Case: 25 year old with irregular cycles, hirsutism, and with BMI: 30 (obese)
Reason for prescription and
additional notes
Copper IUD
● Copper IUD is highly
effective in long-term
contraception even
when used as EC, and
effectiveness does
not depend on weight
● Candidates:
○ Nulliparous
○ Adolescents
○ Immunocomprom
ised women
● Contraindications:
○ Pregnancy (or just
suspicion)
○ Acute PID
○ Postpartum
endometritis or
infected abortion
○ Known or
suspected uterine
or cervical
malignancy
○ Genital bleeding of
unknown origin
○ Previously inserted
IUD that has not
been removed
●
Avoid using
levonorgestrel
because it is more
Mechanism of action
●
●
Induce local inflammation →
environment hostile for the
sperm → fertilization will not
occur
Copper: increases extent of
inflammation → accumulation of
the uterine lumen → penetrates
the fallopian tube and cervix →
○ affects the viability of the
gametes
○ prevents fertilization
○ Lowers chance of
development of zygote
○ ALSO impedes sperm
transportation and
viability in the cervical
mucus
Benefits
●
●
●
●
●
Effectiveness can
last for 10
Tier 1 contraceptive
Reduction in the
risk of the
development of
cervical and
endometrial
carcinoma
Effectiveness
equivalent t tubal
sterilization
Improvement pf
symptoms of
endometriosis and
adenomyosis
Risk and Adverse Effects
● Uterine bleeding: heavy or
prolonged menses or
intermenstrual bleeding.
○ Due to increased
release of
prostaglandin
○ Rarely leads to
anemia
○ Occurs in the first few
months →
reassurance and
supplemental iron
for these patients
● Perforation at the fundus is
caused by the insertion
process
○ Rare
● Complications Relation to
Pregnancy: extrauterine
location (ectopic pregnancy)
●
androgenic in
formulation
Copper allergy and
Wilson Disease
○ In the event of
intrauterine pregnancy,
whether or not the
pregnancy is desired
or not, device should
be removed
○ If pregnancy is not
desired: manual
vacuum aspiration
Infection: PID
● Due to the placement
process
● Routine prophylaxis is not
effective
● If IUD is still not implanted:
delay implantation if infection
is suspected
● If px is already positive with
gonorrhea or chlamydia with
an IUD implanted, give
antibiotics without removing
it.
○ If condition will not
improve (72 hours)
and it progresses into
an tubo-ovarian
abscess: device
should be removed
● Actinomycosis (PID)
○ Associated with the
use of IUD
Vaginal Ring/
Condoms
●
It is a flexible
polymer ring with a
54-mm outer
diameter and a
50-mm inner
●
●
Its core releases a daily dose of
15 ug ethinyl estradiol and 120
ug of the progestin etonogestrel.
These doses effectively inhibit
ovulation,
●
●
A ring may be used
concurrently with
vaginal medications
or with a tampon.
One ring provides
●
However this will not
produce protection for
stds so it is still
advisable to use
condoms.
●
●
OCP: mainly by
suppressing the
ovulation thru
interference of the
GnRH
●
diameter.
These are highly
effective and failure
rate is reported to
be 0.65
pregnancies per
100 woman-years
(Mulders, 2001;
Roumen, 2001).
I.e, < 1 per 100
Tier 2: (6-12
pregnancies per 100
women in 1 year
●
It also thickens the cervical
mucus, which makes it more
difficult for sperm to move
through the cervix, and thins the
lining of the womb so a fertilised
egg is less likely to implant itself.
●
●
Progestin
● Inhibit ovulation
● Thickening of the cervical mucus
● Thinning of the endometrium
●
contraception for a
month, so you don't
have to think about
it every day.
Unlike the pill, the
ring still works if you
have sickness
(vomiting) or
diarrhoea.
period-type
bleeding usually
becomes lighter,
more regular and
less painful.
Decrease acne
(with decreased
androgens/dose)
●
it may cause temporary
side effects, such as
increased vaginal
discharge, headaches,
nausea, breast
tenderness and m
Adverse Effects: (dosage and
potency dependent)
● Nausea
● Breast tenderness
● Weight gain
(contradicting studies)
● headache
Estrogen
● Maintain the endometrium →
prevent unscheduled bleeding
● Inhibit follicular development
Ethinyl estradiol
● Severe adverse
cardiovascular effects
● Minor adverse symptoms
without increasing the
failure rate
Combination:
● Suppress the gonadotropins
● Estrogen: prevents the rise in
FSH and enhances the progestin
component
● Progestin: inhibits ovulation and
Increased risk
● Venous and arterial
thrombosis
○ Obesity is a
risk factor for
this (BMI >40)
●
specifically the LH surge
(Lowest amount to suppress:
ovulation inhibition dose)
Overall suppression of follicular
development
Secondary (changes in):
● Cervical mucus
● Fallopian tube
● Endometrium
○
●
Women who
smoke older
than 35 yrs
Breast cancer