less comfortable, and
have fewer resources to access reproductive health services
including family planning than adults. Adolescents need special
attention, guidance and support to address their specific
concerns, problems and needs and to assist them in developing
responsible behavior and a healthy lifestyle.
The risks are
• Unintended pregnancy
• STI‘s and HIV/AIDS
• Risk of maternal & infant deaths
• Risks of unsafe abortion seeking behavior
• Secondary Sterility
2/20/2023 Reena Bhagat 124
Contd..
Counseling for adolescents should include discussion of
the:
Benefits of certain contraceptive methods (condoms) in
protecting against STIs (including HBV and HIV) as
well as preventing pregnancy.
Safety of contraceptive method and not affecting
long-term fertility.
Appropriate sex education that enables adolescents to
develop the knowledge and confidence to make
decisions related to their sexual behavior, including the
decision not to engage in sexual intercourse until they
are ready to do so.
2/20/2023 Reena Bhagat 125
Contd..
Sexuality and reproductive health with emphasis on
adolescent issues: self-esteem, appearance, negotiating
unwanted sexual advances, pressure from peers or
partners.
Address questions for adolescents on their unique
condition (irregular menstruation, change in body
structure, gender identification, personal hygiene,
menstrual health).
2/20/2023 Reena Bhagat 126
Contd..
Contraception for Adolescents
Barrier Methods: Condoms would be better but diaphragms
and cervical caps are invasive & they are unwilling.
Hormonal Contraception( COCs/PoPs): Suitable for
adolescents as there will be no such diseases
contraindications for adolescents. Reversible and no effect
in future fertility.
Implants are way too long covered for some adolescents.
Depo Provera: Highly recommended for adolescents who
require intermediate duration effective contraception,
especially if they had trouble with compliance while using
another method.
2/20/2023 Reena Bhagat 127
Contd..
IUD: Theoretically contraindicated for adolescents since
it bears a risk of pelvic infections and secondary sterility.
However, protects from illegal repeated abortions and
death.
Other Methods:
Periodic abstinence is not easy for irregular cycles
Withdrawal is not very reliable method for contraception.
2/20/2023 Reena Bhagat 128
Postabortion Contraception
• Women who have received safe abortion service or been
treated for abortion complications need easy and
immediate access to contraceptive services.
• Good counseling gives support to the woman who has
just been through abortion or treated for abortion
complication. In particular:
Try to understand what she has been through
Treat her with respect and avoid judgment and criticism
Ensure privacy and confidentiality
Ask if she wants someone, she trusts to be present during
counseling.
2/20/2023 Reena Bhagat 129
Contd..
• WHO recommends all women should receive
contraceptive information and be offered counseling,
including emergency contraception, before leaving the
healthcare facility. Post-abortion contraceptive counseling
should include the following components:
Counseling about contraceptive needs in terms of the women's
reproductive goals
Choices among various contraceptive methods
Provision of contraceptive service
Access to follow-up care
Information about the need for protection against STIs
including HIV and the importance of condom use for all
women regardless of the contraceptive method chosen.
2/20/2023 Reena Bhagat 130
Contd..
Time to start Postabortion Contraception
• Immediate initiation of contraception following
abortion is critical to reduce the risk of unintended
pregnancy.
• It is important to remind the woman that fertility
returns soon after abortion (even before she can
resume her normal period) whereas ovulation after
abortion takes place within 20 days but in some cases
as early as 8 days.
2/20/2023 Reena Bhagat 131
Contd..
Guidelines for selection of Contraception
Voluntary
female
sterilization
(Minilap)
Technically, minilap procedures usually can
be performed immediately after an abortion.
If infection or severe blood loss is present,
do not perform until fully resolved. e.g. only
when infection is fully resolved (3 months)
or injury is healed.
Voluntary male
sterilization
(Non-Scalpel
Vasectomy)
Technically, NSV procedures can be
performed at any time and timing is not
related to abortion
Progestin-only
Implants
May be inserted immediately after abortion,
preferably on the day of treatment.
2/20/2023 Reena Bhagat 132
Contd..
Guidelines for selection of Contraception
IUCD (CUT380 A) IUCD can be inserted immediately after
surgical abortion (If there is no
complication), preferably on the day of
treatment IUCD can be inserted in
medical abortion only when there is
completion of abortion
InjectablesProgestin only
(E.g. Depoprovera)
Can be given immediately after both
surgical and medical abortion, preferably
on the day of treatment
CoCs (E.g. Nilocon
white/Sunaulo Gulaf) and
PoPs (mini pill)
Can be given immediately after both
surgical and medical abortion, preferably
on the day of treatment
2/20/2023 Reena Bhagat 133
Contd..
Guidelines for selection of Contraception
Barriers (Condoms) Can be used immediately after
both surgical and medical
abortion
Fertility awareness
methods
(Natural Family
Planning Method )
Not recommended for
immediate use as postabortion
contraception
Emergency
Contraceptive Pills
May be used immediately after
abortion
2/20/2023 Reena Bhagat 134
Contraception for women over 35yrs/ near
perimenopause
• Menopause usually occurs between the ages of 45 to 55
years. It is important to prevent pregnancy until it is
clear that she is no longer fertile. She can use any
method if she has no medical condition that limits its
use.
• Women over the age of 35 years are in need of safe and
effective contraception because pregnancy can carry
increased health hazards (morbidity and mortality) for
mothers and their babies. Fertility declines in women
over 35 years. Pregnancies, however, are possible and
therefore contraception should be provided.
2/20/2023 Reena Bhagat 135
Contd..
There are specific problems related to pregnancy in this
age group:
Maternal mortality among women in their forties is
about five times greater than that of women in their
twenties.
Perinatal mortality doubles as maternal age doubles.
Chromosomal abnormalities, particularly Down‘s
syndrome, increases.
Spontaneous abortion rates increase.
2/20/2023 Reena Bhagat 136
Contd..
Considerations for women near perimenopause
COCs  Women aged 35 and older who smoke - regardless
of how much - should not use COC.
 Women aged 35 years and older who are heavy
smokers (>15 cigarettes per day) should not use
monthly injectables. These women should be
encouraged to stop smoking.
 Women aged 35 or older should not use COC if
they have migraine headaches (whether with
migraine aura or not).
 Low-dose COCs are contraceptive of choice for
perimenopausal women; if there is no other
contraindication, because it will regulate the
menstruation cycle and prevents pregnancy.
2/20/2023 Reena Bhagat 137
Contd..
Considerations for women near perimenopause
POCs
(Implants
, PoPs)
A good choice for woman who cannot use methods with
estrogen.
DMPA, if used for prolonged period of time, might
decrease bone mineral density slightly. This may increase
the risk of developing osteoporosis and possibly having
bone fractures later, after menopause.
Implants are highly recommended for women over 35
who want long-term contraception, especially if client has
had trouble using another method or does not want
voluntary sterilization.
IUCDs IUCDs could be a better choice as it is non-hormonal.
Expulsion rates fall as women grow older, and are lowest
in women over 40 years of age. Insertion may be more
difficult due to tightening of the cervical canal.
2/20/2023 Reena Bhagat 138
Contd…
Considerations for women near perimenopause
Condoms
(male and
female)
Only method that protects against other STIs (e.g.,
HBV, HIV).
Affordable and convenient for women who may not
have sex often.
Minilap and
vasectomy
Appropriate for clients/couples who are certain about
desire for permanent contraception
Perimenopausal woman is more likely to have
conditions that require delay, referral or caution for
female sterilization.
Emergency
contraceptive
pills
Can be used by women of any age, including those who
cannot use hormonal methods on a continuous basis.
Fertility
awareness
methods
Lack of regular cycles during perimenopausal period
makes difficult to use these methods reliably
2/20/2023 Reena Bhagat 139
Contd..
Relieving Symptoms of Menopause:
Women experience physical effects before, during, and
after menopause:
ohot flashes,
oexcess sweating,
odifficulty to hold urine, or increase in nocturnal
frequency of urine,
ovaginal dryness that can make sex painful, and
odifficulty sleeping.
2/20/2023 Reena Bhagat 140
Contd..
Providers can suggest ways to reduce some of these
symptoms:
• Deep breathing from the diaphragm may make a hot
flash go away faster.
• Meditation and yoga could be helpful, as it helps in
relaxation and joint mobility.
• Eat foods like soybeans, Tofu, soya nuggets and green
vegetables.
• Eat foods rich in calcium (such as dairy products, beans,
carom seeds and fish).
2/20/2023 Reena Bhagat 141
Contd..
• Engage in moderate physical activity (walking and
some weight bearing exercises) to help slow the loss of
bone density that comes with menopause.
