contraceptionx 2 by liza tarca, md
TRANSCRIPT
Family Planning & Contraception
Liza Tarca-Cruz, MDDepartment of Obstetrics and Gynecology
Emilio Aguinaldo College of Medicine – Medical Center Manila
Family Planning or Contraception
“ a basic human right that benefits everyone”
Tabbakh
Goal
• Enable couples and individuals to choose – How many children they want– When to have them
• Best Achieve– Providing safe and effective methods– Information dissemination
Our Role as Medical Experts
“First do no harm”
(primum non nocere, Hippocrates ) 400 B.C
Philippines
Most Popular Contraception Method
Classification of Contraception
A.Natural or Fertility Awareness Method1. Standard Days Method
2. Calendar Rhythm Method
3. Symptoms Based Methoda. Temperature Rhythm Method
b. Cervical Mucus Rhythm Method
c. Sympthotermal Method
B.Lactation Amenorrhea
1.Artificial Method
1. Medical or Hormonal
2. Barrier
3. Permanent Sterilization
Fertility Awareness Method
• Natural Family Planning (NFP)– Sexual abstinence during fertile period
• Fertility Awareness Combined Method (FACM)– Using barrier method during the fertile time
Natural or Fertility Awareness Method
• Fertility Awareness–Fertile time of the menstrual cycle starts and ends–Ovum is fertilized 12 to 24 hours after ovulation–Ovulation may oocur 6 weeks post partum
•Periodic Abstinence• Natural Family Planning
Standard Days Method
• Avoid unprotected intercourse– Day 8 to 19
• Regular monthly cycles of 26 to 32 days• Use of cycle beads
Cycle Beads
Calendar Rhythm Method
• Counting the number of days in shortest and longest menstrual cycle during 6 to 12 month span
fertile timefertile time
Subtract 18 from the shortest cycle18 from the shortest cycle & 11 from the 11 from the longest cycle.longest cycle.
e.g : shortest cycle is 26 days & longest cycle is 34 days,
abstain from sexual relations from
Day 88 (26-18=8) through Day 2323 (34-11=23)
How to tell when you may be fertile ?
Chances of Pregnancy by Day of Intercourseday zero is ovulation
-5 -4 -3 -2 -1 0 1 2 3
0% 11% 15% 20% 26% 15% 9% 5% 0%
CALENDAR METHOD ( RHYTHM )
Symptom Base Method
• Billings Method – Cervical Mucus Method or Ovulation Method
• Cervical secretions or feeling of wetness
• Basal Body Temperature (BBT)– Slight body temperature rise after released of a fertilized egg– Temperature remains elevated until the start of next cycle
• Symptothermal Method– Combination of BBT and Billings Method
• 2 Day Method
Billings Method• Avoid unprotected sex
when secretions begin until 4 days after the peak day.
• PEAK DAY - last day where the secretions are clear, slippery, stretchy and wet
Billings Method
A = Intermediate type mucous B = Infertile type mucousC = Fertile type mucous
Basal Body Temperature
- Rise in temperature of 0.40F of morning BBT (OVULATION)- Abstain from unprotected intercourse from 1st day up to 3rd day after increase in BBT
Sympthotermal Method
• Change in cervical mucus ➡️ onset of fertility
• Increase in BBT ➡️ end of fertility
2 Day Method
• Presence of any type of secretion ➡️considered fertile for that day and the following day
Effectivity
Lactation Amenorrhea
• Temporary method• Ovulation is not possible during the first 10 weeks
postpartum• Effects of breastfeeding with fertility• 3 criteria for effectiveness
1. Monthly menstruation has not returned
2. Exclusive or nearly exclusive breastfeeding
3. Baby is less than 6 months old
Pathophysiology
• Prevents release of egg during ovulation
• Prevents release of ovulatory hormones
Artificial Method
A. Medical (Hormonal) a. Short Acting
1. Combined Oral Pills
2. Progestin Only Pills
b. Long Acting1. Combined Patch
2. Progesterone Implants
A. Injectables
B. Transvaginal Ring
1. Barrier Method1. Condom
2. Diaphragm & Cervical Cap
c. Spermicide cream & jelly
d. Sponge
e. Intra-uterine Device
C. Permanent Methodsa. Vasectomy
b. Tubal Ligation
Hormonal-Short Acting Combined Oral Contraceptive
Pills• Most widely used and most
successful reversible method of birth control
• Low doses of estrogen & progestin• Taken daily for 3 weeks and omitted
for 1 week during which there is withdrawal uterine bleeding
• Ethinyl Estradiol, Mestranol)• 19 Nortestosterone derivatives• Types• MONOPHASIC – type & dosage of
hormone remains constant during the 21 days
• MULTIPHASIC – dose varies during cycle
Mechanism of Action COC
Mechanism of Action COC
• Progestin– Prevents ovulation by suppressing LH– Thickened mucus ➡️ retards sperm passage– Endometrium ➡️ unfavorable for implantation
• Estrogen– Prevents ovulation by suppressing FSH– Stabilize endometrium ➡️ prevents breakthrough
bleeding
Pill Usage
Missed a pill? What to do?
