CONTRACEPTION Prepared by ekh KKU MD ABHA Introduction

CONTRACEPTION Prepared by: ekh KKU, MD, ABHA

Introduction : Family size is determined by a number of factors, including social and religious customs, economic aspirations, knowledge of contraception and the availability of reliable methods to regulate fertility.

Definitioin The ability to control fertility by reliable artificial methods has transformed both social epidemiological aspects of human reproduction.

Mechanism of contraception: By: • Inhibition of ovulation • Prevention of implantation of the fertilized ovum ◦ • Barrier methods of contraception, whereby the spermatozoa are physically prevented from gaining access to the cervix. The effectiveness of any method of contraception is measured by the number of unwanted pregnancies that occur during 100 women years of exposure, i. e. during 1 year in 100 women who are normally fertile and are having regular coitus.

Classification of contraception method; A) Temporary method: 1 Barrier method of contraception 2 Intrauterine contraceptive Device 3 Hormonal contraception 4 Emergency contraception 5 Non medical contraception (physiological) B)Permanent method Sterilization

1 Barrier method: Uses: 1 To prevents spermatozoa from reaching the female upper genital tract. 2 protection against sexually transmitted infection. The Barrier method include the following : 1 male condom. 2 female condom. 3 Diphragm & cervical caps. 4 spermicide&sponges.

barrier methods Male Condom s A male condom is a thin sheath made of latex or other materials -They have 97 - 9 8% effective with careful use. -although typical failure rates can be as high as 15 pregnancies per 100 women years. -Common causes of failure are: leakage of sperm when the penis is withdrawn, putting the condom on after genital contact, use of lubricants that cause the latex to break and mechanical damage.

Advantges of male condom: No medical side-effects. inexpensive, easily used. Protecting against STDs. men maintain an erection for a longer period.

barrier methods Strong, soft, transparent polyurethane sheath inserted in the vagina before sexual intercourse -Failure rate 21 % 15 cm long X 7 cm diameter

Characteristics of female condoms - protection against STDs -Available without a prescription Are stronger than latex male condoms (40% stronger) Can be used with oil-based lubricants

Diphragm & cervical caps shallow rubber dom with a firm flexible rim These diaphragms vary in size from 45 mm to 100 mm in diameter. ) & inserted to cover the cervix and anterior vaginal wall. The diaphragm must be inserted prior to intercourse and should not be removed until at least 6 hours later. typical failure rates are between 8 and 10 pregnancies per 100 women years. .

Contraindication of diaphragm : --Allergy to rubber, latex, or spermicide (male & female ) --Frequent urinary tract or bladder infections --Aanatomical abnormalities The main advantage: it is free of side effects to the woman, apart from an occasional reaction to the contraceptive cream.

2 -I N T R A U T E R I N E CONTRACEPTIVE DEVICES Defination: A device inserted into the uterus (womb) to prevent conception (pregnancy). Mechanism of action: Intrauterine devices (IUDs) prevent fertilization primarily by interfering with the ability of sperm to survive and to ascend the fallopian tubes, where fertilization occurs. Having a foreign body in the uterus, such as an IUD, causes both anatomical and biochemical changes that appear to be toxic to sperm

Types of device Inert devices Lippes loops, Saf T coils and Margulis spirals are plastic or plastic coated devices. They have a thread attached that protrudes through the cervix and allows the woman to check that the device is still in place. Inert devices tend to be relatively large. They are not now available but may still be found in situ in some older users Pharmacologically active devices The addition of copper to a contraceptive device produces a direct effect on the endometrium by interfering with endometrial oestrogen binding sites and depressing uptake of thymidine into DNA. It also impairs glycogen storage in the endometrium. Examples of such devices are the Copper T or Copper 7 (first generation), the Multiload Copper 250 (second generation) and the Copper T 380 (third generation).

Devices containing progestogen The levonorgestrel releasing intrauterine system or Mirena® contains 52 mg of levonorgestrel ; this provides protection against pregnancy for 5 years with a failure rate of 0. 3 1. 1%, comparable to third generation copper devices

L i fe span of devices The Cu T 380 is licensed for 8 years in the UK (13 in the USA). Other copper devices and the Mirena® are licensed for 5 years. However, IUDs do not need to be replaced in women over 40. They should be left in place until 2 years after the menopause if this occurs under 50 and 1 year otherwise. Contraindications • Previous PID. • Previous ectopic pregnancy. • Known malformation of the uterus. • Copper allergy (but could use an IUS).

