Contraception - Pearl index: 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. MOAs: - Prevent ovulation (pill, patch, vaginal rings, progesterones) Prevent sperm reaching oocyte (female and male sterilisation) Prevent embryo implantation in the uterus (Cu-IUD and LNG-IUS) Poisoning sperm (spermidcides) Allow sperm to enter vagina but block further passage (diaphragm + cap, progesterones) Prevent sperm entering the vagina (condoms, FABs) Barrier methods Condoms Diaphragms and cervical caps MOA Combined and triphasic pills act by suppressing gonadotrophin-releasing hormone (GnRH) and gonadotrophin secretion and, in particular, suppressing the luteinizing hormone peak, and thus inhibiting ovulation. The endometrium also becomes less suitable for nidation and the cervical mucus becomes hostile. Progesterone-only pills act predominantly to reduce the amount and character of the cervical mucus, although they do alter the endometrial maturation as well. Ovulation is completely suppressed in only 40% of women. Hormonal contraception - 2 types: 1. Combinations of oestrogen with a progestogen (combined pill) 2. Progestogen alone (progestogen-only pill) 1. Combined pill (oestrogen + progesterone) 91% effective because pills are often forgotten or missed, but otherwise is 99.7% effective Extremely effective Can also be used to reduce AUB. Thinner endometrium, restablish predictable bleeding patterns, can manipulate your cycle Main MOA: inhibition of progesterone + oestrogen on the pituitary, with the suppression of FSH and LH Preparation is chosen with the lowest oestrogen and progestogen content that is well tolerated and gives good cycle control in the individual woman Taken for 21 days followed by 7 pill-free days (sugar tablets, prevents long term suppression of HPG axis which could make fertilisation difficult), which causes a withdrawal bleed. No reason why women cant take the pill continuously (however can help thin the endometrium) Normal menstruation usually commences fairly soon after discontinuing treatment, and permanent loss of fertility is rare Preparations are monophasic (same doses of hormones throughout), but some are phasc (dose varies) – no advantagement of phasic over monoophasic Produces a ‘pseudo’ (hormonally) pregnant state incompatible with fertilisation. No ovulation takes place. If 2 or more pills are missed, this puts the woman at risk of ovulation. Additional contraceptive cover during the next 7 days of pill taking is advised (condoms, abstinence) -> there are instructions depending on when this took place. One pill missed ->The missed pill should be taken as soon as it is remembered, remaining pills continued at their usual time. - - - 2 pills missed (more than 48 hours late) -> most recent missed pill should be taken ASAP, remaining pills should be continued at usual time. Condoms should be used or sex avoided until 7 pills consecutive active pills have been taken. - Can also use hormonal trandermal patch Hormonal ring – flexible ring that releases estradiol + rogesterone daily -> worn in the vagina. 21 days, then 7 ring free days. Mode of action: Oestrogen inhibits secretion of FSH via negative feedback on anterior pituitary, and thus suppresses development of ovarian follicle Progestogen inhibits secretion of LH and thus prevents ovulation, also makes cervical mucus less suitable for ovulation (prevents sperm entry) Act together to alter the endometrium in a way that discourages implantation May interfere with contractions of cervix, uterus, fallopian tubes that facilitate fertilisation and implantation Common adverse effects: weight gain (fluid retention or anabolic effect), mild nausea, flushing, dizziness, depression, irritability, skin changes (acne, pigmentation), amenorrhoea of variable duration on cessation of taking the pill Reduces risk of colorectal cancer, endometrial, ovarian cancer. Increased clotting tendencies (reduced with combined pill – reduced dramatically by progesterones) Increased risk of breast cancer, increase risk of cervical cancer Beneficial effects: avoiding unwanted pregnancy, decreased menstrual symptoms like irregular periods and intermenstrual bleeding, iron deficiency anaemia, premenstrual tension are reduced, benign breast disease, uterine fibroids, lower incidence of PID and benign ovarian cysts, improves acne - CIs - - - The absolute contraindications include pregnancy, previous pulmonary embolism or deep vein thrombosis, genetic thrombophilia, CV disease, uncontrolled HTN, sickle-cell disease, porphyria, current active liver disease or previous cholestasis (particularly where it is associated with a previous pregnancy), migraine associated with an aura (increased stroke risk) or carcinoma of the breast/genital tract, It is necessary to maintain a high level of vigilance in women with varicose veins, diabetes, hypertension, renal disease and chronic heart failure, migraines with aura, but none of these conditions constitutes an absolute contraindication and, in some cases, the adverse effects of a pregnancy may substantially outweigh any hazard from the pill. Women who smoke and are also over the age of 35 years have a