Combined Oral Contraceptive Pills
Drug Interaction• Phenytoin & Rifampin ➡️ increase breakthrough bleeding &
reduce contraceptive effectiveness• Ascorbic Acid ➡️ competes for active sulfate in the intestinal
wall & increases the bioavailability of ethinyl estradiol results to breakthrough bleeding
• Ovulation – occurs 3 months after discontinuance• Postpill amenorrhea – if COC are stopped
Combined Oral Contraceptive PillsBeneficial Effects• Increase bone density• Decrease risk of ectopic pregnancy• Fewer premenstrual complaints• Reduction on various benign breast disease• Improvement of acne• Decrease incidence & severity of acute salphingitis• Reduce menstrual blood loss & anemia• Improved dysmenorrhea for endometriosis• Decreased risk of endometrial & ovarian cancer• Inhibition of hirsutism progression• Prevention of atherogenesis• Improvement in rheumatoid arthritis
Combined Oral Contraceptive PillsAdverse Effects• T4 and thyroid binding proteins are elevated• Plasma cortisol are also increased• Increase serum levels of triglycerides and total cholesterol• Decrease testoterone• Increase risk of cervical dysplasia and cancer• Lower plasma level of ascorbic acid, folic acid, vitamin B6, B12,
niacin, riboflavin and zinc• Increase risk of thromboembolism if used with CVD patient, > 35
years old and smokers • Increase risk of Chlamydia trachomatis infection• Cervical mucorrhea
Combined Oral Contraceptive Pills
CONTRAINDICATED
• Thrombophlebitis, thromboembolic disease, DVT
• CVD, CAD
• Thrombogenic cardiac valvulopathies & arrythmias
• DM w/ vascular involvement
• Uncontrolled HPN
• Breast, endometrial, hepatic CA
• AUB
• Pregnancy
• Cholestatic jaundice
• Major surgery with prolonged immobilization
Hormonal-Short Acting
Progestin Only Pills• Low dose progestin• Safe for breastfeeding mothers & women who
could not use estrogen like with CVD• Minipills or POPs• Do not inhibit ovulation• Thickens the cervical mucus ➡️ block sperm• Effects on endometrium• Disrupting menstrual cycle by preventing
release of fertilized eggs• Taken same time of the day for maximal
effectiveness• If taken 4 hours late ➡️ BACK UP
CONTRACEPTION x 48 hours
Progestin Only Pills
Benefits • Minimal effect on CHO
metabolism & coagulation• Do not cause or
exacerbates HPN
Disadvantages• Contraception failure• Ectopic pregnancy• Irregular uterine bleeding
– Amenorrhea, spotting, breakthrough bleeding, menorrhagia)
• Functional ovarian cyst
Progestin Only Pills
Contraindicated• Unexplained bleeding• Breast cancer• Liver tumor• Pregnancy• Acute liver disease• Carbamazepines, Phenobarbital, Phenytoin, Rifampicin,
Griseofulvin
Hormonal-Long Acting
Combined Patch • Continuously release progestin &
estrogen directly through the skin to the blood stream
• A new patch is worn every week for 3 consecutive weeks
• No patch on the 4th week so menstruation ensues
• Works primarily by preventing release of ovulated eggs
• 150ug progestin norelgestrinon + 20ug ethinyl estradiol
• First 2 cycle – dysmenorrhea, breast tenderness & breakthrough bleeding
Where to apply?