Complication of IUD:

Complication : 1 -Perforation of the uterus. 2 -Pelvic pain. Pain occurs either in a chronic low grade form or as severe dysmenorrhoea. The incidence is widely variable, with up to 50% of women suffering some pain. 3 -Vaginal Discharge Vaginal discharge may be due to infection but most women with an IUD develop a slight watery or mucoid discharge. 4 -Ectopic pregnancy 5 -abnormal uterine bleeding. Increased menstrual loss occurs in most women with an IUD but can be tolerated by the majority. However, in 15% of such women it is sufficiently severe to necessitate removal of the device. It can be controlled by drugs such as tranexamic acid or trual bleeding may also occur but if the loss is

3 -HORMONAL CONTRACEPTION

Hormonal Methods : Oral Contraceptives. (Birth Control Pill) Injections. Skin paches. Vaginal ring.

oral contraceptives (Ocs)

Types of oral contraceptives (Ocs) a )Combined oral contraceptives (COCs): most widely used , contain both: - An estrogen : Ethinyl Estradiol A progestogen: (levonorgestrel is the most widely used progestogen ) b )Progestin-only pills (POPS): Contain only a progestogen, mostly levonorgestrel (no estrogen). Especially suitable for breastfeeding women , women with contraindications to combined OCPs(e. g. thromboembolic or myocardial diseases. - No absolut containdication for it.

EFFICACY The OC pills is a highly effective method of reversible contraception. With perfect use, the combined OC is 99. 9% effective in preventing pregnancy.

Combined pill The combined pill contains (ethinyloestradiol) and progestogen. The pill is taken for 21 days started at the 5 th day of menstural , followed by a 7 -day pillfree interval during which there is a withdrawal bleed. Every day (ED) preparations include seven placebo pills that are taken instead of a pill free week. The concentration of the hormones may be the same throughout the 21 days (monophasic preparations) or vary across the cycle (biphasic and triphasic preparations) in order to reduce breakthrough bleeding.

Formulations may be : Monophasic (each tablet contains a fixed amount of estrogen and progestin); 2. Biphasic (each tablet contains a fixed amount of estrogen, while the amount of progestin increases in the second half of the cycle); or 3. Triphasic (the amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases). 1.

MECHANISM OF ACTION OF HORMONAL CONTRACEPTIVES Its main mechanism of action is to suppress : gonadotrophin secretion.

Progestogen only pill Start at day 1 of the menstrual cycle Anytime you can be reasonably sure the patient is not pregnant Postpartum: after 6 months if using lactational amenorrhea method (LAM) after 6 weeks if breastfeeding but not using LAM immediately or within 6 weeks if not breastfeeding Postabortion (immediately) They are taken continuously on the basis of one tablet daily. Because of the low dose, they should be taken at the same time every day.

MECHANISM OF ACTION OF HORMONAL CONTRACEPTIVE Combined and triphasic pills are by suppressing gonado-trophin secretion and, in particular, the luteinizing hormone peak. The endometrium becomes unsuitable for nidation and the cervical mucus becomes hostile. Progesteroneonly pills alter the endometrial maturation and affect cervical mucus. Ovulation is suppressed in only 4 0% of women.

INDICATIONS for any woman seeking : a reliable, reversible, coitally independent method of contraception. for women who wish to take advantage of : its noncontraceptive benefits.

NON-CONTRACEPTIVE BENEFITS Cycle regulation 2. Decreased menstrual flow 3. Decreased dysmenorrhea 4. Decreased endometrial cancer 4. Decreased ovarian cancer 5. Decreased risk of fibroids 6. Possibly fewer ovarian cysts 7. Decreased acne 8. Decreased hirsutism 9. Possibly fewer cases of benign breast disease. 10. Protect against pelvic inflamatory diseases. 1.

INITIATIO N

INITIATION 1. PATIENT ASSESSMENT Before prescribing a OC, a complete general history should be taken. Then physical examination should doing. 2. COUNSELLING Adequate counseling prior to initiation of OCs may help to improve compliance (regular use) and adherence (continuation). Discussing risks and warning signs, including when to seek medical care. 3. PRESCRIPTION The OC is started during the first 5 days of the menstrual cycle.