• Vaginal lubricants or moisturizers can be used if
vaginal dryness persists and causes irritation. During
sex, use a commercially available vaginal lubricant,
water, or saliva as a lubricant if vaginal dryness is a
problem.
• Refer to a gynecologist if vaginal dryness is persistent;
she might need local hormonal cream.
2/20/2023 Reena Bhagat 142
Contraception and STI including HIV
• Sexually Transmitted Infections and family planning
services overlap substantially.
• STI/HIV are frequently encountered in family
planning clients, especially among certain high-risk
groups (e.g., clients who have more than one sexual
partner).
• Furthermore, some contraceptive methods have a range
of characteristics— from protecting against STI/HIV
transmission to reducing the risk of complications from
STI/ HIV infection.
2/20/2023 Reena Bhagat 143
Contd..
The main linkages between contraception and STI/HIV
services are:
• Prevention of STI/HIV transmission
• Opportunity for client screening for STI/HIV
• Counseling on FP as well as STI/HIV prevention
• Treatment of STI and its consequences from the same
FP outlets.
2/20/2023 Reena Bhagat 144
Safer Conception for HIV Serodiscordant Couples
When a couple wants to have a child and one partner has
HIV while the other does not (a serodiscordant couple),
counseling on care and treatment is done on the following
basis:
The partner with HIV should take antiretroviral (ARV)
therapy consistently and correctly until HIV is suppressed
to the point that it cannot be detected.
If the partner with HIV is not virally suppressed on ARV
therapy, the partner who does not have HIV (HIV-
negative) can consider taking pre-exposure prophylaxis
(PrEP) during the period when they are trying to
conceive.
2/20/2023 Reena Bhagat 145
Contd..
• If the woman has HIV but the man does not, a safe
option for conception is artificial insemination with the
uninfected partner‘s semen. Both partners should be
properly screened and adequately treated for any other
STI before trying for conception.
2/20/2023 Reena Bhagat 146
Contraception and STI/HIV
• Family planning providers can talk to clients about how
they can protect themselves both from STI, including
HIV, and pregnancy (dual protection).
• Choosing a Dual Protection Strategy Every family
planning client needs to think about preventing STI
including HIV—even people who assume they face no
risk.
• The provider can discuss what situations place a person
at increased risk of STI including HIV and clients can
think about whether these risky situations come up in
their own lives. If so, they can consider 5 dual protection
strategies.
2/20/2023 Reena Bhagat 147
Contd..
Strategy 1: Use a male or female condom correctly
with every act of sex.
One method helps protect against pregnancy and STI
including HIV.
Strategy 2: Use condoms consistently and correctly
plus another family planning method.
Adds extra protection from pregnancy in case a condom
is not used correctly.
May be a good choice for women who want to be sure
to avoid pregnancy but cannot always pressure their
partners to use condoms.
2/20/2023 Reena Bhagat 148
Contd..
Strategy 3: If both partners know they are not
infected, use any family planning method to prevent
pregnancy and stay in a mutually faithful
relationship.
Many family planning clients are in this group and thus
are protected from STI including HIV.
Depends on communication and trust between partners.
2/20/2023 Reena Bhagat 149
Contd.
Strategy 4: Engage only in safer sexual intimacy that
avoids intercourse or otherwise prevents semen and
vaginal fluids from coming in contact with each other’s
genitals.
This strategy will not prevent syphilis, genital herpes, or
infection with human papillomavirus. These infections
may spread even through skin-to-skin contact.
Depends on communication, trust, and self-control.
If this is a person‘s first-choice strategy, it is best to have
condoms at hand in case the couple desire to have sex.
2/20/2023 Reena Bhagat 150
Contd..
Strategy 5: Delay or avoid sexual activity (either
avoiding sex all the time or abstaining for a longer
time).
This strategy is always available in case a condom is not
at hand.
If this is a person‘s first-choice strategy, it is best to have
condoms at hand in case the couple desire to have sex.
People at high risk of HIV infection can take PrEP—
pre-exposure prophylaxis. This daily treatment with oral
antiretroviral drugs greatly reduces the chances of
infection if exposed to HIV.
2/20/2023 Reena Bhagat 151
Counseling Outline and Clinical
Recommendations
Method Remarks Regarding STI
COCs No protection against STI including HBV, HIV.
If high risk behavior or previous STI detected in
screening history, concurrent use of condoms is
recommended.
POCs
(Implants
and Depo)
No protection against STI including HBV, HIV.
If high-risk behavior or previous STI detected in
screening history, concurrent use of condoms is
recommended.
Condoms
(male and
female)
Protect against STI including HBV, HIV. • To be
fully effective, condoms must be worn at all times
during genital contact, and with every act of
intercourse.
2/20/2023 Reena Bhagat 152
Method Remarks Regarding STI
IUCDs  No protection against STI including HBV, HIV.
 Should not be used by women at risk for or with
clinical findings of STI. If such a client insists on
using an IUCD, concurrent use of condoms is
required.
 Should not be used by women with current, recent
(less than 3 months) or having recurrent PID.
 If there is clinical findings of vaginal infection
(candidiasis or bacterial vaginosis), treat and recheck
before IUCD is inserted.
Minilap
and NSV
 No protection against STI including HBV, HIV.
 If high-risk behavior or previous STI detected in
screening history, concurrent use of condoms is
recommended.
2/20/2023 Reena Bhagat 153
2/20/2023 Reena Bhagat 154

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Family Planning Methods.pdf

  • 2. FAMILY PLANNING Prepared By: Reena Bhagat Senior Nursing Instructor Maternal Health Nursing BPKIHS
  • 4. Ideal Contraceptives?? • Safe • Effective • Acceptable • Reversible • Inexpensive • Long lasting • Requires little or no medical supervision 2/20/2023 Reena Bhagat 4
  • 5. Family Planning: Types 1. Natural ( Traditional) Method 2. Temporary( Short/ Long Acting ) Method 3. Permanent Method 2/20/2023 Reena Bhagat 5
  • 6. Family Planning Method: Types • Rhythm (Calendar) method • Basal Body Temperature (BBT) Method • Ovulation or Cervical Mucus Method • Symptothermal method • Coitus Interrupts • Lactation Amenorrhea Method (LAM) A. Natural Method • Barrier Method • Hormonal Method • Intrauterine Devices • Post-coital Method B. Temporary Method • Male Sterilization • Female Sterilization C. Permanent Method 2/20/2023 Reena Bhagat 6
  • 7. A. Natural( Traditional) Method No introduction of chemical of foreign material into the body. Practice may be due to religious belief, ―natural‖ way is best for them. Effectiveness varies greatly, depends on couple‘s ability to refrain from having intercourse on fertile days. Effective in women whose menstrual cycle is regular.. (28-32 days). 2/20/2023 Reena Bhagat 7
  • 8. 1. Rhythm (Calendar) method • Also called fertility awareness method. • ―Fertility awareness‖ means that a woman knows how to tell when the fertile time of her menstrual cycle starts and ends. • Sometimes called periodic abstinence or natural family planning. • Calendar-based methods involve keeping track of days of the menstrual cycle to identify the start and end of the fertile time. – Examples: Standard Days Method, which avoids unprotected vaginal sex on days 8 through 19 of the menstrual cycle, and calendar rhythm method. 2/20/2023 Reena Bhagat 8
  • 9. Fig. Calendar Rhythm Method 2/20/2023 Reena Bhagat 9
  • 10. How to calculate?? Example: If she has 6 menstrual cycles ranging from 25 to 29 days, fertile period would be from 7th day (25- 18) to the 18thday (29-11). i.e. 7th day- 18th day • So, to calculate fertility phase: • Subtract 18 from shortest cycle and 11 from the longest one • * 25- 18= 7 (infertile phase) • * 29-11= 18 (post -ovulatory infertile phase) • To avoid pregnancy, avoid coitus/use contraceptive during those days. 2/20/2023 Reena Bhagat 10
  • 11. 2. Basal Body Temperature (BBT) - Identifying fertile and infertile period of a woman‘s cycle by daily taking and recording of the rise in body temperature during and after ovulation. - At time of ovulation, as a result of increase in her BBT 0.3- 0.60C i.e. ( 0.5-1 0F) rises a full degree (influence of progesterone). DISADVATAGES - NOT reliable method of birth control, especially for women with irregular cycles. 2/20/2023 Reena Bhagat 11
  • 13. 3. Ovulation or Cervical Mucus Method - Cervical mucus, is a fluid produced by small glands near the cervix. This fluid changes throughout her cycle, from scant and sticky, to cloudy and thick. • Cervical Mucus/Ovulation - During the peak of fertility, The consistency of ovulation mucus is like that of an egg white and it can be stretched between the fingers. - After the ovulation, the mucus tends to dry up again. These are also safe days. 2/20/2023 Reena Bhagat 13