Hormonal-Long Acting
Intravaginal or Transvaginal Hormonal Contraceptive Ring
• Flexible polymer ring has an outer diameter 54mm & 4mm cross section
• Releases Ethinyl estradiol 15ug and Etonogestrel 120ug/day
• Inhibits ovulation• Ring is placed w/in 5 days of
onset of menses & removed after 3 weeks of use for 1 week to allow w/drawal bleeding
• Ring replaced w/in 3 hours within intercourse
• Complications: vaginitis, ring related events, leukorrhea
Hormonal-Long Acting
• How to insert/use transvaginal ring
Hormonal-Long Acting
Implants• Small rods or capsules placed
under the skin of a woman’s upper arm (subdermal)
• 3 to 7 years effectiveness• Safe for breastfeeding
beginning 6 weeks post partum• Thickens the cervical mucus
& delay release of eggs from the ovary
• Progestin suppress ovulation• NORPLANT – levonorgestrel
(6)• JADELLE (2)• IMPLANON (1) – 68mg
Etonogestrel
Implants
Hormonal-Long Acting
Injectable Medroxyprogesterone Acetate/Estradiol Cypionate
• Lunelle• 1 injection monthly• Inhibits ovulation• Supress endometrial
proliferation• Estradiol reach peak level 3-
4 days post injection & decline leading to w/drawal bleeding to 20-25days after injection
Hormonal-Long Acting
Benefits• Returns to fertility after
discontinuance• Less breakthrough
bleeding• Amenorrhea more frequent
Disadvantage• Decrease lactation• Weight gain
Hormonal-Long Acting
Progestin Only Injectables
• DMPA – depot medroxyprogesterone acetate
• The “shot” or “jab (150mg every 3 months)
• Depo-provera, Depo, Megestron & Petogen
• NET EN – Norethindrone Enanthate
• Noristerat, Syngestal (200mg every 2 months)
• Intramuscular or subcutaneous (upper outer quadrant buttocks)
• Inhibit ovulation, increase viscosity of cervical mucus, endometrium unfavorable for implantation
Progestin Only Injectables
Benefits• Long duration of action• Minimal to no impaiment of
lactation• Decrease ovarian and
endoetrial cancer
Disadvantage• Irregular menstrual bleeding• Prolonged anovulation after
discontinuance• Delayed fertility resumption• Menses may not resume up to 1
year• Increase risk cervical CA• Breast tenderness• Weight gain• Decrease bone density - REVERSIBLE
Progestin Only Injectables
• Contraindication– Thromboembolism– Stroke– Cerebro/Cardio VD– Pregnancy– Undiagnosed vaginal
bleeding– Breast CA– Liver Disease
Barrier Method-Condom
•Prevents pregnancy & STI•Easy to use• Practical
MALE CONDOM
• Failure rate: 3 or 4 couple-years of exposure
• Lubricants used should be water based– Oil based products can destroy latex condoms
MALE CONDOM
• Maximal effectiveness – condom must be used with every coital act– place before contact of the penis with the vagina– Withdrawal must occur with the penis still erect– The base of the condom must be held during
withdrawal– Either an intravaginal spermicide or a condom
lubricated with spermicide should be employed
Proper USE of MALE CONDOM
FEMALE CONDOM
• Pregnancy rate higher than male condom• Polyurethane sheath with one flexible
polyurethane ring at each end–Open ring remains outside the vagina–Closed internal ring is fitted under symphysis
DO NOT USE SIMULTANEOUS WITH MALE CONDOM SINCE FRICTION LEADS TO SLIPPING, TEARING & DISPLACEMENT
Proper USE of FEMALE CONDOM
Barrier Method-Diaphragm
•Soft latex cup that covers the cervix•Spring along the rim to keep it in place•Used with spermicidal creams/jelly or sponge for effectiveness•Inserted few hours before intercourse ➡️ add spermicide•Should not be remove <6hrs, and not stay >6hours ➡️ TSS•Increase rate UTI
Barrier Method-Cervical Cap
•Soft, deep, latex or rubber cup that covers the cervix•Prevents the sperm to enter the cervix•Best used with spermicides•Compatible to diaphragm
Barrier Method-Spermicides• Physical barrier to sperm penetration• Chemical spermicidal - sperm killing substance inserted
deep into the vagina, near the cervix prior to sexual intercourse
• Nonoxynol 9 – most popular• benzalkonium chloride, chlorhexidine, menfegol, octoxynol-9, and
sodium docusate• Duration of Efficacy: 1 hour• Non teratogenic
Barrier Method-Spermicides
• foaming tablets, melting or foaming suppositories, cans of pressurized foam, melting film, jelly, and cream
– Jellies, creams, and foam from cans can be used alone, with a diaphragm, or with condoms.
