Progesterone only contraceptives
COCs
[Combined oral Contraceptives]
[Prog. only Pills]
=Minipills
Generations
EE2
Gestagens
1st generation
Types & Composition
POPs
50 µg 1st generation
gestagens[NET]
nd
30
-35
2 generation
2nd generation
gestagens[LNG]
rd
3 generation 20 -30 3rd generation
gestagens
[desogestril,
norgestimate &
gestodene]
th
20
-30
4 generation
drospirenone
(Yasmin)
Contain gestagen
only → mainly (LNG)
mostly 30µg
e.g, Microlut: 35pills
Long acting
injectables
=PICs
Depot-provera
[DMPA]
150 mg, every 3m'
Noristerat
 [NET-EN]
200 mg, every 2m'
Norplant
6 match sized capsules
Gestagen LNG
[levonorgestrel]
Duration  5 y'
Implanon
1 rod capsule
[4cm X 2mm]
Gestagen 
Etonogestrel
[3-keto-desogestril]
Intra uterine device
(IUD/IUCD)
Non-medicated IUD
(inert)
-Obsolete now
-Polyethylene & barium only
1-Lippes loop
double S-shaped + 2 nylon
threads
less effective
inserted by pushing tech. (high
incidenc of perforation)
 life long
2-Safe T-coil &Dalkon Shield
Medicated IUD
(active)
in a rate of 40 mg/d'
-Used nowadays
Duration  3 y'
-Polyethylene & barium + loaded
Types
Monophasic (same dose of EE2 & gestagen)
EE2 Dose
Use
Emergency
high dose pills > 50 µg
contraception
(HDP)
Not used now
moderate dose 50 µg
pills (MDP)
low dose pills
20-30 µg used now
(LDP)
Biphasic pills (not used now)
7d' 14d'
EE2 30 30 µg
NET 0.5 1 mg
Triphasic pills (not used now)
6d' 5d'
10d'
EE2 30 40 µg 50
LNG 50 75 µg 125
Subdermal
implants
Javelle
with certain material May be:
1-Cupper medicated
as norplant but 2 rods  Types
EE2 =ethinyl estradiol
NET=norethisterone family
NET-EN= norethisterone enanthate
LNG= levonorgestrel
Oral MPA [Provera] =medroxy progesterone acetate
Injection  DMPA [Depo MPA or Depo Provera]
-cupper T T2oo, T220, T380 A
(most used)
(No. represent SA of cupper wire)
-cupper 7 200
‐multiload  350, 375
-cupper & silver  nova –T
 more effective.
 inserted by withdrawal tech.
(less perforation)
 duration for 10 y
2-Progesterone medicated
(merina) (IUS)
T-shaped with progesterone in
vertical limb (duration 5 y)
3-Anti-fibrinolytic
medicated
1
COCs
[Combined oral Contraceptives]
 Central [Estrogen& progesterone]
Estrogen (-ve) feedback e' FSH
Progesterone  (-ve) feedback e' LH
Both  (--) ovulation  [anovulation]
Mechanism of action
 Peripheral [Progesterone]
 hostile cervical mucous not suitable for
penetration
 atrophic endometrium not suitable for
implantation
 ↓ motility of the tubes
(less effect as estrogen is antagonistic)
Progesterone only contraceptives
POPs
[Prog. only Pills]
Long acting
injectables
Subdermal
implants
Central
(-ve) feedback e' LH → (--) ovulation → [anovulation]
Peripheral
 hostile cervical mucous not suitable for penetration
 atrophic endometrium not suitable for implantation
 ↓ motility of the tubes.
Intra uterine device (IUD/IUCD)
Polyethylene & barium
components
Local sterile inflammatory
reaction in endometrium
-swollen, edematous, devitalized
endometrium Not suitable for implantation.