significantly increased risk of coronary artery and thromboembolic disease, advise progesterone only instead (mirena) S/Es The occurrence of migraine for the first time, severe headaches or visual disturbances, or transient neurological changes are indications for immediate cessation of the pill. There are a series of minor side effects that may sometimes be used to advantage or may be offset by using a pill with a different combination of steroids Major S/Es - Venous thrombosis + arterial disease. Women who are undergoing long distance travel should take appropriate exercise on the journey and consider wearing graduated compression stockings Although some reports have suggested there is a small increase in the relative risk of breast (relative risk 1.24) and cervical cancer (relative risk 1.5–2) in pill users, especially if it is commenced before a first pregnancy, the breast cancer increased risk is not definitely proven, and the cervical cancer risk is probably due to the incidence of wart virus infection and not the taking of the oral contraceptive pill (OCP). COCPs are contraindicated in women with a current or past history of VTE or a known thrombogenic mutation. Other risk factors to exclude before prescribing a COCP include: a family history of VTE or thrombophilia in a first degree relative obesity (body mass index [BMI] 35 kg/m2 or greater) prolonged immobilisation being under 21 days post partum. - COCP metabolised by cp450 – drugs that upregulate this system can reduce concentrations of relevant contraceptive hormones, resulting in pregnancies. Interactions with St John's wort, griseofulvin, protease inhibitors and older antiepileptic drugs (eg phenytoin, carbamazepine, primidone) are commonly reported. Current evidence suggests that most antibiotics do not interact with combined hormonal contraceptives. The only exception is for those that induce liver enzymes (ie rifabutin, rifampicin). When taking either of these antibiotics, no combined hormonal contraceptive at any dose can be considered effective—alternative methods (eg intrauterine contraception) need to be considered. . - When should it be commenced? It is best commenced on day 2–3 of the next period but can be commenced at any time. Many combined pills include 7 days of placebo (‘sugar’) tablets so that the user takes a pill every day of the month and so reduces the risk of forgetting when to restart the pill after the normal 7 ‘pill free’ days each cycle (sometimes labelled ‘ED’ or everyday preparations). Each tablet including the placebos are labelled with a day of the week in these calendar packs with the placebos being a different colour. With these pills a woman should start taking the pill on the first day of her next period starting with the inactive tablet corresponding to the current day of the week. When changing from a higher to a lower dose pill preparation women should be advised to start taking the active tablets of the new pill immediately on completing the last tablet of her previous pill, omitting the normal 7 day gap Pills and surgery The pill increases the risk of deep vein thrombosis and should therefore be stopped at least 6 weeks before major surgery. It should not be stopped before minor procedures – particularly before laparoscopic sterilization procedures. The risk of an unwanted pregnancy occurring before admission is substantially greater than the risk of thromboembolism. Progesterone only methods (99.7% effective if taken perfectly, but in real life only 91% because pills can be forgotten/missed) - - - - - Pill Taken daily without interruption Mode of action is mainly on cervical mucus, thickens it so it is inhospitable to sperm, also hinders implantation due to thinning effects on endometrium and decreasing mobility/secretions of fallopian tubes. They act on the hypothalamus and suppress pituitary LH surge and may inhibit ovulation. Main MOA is via mucus, not as much in inhibiting ovulation Beneficial effects: suitable alternative to combined pill in women in whom it is contraindicated or women whose blood pressure increases unacceptably during oestrogen treatment, or in those who are breastfeeding Unwanted effects: contraceptive effect less reliable than pill and missing a dose may lead to contraception, disturbances of menstruation are common especially irregular bleeding (periods may be normal, less frequent, may be spotting between), long-term safety data is Low dose POP – only inhibits 50% of cycles. Mainly rely on thickening of cervical mucous. Low dose pills inhibit ovulation in less than half the cycles Must be taken within a small window at same time each day (3hr window) – due to low dose. Strict concordance is essential due to its effect on vaginal mucus, which can be lost if the POP is delayed for even a few hours, it doesn’t reliably suppress ovulation S/E: weight gain, mood changes, acne, loss of libido, persistent follciles (simple cysts) If a pill is missed then the woman should continue taking the POP and use extraprecautions for the next 48 hours until the progesterone effect of the mucus builds up When taking the POP while breastfeeding, irregular bleeding may signify