ContraceptivesLectures on Gynecology

Dr Magda Helmi

Hormonal contraceptivesHormonal means of contraception include the following:Injectable depomedroxyprogesterone acetate.Progestin-only oral contraceptives.91-day combination oral contraceptives.Combination patch contraceptive.Contraceptive vaginal ring.

Combined hormonal contraceptives

The Combined Oral Contraceptive Pill, usually called simply ‘the Pill’, contains two hormones, oestrogen and progestogen. The main way the Pill works is by stopping a woman’s ovaries from releasing an egg each month, which means that a pregnancy cannot begin.With perfect use the Pill is 99.7% effective. Providing

there are no medical reasons not to take the Pill, women can safely use the Pill up to the age of 50.

Formulations: Oral contraceptives come in a variety of formulations. The main division is between combined oral contraceptive pills, containing both estrogen and progestin and progestin only pills. Combined oral contraceptive pills also come in varying types, including varying doses of estrogen, and whether the dose of estrogen or progestin changes from one week to the next.

Prevention of ovulation is considered the dominant mechanism of action, with the combination of the 2 steroids creating a synergistic effect that greatly increases their antigonadotropic and ovulation-inhibitory effects; these contraceptives also alter the consistency of cervical mucus, affect the endometrial lining, and alter tubal transport

Formulations: Oral contraceptives come in a variety of formulations. The main division is between combined oral contraceptive pills, containing both estrogen and progestin and progestin only pills. Combined oral contraceptive pills also come in varying types, including varying doses of estrogen, and whether the dose of estrogen or progestin changes from one week to the next.

Absolute contraindicationsBreastfeeding <6 weeks postpartum.Smoking 15 cigarettes/day and age 35. Multiple risk factors for cardiovascular disease, Hypertension: systolic pressure 160 or diastolic 100 mmHg, Hypertension with vascular disease, Current or history of deep-vein thrombosis/pulmonary embolism, Major surgery with prolonged immobilization, Known thrornbogenicmutations.Current or history of ischaemic heart disease and or strok, Complicated valvular heart disease.Diabetes for 20 years or with severe vascular disease or with severe nephropathy, retinopathy or neuropathy.Active viral hepatitis, Severe cirrhosis.Current breast cancer, Benign or malignant liver tumors. Migraine with aura.

Relative contraindications

Multiple risk factors for arterial disease, Hypertension: systolic blood pressure 140-159 or diastolic pressure 90-99 mmHg, or adequately treated to below 140/90 mml-IgSome known hyperlipidaemias, Current or medically treated gallbladder disease, Mild cirrhosis, History of cholestasis related to combined oral Contraceptives.Obesity, Diabetes mellitus with vascular disease.Smoking (<15 cigarettes/day) and age 35 years.Migraine, even without aura, and age 35 years.Breast cancer with >5 years without recurrence, Breastfeeding until six months postpartum, Postpartum and not breastfeeding until 21 days, after childbirth.Taking rifampicin (rifampin) or certain anticonvulsants.

Commonly reported side effects of COC

Central nervous: Depressed mood, System Mood swings, Headaches, Loss of libido.Gastrointestinal Nausea: Perceived weight gain, Bloatedness.Reproductive system: Breakthrough bleeding, Increased vaginal discharge.Breasts: Breast pain, Enlarged breasts.Miscellaneous: Chloasma (facial pigmentation which worsens with time on COC), Fluid retention, Change in contact lens.

A patient's choice of contraceptive method involves factors such as efficacy, safety, no contraceptive benefits, cost, and personal considerations.

About 222 million women who want to avoid pregnancy in developing countries are not using a modern birth control method. Birth control use in developing countries has decreased the number of maternal deaths by 40% (about 270,000 deaths prevented in 2008) and could prevent 70% if the full demand for birth control were met.

Combined hormonal vaginal ringsA combined contraceptive vaginal ring is licensed in the UK.

It is made of latex-free plastic and has a diameter of 54 mm.

It releases a daily dose of ethinyl estradiol 15 pg and etonorgestrel 120 pg.

The ring is worn for 21 days and removed for 7 days, during which time a

Withdrawal bleed occurs.

Insertion and removal of the ring is easy and it does not need to it in any

special place in the vagina.

The cycle control is excellent and probably better than with COC. As with

combined patches, the vaginal ring has the same risks and benefits as COC but

is more expensive.

Progestogen-only

contraception

Progestogen-only contraception avoids the risks and side effects of oestrogen.The current methods of progestogen-only contraception are:•progestogen-only pill, or ‘mini-pill’•subdermal implant (Implanon)•injectables (Depo-Provera®, Noristerat®)•hormone-releasing intrauterine system (Mirena)All progestogen-only methods work by:Local effect; on cervical mucus, and on the endometrium, preventing implantation and sperm transport. • Central effect; by and inhibiting

ovulation.