-↑ acidity in endometrium→ hostile for
Sperms &early developed zygote
-↑ Mφ (engulf sperm or early zygote)
-Leucocytic infiltration
Local PGs release
Uterine Contraction &  Tubal Motility
-Prevention of implantation
-expulsion of early implanted ovum
Mechanical factor
Dislodge the zygote
Medications
1-Cu 
-↑ local sterile inflammatory reaction
-↑ Mφ release
- Disturb the enzymes & glycogen
metabolism of endometrial cells needed
for growth of implanted zygote
- Silver [ ↓ fragmentation of Cu ]→
prolong of life span of IUD
2-Progesterone 
-As a Contraceptive  see periph action of
POPs
-As a ttt of DUB see DUB
3-Antifibrinolytics 
-↓ bleeding with IUD
2
COCs
[Combined oral Contraceptives]
Progesterone only contraceptives
POPs
Long acting
Subdermal
[Prog. only Pills]
injectables
implants
Initiating
During 1st 7 days of the cycle
(preferably on 1st day of menses)
At any time provided that
pregnancy is surely excluded
Postpartum:
Non-breastfeeding women →
Delay until 6 wks after birth
(d2 high postpartum risk of DVT)
Breastfeeding women →
Delay until 6 m' after childbirth
or until breastfeeding is discontinued
(Estrogen component ↓↓ breast milk)
Post abortion: → Start immediately
How to use
or within 1st 7 days after abortion
Schedule
Whatever type of pill 
-take 1 pill every day till all pills in pack
are finished (21 pills)
-then rest for 7 d' [during w' withdrawal
bleeding "pseudomenstruation" occurs]
-then start again
Missed pill regimen
Missed 1 pill
■Take missed pill as soon as
remembered.
■ Keep taking remaining pills
on schedule
■ No need for backup method
Missed ≥2 pill
■Take 1 pill immediately & the other
next day
■ Take remaining as usual
■ Backup method for 7 d'
Intra uterine device (IUD/IUCD)
Initiating
Insertion
During 1st 7 days of the menstrual cycle
(preferably on 1 day of menses)
st
At any time provided that pregnancy is surely
excluded
Postpartum
Non-breastfeeding women → after 3 wks
Breastfeeding women →
Delay until 6 wks after childbirth
Post abortion: → Start immediately or within
1st 7 days after abortion
DMPA 
Injection
/3m' ± 2 wk
(not > 2 wks to
maintain efficacy)
Norplant 
implants / 5 y'
Implanon
implants / 3 y'
NET-ET 
Injection
/2m' ± 2wk
ⓑNot breast feeding or > 6m'
■ Backup method for 48h'
after delivery of placenta or CS
Advantages
-Cx is fully dilated easy painless
Insertion
-Spotting after insertion is mistaken
e' Lucia
 Incidence of infection, inflam,
displacement & perforation
ⓑDelayed postpartum: →
Missed pill regimen for POPs Insertion
ⓐBreast feeding within 1st 6m'
cycle because
1- Pregnancy is excluded.
2- Cx is still opened 
easy & painless Insertion
3- Spotting after insertion is
mistaken as menses
At any time provided that
pregnancy is surely excluded
Postpartum
Disadvantages
(not > 2 wks to
maintain efficacy)
Late in taking pills > 3 h'
During last few days of the
ⓐImmediate postpartum
Schedule
-Take 1 pill/day
until all pills in
pack finished
&repeat again
èout break.
-Taken èin 3 h'
of same time
each day
Timing
By minor surg
technique using
special applicator
Removal
By minor surg
technique
removed at date
or on request
Implanon  easier
in removal &
Insertion
After 4 wks of birth (vaginal or C/S)
Post abortion: → Immediately or
after 4 wks of abortion
Methods
Pushing tech.(e' Lippes)→ ↑ incidence of
perforation
Withdrawal tech.(e' other types) → ↓
incidence of perforation .
Removal
Removed after expiry e.g, Cu-T 380 A → 10y'
3
COCs
[Combined oral Contraceptives]
Indication
Contraceptive Use
females 20-35y' if not C/I
Non-Contraceptive Use
1-DUB
2-Endometriosis.
3-Hirsuitism
4-Spasmodic dysmenorrhea.