  • 15. Symtothermal Method • Combines the cervical mucus and BBT methods. Watches temp. daily and analyzes cervical mucus daily. • Watch for midcycle abdominal pain. Couple must abstain from intercourse until 3 days after rise in temp. or 4th day after peak of mucus change. • More effective than BBT or CM method alone. - Ideal Failure rate: 2% 2/20/2023 Reena Bhagat 15
  • 17. 5. Coitus Interrupts Method  One of oldest known methods of voluntary contraception.  Couple proceeds with coitus until the moment of ejaculation which offers little protection, i.e withdrawal of penis just before ejaculation.  Effectivity: 75% 2/20/2023 Reena Bhagat 17
  • 18. 6. LactationAmenorrhea Method(LAM) LAM: Natural birth control technique based on the fact that lactation (breast milk production) causes amenorrhea (lack of menstruation). • How it works: Breastfeeding interferes with the release of the hormones needed to trigger ovulation. 2/20/2023 Reena Bhagat 18
  • 19. Contd.. • The lactational amenorrhea method (LAM) requires 3 conditions. All 3 must be met: 1. The mother‘s monthly bleeding has not returned. 2. The baby is fully or nearly fully breastfed and is fed often, day and night. 3. The baby is less than 6 months old. Works primarily by preventing the release of eggs from the ovaries (ovulation). Frequent breastfeeding temporarily prevents the release of the natural hormones that cause ovulation. 2/20/2023 Reena Bhagat 19
  • 21. How Effective? • Effectiveness depends on the user: Risk of pregnancy is greatest when a woman cannot fully or nearly fully breastfeed her infant. • As commonly used, about 2 pregnancies per 100 women using LAM in the first 6 months after childbirth. • When used correctly, less than 1 pregnancy per 100 women using LAM in the first 6 months after childbirth. • Return of fertility after LAM is stopped: Depends on how much the woman continues to breastfeed • Protection against sexually transmitted infections: None 2/20/2023 Reena Bhagat 21
  • 23. 1. Barrier Methods A. Mechanical Condoms (male and female) Diaphragm Cervical cap B. Chemical Spermicidal Sponge 2/20/2023 Reena Bhagat 23
  • 24. A. Mechanical Methods Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy. Condoms( both male and female) are the only contraceptive method that can protect against both pregnancy and sexually transmitted infections. 2/20/2023 Reena Bhagat 24
  • 26. 1.Condoms( Male) Sheaths, or coverings, that fit over a man‘s erect penis. Also called rubbers, ―raincoats,‖ ―umbrellas,‖ skins, prophylactics; known by many different brand names. Most are made of thin latex rubber. Male condoms also are made from other materials, including polyurethane, polyisoprene, lambskin, and nitrile. Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy. Also keep infections in semen, on the penis, or in the vagina from infecting the other partner. 2/20/2023 Reena Bhagat 26
  • 27.  Male condoms help protect against sexually transmitted infections, including HIV.  Condoms are the only contraceptive method that can protect against both pregnancy and sexually transmitted infections. 2/20/2023 Reena Bhagat 27
  • 28. How Effective?? Effectiveness depends on the user: Risk of pregnancy or sexually transmitted infection (STI) is greatest when condoms are not used with every act of sex. As commonly used, about 13 pregnancies per 100 women whose partners use male condoms over the first year. When used correctly with every act of sex, about 2 pregnancies per 100 women whose partners use male condoms over the first year. Return of fertility after use of condoms is stopped: No delay 2/20/2023 Reena Bhagat 28
  • 29. Contd.. Protection against HIV and other STIs: Male condoms significantly reduce the risk of becoming infected with HIV when used correctly with every act of vaginal or anal sex. When used consistently and correctly, condom use prevents 80% to 95% of HIV transmission that would have occurred without condoms. Protect best against STIs spread by discharge, such as HIV, gonorrhea, and chlamydia. – Also protect against STIs spread by skin-to-skin contact, such as herpes and human papillomavirus. 2/20/2023 Reena Bhagat 29
  • 30. Side effects: None Known Health Benefits Help protect against: Risks of pregnancy STIs, including HIV May help protect against: Conditions caused by STIs: Recurring pelvic inflammatory disease and chronic pelvic pain Cervical cancer Infertility (male and female) Known Health Risks Extremely rare: • Severe allergic reaction (among people with latex allergy) 2/20/2023 Reena Bhagat 30
  • 31. Condoms( Female) Sheaths, or linings, that fit loosely inside a woman‘s vagina, made of thin, transparent, soft film. Have flexible rings at both ends – One ring at the closed end helps to insert the condom – The ring at the open end holds part of the condom outside the vagina Female condoms are made of various materials, such as latex, polyurethane, and nitrile. Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy. Also helps to keep infections in semen, on the penis, or in the vagina from infecting the other partner. 2/20/2023 Reena Bhagat 31
  • 33. How Effective?? Effectiveness depends on the user: Risk of pregnancy or sexually transmitted infection (STI) is greatest when female condoms are not used with every act of sex. Few pregnancies or infections occur due to incorrect use, slips, or breaks. Protection against pregnancy: As commonly used, about 21 pregnancies per 100 women using female condoms over the first year. When used correctly with every act of sex, about 5 pregnancies per 100 women using female condoms over the first year. 2/20/2023 Reena Bhagat 33
  • 34. Contd..  Return of fertility after use of female condom is stopped: No delay  Protection against HIV and other STIs: Female condoms reduce the risk of infection with STIs, including HIV, when used correctly with every act of sex.  Side effects: None  Known Health Benefits Help protect against:  Risks of pregnancy  STIs, including HIV  Known Health Risks: None 2/20/2023 Reena Bhagat 34
  • 35. 2. Diaphragms oA soft latex cup that covers the cervix. Plastic and silicone diaphragms may also be available. oThe rim contains a firm, flexible spring that keeps the diaphragm in place. oUsed with spermicidal cream, jelly, or foam to improve effectiveness. oMost diaphragms come in different sizes and require fitting by a specifically trained provider. oWorks by blocking sperm from entering the cervix; spermicide kills or disables sperm. Both keep sperm from meeting an egg. 2/20/2023 Reena Bhagat 35
  • 36. How Effective?? Effectiveness depends on the user: Risk of pregnancy is greatest when the diaphragm with spermicide is not used with every act of sex. As commonly used, about 17 pregnancies per 100 women using the diaphragm with spermicide over the first year. When used correctly with every act of sex, about 16 pregnancies per 100 women using the diaphragm with spermicide over the first year. Return of fertility after use of the diaphragm is stopped: No delay 2/20/2023 Reena Bhagat 36
  • 38. Diaphragms  Protection against STIs: May provide some protection against certain STIs but should not be relied on for STI prevention  Side Effects: Some users report the following:  Irritation in or around the vagina or penis  Other possible physical changes: Vaginal lesions 2/20/2023 Reena Bhagat 38
  • 39. Contd.. • Insert the diaphragm less than 6 hours before having sex • Leave the diaphragm in place at least 6 hours after having sex but no longer than 24 hours. • Leaving the diaphragm in place for more than one day may increase the risk of toxic shock syndrome. It can also cause a bad odor and vaginal discharge. (Odor and discharge go away on their own after the diaphragm is removed. 2/20/2023 Reena Bhagat 39
  • 40. Contd.. Known Health Benefits Help protect against:  Risks of pregnancy  May help protect against: Certain STIs (chlamydia, gonorrhea, pelvic inflammatory disease, trichomoniasis) Cervical precancer and cancer Known Health Risks Common to uncommon: Urinary tract infection Uncommon: Bacterial vaginosis Candidiasis Rare: Frequent use of nonoxynol-9 may increase risk of HIV infection Extremely rare: Toxic shock syndrome 2/20/2023 Reena Bhagat 40
  • 41. 3. Cervical Cap • A soft, deep, latex or plastic rubber cup that snugly covers the cervix. • Comes in different sizes; requires fitting by a specifically trained provider. 2/20/2023 Reena Bhagat 41
  • 42. How effective? Effectiveness depends on the user: Risk of pregnancy is greatest when the cervical cap with spermicide is not used with every act of sex. Women who have given birth: One of the least effective methods, as commonly used. As commonly used, about 32 pregnancies per 100 women using the cervical cap with spermicide over the first year. When used correctly with every act of sex, about 26 pregnancies per 100 women using the cervical cap over the first year. 2/20/2023 Reena Bhagat 42
  • 43. Contd.. More effective among women who have not given birth: As commonly used, about 16 pregnancies per 100 women using the cervical cap with spermicide over the first year. When used correctly with every act of sex, about 9 pregnancies per 100 women using the cervical cap over the first year. Return of fertility after use of cervical cap is stopped: No delay Protection against sexually transmitted infections: None 2/20/2023 Reena Bhagat 43
