CONTRACEPTION RAHAF HASANEIN DEFINITION Methods used to prevent

CONTRACEPTION RAHAF HASANEIN

DEFINITION Methods used to prevent pregnancy for a period of time acc. to patient needs. Family planning: a method to organize pregnancies number, frequency and in-between pregnancy interval. Pearl Index (PI): the number of women having regular intercourse who become pregnant within a year out of 100 couples using the same method.

CHARACTERISTICS THAT SHOULD BE IN ANY CONTRACEPTION? Affordable Reversible High success rate (efficacy) Minimal side effects (safe) Easy to use Doesn’t counteract social, personal or religious background of the patient.

CONTRACEPTION METHODS Natural Hormonal Types Barriers Mechanic al Surgical

NATURAL METHODS

1. CALENDAR METHOD: This method is based on avoiding sexual intercourse around the time of predicted ovulation.

2. WITHDRAWAL (COITUS INTERRUPTUS) - Ejaculation outside. - High degree of discipline required. - Semen can enter vagina and cervical mucus prior to ejaculation.

3. LACTATIONAL AMENORRHEA?

BENEFITS OF NATURAL METHODS 1. Minimal side effects. 2. Cost free. 3. Easy to use. 4. Reversible. 5. Acceptable.

NATURAL METHODS Maximum success rate(80 -85%), but variable due to personal errors. Depends on psychological state of the couple especially in coitus interruptus (so personal errors are high). No protection against STDs.

HORMONAL METHODS

1. ORAL Mini combined

MINI-PILLS Thickening of cervical mucous PI: 2 -3% Progesterone: peripheral action. - central action? Atrophy of endometrium Reduce cilia motion in the fallopian tube

MINI-PILLS Continuous/ daily No withdrawal bleeding.

PROGESTIN-MEDIATED METABOLIC EFFECTS Breakthrough bleeding Mood changes and depression from decreased serotonin levels. Androgenic effects (e. g. , weight gain, acne). Unhealthy lipid profile changes (decreased HDL, increased LDL). increased prevalence of follicular ovarian cysts.

COMBINED PILLS PI: 1 -2% Estrogen effect (central). Prevent ovulation Thickening of cervical mucous Progesterone (peripheral) Atrophy of endometrium Reduce cilia motion in the fallopian tube

COMBINED PILLS/ HOW TO USE? Daily for 3 weeks (21 days). 7 days free for Withdrawal bleeding.

COMBINED CONTRACEPTIVES SIDE EFFECTS 1. Arterial and venous thromboembolic disease 2. Headache 3. Nausea+ vomiting 4. Breast tenderness 5. Increase incidence of breast Ca. 6. HTN 7. Gallstones 8. Weight gain 9. Fluid retention

CONTRAINDICATIONS: 1. Undiagnosed vaginal bleeding 6. Uncontrolled DM or HTN 2. pregnancy 7. Gallstones 3. Hormone dependent Ca. 8. migraines with auras 4. Chronic liver or renal disease 9. lactation. 5. history of vascular disease (e. g. , 10. Thrombophilia/ coagulation disorders. thromboembolism, deep venous thrombosis [DVT], cerebrovascular accident [CVA], systemic lupus erythematosus [SLE]

RELATIVE CONTRAINDICATIONS: (MINOR) 1. Obesity 2. Smoker 3. >35 years.

OTHER USES/ SYMPTOMATIC RELIEF 1. Dysmenorrhea 2. Endometriosis 3. Fibroids 4. Menorrhagia 5. PCOS 6. PMS

BENEFITS 1. Protective against endometrial, ovarian and rectal Ca. 2. Decrease PID and ectopic pregnancy. 3. Treat anemia by decreasing menorrhagia 4. Reduce osteoporosis.

2. INJECTION (PROGESTERONE) medroxyprogesterone acetate (depot) 12 weeks IM injection Norethisterone 8 weeks

Advantages Disadvantages 1. Better Compliance. 1. Breakthrough bleeding. 2. Affordable 2. Post-pill amenorrhea and Prolonged time for 3. Avoids GI side effects. 4. Pearl index (<1%) fertility to back. 3. Functional ovarian cyst with prolong use. 4. Osteoporotic changes (increase osteoclastic activity). 5. Injection site pain.

3. TRANSDERMAL PATCH (ORTHO EVRA) COMBINED 3 weeks then 1 week free (change it every week) In outer aspect of arm. Waterproof, Painless Better compliance than oral. Easy to use, Reversible. Avoid GI side effects. Pearl index (2%) More expensive to people. serum level?