5-PMS 6-Acne
7-Functioning ovarian cyst
8-Postpone menstruation
Long acting
injectables
POPs
[Prog. only Pills]
Subdermal
implants
Contraceptive Use
Contraceptive Use
-lactating
-if age > 35 y'
-if COCs is C/I
-in lactating mothers
-if age > 35 y'
-if COCs is C/I
Intra uterine device (IUD/IUCD)
if preg. spacing
for many years
or terminal
contraception
-if pregnancy spacing
>1 y or Terminal
contraception
-sickle cell disease
[↓↓ frequency & severity of crisis]
-Epilepsy
[↑↑ seizers threshold & not
-in lactating mothers
-if age > 35 y'
-Female refusing hormonal
contraception
-In multipara having children (never
in nulligravida as it causes PID)
Non-Contraceptive Use
1-DUB by prog. & antifibrinolytic IUD
2-After adheseolysis in Asherman's
syndrome by Lippe's IUD
[only indication of Lippe's nowadays]
affected by antiepileptic drugs]
Non-Contraceptive
Use
Effectiveness
1-DUB
2-Endometriosis.
3-Hirsuitism
4-Endometrial Carci
5-Fibroid.
6-Precoicous puberty
Use Failure = 1-2 /HWY
Method failure = 0.1
MC cause of failure  incorrect use
Use Failure =
2-4 /HWY
Use Failure  < 1 /HWY
Use Failure = 2-4 /HWY
Nearly as tubal sterilization
4
COCs
[Combined oral Contraceptives]
POPs
[Prog. only Pills]
Long acting
injectables
Subdermal
implants
Intra uterine device (IUD/IUCD)
ⓐGeneral advantages  from Scheme
Advantages
General advantages of any Contraceptive methods
Effective*
 Reliable
Easy to use*
 Reversible
[Rapid return fertility]
Cheap*
 Available
Safe [ S/E]
 No need medical supervision
Not affect sexual relation Accepted by couple
Except in…….
POPs
Progesterone only injectable
COC
*Subdermal Implant  Not Cheap & Not easy to use [Inserted, removed by minor surgical technique]
*IUD  Not Effective [High failure rate] & Not easy to use [need doctor for Insertion & removal]
l
ⓑRisk of
ⓑSuitable for Lactating mother & When COCs are C/I
1-Ovarian & endometrial cancers
2-Bg breast dse
3-Ectopic pregnancy 4-PID
5-Anemia.
6-Menst. Irregularities
ⓒRisk of
ⓒNon-Contraceptive use
ⓓNon-Contraceptive use
ⓑSuitable for Lactating mother &
When COCs are C/I
1-Ovarian & endometrial cancers
2-fibroids 3-↓ Endometriosis symptoms
ⓒNon-Contraceptive use
4-Ectopic pregnancy 5-PID.
6-↓ frequency & severity of sickle cell crisis ⓓDurable & can be removed at
ⓓDurable & can be
any time e' rapid return of fertility
Disadvantages
removed at any time
e' rapid return of
fertility
ⓐRequires regular daily intake
ⓐRequires
ⓐ Inability to
ⓐ Minor surgical
ⓐInsertion & removal need
& resupply.
regular daily
………
withdraw the drug
interference &
Complications 
trained HCW
ⓑLess Effective
ⓑLess
Effective
ⓑDelayed return of
fertility (at least 4 m')
Incorrect use & missed pills are
common → ↓↓ efficacy
ⓑ Delayed return of fertility
(May reach 3 m')
[Contraceptive effect &S/E can't be
stopped immediately]
Abscess & difficult
removal d2 fibrosis
ⓑCosmetic or
tender
ⓒNo protection against STDs including HIV
ⓓ Side effects (‫)تُكتب‬
5
COCs
[Combined oral Contraceptives]
Menstrual disturbances
Anticosmotic effect
S/E [risks-Complications]
Wt gain,
Skin pigmentation & Acne
Alopecia
Pseudopregnancy state
E2
Progesterone
Nausea,
-Loss of
vomiting,
appetite
headache
-Depression
dizziness
Breast effect
- Suppression of lactation
- Breast tenderness
-↑ incidence of cancer breast
-↓ incidence of Bg breast lesion
Oncogenic effect
- ↑ incidence of cancer breast if
used before 36 y'
- ↑ Bg & Mg Tm of the liver
- ↑ incidence of fibroids &
endometriosis [HDP]
- ↑ risk of invasive cancer Cx
if used >5 y'
may be d2 other factors e.g, smoking &
multiple sexual partners
POPs
[Prog. only Pills]
Long acting
injectables
Subdermal
implants
Menstrual disturbances
MC & the main cause of discontinuation.
1) Breakthrough bleeding or spotting.
2) Amenorrhea.