– Films, suppositories, foaming tablets, or foaming suppositories can be used alone or with condoms
• causing the membrane of sperm cells to break, killing them or slowing their movement
Barrier Method-Sponge • Plastic contains spermicides
• Inserted 24 hours prior to intercourse, removed 6 hours post intercourse
• Moistened with water and inserted into the vagina so that it rests against the cervix
• Used only once
• not widely available
• Less effective
• Nonoxynol 9 impregnated disc– 2.5cm thick, 5.5cm wide
• May cause irritation and
vaginitis
Lea’s Shield
• Reusable, washable barrier made of silicone
• Placed against the cervix • Inserted any time prior to
intercourse and must be left in place for at least 8 hours afterwards
Barrier Method-IUD
-Insert near end of normal menses-w/hold insertion for at least 8 weeks post partum-RANDALL STONE CLAMP
Barrier Method-IUD
• copper-bearing intrauterine device– small, flexible plastic frame with copper sleeves or wire around it
• trained health care provider inserts it into a woman’s uterus through her vagina and cervix ➡️ reduce pelvic infection
• causing a chemical change that damages sperm and egg before they can meet ➡️ interfere implantation
• Local inflammatory response (uterus) ➡️ Lysosomal Activation & Inflammatory Actions ➡️ SPERMICIDAL
• Effectiveness: Equivalent to BTL
Barrier Method-IUD
• Paragard T 380A– Copper– 10 years– Chemically inert
• Mirena– Levonogrestel– 5 years– Reduce menstrual loss– Treat menorrhagia– Reduce dysmenorrhea, PID
Chemically inert – nonabsorbable material (polyethylene) impregnated in Barium Sulfate (for radioopacity)
Chemically active – continuous elution of copper or progestational agent
Barrier Method - IUD
IUD Insertion
Barrier Method-IUD
• Disadvantages– Uterine perforation– Dysmennorhea– AUB– Expulsion– Iron deficiency anemia– Infection
NEVER ASSUME THAT THE DEVICE HAS BEEN EXPELLED UNLESS IT WAS SEEN!
