CONTRACEPTION
Associate Professor Dr Hanifullah Khan
Objectives
1. Understand the definition, classification &
terminology
2. Understand the reason for contraception
3. Know the advantages & side-effects
4. Know the proper use of each method
5. To be able to advise on the use
Introduction
• Definition – any
method used to
prevent pregnancy
19 May 07
• Allows to choose
whether & when to
have a child
3
Reproduction
• Ovulation
• Fertile period
• Fertilisation
19 May 07
4
Consequences of unintended
pregnancies - fetus
• Late booking or no booking.
• Fetus more likely to be exposed to harmful substances (smoking tobacco and drinking alcohol).
• The child is at greater risk of
–
weighing < 2.5kg at birth
–
of dying in its first year of life
–
of being abused
–
of not receiving sufficient resources for healthy
development.
Cleland NEJM 2011
5
Consequences of unintended
pregnancies - mother
• Late booking or no booking – increased antenatal
risks
• The mother may be at greater risk of physical
abuse
• Her relationship with her partner is at greater risk
of dissolution.
• Both mother and father may suffer economic
hardship and fail to achieve their educational and
career goals.
October NEJM
Cleland
2003 2011
6
Reproductive age
• The typical woman - capacity to bear children for
an 39 years of her life
• Different contraceptive methods required for each
life stage
–
to accommodate the complex factors accompanying
each stage
• Without contraception - 85% of couples conceive
within 1 year.
Trussell J. Contraception 2010
Female Contraception
Reversible
Non-Reversible
Hormonal
Tubal ligation
Non-Hormonal
COC
IUD
POP
Barriers
POP
Spermicides
Injectables
Implants
Emergency
Mirena
7 June 2006
8
COMBINED CONTRACEPTION
Combined Oral Contraception I
• Large number of users
• Prompt return of ovulation
–
70% in 1st cycle , 98% by 3rd cycle*
• No permanent loss of fertility
• Beneficial effects on future fertility
–
↓ ascending infection & PID (progestogenic effect)
–
↓ risk of EP
–
↑ ferritin levels & Hb
*Rice-Wray E et al. Return of ovulation after discontinuation of oral
contraception. Fertil Steril 1967;18:212-8.
Combined Oral Contraception II
• Women who conceive after discontinuation of
COC:
–
No ↑ risk of pregnancy loss or EP
–
No alteration in sex ratio
• No ↑ miscarriage rate or chromosomal
abnormalities in women who continue COC
during early pregnancy*
• No risk of masculinization
*Huggins GR. Fertility after contraception or abortion.
Fertil Steril 1990;54:559-73.
Patch
• Transdermal supply of 750 µg ethinyl estradiol (an
estrogen) and 6000 µg norelgestromin (a progestin)
• Side effects similar to COC
• ? Slightly increased risk of TED
PROGESTOGEN ONLY
CONTRACEPTION
Progestogen-only Methods
POP
● Subdermal implants
● Injectables
● Combined injectables
● Emergency contraception
● Mirena
●
Progestogen-only Methods Of Contraception*
Route of
administration
Very low dose
Oral
Progestogen-only pill
Subdermal
High dose
Etonogestrel-releasing
implant (Implanon®)
Levonorgesterelreleasing implant
(Norplant®)
Intrauterine
Levonorgesterelreleasing intrauterine
system (Mirena®)
Vaginal
Vaginal rings (under
development)
Intramuscular
injection
Low dose
DepoProvera®
POP - Effects
• Local effect on cervical mucous & endometrium
– inhibits gamete transport & implantation
• No effect on future fertility
• Does not offer same protection against EP as
COC
Subdermal Implants
• Implanon – single rod. Between biceps & triceps
of non-dominant arm.
–
3 year efficacy.
–
Inhibits LH surge – ovulation inhibition
–
Oestradiol levels unchanged
–
The only contraceptive method to have a Pearl Index
of 0.*
–
Prompt return of fertility*
• Norplant – older. 6 rods.
*Croxatto HB. The pharmacodynamics and efficacy of Implanon. An
overview of the data. Contraception 1998;58:91S-97S.