3) Heavy or prolonged bleeding ‫تكتبُمعُ؟؟‬
Wt gain & Depression
 incidence of
ectopic pregnancy
d2  motility of
tubes
Breast enlargement &
mastodenia
Bone density
( Risk osteoporosis)
Carcinogenesis
[controverse]
-Overall incidence is
not ed, but ↑ may
be d2 early diagnosis
since regular visits or
pre-existing breast
cancer
Intra uterine device (IUD/IUCD)
Menstrual disturbances
ⓐBleeding  MC complication
mainly menorrhagia
A/E -IUD disturb PGs → 2ry DUB
-local causes e.g, polyp .
ttt 
exclude local causes then deal as 2ry DUB
(may give prog. medicated IUD)
ⓑAmenorrhea [Missed period]
IUD +Missed period 
pregnancy until proved otherwise &
this pregnancy is ectopic till proved
otherwise.
-If pregnancy excluded → it's a case
of 2ry amenorrhea (IUD has no role)
Insertion complications
vaso-vagal attack, perforation,
failure of insertion
Expulsion
Extraction difficulties
 PID & Pain
Discharge [serous, serosanginous or
mucous]
 Failure (Pregnancy)
Threads
Inability to feel threads (missed IUD)
Discomfort of male d2 very long
Threads
6
COCs
Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives]
Fertility
-Proteins  anabolic →↑ weight (E2)
Mainly d2 faulty
insertion
Expulsion
-unskilled
provider
-postpartum
insertion
-high parity
-nulliparity
-big IUD
-closed IUD
A/E
3m' after stoppage of pills
Teratogenic
if given in 1st trimester
causing anomalies in
Vertebral bodies & Limb
Esophageal, Tracheal &Anorectal,
Cardiac & Renal
Metabolic effects
Perforation
- Delayed
-CHO  diabetogenic (E2)
PID
-Septic IUD
-Pelvic
Actinomycosis Israeli
-threads act as a
ladder
Incidence
1.5 times > normal
(specially in 1st m'
after insertion).
-H2O  salt & water retention → ↑ wt. (E2)
⓫GIT effects
- Nausea, vomiting & malabsorption
- ↑ incidence of gall stone formation,
cholecystitis, hepatic Tm
pelvic congestion &
Cx erosion .
Acute abdominal pain
d2 perforation , acute
PID & ectopic
pregnancy .
Chronic lower
abdominal heaviness
d2 chronic PID &
pelvic congestion .
d2 abnormal position
inside uterus
C/P
CVS effects
-E2 → ↑ incidence of thrombosis, salt &
water retention
-Progesterone → ↑ incidence of
atherosclerosis
So, ↑ incidence of -IHD -Systemic Vascular
occlusions - HTN
-DVT & Pul. embolism
CNS effects
- ↑ incidence of headache, migraine & mood
changes
- ↑ incidence of cerebral strokes
Low backache MC
Uterine cramps &
dysmenorrhea
-Clotting  ↑ clotting (E2)
ttt
S/E [risks-Complications]
-Fat  ↑ LDL & ↓ HDL (progesterone)
Pain
acute abd. pain
during insertion
-vaginal spotting
localized
peritonitis
[e' medicated]
See missed IUD
-Irreg
bleeding
-Pain
-Pregnancy
see PID
tubal adhesions →
infertility (never used
in nullipara)
Loop extraction & ttt
of PID
ttt of the cause &
analgesics
Failure of IUD (Pregnancy) (missed period)
-IUD + amenorrhea → pregnancy until ………….(1/30 pregnancies).
-If pregnancy is extrauterine  ectopic preg.→ deal as ectopic pregnancy
-If pregnancy is intrauterine  pregnancy on top of IUD
A/E -Perforation -Expulsion -low insertion of IUD -Expiry
- Cong. anomalies of uterus e.g, bicornuate uterus .
Risks abortion : septic abortion till proved otherwise.(50%)
preterm labor (4 times ↑ risk) & no ↑ risk of congenital anomalies .