Side effects of oral contraceptives: - -venous thrombosis : the risk increas. -arterial disease : the risk increase. -breast and cervical cacer : small increase in relative risk. -gall stone formation & cholecystitis and glucose intolerance : the risk increase.

Contraindications There are various contraindications to the pill, some being more absolute than others.

ABSOLUTE CONTRAINDICATIONS 1. 2. 3. 4. 5. 6. 7. 8. Pregnancy & < 6 weeks postpartum if breastfeeding Smoker over the age of 35 (≥ 15 cigarettes per day) Hypertension (systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg) Current or past history of venous thromboembolism (VTE) Ischemic heart disease History of cerebrovascular accident Complicated valvular heart disease Migraine headache with focal neurological symptoms

RELATIVE CONTRAINDICATIONS 1. 2. 3. 4. 5. 6. 7. Adequately controlled hypertension Hypertension (systolic 140– 159 mm Hg, diastolic 90– 99 mm Hg) Migraine headache over the age of 35 Currently symptomatic gallbladder disease Mild cirrhosis History of combined OC related cholestasis Users of medications that may interfere with combined OC metabolism

Injectable contraceptives

Introduction Injectable contraceptives contain hormonal drugs that provide women with safe, highly effective, and reversible contraceptive protection. There are currently two main types: 1 Depo Provera® contains 150 mg of medroxyprogesterone acetate and is given as a 3 monthly intramuscular injection 2 Implanon® is a single Silastic rod containing etono gestrel that is inserted subdermally in the upper arm and is effective for up to 3 years.

Mode of Action injectable contraceptives exert their contraceptive effect mainly by suppressing ovulation. In addition, thickening of the cervical mucus (mainly due to the progestagen) presents an obstacle to sperm penetration. There additional changes in the endometrium that make it unfavourable to implantation; however, the first two effects make fertilisation highly unlikely.

Efficacy The reported failure rates are low, and come within the narrow range of 0. 1% to 0. 6%.

Beneficial Effects Prevention of pregnancy. Sickle cell disease: : fewer crises. Anaemia: increase haemoglobin concentration, mainly by reducing menstrual blood loss. Endometrial cancer: protect against this form of cancer. against pelvic inflammatory disease (PID).

Side effects of injectable contraceptives: Menstrual changes: should be clearly explained to women before use (more common with progestin only injectables than com bined injectables) Spotting, irregular bleeding Prolonged or heavy bleeding Amenorrhea Weight gain Less common side effects include headaches, dizziness, breast tenderness and mood changes

Contra indication Pregnancy Unexplained vaginal bleeding Breast cancer Complicated diabetes Current or past history of ischaemic heart disease Past cerebrovascular accident (stroke) Active liver disease, cirrhosis, liver tumors Breastfeeding mothers less than 6 weeks following childbirth

Contraceptive Vaginal Ring

Contraceptive vaginal rings The contraceptive vaginal ring is a flexible, soft, transparent ring. The ring can be easily inserted in the vagina and removed by the women herself. After insertion, the ring is left in the vagina for three weeks and then removed. The woman remains ring free for one week after which a new ring is inserted. The ring can be inserted any time during the first 5 days of the menstrual cycle.

Contraceptive vaginal rings The method prevents pregnancy mainly by inhibition of ovulation that is achieved by a lower dose of ethinyl estradiol than the oral pills It is highly effective, and induces good cycle control. Most common causes for discontinuation are a foreign body sensation, coital problems and expulsion of the device

contraceptive patch

contraceptive patch A contraceptive patch is a transdermal patch applied to the skin that releases synthetic estrogen and progestin hormones to prevent pregnancy. They have been shown to be as effective as the combined oral contraceptive pill with perfect use , which means she does not release an egg that could be fertilized by a man's sperm. The patch also thickens a woman's cervical mucus, which makes it harder for sperm to enter the womb, and the patch may be more effective in typical use.