Implanon
Injectables
• DMPA
• Inhibition of ovulation caused by Gn suppression
• Ovulation returns after 4-5 months & median
conception time of 5-7 months*
• No permanent effect on fertility. However, may
take 2 years to return.**
• Delay may be due to slow drug metabolism
(microcrystalline deposits in muscle)***
*Kaunitz AM. Ob/Gyn 1993
** Kaunitz AM. Int J Fertil Womens Med 1998
***Hickey M. Clin Obstet Gynecol 1995
Emergency contraception I
• ECP/ "morning-after pills
• a short course
–
–
–
either a high-dose combination of estrogen & progestin or
progestin-only
used within 72 hours of unprotected intercourse to prevent
pregnancy
• taken after SI but before implantation
• more effective the sooner they are initiated after SI.
• estrogen-progestin combinations (commonly known as the
Yuzpe regimen)
–
may reduce the risk of pregnancy by 75% and the progestinonly formulation by 88%
EC IUCD
• copper-containing intrauterine device (IUD)
inserted within 120 hours of unprotected
intercourse to prevent pregnancy
• work by the same mechanisms of action as OC inhibit ovulation, fertilization, or implantation.
• They will not terminate an existing pregnancy
Emergency Contraception III
Levonorgestrel
0.15 mg +ethinyl
estradiol 30 mcg
Nordette
(light orange
tablets)
4 tablets/dose
2 doses
Levonorgestrel
0.75 mg
Plan B
1 tablet/dose
2 doses
First dose within 72 hours of
unprotected intercourse;
second dose 12 hours
later(no anti-emetic required)
NATURAL METHOD
Wednesday 15
23
Body changes during menstruation
• Likelihood of pregnancy high if SI just before or
after ovulation
• During the menstrual cycle, a number of changes
occur in a woman's body
–
By keeping track of these changes, couples can plan
when to have intercourse and when to avoid
intercourse, depending on whether they are trying to
achieve or avoid pregnancy.
Wednesday 15
24
What is natural family planning?
• A way to help decide when SI can or cannot
result in pregnancy
• Learn to recognise the changes in a woman’s
body that shows when she is fertile each month
• Avoid sex at the fertile times, or use condoms or
a diaphragm.
Wednesday 15
25
Advantages:
•
•
•
•
•
Acceptable to most faiths and cultures
No need to take any hormones
No side effects
Gives a greater awareness of fertility
Can be used to plan pregnancy as well as avoid it
Wednesday 15
26
Disadvantages
•
•
•
•
•
No protection against STIs
Takes a long time to learn (3 to 6 months)
Daily tests and records need to be made
Illness, stress and travel can affect fertility indicators
Both partners need to be committed to using the
method
• Unsuitable for:
–
–
–
Women who can't check their temperature and cervix every
day
Couples who are even slightly disorganised
Women with very irregular periods
Wednesday 15
27
Methods
• Coitus Interruptus
• Rhythm Method
–
–
–
–
–
Calendar
BBT
Cervical Mucous (Ovulation)
Symptothermal
Ovulation Predictor Kits
• Abstinence
• Lactational Amenorrhoea Method
Wednesday 15
28
Coitus Interruptus
Wednesday 15
29
Coitus Interruptus (Withdrawal)
• The penis is withdrawn from the vagina prior to
ejaculation
• When done correctly - failure rate of 6.7% (6.7 out
of every 100 women)
• Advantages - immediately available and it is free
• Disadvantages
–
unsure able to withdraw before ejaculating
–
preejaculatory fluids may contain viable sperm
Wednesday 15
30
Effectiveness
Among typical couples - 19 in 100 will experience an
accidental pregnancy in the first year
o Some men cannot tell when they are going to ejaculate.
o Some men ejaculate very quickly, before they realize it.
o Before ejaculation, almost all penises leak fluid that contains
sperm that can cause pregnancy.
o Some men lack the experience and self-control to pull out in
time.
o Some men are unreliable
o It offers no protection against STD's and infections.
o It's free
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31
Rhythm Method
Wednesday 15
32
What is it?
• Also known as "fertility awareness"
• Uses the menstrual cycle to predict the most
fertile time of the month .
• Once the fertile time has been identified - don't
have sex or use a barrier method during that
period.
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33
How does it work?
• Based on the fact that:
–
The fertile period lasts about 4 days following
ovulation, when the mature ovum travels through the
fallopian tubes to the uterus and can be fertilized
• Sperm may live in the female reproductive tract for
up to 7 days
• The female egg lives for only a day
• fertilization may occur even days after intercourse
• "safe days" occur 2 days after ovulation and
continue until the next period
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How effective is it?