Nova ring

Subdermal implantsIrnplanon consists of a single silastic rod that is inserted subdermally under local unaesthetic, into the upper arm. It releases the progestogenetonogestrel 25-70 mg daily (the dose released decreases with time), which is metabolized to the third-generation progestogen desogestrel. Irregular bleeding is very common and is the major reason for early discontinuation. There is a rapid return of fertility when it is removed.

norplant

Injectable:I depot medroxyprogesterone acetate 150 mg (Depo-Provera/DMPA);2 norethisterone enanthate 200 mg (Noristerat).

Acts by inhibiting ovulation with the suppression of follicle-stimulating hormone (FSH) and LH levels and by eliminating the LH surg.side effects of Depo-Provera include:weight gain of around 2-3 kg in the first year of use; delay in return of fertility.persistently irregular periods.higher risk of osteoporosis in later life. Bone density seems to recover when Depo-Provera is stopped.

Progestin-only oral contraceptives:they contain the second-generation progestogen

norethisterone or norgestrel (or their derivatives) and the third-generation progestogen desogestrel.

Mechanisms of action:(1) suppression of ovulation;(2) a variable dampening effect on the midcycle peaks of LH

and FSH; (3) an increase in cervical mucus viscosity; (4) a reduction in

the number and size of endometrial glands; and (5) a reduction in cilia motility in the fallopian tube Particular

indications for the POP include:breastfeeding;older age;cardiovascular risk factors, for example high blood pressure, smoking or diabetes.

•91-day combination oral contraceptives - Reduce the number of menstrual cycles per year•Combination patch contraceptive - Releases estrogen and progesterone directly into the skin•Contraceptive vaginal ring - Hormones are absorbed directly by the reproductive organs

The common side effects of progestogen-only

methods include:

•erratic or absent menstrual bleeding;

•simple, functional ovarian cysts;

•breast tenderness;

acne

The current intrauterine devices (IUD) are small devices, often 'T'-shaped, often containing either copper or levonorgestrel, which are inserted into the uterus. They are one form of long-acting reversible contraception which are the most effective types of reversible birth control.Failure rates with the copper IUD is about 0.8% while the levonorgestrel IUD has a failure rates of 0.2% in the first year of use.

It is generally believed that an IUD prevents the sperm meeting and fertilizing an egg cell as well as implantation of the fertilized egg cell.The most widely used form of reversible contraception, with more than 180 million users worldwide (IUDs).An important discovery was that the reliability of IUDs is greatly improved by adding copper.

Copper T

polyethylene IUD with fine copper wire wrapped around the vertical stem,

(250-370)

Nova T• Nova T 380 is an intrauterine

device made of polyethylene and wound with copper wire with a silver core.

• The surface area of the copper is 380 mm².

• The polyethylene body, shaped as a modified T is impregnated with barium sulphate.

• Removal threads, pigmented with iron oxide are attached to the base of the vertical arm of the T.

multiloud

It is a small plastic rod, called stem, with two small flexible side-arms.

The plastic is a mixture of high density polyethylene, ethylene vinyl acetate copolymer and barium sulphate in a weight ratio 44/36/20.

A copper wire is wound around the stem.

A nylon thread with two ends is attached to the bottom end of the stem.

Dalcon

multiloud

Mirena - Skyla

T-shaped, polyethylene IUD with a reservoir that contains levonorgestrel, a progesterone

Barrier methods of contraception

They prevent pregnancy by creating a physical barrier to the sperm reaching and fertilizing the egg. They can be used in conjunction with a hormonal method or IUD to give personal protection against infection and to increase contraceptive efficacy.

Condoms

Spermicides Emergency contraceptive methods:sometimes misleadingly referred to as "morning-after pills" or devices used after unprotected sexual intercourse with the hope of preventing pregnancy.

They work primarily by preventing ovulation or fertilization.

A number of options exist, including high dose birth control pills, levonorgestrel, mifepristone, ulipristal and IUDs.

Levonorgestrel pills, when used within 3 days, decrease the chance of pregnancy after a single episode of unprotected sex or condom failure by 70% (resulting in a pregnancy rate of 2.2%)

They all contain the active ingredient

nonoxynol-9. Spermicides are designed to be used

with another barrier method to make them more

effective.

Withdrawal

• Other forms of :

male contraception

Are in various stages of

research and development.

These include methods like RISUG/VasalGel (which has completed a small phase II clinical trial in humans in India), and ultrasound (with results so far obtained in experimental animals.

withdrawal, or coitus interruptus, is a widespread

practice and obviously does not require any medical

advice or supplies. Unfortunately, it is not particularly reliable, as pre-

ejaculatory secretions may contain millions of sperm

and young men often find it hard to judge the timing

of withdrawal.

Sterilization tubal ligation for women and vasectomy for men

During a tubal ligation, the fallopian tubes are cut or blocked to permanently prevent pregnancy. A tubal ligation disrupts the movement of the egg to the uterus for fertilization and blocks sperm from traveling up the fallopian tubes to the egg. A tubal ligation can be done at any time, including after childbirth or in combination with another abdominal surgical procedure, such as a C-section. It's possible to reverse a tubal ligation — but reversal requires major surgery and isn't always effective.

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.