the return of ovulation and fluctuating hormone concentrations. Other causes (eg pregnancy, Chlamydia trachomatis infection) need to be excluded. As long as the POP is being taken correctly, this method of contraception can be continued. If a woman finds the bleeding unacceptable, she can switch to another progestin-only contraception method (eg etonogestrel implant, intrauterine system). Take pill continuously S/E – simple ovarian cysts, irregular bleeding, acne, headaches, breakthrough bleeding, tender breasts Implant (Implanon, Dep-Provera) (progesterone only) (99.9% effective) Subdermally in medial epicondyle, in 1st 5 days of the menstrual cycle Provides contraception for three years, can remove at any time MOA – stops ovaries from releasing an egg each month Releases steady low dose progesterone Main A/E – irregular bleeding patterns, amenorrhoea in 22%. However, they may cause irregular bleeding or amenorrhoea, which can be a source of anxiety because of the possibility of pregnancy 1:5: unpredictable bleeding, 1:5 no bleeding, 3:5 somewhere in the middle each of these injectable preparations works by making the cervical mucus hostile, the endometrium hypotrophic and by also suppressing ovulation. Fertility restored immediately after removal Sometimes manage with pill to control bleeding Injection (99% effective, 94% if youre late for injection) depot injection of medroxyprogesterone acetate – IM or SC inhibit ovulation every 12-14 weeks get injection 50% amenorrhoea rates per year Inhibits ovulation May delay return of fertility after discontinuation (make take up to 1 year after last injection for ovulation to return) The first injection should be given during the first 5 days of the menstrual cycle, because this provides immediate contraceptive protection. - - S/E – possible weight gain After stopping DMPA the time for fertility to return varies, due to persisting anovulation. The effect on fertility is not permanent. The median conception time is 8 to 10 months after the last injection. Seventy-eight per cent of women wanting to conceive do so within 12 months of their most recent injection, and 95% within 2 years. Some women have erratic and prolonged bleeding as DMPA wears off after their last injection. A COCP can be used to maintain regular cycles during DMPA withdrawal, if pregnancy is not desired. Only hormonal method that may delay return of fertility after discontinuation - As with all progestin-only forms of contraception, the main adverse effect of DMPA is unpredictable bleeding patterns. Other possible adverse effects are weight gain, acne, mood changes, depression and increased risk of bone loss (with prolonged use). The decline in bone mineral density associated with DMPA is reversible, but its use in two populations has potential concern. Progestin only contraception – Cis Progestin-only contraception is contraindicated in women with active breast cancer within the last 5 years, but has relatively few other contraindications. The harms outweigh the benefits in the following conditions: antiphospholipid antibodies with systemic lupus erythematosus, unexplained vaginal bleeding, ischaemic heart disease or stroke, severe cirrhosis or hepatocellular carcinoma. Emergency contraception Oral - - - After unprotected intercourse, missed combined pill or a burst condom, a single 750 mg levonorgestrel tablet is taken within 72 hours of intercourse, followed by a second dose exactly 12 hours later. 96 hours after unprotected sex is effective The levonorgestrel-only method has fewer side effects than the previously used combined method and, in some countries, is available to women over the age of 16 years directly from pharmacists. Side effects include mild nausea, vomiting (an additional pill should be taken if vomiting occurs within 2–3 hours of the first dose) and bleeding. Work by delaying ovulation so that the sperm present in the reproductive tract will have lost the ability to fertilise the oocyte when it is eventually released Oral EC is much less effective than CU-IUD for EC and is estimated to prevent only 2/3 of pregnancy Another option is progesterone receptor modular ulipristal aetate – 96 hours after unprotected sex Cu-IUD - Most effective method Its effect on endometrium is thought to prevent implantation if fertilisation has occurred Since the blastocyst implants 6-10 days after the fertilisation, it can be inserted up to 5 days after unprotected sex or 5 days after predicted ovulation Can be used in emergency contraception S/E- pills can be heavier and more painful Non-medical methods of contraception The most fertile phase of the menstrual cycle occurs at the time of ovulation. In a 28-day cycle, this occurs on day 13 or 14 of the cycle. The fertile phase is associated with changes in cervical mucus that a woman can learn to recognize by selfexamination and hormone changes that can be measured by home urine testing kits. Avoidance of the fertile period can be an extremely effective method in well-motivated couples. Natural methods of family planning include the following: • The rhythm method: Avoiding intercourse mid-cycle and for 6 days before