• Choose a fertility awareness method only if:
–
There is a cooperative partner
–
A regular, steady monthly cycle
–
Willing to invest time and effort required to learn about
fertility awareness methods
–
accept the fact that protection against pregnancy is not
perfect
• There are no side effects
Wednesday 15
35
Several Methods
• Several methods of determining which are the
most fertile days of the cycle:
–
Calendar Rhythm Method
–
Basal Body Temperature Method
–
Ovulation Method
–
Symptothermal Method
–
Ovulation Predictor Kits
Wednesday 15
36
Calendar Rhythm Method
• Requires keeping track of the cycle for 6 to 12 months to
determine the pattern of ovulation -will determine when it is
most "dangerous" to have sexual intercourse.
• Estimate the first and last days of the fertile period
–
subtract 18 from the length of the shortest cycle and 11 from the
length of the longest cycle
–
if the shortest cycle is 28 days and her longest cycle is 32 days, the
first and last days of the fertile period should be days 10 and 21
–
should abstain from SI for 12 days, starting on the 10th day after the
beginning of the menstrual cycle
• The failure rate for this method is 40% (40 out of 100
women).
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37
Shortest cycle (S) minus 18
= Last infertile day of the pre-ovulatory phase
Longest cycle (L) minus 11
= Last fertile day
For example:Length of cycles during last six months = 28, 29, 28, 27, 30, 28
(S = 27)
S - 18
= Last infertile day
27 - 18 = 9
(L = 30)
L - 11
= Last fertile day
30 - 11 = 19
Wednesday 15
38
Basal Body Temperature Method
• Keeping track of body temperature
• Body temperature rises two days prior to ovulation.
Wednesday 15
39
RECORDING & CHARTING THE BBT
• The temperature should
be taken immediately on
waking before getting
out of bed, drinking tea
or any other activity,
and at about the same
time each morning
Wednesday 15
40
THERMOMETERS
• Two types of
thermometer
–
Glass / mercury fertility
thermometer
–
Digital thermometer
• covers only the range
from 35-39 deg. C
Wednesday 15
41
Ovulation (Billing) Method
• Requires feeling and observing the cervical
mucus to determine the time of ovulation.
• Note the production of clear, watery mucus in the
days immediately before ovulation
• To avoid pregnancy, intercourse is avoided for
several days following change in the color and
consistency of cervical mucus.
Wednesday 15
42
Changes in the Cervix - in Relation to
Ovulation
Cervical changes take
place over an interval of
around 10 days.
Approximately 6/7
before the shift in
temperature the cervix
will begin to show fertile
characteristics.
Following ovulation, the
cervix returns to its
infertile state within 2448 hours
Wednesday 15
43
RECOGNISING THE CHANGES IN
CERVICAL MUCUS
• Sensation - at the vulva :the sensation may be a distinct
feeling of dryness, of dampness or moistness, stickiness,
wetness, slipperiness or lubrication.
• Appearance – use toilet tissue to blot or wipe the vulva white, creamy, opaque, or transparent (clear).
–
Mucus is often noticed on underclothing, where it will have dried
slightly causing some alteration in its characteristics
• Finger Testing - finger-tip applied to the mucus on the tissue
and then pulled gently away to test its capacity to stretch
–
–
It may feel sticky and break easily
or it may feel smoother and slippery like raw egg white and stretch
between the thumb and first finger, from a little up to several inches
before it breaks. This stretchiness is described as the Spinnbarkeit or
Spinn effect, and shows that the mucus is highly fertile.