  • 44. Contd.. • Insert the cervical cap any time up to 42 hours before having sex. Removing • Leave the cervical cap in for at least 6 hours after her partner‘s last ejaculation, but not more than 48 hours from the time it was put in. • Leaving the cap in place for more than 48 hours may increase the risk of toxic shock syndrome and can cause a bad odor and vaginal discharge. 2/20/2023 Reena Bhagat 44
  • 45. Barrier Methods: Mechanical Advantages: o Comparatively Inexpensive oDo not require medical consultation Disadvantages: oDemonstration by trained person needed for proper use. oFailure most common- due to displacement of device oCervicitis( inflammation of cervix) & local irritation 2/20/2023 Reena Bhagat 45
  • 47. Spermicides • Sperm-killing substances inserted deep in the vagina, near the cervix, before sex. • Nonoxynol-9 is most widely used. Others include benzalkonium chloride, chlorhexidine, menfegol, octoxynol-9, and sodium docusate. • Available in foaming tablets, melting or foaming suppositories, cans of pressurized foam, melting film, jelly, and cream. • Work by causing the membrane of sperm cells to break, killing them or slowing their movement. This keeps sperm from meeting an egg. 2/20/2023 Reena Bhagat 47
  • 48. How Effective? • Effectiveness depends on the user: Risk of pregnancy is greatest when spermicides are not used with every act of sex. • One of the least effective family planning methods. • As commonly used, about 21 pregnancies per 100 women using spermicides over the first year. • When used correctly with every act of sex, about 16 pregnancies per 100 women using spermicides over the first year. • Return of fertility after spermicides are stopped: No delay 2/20/2023 Reena Bhagat 48
  • 49. Contd… • Protection against sexually transmitted infections (STIs): None. Frequent use of nonoxynol-9 may increase risk of HIV infection. • All women can safely use spermicides except those who: Are at high risk for HIV infection Have HIV infection • Side Effects: Some users report the following: Irritation in or around the vagina or penis Other possible physical changes: Vaginal lesions 2/20/2023 Reena Bhagat 49
  • 50. Contd.. Known Health Benefits Help protect against: Risks of pregnancy Known Health Risks Uncommon: Urinary tract infection, especially when using spermicides 2 or more times a day Rare: Frequent use of nonoxynol-9 may increase risk of HIV infection 2/20/2023 Reena Bhagat 50
  • 51. Vaginal contraceptive sponge (widely available as Today)  The sponge is a doughnut- shaped device  Made of soft foam coated with spermicide, (polyurethane with 1gm of nonoxynol-9) as a spermicide.  It releases spermicide during coitus, absorbs ejaculate and blocks the entrance of cervical canal. 2/20/2023 Reena Bhagat 51
  • 52. Chemical Methods Advantages:  Comparatively Inexpensive Well tolerated Good protection Disadvantages Local irritation & burning sensation 2/20/2023 Reena Bhagat 52
  • 54. a. Combined Oral Contraceptives( COCs) • Pills that contain low doses of 2 hormones—a progestin and an estrogen—like the natural hormones progesterone and estrogen in a woman‘s body. • Combined oral contraceptives (COCs) are also called ―the Pill,‖ low-dose combined pills, OCPs, and OCs. • Work primarily by preventing the release of eggs from the ovaries (ovulation). 2/20/2023 Reena Bhagat 54
  • 55. Contd.. • Commonly available as ‗Nilocon White’ or ‗Gulaf’. • Its one cycle contains 21 hormonal tablets and 7 Iron tablets. • The composition of each white colored tablet contains Levonorgestrel 0.15 mg, Eithinyl Estradiol 0.03 mg and each brown tablet contains Ferrous Fumarate 75 mg. 2/20/2023 Reena Bhagat 55
  • 56. How Effective? • Effectiveness depends on the user: Risk of pregnancy is greatest when a woman starts a new pill pack 3 or more days late, or misses 3 or more pills near the beginning or end of a pill pack. • As commonly used, about 7 pregnancies per 100 women using COCs over the first year. • When no pill-taking mistakes are made, less than 1 pregnancy per 100 women using COCs over the first year (3 per 1,000 women). • Return of fertility after COCs are stopped: No delay • Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 56
  • 57. Contd..  Side Effects: Some users report the following: • Changes in bleeding patterns, including: Lighter bleeding and fewer days of bleeding – Irregular bleeding – Infrequent bleeding – No monthly bleeding • Headaches • Dizziness • Nausea • Breast tenderness • Weight changes • Mood changes 2/20/2023 Reena Bhagat 57
  • 58. Contd.. • Acne (can improve or worsen, but usually improves) • Other possible physical changes: Blood pressure increases a few points (mm Hg). When increase is due to COCs, blood pressure declines quickly after use of COCs stops.  Known Health Benefits • Help protect against: oRisks of pregnancy oCancer of the lining of the uterus (endometrial cancer) oCancer of the ovary oSymptomatic pelvic inflammatory disease 2/20/2023 Reena Bhagat 58
  • 59. Contd.. • May help protect against: oOvarian cysts oIron-deficiency anemia • Reduce: oMenstrual cramps oMenstrual bleeding problems oOvulation pain oExcess hair on face or body oSymptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body) oSymptoms of endometriosis (pelvic pain, irregular bleeding) 2/20/2023 Reena Bhagat 59
  • 60. Contd.. Known Health Risks Very rare: • Blood clot in deep veins of legs or lungs (deep vein thrombosis or pulmonary embolism) Extremely rare: • Stroke • Heart attack 2/20/2023 Reena Bhagat 60
  • 61. b. Progestin Only Pills(POPs)  Pills that contain very low doses of a progestin like the natural hormone progesterone in a woman‘s body.  Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen.  Progestin-only pills (POPs) are also called ―minipills‖ and progestin-only oral contraceptives.  Work primarily by: Thickening cervical mucus (this blocks sperm from meeting an egg) Disrupting the menstrual cycle, including preventing the release of eggs from the ovaries (ovulation) 2/20/2023 Reena Bhagat 61
  • 62. How Effective? Effectiveness depends on the user: For women who have monthly bleeding, risk of pregnancy is greatest if pills are taken late or missed completely. Breastfeeding women: As commonly used, about 1 pregnancy per 100 women using POPs over the first year. When pills are taken every day, less than 1 pregnancy per 100 women using POPs over the first year (3 per 1,000 women). 2/20/2023 Reena Bhagat 62
  • 63. Contd.. Less effective for women not breastfeeding: As commonly used, about 7 pregnancies per 100 women using POPs over the first year. When pills are taken every day at the same time, less than 1 pregnancy per 100 women using POPs over the first year (3 per 1,000 women). • Return of fertility after POPs are stopped: No delay • Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 63
  • 64. Contd.. Side Effects: Some users report the following: • Changes in bleeding patterns, including: For breastfeeding women, longer delay in return of monthly bleeding after childbirth (lengthened postpartum amenorrhea) – Frequent bleeding – Irregular bleeding – Infrequent bleeding – Prolonged bleeding – No monthly bleeding.  Breastfeeding also affects a woman‘s bleeding patterns. • Headaches • Dizziness • Mood changes 2/20/2023 Reena Bhagat 64
  • 65. Contd.. • Breast tenderness • Abdominal pain • Nausea • Other possible physical changes: For women not breastfeeding, enlarged ovarian follicles • Known Health Benefits: Help protect against: Risks of pregnancy • Known Health Risks: None 2/20/2023 Reena Bhagat 65
  • 66. Progestin-Only Injectables( Depo Provera) oThe injectable contraceptives depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN) each contain a progestin like the natural hormone progesterone in a woman‘s body. oDo not contain estrogen, and so can be used throughout breastfeeding, starting 6 weeks after giving birth, and by women who cannot use methods with estrogen. oGiven by injection into the muscle (intramuscular injection). The hormone is then released slowly into the bloodstream. oWork primarily by preventing the release of eggs from the ovaries (ovulation). 2/20/2023 Reena Bhagat 66
  • 67. Dose: 150 mg IM Provide protection for 3 months. 2/20/2023 Reena Bhagat 67
  • 68. How Effective? • Effectiveness depends on getting injections regularly: Risk of pregnancy is greatest when a woman misses an injection. • As commonly used, about 4 pregnancies per 100 women using progestin-only injectables over the first year. • When women have injections on time, less than 1 pregnancy per 100 women using progestin-only injectables over the first year (2 per 1,000 women). • Return of fertility after injections are stopped: An average of about 4 months longer for DMPA and 1 month longer for NET-EN than with most other methods • Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 68
  • 69. Contd.. Side Effects: Most users report some changes in monthly bleeding. • Typically, these include, with DMPA: First 3 months: – Irregular bleeding – Prolonged bleeding At one year: – No monthly bleeding – Infrequent bleeding – Irregular bleeding • Some users report the following: Weight gain Headaches Dizziness Abdominal bloating and discomfort 2/20/2023 Reena Bhagat 69