4. IMPLANT (PROGESTERONE) Subdermal (in inner aspect) Avoid compliance (3 years duration) Avoid GI side effects Pearl index (1 -2%). Reversible by next period.

IMPLANT/ DISADVANTAGES Incision Local anesthesia. Trained person to put and remove Breakthrough bleeding (decrease compliance)

5. VAGINAL RING (NUVA RING) ESTROGEN AND 3 weeks and 1 week break for withdrawal bleeding. Decrease GI side effects Disadvantages: 1. Expensive 2. Not always available 3. Difficult to use PROGESTIN.

BARRIERS Local devices preventing entry of sperm in through the cervix, thus preventing pregnancy. No systemic side effects.

BARRIERS Failure rate near 15 -20%. Coitally dependent, requiring a decision for each use. Risk of rupture.

FEMALES: DIAPHRAGM/CAP/SPONGE 1. Difficult to use (Needs training). 2. Not affordable 3. Need spermicide (chronic use cause mucosa friability) 4. Not protective against STDs 5. Individual fitting is required (if too large a size is used, can result in urinary retention).

MALES (CONDOMS) Advantages: Disadvantages: Prevent STDs. Allergy to latex Easy, affordable and reversible. Pre-ejaculatory discharge.

MECHANICAL (IUCD) long-acting reversible contraceptive method that involves placement of a small T-shaped object inside the uterus.

MECHANICAL (IUCD): HORMONAL AND COPPER Mechanism of action: - Induce sterile inflammatory reaction in uterus. (hostile environment for implantation) - Progesterone effect: thinning of endometrium and thickening of cervical mucosa. - Spermicidal effect. Success rate 99. 5% Copper (up to 10 years) Hormonal (3 -5 years)

SHORT-TERM COMPLICATIONS (UP TO 6 WEEKS) 1. Bleeding 2. Perforation 3. Infection (cupper higher rate of infection) 4. Migration. 5. Expulsion ( higher in postpartum).

LONG-TERM COMPLICATIONS (> 6 WEEKS) 1. Migration. 2. Expulsion ( higher in postpartum).

SPECIFIC COMPLICATIONS Copper Menorrhagia and increase menstrual pain. Hormonal Oligomenorrhea Amenorrhea in 15% Less than 5% will have menorrhagia.

Absolute contraindications undiagnosed vaginal bleeding confirmed or suspected pregnancy. Known or suspected pelvic malignancy Acute PID or acute on top of chronic. Abnormal uterine size or shape. Relative contraindications Medical condition (e. g. , corticosteroid therapy, valvular heart disease, or any instance of immune suppression increasing the risk of infection), History of ectopic pregnancy.

PREGNANCY WHILE USING IUCD? Remove it if in the 1 st trimester and easy to remove. After that keep it.

SURGICAL

MALES Bilateral vasectomy - Outpatient - No general anesthesia - Contraception not immediately. Surgical side effects: 1. Bleeding 2. Pain Long-term side effects: development of anti-sperm antibodies And chronic testicular pain Intended to be irreversible. (microsurgery)

FEMALES Bilateral tubal ligation - Contraception starts immediately. - General anesthesia/admission Surgical Side effects: 1. Infection 2. Bleeding 3. Nearby organ trauma Long-term side effects: Period changes - Not pregnant/ no unprotected intercourse before procedure/ immediately after period. Intended to be irreversible (microsurgery) Failure?

HYSTEROSCOPIC STERILIZATION (ESSURE) This a permanently implanted device for female sterilization that requires no surgical incision. In an office procedure, flexible coils are hysteroscopically placed through the vagina and uterus into the isthmic portion of the fallopian tubes. Over about three months, scar tissue forms around the inserts. The build-up of tissue creates a barrier that keeps sperm from reaching the eggs, thus preventing conception. A hysterosalpingogram is used to confirm tubal blockage.

EMERGENCY CONTRACEPTION

1. PROGESTERONE Higher in dose than the regular. 1 st dose within 72 hours then another dose next 12 hours.

2. IUCD (COPPER) Within 5 days of unprotected intercourse. Or up to 5 days of expected ovulation.

3. COMBINED 2 doses 12 hours apart.

MISSED TABLETS

Minipills <12 hours >12 hours

combine d 1 st 2 weeks 2 pills or less 3 rd week More than 2

THANK YOU