ovulation and 2 days after it. The efficacy of this method depends on being able to predict the time of ovulation. If a regular 28 day cycle occurs, ovulation is predicted for day 14, and abstinence should be from days 8 to 16. If the cycles are very variable, varying between 24 and 32 days, the earliest ovulation would be on day 10 and the latest on day 18, so abstinence would be required between days 4 and 20. • The ovulation method : This method takes into account the ability of a woman to recognize the increase in vaginal wetness due to cervical mucus productionin the phase before ovulation, and abstaining from sex during that time and for 2 days after the peak wetness has been observed. This method is much better than the rhythm method, but many women only get 4 days advanced warning of the time of ovulation, so intercourse on the preceding 2 days can result in a pregnancy. • Coitus interruptus (withdrawal): A traditional and still widely used method of contraception that relies on withdrawal of the penis before ejaculation. It is not a particularly reliable method of contraception, because the best sperm often reach the tip of the penis before the male experiences the imminent ejaculation, or he forgets in the ‘heat’ of the moment. • Lactational amenorrhoea method: Breastfeeding has historically been the most important means of family ‘spacing’. Ovulation resumes on average 4–6 months later in women who continue to breastfeed. During the first 6 months after birth this is an effective method of contraception in mothers providing they are fully breastfeeding, not giving the baby any nonbreast milk or other food, AND have remained amenorrhoeic, with failure rates as low as 1/100 women being seen Intrauterine contraceptive device - These devices have the advantage that, once inserted, they are retained without the need to take alternative contraceptive precautions. It seems likely that they act mainly by preventing fertilization. This is a result of a reduction in the viability of ova and the number of viable sperm reaching the tube. Progesterone releasing intrauterine system (99.8% effective) - Release the progesterone levonorgesterel into the uterus Mirena (LNG-IUS) – 5 years of contraception Exerts a potent hormonal effect on the endometrium, preventing endometrial proliferation + implantation, also has thickening of the mucus It does not prevent ovulation – in first few months women may have unpredictable bleeding. Usually improves with time and get lighter/absent periods It should be inserted in the first 7 days of the menstrual cycle, 6 weeks post partum, can be inserted at any time, as long as are certain woman is not pregnant Reduces HMB + dysmenorrhoea Most common S/E – acne, breast tenderness, mood disturbance, headaches Most notable effect is reducing HMB, more effective than COCP and transaexamic acid at this Also beneficial for dysmenorrhoea, pain with endo, adenomyosis, protect endometirum from hyperplasia S/E – can be painful when inserting especially if haven’t given birth before Cu-IUD (99%) - - - Duration of use between 3-10 years 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 Stimulates inflamm reaction in the uterus, effects are toxic to both sperm + egg May experience painful or heavier menses. Can be tolerated by most, 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 mefenamic acid If pregnancy occurs with it in-situ, an USS should be conducted to exclude ectopic pregnancy - Advisable that IUDs should be removed before 12 weeks gestation in view of the greater risk of miscarriage, preterm delivery, septic abortion and chorioamntiotis if the device is left in situ Risks - - - - Associated with risks: Perforation (increased risk if breastfeeding/less than 6 months post partum) Expulsion (1 in 20 will be expelled in first 3 months, but after this, risk decreasesz0 Infection (risk of infection in first 3 weeks following insertion is low) Missing threads (indicates pregnancy, expulsion or perforation) – pregnancy test done and emergency contraception given If do fall pregnant, then risk of ectopic pregnancy is high,., should be removed before 12 weeks gestation in view of greater risk of miscarriage/preterm delivery/septic abortion/chorioamnionitis Pre-existing PID is a contraindication to this method of contraception. There is a small increase in the risk of acute PID in IUD users, but this is largely confined to the first 3 weeks after insertion. If PID does occur, antibiotic therapy is commenced and, if the response is poor, the device should be removed. 