  • 70. Contd.. Known Health Benefits: DMPA Helps protect against: • Risks of pregnancy • Cancer of the lining of the uterus (endometrial cancer) • Uterine fibroids • May help protect against: • Symptomatic pelvic inflammatory disease • Iron-deficiency anemia • Reduces: • Sickle cell crises among women with sickle cell anemia • Symptoms of endometriosis (pelvic pain, irregular bleeding) Known Health Risks: None 2/20/2023 Reena Bhagat 70
  • 71. Implants( Jadelle) • Small plastic rods, each about the size of a matchstick, that release a progestin like the natural hormone progesterone in a woman‘s body. • A specifically trained provider performs a minor surgical procedure to place one or 2 rods under the skin on the inside of a woman‘s upper arm. • Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen. 2/20/2023 Reena Bhagat 71
  • 72. Contd.. Types of implants: Jadelle: 2 rods containing levonorgestrel, highly effective for 5 years Implanon NXT (Nexplanon): 1 rod containing etonogestrel, labeled for up to 3 years of use (a recent study shows it may be highly effective for 5 years). Implants are small flexible rods that are placed just under the skin of the upper arm. Provide long-term pregnancy protection. Very effective for 3 to 5 years, depending on the type of implant. Immediately reversible. 2/20/2023 Reena Bhagat 72
  • 73. Work primarily by: - Preventing the release of eggs from the ovaries (ovulation) - Thickening cervical mucus (this blocks sperm from reaching an egg) 2/20/2023 Reena Bhagat 73
  • 74. How Effective?  One of the most effective and long-lasting methods: Far less than 1 pregnancy per 100 women using implants over the first year (1 per 1,000 women). Less than 1 pregnancy per 100 women over the duration of use. Return of fertility after implants are removed: No delay Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 74
  • 75. Contd.. • Side Effects : Some users report the following: • Changes in bleeding patterns, including: First several months to a year: – Lighter bleeding and fewer days of bleeding – Prolonged bleeding – Irregular bleeding – Infrequent bleeding – No monthly bleeding • After about one year: – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Infrequent bleeding – No monthly bleeding • Headaches • Abdominal pain • Acne (can improve or worsen) 2/20/2023 Reena Bhagat 75
  • 76. Contd... • Weight change • Breast tenderness • Dizziness • Mood changes • Nausea • Other possible physical changes: Enlarged ovarian follicles 2/20/2023 Reena Bhagat 76
  • 77. Contd.. Known Health Benefits Help protect against: • Risks of pregnancy, including ectopic pregnancy • Symptomatic pelvic inflammatory disease May help protect against: • Iron-deficiency anemia • Reduces: Risk of ectopic pregnancy • Known Health Risks: None 2/20/2023 Reena Bhagat 77
  • 78. Contd.. • Complications Uncommon:  Infection at insertion site (most infections occur within the first 2 months after insertion)  Difficult removal (rare if properly inserted and the provider is skilled at removal) Rare: Expulsion of implant (expulsions most often occur within the first 4 months after insertion) Extremely rare: There are a few reports of implants found in another place in the body due to improper insertion, for example, in a blood vessel. 2/20/2023 Reena Bhagat 78
  • 79. Combined Patch( EVRA) • A small, thin, square of flexible plastic worn on the body. • Continuously releases 2 hormones—a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman‘s body— directly through the skin into the bloodstream. • The woman puts on a new patch every week for 3 weeks, then no patch for the fourth week. During this fourth week the woman will have monthly bleeding. • Also called Ortho Evra and Evra. • Works primarily by preventing the release of eggs from the ovaries (ovulation) 2/20/2023 Reena Bhagat 79
  • 81. How Effective? • Effectiveness depends on the user: Risk of pregnancy is greatest when a woman is late to change the patch. • As commonly used, about 7 pregnancies per 100 women using the combined patch over the first year. • When no mistakes are made with use of the patch, less than 1 pregnancy per 100 women using a patch over the first year (3 per 1,000 women). • A woman wears a small adhesive patch on her body at all times, day and night. A new patch is put on each week for 3 weeks, and then no patch for the fourth week. 2/20/2023 Reena Bhagat 81
  • 82. Contd.. • Bleeding changes are common but not harmful. Typically, irregular bleeding for the first few months and then lighter and more regular bleeding. • Pregnancy rates may be slightly higher among women weighing 90 kg or more. • Return of fertility after patch use is stopped: No delay • Protection against sexually transmitted infections: None 2/20/2023 Reena Bhagat 82
  • 83. Contd.. Side Effects : Some users report the following: • Skin irritation or rash where the patch is applied • Changes in bleeding patterns: – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Prolonged bleeding – No monthly bleeding • Headaches • Nausea • Vomiting • Breast tenderness and pain • Abdominal pain • Flu symptoms/upper respiratory infection 2/20/2023 Reena Bhagat 83
  • 84. 3. Intrauterine Devices(IUDs) IUD( a LARC) is a small, T-shaped, plastic device that is inserted and left inside the uterus to prevent pregnancy. After insertion, the effective contraceptive action lasts at least 12 years. The usual timings are: Immediate Postpartum: Post-placental: Insertion within 10 minutes after expulsion of the placenta following a vaginal delivery on the same delivery table. Intracesarean: Insertion that takes place during a cesarean delivery, after removal of the placenta and before closure of the uterine incision. 2/20/2023 Reena Bhagat 84
  • 85. contd.. Within 48 hours after delivery: Insertion within 48 hours of delivery and prior to discharge from the postnatal ward. Postabortion: Insertion following an abortion, if there is no infection, Mending or any other contraindications. Extended Postpartum/Interval: Insertion any time after 6 weeks postpartum. 2/20/2023 Reena Bhagat 85
  • 86. Contd.. Mode of Action • The IUD interferes with the ability of sperm to survive and to ascend the fallopian tubes where fertilization occurs. It alters or inhibits sperm migration, ovum transport and fertilization. It stimulates a sterile foreign body reaction in endometrium potentiated by copper. • 2/20/2023 Reena Bhagat 86
  • 87. Contd.. • Ideal candidates for IUD oHas born one child oNormal menstrual cycle oNo pelvic inflammation oReady to check the device 2/20/2023 Reena Bhagat 87
  • 88. IUD Classification First generation Second generation Third generation  Non-medicated made up of polyethylene.  LIPPE’S LOOP  Double ‗s‘ shaped device, made up of polyethylene material.  Non- toxic, non- tissue reactive and extremely durable.  Made up of metal Copper Copper-T(Cu-T) • Most commonly used • Made of Cu • T-shaped attatched with a nylon thread( tail).  Hormones releasing IUD PROGESTASTERT  Most commonly used T shaped device filled with 38 mg progesterone  Effective for 1 year  LNG- mirena  Mirena (levonorgestrel- releasing intrauterine device) and Releases 20 µg of levonorgestrel. Effective for 5 years. 2/20/2023 Reena Bhagat 88
  • 89. How Effective?? One of the most effective and long-lasting methods: Less than 1 pregnancy per 100 women using an IUD over the first year (6 per 1,000 women who use the IUD perfectly, and 8 per 1,000 women as commonly used). • Return of fertility after IUD is removed: No delay • Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 89
  • 90. Contd.. Side Effects: Some users report the following: • Changes in bleeding patterns (especially in the first 3 to 6 months), including: – Prolonged and heavy monthly bleeding – Irregular bleeding – More cramps and pain during monthly bleeding Known Health Benefits: Helps protect against: Risks of pregnancy May help protect against: Cancer of the lining of the uterus (endometrial cancer) Cervical cancer Reduces: Risk of ectopic pregnancy 2/20/2023 Reena Bhagat 90
  • 91. Contd.. Complications: Rare: Puncturing (perforation) of the wall of the uterus by the IUD or an instrument used for insertion. Usually heals without treatment. Miscarriage, preterm birth, or infection in the rare case that the woman becomes pregnant with the IUD in place. 2/20/2023 Reena Bhagat 91
  • 92. Contd.. Known Health Risks: Uncommon: • May contribute to anemia if a woman already has low iron blood stores before insertion and the IUD causes heavier monthly bleeding Rare: • Pelvic inflammatory disease (PID) may occur if the woman has chlamydia or gonorrhea at the time of IUD insertion 2/20/2023 Reena Bhagat 92
  • 93. Contd.. Contraindications for Insertion of IUCD: 1. Presence of pelvic infection current or within 3 months; 2. Undiagnosed genital tract bleeding; 3. Suspected pregnancy; 4. Distortion of the shape of the uterine cavity as in fibroid or congenital uterine-malformation; 5. Severe dysmenorrhea; 6. Past history of ectopic pregnancy; 7. Within 6 weeks following cesarean section; 2/20/2023 Reena Bhagat 93
  • 94. Contd.. 8. STIs: Current or within 3 months; 9. Significant immunosuppression. Additionally for CuT are: 11. Wilson disease and 12. Copper allergy. For LNG-IUS are: 13. Hepatic tumor or hepatocellular disease (active); 14. Current breast cancer and 15. Severe arterial disease 2/20/2023 Reena Bhagat 94