Wednesday 15
44
Sensation
at Vulva
Finger Test
Appearance
Moist
or
Sticky
Early Mucus
Scanty
Thick
White
Sticky
Holds its shape
Wetter
Transitional Mucus
Increasing Amounts
Thinner
Cloudy
Slightly Stretchy
Slippery
Highly Fertile Mucus
Profuse
Thin
Transparent
Stretchy
(like raw egg white)
Wednesday 15
45
Mucus changes throughout the cycle
Complete cycle showing typical pattern of menstruation, preovulatory dry days,
mucus days with increasingly fertile characteristics approaching
peak day,
the abrupt change back to less fertile characteristics,
the count of four after peak day and post-ovulatory dry days
Wednesday 15
46
Symptothermal Method
• A combination of the calendar and cervical mucus methods
and the woman's basal body temperature (BBT)
• The first day is estimated by subracting 21 from the shortest
menstrual cycle (the calendar method) or noting the first day
of cervical mucus associated with ovulation (the cervical
mucus method), whichever comes first
• BBT is used to predict the end of the fertile period. The
woman takes her temperature every morning and notes when
body temperature rises, indicating that the corpus luteum is
producing progesterone and ovulation has occurred
• She can resume sexual intercourse 3 days after this so-called
thermal shift
Wednesday 15
47
Interpretation of the Sympto-Thermal Chart
This sympto-thermal chart shows the correlation between all
indicators of fertility
Wednesday 15
48
Fertility Chart
Wednesday 15
49
Ovulation Predictor Kits
• used to test urine to identify
hormones that indicate ovulation is
about to occur
• electronic fertility computer tells a
woman which days she is fertile
• Persona: fertile days are indicated
with a red light and infertile days
with a green light
• failure rate as low as 6% among
women who abstain on fertile days
as indicated by the device
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Anovulation
• A monophasic chart indicates that there has been no
ovulation in this cycle.
• The temperature remains on one level.
• The bleed, not a true period, is often lighter than
usual.
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Faulty technique
• Erratic temperature chart - result of poor technique.
• Implications of disturbances, such as illness, alcohol,
medication, or disturbed sleep patterns and note their occurrence.
• A temperature chart showing erratic and abnormally low
readings usually indicates faulty technique.
Wednesday 15
52
Abstinence
Wednesday 15
53
Easily stated, not always easily done
• takes commitment from both partners
• Abstinence is the most effective method of
preventing pregnancy and transmitting sexual
disease
• Not having traditional sexual intercourse, so the
penis does not enter the vagina, at all
• Become familiar with the fertility patterns - abstain
from vaginal intercourse on the days pregnancy can
occcur
• Effectiveness - If practiced perfectly, there should
not be any pregnancy.
Wednesday 15
54
Pros and Cons
• The Pros
–
–
–
–
–
–
–
1) Anyone can do it, with commitment.
2) It's free.
3) Encourages the building of a relationship. Trust.
4) No supplies
5) No infections or STI's
6) Endorsed by some religions.
7) No hormonal side effects.
• The Cons
–
–
1) It can be frustrating for some couples.
2) If not used properly, infections can be acquired. i.e.
oral sex transmission.
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55
Lactational Amenorrhea
Method
Wednesday 15
56
LAM
• Average Failure Rate: 6%
• Most BF women do not ovulate for 4-24 months
postpartum
– whereas non-breastfeeding women can ovulate as early as 1-2
months
• Conditions to be fulfilled
–
–
–
Fully BF
No periods
Recommended up to 6 months - the longer LAM is used, the
more likely it is that ovulation will precede the first menses
• Cervical mucus changes herald the first ovulation
–
should start checking daily at six weeks postpartum
• Women with no periods who BF without practicing
LAM - pregnancy rate of 6% over a year. Perfect users
can expect a failure rate of only 0.5%.
Wednesday 15
57
What are the advantages of natural family
planning?
• Does not involve the use of medicines, mechanical
devices or chemicals.
–
Side effects or risks that may occur with the use of such
medicines or devices will not occur
• Inexpensive
• Require partners to share the responsibility for
planning or avoiding pregnancy
–
Typically, couples who use these methods notice an
increase in communication and in cooperation.
Wednesday 15
58
INTRAUTERINE DEVICES
Introduction
a small device
made of plastic or
copper that is placed
into the uterus as an
effective method of
contraception
60
19 May 07
Types
Levonorgestrelreleasing device
19 May 07
Copper-releasing
device
61
Copper IUDs: Mechanisms of Action
Interfere with
ability of sperm to
pass through
uterine cavity
Thicken cervical
mucus
Interfere with
reproductive
process before ova
reach uterine cavity
Change
endometrial
lining
IUDs: Contraceptive Benefits
• Highly effective
• Effective immediately
• Long-term method (up to 10 years protection with
Copper T 380A)
• Do not interfere with intercourse
• Immediate return to fertility upon removal
• Do not affect breastfeeding
1
Trussell et al 1998.