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. However, the pain may be acceptable if it is not severe, and this is a decision that has to be made by the patient in relation to the convenience of the method. Vaginal discharge – slightly watery/mucoid discharge Erratic bleeding and spotting. specially in the first 3 to 5 months, but blood loss decreases dramatically over 6 months. Amenorrhoea or light bleeding occurs in up to 65% of women after 12 months of use. Women should be reviewed 4 to 6 weeks after the LNG-IUS has been inserted, to: exclude post-insertion pelvic inflammatory disease (rare) ensure the strings attached to the LNG-IUS have not lengthened (suggesting partial expulsion). Women should be reviewed annually after that. They should be told to return immediately if they develop: pelvic pain pain during intercourse a dramatic change in bleeding patterns, after initial changes settle. Sterilisation - Women should be advised to continue to use other contraception until the period occurs following the sterilization procedure. Men should be advised to use alternative contraception until they have had two consecutive semen analyses showing azoospermia 2–4 weeks apart, with these analyses not done until at least 10 ejaculations have occurred. Timing of sterilisation - Can be done anytime in the cycle but done in follicular phase A pregnancy test should be performed preoperatively if a woman has a late or missed period or thinks she may be pregnant. Lap sterilisation - The majority of procedures involves interruption of the Fallopian tubes but may vary from the application of clips on the tubes to total hysterectomy. In general terms, the more radical the procedure the less likely there is to be a - failure. However, very low failure rates can now be achieved using methods with high reversibility prospects and these should be the methods of choice. Effective contraception is required until the menstrual period following lap procedure or 3 months following hysteroscopic procedure Method is considered as irreversible, failure rate 1:200 lap, 1:400 hysteroscopic, risks and complications (1:1000 risk of traumat o bowel, bladder, blood vessels) Vasectomy is safter, quicker, easier, less morbidity It does not protect against STIs Pregnancy is extremely rare, but there is an increased risk of ectopic Reversal is highly skilled, cannot be performed after hysteroscopy csterilisation, and if conducted effectively after lap, then it is associated with an increased risk of ectopic pregnancy emember the reported failure rate for third-generation/levonorgestrel IUDs is comparable to that of sterilization but male sterilization has a significantly lower failure rate. Apart from the complications of laparoscopy, if it was performed to enable sterilization, the longer-term complications of any tubal sterilization are tubal recanalization and pregnancy, ectopic pregnancy, menstrual irregularity and loss of libido. Apart from the complications of laparoscopy, if it was performed to enable sterilization, the longer-term complications of any tubal sterilization are tubal recanalization and pregnancy, ectopic pregnancy, menstrual irregularity and loss of libido. - - - Tubal clips Most widely used Advantage: minimal damage to the tube, disadvantage – higher failure rate 1:200 failure rate Tubal coagulation and division Sterilization is effected by either unipolar or bipolar diathermy of the tubes in two sites 1–2 cm from the uterotubal junction. A considerable amount of tube can be destroyed with this technique. Division of the diathermied tube is said to reduce the risk of ectopic pregnancy. The failure rate depends on the length of tube destroyed. Because of the risk of thermal bowel injury with subsequent leakage and faecal peritonitis, diathermy should not be used as the primary method of sterilization unless mechanical methods of tubal occlusion are technically difficult or fail at the time of the procedure. Tubal ligation These procedures are usually performed through a small abdominal incision (mini-laparotomy) or at the time of caesarean section. They are less widely used with the increase in laparoscopic procedures. Even when laparoscopy is contraindicated for some reason it is still more common now to use clips to occlude the tubes. Hysteroscopic sterilisation - Outpatient procedure This procedure consists of insertion of a small device into each tube at the time of a hysteroscopic examination, with this device resulting in fibrosis and ultimate occlusion of the tube on each side. This insertion can often be done without anaesthesia and does not require a laparoscopy Timing - The operation can be performed at any time in the menstrual cycle, but is best done in the follicular phase of the cycle. A pregnancy test should be performed preoperatively if a woman has a late or missed period or thinks she may be pregnant. Vasectomy - Performed under LA - - Two small incisions are made over the spermatic cord and 3–4 cm of the vas deferens is excised . The advantage of the technique is its simplicity. The disadvantages are that sterility is not immediate and should not be assumed until all spermatozoa have disappeared from the ejaculate. On average, this takes at least 10 ejaculations. Post vasectomy semen analysis should be conducted at 12 weeks to confirm the absence of sperm in ejaculate. Harder to reverse than female sterilisation Failure rate 1/2000 Safer, quicker, less morbidity Risk of scrotal haematoma and infection with this procedure - Condoms Failure rate 24% 98% effective, but less effective in real life (82%) as break/not always used correctly Preventing against STIs Diaphragm and cap - 18% failure rate 82-86% effective Withdrawal method - 78-96% effective, not recommended