  • 95. Post coital method: Emergency contraceptives Emergency contraception is contraception provided to women to prevent unwanted pregnancy following an unprotected sexual intercourse. ECPs are sometimes called ―morning after‖ pills or postcoital contraceptives. ECPs may include Special ECP product with levonorgestrel only Progestin-only pills with levonorgestrel or norgestrel Combined oral contraceptives with estrogen and a progestin— levonorgestrel, norgestrel, or norethindrone (also called norethisterone) The copper-bearing IUD 2/20/2023 Reena Bhagat 95
  • 96. Contd.. Work by: preventing fertilization by affecting the cervical mucus Preventing implantation by hypermotility of fallopian tubes and uterus. delaying the release of eggs from the ovaries (ovulation). 2/20/2023 Reena Bhagat 96
  • 97. Contd.. Indications of emergency contraception:  Sexual assault  Any unprotected sex  Mistakes using contraception such as: Condom was used incorrectly, slipped, or broke Couple incorrectly used fertility awareness method (for example, failed to abstain or to use another method during the fertile days) Failure to withdraw, as intended, before ejaculation Woman has had unprotected sex after she has missed 3 or more combined oral contraceptive pills or has started a new pack 3 or more days late 2/20/2023 Reena Bhagat 97
  • 98. Contd.. IUCD has come out of place. Woman has had unprotected sex when she is more than 4 weeks late for her repeat injection of DMPA. • If a woman is breastfeeding but not using: Post-partum Contraception and LAM) and thinks she might be at risk of pregnancy, emergency contraception may be used (except Estrogen containing). 2/20/2023 Reena Bhagat 98
  • 99. Most commonly used ECP is the POP, which contains 1.5mg levonorgestrel. The pill is available as either a single dose containing dthe full 1.5mg or two doses of 0.75mg taken 12-24 hours apart. When to Take Them?  The sooner ECPs are taken after unprotected sex, the better they prevent pregnancy.  Within 120 hours or 5 days after unprotected sex. 2/20/2023 Reena Bhagat 99
  • 100. How Effective?? • If all 100 women used ulipristal acetate ECPs, fewer than one woman would likely become pregnant. • If all 100 women used progestin-only ECPs, one woman would likely become pregnant. • Return of fertility after taking ECPs: No delay. A woman can become pregnant immediately after taking ECPs. Taking ECPs prevents pregnancy only from acts of sex that took place in the 5 days before. They will not protect a woman from pregnancy from acts of sex more than 24 hours after she takes ECPs. • Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 100
  • 101. Contd.. Side Effects: Some users report the following: • Changes in bleeding patterns, including: – Slight irregular bleeding for 1–2 days after taking ECPs – Monthly bleeding that starts earlier or later than expected In the first several days after taking ECPs: • Nausea • Abdominal pain • Fatigue • Headaches • Breast tenderness • Dizziness • Vomiting 2/20/2023 Reena Bhagat 101
  • 102. Contd.. • Contraindication: There are no known contraindications to the use of hormonal emergency contraception. The dose of hormones used in emergency contraception is small and the pills are given for a short time, so the contraindications associated with continuous use of combined hormonal contraception do not apply. • Known Health Benefits: Help protect against: Risks of pregnancy • Known Health Risks : None 2/20/2023 Reena Bhagat 102
  • 103. 3. Permanent Sterilization STERILIZATION • It is most effective method its failure rate is 1/2000 so in this there is permanent termination. •  VASECTOMY( Male Sterilization)  TUBECTOMY( Female Sterilization) 2/20/2023 Reena Bhagat 103
  • 104. a. Female Sterilization Permanent surgical contraception for women who will not want more children. The 2 surgical approaches most often used: Minilaparotomy involves making a small incision in the abdomen. The fallopian tubes are brought to the incision to be cut or blocked. Laparoscopy involves inserting a long, thin tube containing lenses into the abdomen through a small incision. This laparoscope enables the doctor to reach and block or cut the fallopian tubes in the abdomen. 2/20/2023 Reena Bhagat 104
  • 106. Contd.. Also called tubal sterilization, tubal ligation, voluntary surgical contraception, tubectomy, bi-tubal ligation, tying the tubes, minilap, and ―the operation.‖ Works because the fallopian tubes are blocked or cut. Eggs released from the ovaries cannot move down the tubes, and so they do not meet sperm. 2/20/2023 Reena Bhagat 106
  • 107. Contd.. Indications: • Family planning purposes. • Socioeconomic: An individual is adopted to accept the method after having the desired number of children. • Medico-surgical indications (therapeutic): Medical diseases such as heart disease, diabetes, chronic renal disease, hypertension are likely to worsen, if repeated pregnancies occur and hence sterilization is advisable. During third time repeat cesarean section or repair of prolapse operation, to avoid the risks involved in the future childbirth process, sterilization operation should be seriously considered. 2/20/2023 Reena Bhagat 107
  • 108. Contd.. Time of Operation: (1) During puerperium (puerperal):If the patient is otherwise healthy, the operation can be done 24–48 hours following delivery. (2) Interval: The operation is done beyond 3 months following delivery or abortion. The ideal time of operation is following the menstrual period in the proliferative phase. (3) Concurrent with MTP: Sterilization is performed along with termination of pregnancy. This is mostly done especially in the urban centers. 2/20/2023 Reena Bhagat 108
  • 109. How Effective? One of the most effective contraceptive methods but carries a small risk of failure: • Less than 1 pregnancy per 100 women over the first year after having the sterilization procedure (5 per 1,000). • Effectiveness varies slightly depending on how the tubes are blocked, but pregnancy rates are low with all techniques. One of the most effective techniques is cutting and tying the cut ends of the fallopian tubes after childbirth (postpartum female sterilization). • Protection against sexually transmitted infections ( STIs): None 2/20/2023 Reena Bhagat 109
  • 110. Contd.. • Side Effects: None • Known Health Benefits Helps protect against: Risks of pregnancy Pelvic inflammatory disease ( PID) Reduces: Risk of ectopic pregnancy • Known Health Risks • Uncommon to extremely rare: Complications of surgery and anesthesia 2/20/2023 Reena Bhagat 110
  • 111. Contd.. Complications of Surgery: Uncommon to extremely rare: • Female sterilization is a safe method of contraception. It requires surgery and anesthesia, however. Like other minor surgeries, female sterilization carries some risks, such as infection or abscess of the wound. Serious complications are uncommon. • Death, due to the procedure or anesthesia, is extremely rare. • Complications can be kept to a minimum if appropriate techniques are used and if the procedure is performed in an appropriate setting by a skilled provider. 2/20/2023 Reena Bhagat 111
  • 112. b. Male Sterilization( Vasectomy)  Permanent contraception for men who will not want more children.  Also called male sterilization and male surgical contraception.  Non-scalpel vasectomy(NSV) is done under local anesthesia making a tiny puncture over the stretched skin of the vasa. Through a puncture or small incision in the scrotum, the provider locates each of the 2 tubes that carries sperm to the penis (vas deferens) and cuts or blocks them by cutting and tying them closed or by applying heat or electricity (cautery).  Works by closing off each vas deferens, keeping sperm out of semen. Semen is ejaculated, but it cannot cause pregnancy 2/20/2023 Reena Bhagat 112
  • 113. How Effective? • One of the most effective methods but carries a small risk of failure: less than 2 women in every 1,000 will become pregnant. • Permanent. Intended to provide life-long, permanent, and very effective protection against pregnancy. Reversal is usually not possible. • Involves a safe, simple surgical procedure. 3-month delay in taking effect. The man or couple must use condoms or another contraceptive method for 3 months after the vasectomy. • Does not affect male sexual performance. 2/20/2023 Reena Bhagat 113
  • 114. Contd.. • If the partner of a man who has had a vasectomy becomes pregnant, it may be because: The couple did not always use another method during the first 3 months after the procedure The provider made a mistake The cut ends of the vas deferens grew back together The procedure is intended to be permanent. Reversal surgery is difficult, expensive, and not available in most areas. When performed, reversal surgery often does not lead to pregnancy. Protection against sexually transmitted infections (STIs): None 2/20/2023 Reena Bhagat 114
  • 116. Contd.. Advantages: (1) The operative technique is simple and can be performed by one with minimal training (2) The operation can be done as an outdoor procedure or in a mass camp even in remote villages (3) Complications—immediate or late are few (4) Failure rate is minimal—0.15 percent and there is a fair chance of success of reversal anastomosis operation (70–80 percent) (5) The overall expenditure is minimal in terms of equipment, hospital stay and doctor‘s training. 2/20/2023 Reena Bhagat 116