19 May 07
63
IUDs: Contraceptive Benefits continued
• Few side effects
• After followup visit, client needs to return to
clinic only if problems
• No supplies needed by client
• Can be provided by trained nonphysician
• Inexpensive (Copper T 380A)
19 May 07
64
IUDs: Noncontraceptive Benefits
• Decrease menstrual cramps (progestin-releasing
only)
• Decrease menstrual bleeding (progestinreleasing only)
19 May 07
65
Who Can Use IUDs
Women of any reproductive age or parity who:
– Want highly-effective, long-term contraception
– Are breastfeeding
– Are postpartum and not breastfeeding
– Are postabortion
– Are at low risk for STDs
– Cannot remember to take a pill every day
– Prefer not to use hormonal methods or should not use
them
– Are in need of emergency contraception
19 May 07
66
IUDs: Who Should Not Use
(WHO Class 4)
IUDs should not be used if woman:
–
–
–
–
–
–
–
–
Is pregnant (known or suspected)
Has unexplained vaginal bleeding until the cause is
determined and any serious problems are treated
Has current, recent PID
Has acute purulent (pus-like) discharge
Has distorted uterine cavity
Has malignant trophoblast disease
Has genital tract cancer
Has an active genital tract infection (e.g., vaginitis,
cervicitis)
Source: WHO 1996.
19 May 07
67
IUDs: Common Side Effects
Copper-releasing:
–
–
–
–
–
Heavier menstrual bleeding
Irregular or heavy vaginal bleeding
Intermenstrual cramps
Increased menstrual cramping or pain
Vaginal discharge
Progestin-releasing:
–
Amenorrhea or very light menstrual
bleeding/spotting
19 May 07
68
IUDs: Possible Other Problems
• Missing strings
• Slight increased risk of pelvic infection (up to 20
days after insertion)
• Perforation of the uterus (rare)
• Spontaneous expulsion
• Ectopic pregnancy
• Spontaneous abortion
• Partner complains about feeling strings
19 May 07
69
IUD Insertion: Withdrawal Method
(2)
Withdraw
inserter tube
(1)
Hold
plunger
Source: PATH and Population Council 1989.
19 May 07
70
Postpartum insertion
• Delayed (4-6 weeks) or immediate postpartum
insertion
• safe and effective
• Expulsion - more common for immediate than
with interval insertions
19 May 07
71
Postabortal insertion
•
•
•
•
Safe and practical
Convenient
Avoid some discomfort from the procedure
Expulsion of the device is marginally increased
19 May 07
72
Benefits of IUDs
• Long-acting reversible contraceptives
• Require no adherence on the part of the user
–
leaving virtually no scope for user error
• More than 99% effective
• Once they’ve been inserted, users need not take
any action to continue using them
–
Reduce the number of unintended pregnancies that are
due to user error or contraceptive failure.
• Exceptionally cost-effective.
Trussell J. Contraception 2010
CURRENT CONCEPTS IN
CONTRACEPTION
Guidelines Regarding the Use of Combination Estrogen-Progestin Contraceptives in Women >=35 Years
of Age, According to Risk Factors
Kaunitz A. N Engl J Med 2008;358:1262-1270
Breast feeding
• Previously, progestin-only
• Low dose COC still possible
19 May 07
76
Cancer risk
•
Long
term
–
• If used for more than a
protect against Ca
year – protect against Ca
ovary
endometrium
• Ca breast? uncertain
• Those with Ca
breast should not
take pill
Failure Rates
User Failure
19 May 07
Method Failure
78
Failure rates
•
•
•
•
•
•
•
Implants, IUDs and LNG-IUS - <1%
Contraceptive pills - 5%
Male condoms - 14%
Diaphragm with spermicide - 20%
Cap with spermicide - 20-40%
'Natural' methods - 35%
Withdrawal - 19%
19 May 07
79
1. Contraception provides an effective means to plan a
family
2. Many methods are available suitability has to be decided based on a proper history & examination
3. Pregnancy should be ruled out first
4. You should know the advantages & side effects
5. Contraception also provides non-contraceptive benefits
KEY POINTS
Further reading
• Cleland et al. Family Planning as a cost saving
preventive health service. NEJM April 20, 2011.
• Trussell J. Update on the cost effectiveness of
contraceptives in the United States.
Contraception 2010;82:391.