Method of use A woman applies her first patch onto her upper outer arm, buttocks, abdomen or thigh on either the first day of her menstrual cycle. The patch is used on a weekly 28 day cycle, similar to birth control pills. Each box contains three patches. A patch is worn for a 7 day period, then removed and replaced with a new patch. Every new patch should be applied on the same day of the week. After using three patches in a row, no patch is worn during the fourth week. This "hormone free" week allows a woman to get her menstrual

How effective is it? When used correctly, the patch is 99% effective. It may be less effective in women weighing more than 90 Kg. patch within 24 hours of getting her menstrual period. 3% failure rate with typical use.

4 - Emergency contraception: Emergency contraception (EC), or emergency postcoital contraception, refers to contraceptive measures that, if taken after sex, may prevent pregnancy , ECPs are effective when used shortly before intercourse, and are licensed for use up to 72 hours after sexual intercourse.

Emergency contraception

Forms of EC include: Emergency contraceptive pills (ECPs): sometimes referred to the "morning-after pill"— are drugs that act both to prevent ovulation or fertilization and possibly post-fertilization implantation of blastocyte(emberyo). (IUDs): usually used as a primary contraception method, but sometimes used as emergency contraception

Types of ECPs: The progestin-only method uses the progestin levonorgestrel such as Levonelle , Nor. Levo & Postinor-2. The combined uses large doses of both estrogen and progestin, taken as two doses at a 12 hour interval. This method is now believed to be less effective and less well tolerated than the progestin only method. The drug mifepristone may be used as an ECP or as abortion pill. Higher doses of mifepristone can disrupt implantation and, unlike levonorgestrel, mifepristone is effective in terminating established pregnancies. So it is used also for abortion. Ulipristal acetate (Ellaone), a drug similar to mifepristone. Morning after pills (ECPs) are not to be confused with mifepristone used as an “abortion pill"

Side effects: The most common side effect reported by users of emergency contraceptive pills was nausea; vomiting. abdominal pain, fatigue, headache, dizziness, and breast tenderness. Side effects usually do not occur for more than a few days after treatment, and they generally resolve within 24 hours. Temporary disruption of the menstrual cycle is also commonly experienced.

5 -NONMEDICAL METHODS OF CONTRACEPTION: It depends on the physiology of the mens. Cycle. The most fertile phase occur at the time of ovulation which occur between day 12 & day 14. There are natural methods of family planning include the following : 1)Rhythm method: avoid mid cycle intercourse for 3 4 days either side the mid cycle. 2)Coitus interruptus ( withdrawal ) : relies on withdrawal of penis before ejaculation. 3)Lactational Amenorrhoea : breastfeding is the most important means of the family planning. Ovulation resumes on average 4 6 months later in women who continue to breastfeed & during the 1 st 6 months after birth.

Sterilization: Female Sterilization is a permanent means of contraception. Tubal ligation (also known as tubal sterilization). A procedure called hysteroscopic sterilization is another method of permanent female sterilization. Tubal ligation; involves closing off the fallopian tubes to prevent the egg from reaching the uterus, where it can be fertilized. The ends of the fallopian tubes are closed off by burning them (using electro cauterization or electro coagulation) with a laser, or by putting clips or bands around them.

There are 3 methods of tubal ligation; the most common are the minilaparotomy and laparascopy: A minilaparotomy : involves making a small incision in the abdomen, locating the tubes, and cutting and closing them off. A laparoscopic tubal ligation: involves inflating the abdomen with carbon dioxide or nitrous oxide gas, making a small incision in the abdominal wall, and inserting a fiberoptic light and an instrument that coagulates the tubes with an electric current or puts a clip or plastic band around the end of each tube. Laparascopy requires a smaller incision than a minilaparatomy, is less painful. Tubal sterilization is reversible. With microsurgical techniques, the success rate of reversal surgery is about 75 -85% in women who are able to undergo reversal surgery. . Thus, despite the fact that it is reversible, female sterilization is considered a permanent method of contraception.

Male Sterilization: Vasectomy A vasectomy is considered a permanent method of birth control. A vasectomy prevents the release of sperm when a man ejaculates. During a vasectomy, the vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing with the semen that is ejaculated from the penis. An egg cannot be fertilized when there are no sperm in the semen. The testicles continue to produce sperm, but the sperm are reabsorbed by the body. (This also happens to sperm that are not ejaculated after a while, regardless of whether you have had a vasectomy. ) Because the tubes are blocked before the seminal vesicles and prostate, you still ejaculate about the same amount of fluid