Management
if threads accessible→ immediate removal & follow up (↓ risk of abortion to 25 %)
if not accessible→ leave IUD & follow up as high risk pregnancy
7
COCs
Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives]
⓬Drug interaction
Missed IUD [ Inability to feel threads]
▶ Drugs that ↑ activity of hepatic
microsomal enzymes → ↑ destruction E2 &
Progesterone → ↑ failure rate
e.g, Rifampicin, tetracycline, sedatives,
hypnotics
Definition
S/E [risks-Complications]
▶↓ Action of 
Anticoagulants.
Antidiabetic [oral hypoglycemics]
Antihypertensive
Patient unable to feel the threads
A/E
Deep vagina + short fingers Adherent threads to vaginal wall or Cx Cut threads
Pregnancy  Expulsion  Perforation Abnormal position of IUD in uterus
Management
Careful Vaginal examination [PV & speculum]

Threads are present
Threads are not present
Thread not felt d2
d2 one of the following
Deep vagina + short fingers
Pregnancy
Adherent threads to vaginal wall or Cx  Expulsion
Cut threads
 Perforation
Abnormal position of IUD in uterus
Continue by the following investigations
1-Pregnancy test 
+ve  Pregnant
-ve Do Pelvi-abdominal x-ray
not Seen Expulsion
IUD seen Do Old or recent methods
2-Pelvi-abdominal x-ray IUD
3-Plain x-ray + sound intrauterine[ If overlapping in x-ray e' sound Intrauterine IUD]
or HSG [old methods]
TVS or Hysteroscope [recent methods]
Intrauterine IUD  Perforation
Laparoscopic removal or If not removed mini laparotomy & removal + repair of any injury
Extrauterine IUD  Abnormal position of IUD in uteru
Try to remove by Bozeman's forceps or Novack currette
If not removed hysteroscopic extraction (or D & C if no hysteroscope available)
8
[Indications to stop]
Warning signs
COCs
Pill-danger sign
POPs
[Prog. only Pills]
Abdominal pain
(may be ectopic preg.)
Abdominal pain (may be MVO)
Chest pain (may be pul. embolism) Missed period
(may be pregnancy)
Severe Headache
(may be prodroma of cerebral stroke)
Long acting
injectables
Subdermal
implants
Weight gain
Depression
Heavy vaginal bleeding
Headache
Eye symptoms
Intra uterine device (IUD)
pain (severe abdominal pain
may be ectopic pregnancy)
 Amenorrhea (may be
pregnancy)
Inability to feel the threads
Noticeable discharge e' fever
(infection)
(may be retinal artery occlusion)
Absolute C/I
WHO MEC*  category 4
C/I
1-Pregnancy
WHO MEC  category 4 WHO MEC for starting
injectable  category 4
2-Unexplained vaginal bleeding.
4-Breastfeeding < 6 wks after
childbirth
5- Heavy smokers
6-Complicated diabetes.
7-Severe HTN
8-Current or past Hx of IHD
9-Current or past Hx. of
thromboembolism .
10-Valvular Ht dse e' complication.
11-Past thrombo-vascular accidents.
12-Prolonged immobilization
13-Migraine.
14-Epilepsy.
15-Active liver dse, cirrhosis, liver Tm
3-Breast cancer
4- Breastfeeding <6wks
after childbirth
5- Current ttt with ABx
(rifampin, griseofulvin)
or AED
6-Gallbladder dse.
7-Active liver dse,
cirrhosis, liver Tm
WHO MEC for starting IUD 
category 4
1-Pregnancy
2-Unexplained vaginal bleeding.
3-Cx, endometrial or ovarian
cancer.
4-Current or recent PID, STDs,
septic abortion or pelvic TB.
5-Distorded uterine cavity
*Standard abbreviation for Medical Eligibility Criteria
AED =Antiepileptic drugs
Relative C/I
WHO MEC category 3
1-Age ≥35
2-light smoker.
3-Breastfeeding 6w'- 6m' postpartum
4-Non-breastfeeding women 3wk
postpartum [after childbirth]
5-Mild and moderate HTN
6-Certain ABx or AED**
7-Gallbladder diseases
WHO MEC for starting
injectable category3
1-Breastfeeding <6wks
2-Severe HTN
3-Complicated diabetes.
4-Current or past Hx of IHD
5-Past thrombo-vascular
accidents.
6-Active liver dse, cirrhosis,
liver Tm
WHO MEC for starting IUD 
category 3
1-Risk of developing STDs
2-HIV/AIDS infection.
9