  • 117. Contd.. Drawbacks: (1) Additional contraceptive protection is needed for about 2–3 months following operations, i.e. till the semen becomes free of sperm. (2) Frigidity or impotency when occurs is mostly psychological. (3) Selection of candidates: Sexually active and psychologically adjusted husband having the desired number of children is an ideal one. 2/20/2023 Reena Bhagat 117
  • 118. Contd.. • Side Effects None • Complications: Uncommon to rare: • Severe scrotal or testicular pain that lasts for months or years. Uncommon to very rare: Infection at the incision site or inside the incision (uncommon with conventional incision technique; very rare with no-scalpel technique; Rare: Bleeding under the skin that may cause swelling or bruising (hematoma). 2/20/2023 Reena Bhagat 118
  • 120. Benefits of Family Planning Family Planning has multiple benefits for men, women, children, community and nation. For saving women’s lives: Reduce maternal mortality and morbidity by reducing the number of pregnancies, the number of abortion and the proportion of the births at high risk. It has been estimated that meeting women‘s need for modern contraceptives would prevent about one quarter to one third of maternal deaths. 2/20/2023 Reena Bhagat 120
  • 121. Contd.. Family Planning saves women‘s lives by: 1. Avoiding unsafe abortion. 2. Limiting risks of pregnancy and child birth 3. Limiting pregnancy to the healthiest ages, frequency and interval 4. Improve health status of adolescents For families: • Health birth spacing and smaller families which improve women‘s health. • Improved education and status for women 2/20/2023 Reena Bhagat 121
  • 122. Contd.. • Health birth spacing and smaller families which improve women‘s health. • Improved education and status for women • Improved well being of families because of mothers survival • Better nutrition and education for children specially girls For Children • Family Planning is an important part of effort to improve infant and child survival. Family Planning saves the lives of children by: 1. Spacing Birth 2. Limiting child bearing to the healthiest age 3. Spacing births helps assure that babies are adequately breastfed. 2/20/2023 Reena Bhagat 122
  • 123. Contraception forAdolescent • World Health Organization definition of adolescence as the period between 10-19 years of age. Adolescence is a period of transition from childhood to adulthood and this is not only period of growth, exploration and opportunities, but also a time of risk taking, experimentation, and vulnerability. • While adolescence generally is a healthy period of life, adolescents are often not well-informed about how to protect their sexual and reproductive health, thus are at potential risk of unwanted pregnancies, unsafe abortion, STIs, and HIV. 2/20/2023 Reena Bhagat 123
  • 124. Contd.. • They are less informed, less experienced, less comfortable, and have fewer resources to access reproductive health services including family planning than adults. Adolescents need special attention, guidance and support to address their specific concerns, problems and needs and to assist them in developing responsible behavior and a healthy lifestyle. The risks are • Unintended pregnancy • STI‘s and HIV/AIDS • Risk of maternal & infant deaths • Risks of unsafe abortion seeking behavior • Secondary Sterility 2/20/2023 Reena Bhagat 124
  • 125. Contd.. Counseling for adolescents should include discussion of the: Benefits of certain contraceptive methods (condoms) in protecting against STIs (including HBV and HIV) as well as preventing pregnancy. Safety of contraceptive method and not affecting long-term fertility. Appropriate sex education that enables adolescents to develop the knowledge and confidence to make decisions related to their sexual behavior, including the decision not to engage in sexual intercourse until they are ready to do so. 2/20/2023 Reena Bhagat 125
  • 126. Contd.. Sexuality and reproductive health with emphasis on adolescent issues: self-esteem, appearance, negotiating unwanted sexual advances, pressure from peers or partners. Address questions for adolescents on their unique condition (irregular menstruation, change in body structure, gender identification, personal hygiene, menstrual health). 2/20/2023 Reena Bhagat 126
  • 127. Contd.. Contraception for Adolescents Barrier Methods: Condoms would be better but diaphragms and cervical caps are invasive & they are unwilling. Hormonal Contraception( COCs/PoPs): Suitable for adolescents as there will be no such diseases contraindications for adolescents. Reversible and no effect in future fertility. Implants are way too long covered for some adolescents. Depo Provera: Highly recommended for adolescents who require intermediate duration effective contraception, especially if they had trouble with compliance while using another method. 2/20/2023 Reena Bhagat 127
  • 128. Contd.. IUD: Theoretically contraindicated for adolescents since it bears a risk of pelvic infections and secondary sterility. However, protects from illegal repeated abortions and death. Other Methods: Periodic abstinence is not easy for irregular cycles Withdrawal is not very reliable method for contraception. 2/20/2023 Reena Bhagat 128
  • 129. Postabortion Contraception • Women who have received safe abortion service or been treated for abortion complications need easy and immediate access to contraceptive services. • Good counseling gives support to the woman who has just been through abortion or treated for abortion complication. In particular: Try to understand what she has been through Treat her with respect and avoid judgment and criticism Ensure privacy and confidentiality Ask if she wants someone, she trusts to be present during counseling. 2/20/2023 Reena Bhagat 129
  • 130. Contd.. • WHO recommends all women should receive contraceptive information and be offered counseling, including emergency contraception, before leaving the healthcare facility. Post-abortion contraceptive counseling should include the following components: Counseling about contraceptive needs in terms of the women's reproductive goals Choices among various contraceptive methods Provision of contraceptive service Access to follow-up care Information about the need for protection against STIs including HIV and the importance of condom use for all women regardless of the contraceptive method chosen. 2/20/2023 Reena Bhagat 130
  • 131. Contd.. Time to start Postabortion Contraception • Immediate initiation of contraception following abortion is critical to reduce the risk of unintended pregnancy. • It is important to remind the woman that fertility returns soon after abortion (even before she can resume her normal period) whereas ovulation after abortion takes place within 20 days but in some cases as early as 8 days. 2/20/2023 Reena Bhagat 131
  • 132. Contd.. Guidelines for selection of Contraception Voluntary female sterilization (Minilap) Technically, minilap procedures usually can be performed immediately after an abortion. If infection or severe blood loss is present, do not perform until fully resolved. e.g. only when infection is fully resolved (3 months) or injury is healed. Voluntary male sterilization (Non-Scalpel Vasectomy) Technically, NSV procedures can be performed at any time and timing is not related to abortion Progestin-only Implants May be inserted immediately after abortion, preferably on the day of treatment. 2/20/2023 Reena Bhagat 132
  • 133. Contd.. Guidelines for selection of Contraception IUCD (CUT380 A) IUCD can be inserted immediately after surgical abortion (If there is no complication), preferably on the day of treatment IUCD can be inserted in medical abortion only when there is completion of abortion InjectablesProgestin only (E.g. Depoprovera) Can be given immediately after both surgical and medical abortion, preferably on the day of treatment CoCs (E.g. Nilocon white/Sunaulo Gulaf) and PoPs (mini pill) Can be given immediately after both surgical and medical abortion, preferably on the day of treatment 2/20/2023 Reena Bhagat 133
  • 134. Contd.. Guidelines for selection of Contraception Barriers (Condoms) Can be used immediately after both surgical and medical abortion Fertility awareness methods (Natural Family Planning Method ) Not recommended for immediate use as postabortion contraception Emergency Contraceptive Pills May be used immediately after abortion 2/20/2023 Reena Bhagat 134
  • 135. Contraception for women over 35yrs/ near perimenopause • Menopause usually occurs between the ages of 45 to 55 years. It is important to prevent pregnancy until it is clear that she is no longer fertile. She can use any method if she has no medical condition that limits its use. • Women over the age of 35 years are in need of safe and effective contraception because pregnancy can carry increased health hazards (morbidity and mortality) for mothers and their babies. Fertility declines in women over 35 years. Pregnancies, however, are possible and therefore contraception should be provided. 2/20/2023 Reena Bhagat 135
