FAMILY PLANNING CONTRACEPTION ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU

FAMILY PLANNING & CONTRACEPTION ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, Ph. D

FAMILY PLANNING Aspects of the problem l national l social l personal l ethnic In no other branch of medicine are social, religious, and political forces more obvious than in family planning.

CONTRACEPTION l Definition – avoiding an unwanted pregnancy Elective abortion is not a contraceptive technique. l l no contraception + presumably fertile sex partners = about 90 % of women will conceive within 1 year. While there is no totally safe contraceptive method, and the lack of contraception is even more dangerous, both are less dangerous than driving an automobile for 1 year.

CONTRACEPTION l Classification of the methods 1. the user – male / female 2. the duration – temporary (reversible) / permanent (irreversible) 3. the type: hormonal, mechanical, chemical, natural, surgical, mixed 4. emergency or routine contraception

CONTRACEPTION l Effectiveness – Pearl Index Total no. of accidental pregnancies x 1200 / total months of use = % per 100 women-years of exposure l Failure rates for some methods vary considerably, largely because of the potential for failure caused by imperfect use (user failure) rather than an intrinsic failure of the method itself.

CONTRACEPTION The characteristics of the ideal contraceptive method • highly effective • no side effects • cheap / gratis • independent of intercourse • rapidly reversible • widespread availability • acceptable to all cultures and religions • easily distributed • easily administrated (by non - healthcare personnel).

CONTRACEPTION l. Contraceptive counselling q the contraceptive choice q the provision of method q the advice on using the method

CONTRACEPTION Classification Hormonal contraception l Intrauterine contraception Copper intrauterine device (IUD) Hormone-releasing intrauterine system (IUS) l Barrier methods Condoms (male, female) Female barriers l Natural family planning methods: Periodic abstinence, Coitus interruptus, Lactation l Emergency contraception l Sterilization Female sterilization Vasectomy l

CONTRACEPTION l Hormonal contraception 1) Combined oral contraceptive pills (COC) 2) Combined hormonal patches 3) Vaginal ring 4) Progestogen-only preparations - Progestogen-only pills (POP) - Injectables - Subdermal implants

Hormonal contraception • Combined hormonal patches – Ortho Evra Vaginal ring - Nuva. Ring etonogestrel + EE •

Hormonal contraception Progestogen-only preparations Progestogen-only pills (POP) – Cerazette contains desogestrel. l Injectables - norethindrone enanthate (NET – EN) – 8 weeks - medroxiprogesteron acetate depot (DMPA) – 12 weeks l

Hormonal contraception Subdermal implants l delivery of a steroid progestin from polymer capsules or rods placed under the skin. l Implanon - 4 cm/ 2 mm Implanon rod contains 68 milligrams of etonogestrel milligrams of which is released over a 3 year period.

COMBINED ORAL CONTRACEPTIVE PILL

Formulations 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); 3. Triphasic (the amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases). 1.

Estrogens l Types of estrogen ethinyl estradiol, mestranol, a “prodrug” that is converted in vivo to ethinyl estradiol, ex: Zoely - acetat de nomegestrol + estradiol estetrol

Progestins can be classified according to their chemical structure as 19 -nortestosteron derivatives: norethisteron, linestrenol, etinodiol diacetat şi levonorgestrel; 17 alfa-hidroxiprogesteron derivatives: medroxiprogesteron acetat, clormadinon acetat, cyproteron acetate; progestines of the new generation: desogestrel, gestodene, dienogest, norgestimate spironoloctone derivatives - drospirenone l

EFFICACY l The combined OC = a highly effective method of reversible contraception. l With perfect use, the combined OC is 99. 9% effective in preventing pregnancy. l However, typical use = failure rates range from 3 - 8%.

MECHANISM OF ACTION l. Main mechanism of action is to suppress gonadotropin secretion, thereby inhibiting ovulation.

MECHANISM OF ACTION l Additional 1. endometrial mechanisms of action atrophy, making the endometrium unreceptive to implantation; 2. Increased viscousity of the cervical mucus impedes sperm transport; 3. effect on fluid secretion and peristalsis within the fallopian tube, which interferes with ovum and sperm transport.

INDICATIONS l In the absence of contraindications, use of the combined OC may be considered for any woman seeking a reliable, reversible, coitally-independent method of contraception.

CONTRAINDICATIONS l The World Health Organization (WHO) has developed a list of absolute and relative contraindications to the use of combined OCs, based on the available evidence of risks

ABSOLUTE CONTRAINDICATIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. < 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 Breast cancer (current)

RELATIVE CONTRAINDICATIONS 1. 2. 3. 4. 5. 6. 7. 8. Smoker over the age of 35 (< 15 cigarettes per day) 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

SIDE-EFFECTS l. Some combined OC users will experience minor side-effects, most commonly during the first 3 cycles. l. These side-effects may lead to discontinuation of the combined OC.

SIDE-EFFECTS The most common reason patients discontinue combined OC use 1. Abnormal menstrual bleeding, 2. Nausea, 3. Weight gain, 4. Mood changes, 5. Breast tenderness, 6. Headache. l

WEIGHT GAIN l Placebo-controlled trials have failed to show any association between low-dose combined COC and weight gain. l Studies comparing the COC to other contraceptive methods have failed to show a significant associated weight gain.

BREAST CANCER l The risk of breast cancer in combined OC users is still controversial. l The research suggested that there was a small but significant increase in risk of breast cancer in women who are smokers and currently taking the combined OC and in the first 10 years after discontinuing it.

CERVICAL CANCER l Long-term COC use may increase the risk of cervical cancer in women who are HPV positive but not in women who are HPV negative. l Infection with HPV, as the major risk factor for cervical cancer, is related to sexual behaviour.

NON-CONTRACEPTIVE BENEFITS 1. Decreased 2. endometrial 3. cancer 4. 2. Decreased 5. ovarian cancer 6. 3. Decreased 7. risk of 8. fibroids, endometriosis 9. 1. Cycle regulation Decreased menstrual flow Increased bone mineral density Decreased dysmenorrhea Decreased peri-menopausal symptoms Decreased acne Decreased hirsutism Decreased incidence of salpingitis and PID Possibly fewer ovarian cysts 10. Possibly fewer cases of benign breast disease 11. Possibly less colorectal carcinoma

1. PATIENT ASSESSMENT Before prescribing a COC, a thorough history should be taken, including potential contraindications, smoking history, and medications. l The physical examination should include a blood pressure measurement. l

1. PATIENT ASSESSMENT l. No routine laboratory screening is required. 2. Counselling

I. U. D. (Intra Uterine Device for contraception)

First generation I. U. D. is Lipes loop Second generation I. U. D. is Copper T-200 Third generation I. U. D. is Gyne-T 380 With 8 years Intra uterine life

MIRENA Jaydess A capsule on the Stem contain mixture Of silicon rubber & 60 mg of progestin 60 mg Levonorgestrel Developed by steroid research Laboratory-Finland Forth generation I. U. D. releasing 20 mcg per day estimated to last 5 years.