Barrier Method-IUD
• Benefit– Reversible method– Fertility not impaired– No increase risk of genital tract or breast neoplasia– No loss of bone mineral density and weight gain
Barrier Method-IUD• Contraindicated
– Pregnancy– Abnormal uterus– Acute PID– Postpartum endometritis or infected abortion (past 3 months)– Uterine or cervix malignancy– Abnormal papsmear– AUB– Untreated cervicitis, vaginitis, bacterial vaginosis– Multiple sexual partners– Susceptible infections, genital actinomyosis– History of ectopic pregnancy– IUD not removed
– Copper ➡️Wilson’s Dse., Copper Allergy– Mirena ➡️ breast CA, acute liver disease, hypersensitivity
Emergency Contraception
• The Morning-After Pill– diethylstilbestrol (DES)
• Yuzpe method (1974)– 100 g ethinyl estradiol
plus 1.0 mg dL-norgestrel
• Plan B (1999)– first progestin-only
emergency contraceptive
Emergency Contraception• Yuzpe
– COC + 2 POP– 2 tabs w/in 72hrs then 12hrs after
• POP– 1st dose w/in 72hrs then 12hrs after
• Ovrette– 20 pills w/in 72hrs then 12hrs after
• Copper IUD– Postcoital contraception– Inserted up to 5 days after
unprotected intercourse
• Misoprostol/Epostane– Block progesterone production
– Interfere w/ progesterone action– Menstruation – implantation
prevented
• Inhibition or delay ovulation
• Alteration of endometrium, sperm penetartion, tubal motility
• SE: nausea/vomiting – estrogen related
• If (+) vomiting w/in 2hours – repeat dose
Vasectomy
• Meant to be permanent• Use another method for the first
3 months, until the vasectomy starts to work (20 ejaculations)
• Very effective after 3 months but not 100%
• Safe, simple, convenient surgery • No effect on sexual ability or
feelings
• Works by closing off each vas deferens, keeping sperm out of semen
• Semen is ejaculated, but it cannot cause pregnancy
Vasectomy
• One of the most effective methods but carries a small risk of failure
– If semen is not examined 3 months after the procedure to see if it still contains sperm, pregnancy rates are about 2 to 3 per 100 women over the first year after their partners have had a vasectomy.
– If semen was examined after vasectomy, less than 1 pregnancy per 100 women over the first year after their partners have had vasectomies (2 per 1,000).
Vasectomy
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 it by cutting and tying it closed or by applying heat or electricity (cautery).
Tubal Ligation
• Female sterilization• Permanent• Effectiveness varies slightly
depending on how the tubes are blocked
• Fertility does not return because sterilization generally cannot be stopped or reversed
• fallopian tubes are blocked or cut Eggs released from the ovaries cannot move down the tubes do not meet sperm
Tubal Ligation
• Reversal surgery is difficult, expensive, and not readily available.– often does not lead to pregnancy
Tubal Ligation
• 2 surgical approachesMinilaparotomy - making a small incision in the abdomen. The fallopian tubes are brought to the incision to be cut or blocked.
Laparoscopy - inserting a long thin tube with a lens in it into the abdomen through a small incision. This laparoscope enables the doctor to see and block or cut the fallopian tubes in the abdomen
Conditions & Suggested Contraception
• Migraine POP• Lactation POP (up to 6 months postpartum)
intermittent breastfeeding – use effective contraception as soon as 3 weeks postpartum
• CVD, HPN, smoker POP• > 35 y.o IUD, COC, DMPA
Condition and Unsafe MethodCondition Methods Not Advised
Smoke cigarettes and also age 35 or older
Combined oral contraceptive pills (COCs). If you smoke heavily, monthly injectables.
Known high blood pressure COCs, monthly injectables. If severe high blood pressure, 2- and 3-month injectables.
Fully or nearly fully breastfeeding in first 6 months
Breastfeeding in first 6 weeks
First 21 days after childbirth, not breastfeeding
COCs, monthly injectables.2- and 3-month injectables,
implants, progestin-only pills (POPs).COCs, monthly injectables.
Wait until 6 weeks after childbirth to fit diaphragm correctly.
Certain uncommon serious diseases of the heart, blood vessels, or liver, or breast cancer.
COCs, injectables, POPs, implants. Ask your provider.
Condition and Unsafe MethodCondition Methods Not Advised
Migraine headaches (a type of severe
headache) and also age 35 or older.
COCs, monthly injectables. Ask your provider.
Gall bladder disease COCs. Ask your provider.Certain uncommon
conditions of female organsIUD. Ask your provider.
Sexually transmitted infections of the cervix, very high individual risk of getting these infections, pelvic inflammatory disease (PID), or untreated AIDS
IUD. Use condoms even if also using another method.
Women with HIV, including women with AIDS and those on treatment, can generally use any family planning method they choose.
Known pregnancy No method needed.