  • 136. Contd.. There are specific problems related to pregnancy in this age group: Maternal mortality among women in their forties is about five times greater than that of women in their twenties. Perinatal mortality doubles as maternal age doubles. Chromosomal abnormalities, particularly Down‘s syndrome, increases. Spontaneous abortion rates increase. 2/20/2023 Reena Bhagat 136
  • 137. Contd.. Considerations for women near perimenopause COCs  Women aged 35 and older who smoke - regardless of how much - should not use COC.  Women aged 35 years and older who are heavy smokers (>15 cigarettes per day) should not use monthly injectables. These women should be encouraged to stop smoking.  Women aged 35 or older should not use COC if they have migraine headaches (whether with migraine aura or not).  Low-dose COCs are contraceptive of choice for perimenopausal women; if there is no other contraindication, because it will regulate the menstruation cycle and prevents pregnancy. 2/20/2023 Reena Bhagat 137
  • 138. Contd.. Considerations for women near perimenopause POCs (Implants , PoPs) A good choice for woman who cannot use methods with estrogen. DMPA, if used for prolonged period of time, might decrease bone mineral density slightly. This may increase the risk of developing osteoporosis and possibly having bone fractures later, after menopause. Implants are highly recommended for women over 35 who want long-term contraception, especially if client has had trouble using another method or does not want voluntary sterilization. IUCDs IUCDs could be a better choice as it is non-hormonal. Expulsion rates fall as women grow older, and are lowest in women over 40 years of age. Insertion may be more difficult due to tightening of the cervical canal. 2/20/2023 Reena Bhagat 138
  • 139. Contd… Considerations for women near perimenopause Condoms (male and female) Only method that protects against other STIs (e.g., HBV, HIV). Affordable and convenient for women who may not have sex often. Minilap and vasectomy Appropriate for clients/couples who are certain about desire for permanent contraception Perimenopausal woman is more likely to have conditions that require delay, referral or caution for female sterilization. Emergency contraceptive pills Can be used by women of any age, including those who cannot use hormonal methods on a continuous basis. Fertility awareness methods Lack of regular cycles during perimenopausal period makes difficult to use these methods reliably 2/20/2023 Reena Bhagat 139
  • 140. Contd.. Relieving Symptoms of Menopause: Women experience physical effects before, during, and after menopause: ohot flashes, oexcess sweating, odifficulty to hold urine, or increase in nocturnal frequency of urine, ovaginal dryness that can make sex painful, and odifficulty sleeping. 2/20/2023 Reena Bhagat 140
  • 141. Contd.. Providers can suggest ways to reduce some of these symptoms: • Deep breathing from the diaphragm may make a hot flash go away faster. • Meditation and yoga could be helpful, as it helps in relaxation and joint mobility. • Eat foods like soybeans, Tofu, soya nuggets and green vegetables. • Eat foods rich in calcium (such as dairy products, beans, carom seeds and fish). 2/20/2023 Reena Bhagat 141
  • 142. Contd.. • Engage in moderate physical activity (walking and some weight bearing exercises) to help slow the loss of bone density that comes with menopause. • Vaginal lubricants or moisturizers can be used if vaginal dryness persists and causes irritation. During sex, use a commercially available vaginal lubricant, water, or saliva as a lubricant if vaginal dryness is a problem. • Refer to a gynecologist if vaginal dryness is persistent; she might need local hormonal cream. 2/20/2023 Reena Bhagat 142
  • 143. Contraception and STI including HIV • Sexually Transmitted Infections and family planning services overlap substantially. • STI/HIV are frequently encountered in family planning clients, especially among certain high-risk groups (e.g., clients who have more than one sexual partner). • Furthermore, some contraceptive methods have a range of characteristics— from protecting against STI/HIV transmission to reducing the risk of complications from STI/ HIV infection. 2/20/2023 Reena Bhagat 143
  • 144. Contd.. The main linkages between contraception and STI/HIV services are: • Prevention of STI/HIV transmission • Opportunity for client screening for STI/HIV • Counseling on FP as well as STI/HIV prevention • Treatment of STI and its consequences from the same FP outlets. 2/20/2023 Reena Bhagat 144
  • 145. Safer Conception for HIV Serodiscordant Couples When a couple wants to have a child and one partner has HIV while the other does not (a serodiscordant couple), counseling on care and treatment is done on the following basis: The partner with HIV should take antiretroviral (ARV) therapy consistently and correctly until HIV is suppressed to the point that it cannot be detected. If the partner with HIV is not virally suppressed on ARV therapy, the partner who does not have HIV (HIV- negative) can consider taking pre-exposure prophylaxis (PrEP) during the period when they are trying to conceive. 2/20/2023 Reena Bhagat 145
  • 146. Contd.. • If the woman has HIV but the man does not, a safe option for conception is artificial insemination with the uninfected partner‘s semen. Both partners should be properly screened and adequately treated for any other STI before trying for conception. 2/20/2023 Reena Bhagat 146
  • 147. Contraception and STI/HIV • Family planning providers can talk to clients about how they can protect themselves both from STI, including HIV, and pregnancy (dual protection). • Choosing a Dual Protection Strategy Every family planning client needs to think about preventing STI including HIV—even people who assume they face no risk. • The provider can discuss what situations place a person at increased risk of STI including HIV and clients can think about whether these risky situations come up in their own lives. If so, they can consider 5 dual protection strategies. 2/20/2023 Reena Bhagat 147
  • 148. Contd.. Strategy 1: Use a male or female condom correctly with every act of sex. One method helps protect against pregnancy and STI including HIV. Strategy 2: Use condoms consistently and correctly plus another family planning method. Adds extra protection from pregnancy in case a condom is not used correctly. May be a good choice for women who want to be sure to avoid pregnancy but cannot always pressure their partners to use condoms. 2/20/2023 Reena Bhagat 148
  • 149. Contd.. Strategy 3: If both partners know they are not infected, use any family planning method to prevent pregnancy and stay in a mutually faithful relationship. Many family planning clients are in this group and thus are protected from STI including HIV. Depends on communication and trust between partners. 2/20/2023 Reena Bhagat 149
  • 150. Contd. Strategy 4: Engage only in safer sexual intimacy that avoids intercourse or otherwise prevents semen and vaginal fluids from coming in contact with each other’s genitals. This strategy will not prevent syphilis, genital herpes, or infection with human papillomavirus. These infections may spread even through skin-to-skin contact. Depends on communication, trust, and self-control. If this is a person‘s first-choice strategy, it is best to have condoms at hand in case the couple desire to have sex. 2/20/2023 Reena Bhagat 150
  • 151. Contd.. Strategy 5: Delay or avoid sexual activity (either avoiding sex all the time or abstaining for a longer time). This strategy is always available in case a condom is not at hand. If this is a person‘s first-choice strategy, it is best to have condoms at hand in case the couple desire to have sex. People at high risk of HIV infection can take PrEP— pre-exposure prophylaxis. This daily treatment with oral antiretroviral drugs greatly reduces the chances of infection if exposed to HIV. 2/20/2023 Reena Bhagat 151
  • 152. Counseling Outline and Clinical Recommendations Method Remarks Regarding STI COCs No protection against STI including HBV, HIV. If high risk behavior or previous STI detected in screening history, concurrent use of condoms is recommended. POCs (Implants and Depo) No protection against STI including HBV, HIV. If high-risk behavior or previous STI detected in screening history, concurrent use of condoms is recommended. Condoms (male and female) Protect against STI including HBV, HIV. • To be fully effective, condoms must be worn at all times during genital contact, and with every act of intercourse. 2/20/2023 Reena Bhagat 152
  • 153. Method Remarks Regarding STI IUCDs  No protection against STI including HBV, HIV.  Should not be used by women at risk for or with clinical findings of STI. If such a client insists on using an IUCD, concurrent use of condoms is required.  Should not be used by women with current, recent (less than 3 months) or having recurrent PID.  If there is clinical findings of vaginal infection (candidiasis or bacterial vaginosis), treat and recheck before IUCD is inserted. Minilap and NSV  No protection against STI including HBV, HIV.  If high-risk behavior or previous STI detected in screening history, concurrent use of condoms is recommended. 2/20/2023 Reena Bhagat 153