CONTRACEPTION
Dr Habiba Sharaf ali
Characteristic of ideal
contraceptive
Highly effective
 No side effects
 Independent of side effects.
 Rapidly reversible
 Cheap
 Widespread availability
 Acceptable to all cultures and religions
 Administration by healthcare personnel
not required
 Easily distributed.

CLASSIFICATION
Barrier methods
 Condoms
 Female barriers
 Natural family planning
 Emergency contraception
 Sterilization
 Female sterilization
 Vasectomy

CLASSIFICATION
Hormonal contraception
 Combined oral contraceptive pills
 Progestogen-only preparations
 Progestogen only pills
 Injections
 Sub dermal implants
 Intrauterine devices
 Conventional IUDs
 Hormonal-releasing IUD.

FAILURE RATES
FAILURE RATES PER 100 WOMEN YEARS
 Combined oral contraceptive pill 0.1-1
 Progestogen only pill
1-3
 Depot Provera
0.1-2
 Norplant
0.2-1
 Copper bearing IUD
1-2
 Levonorgestrel-releasing IUD
0.5
 Male condoms
2-5
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Barrier Methods
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Condom
* Male method, reversible, use each time have sex
* Prevents sexually transmitted infection
* Failure rate high for preventing pregnancy
Femidom
* Female method, reversible, use each time have sex
* Prevents sexually transmitted infection
* Failure rate high for preventing pregnancy compared to other
methods
Barrier Methods
Diaphragm & cap
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* Female method, reversible, use each time have sex
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* Not as good as condom and Femidom at preventing STDs
* Failure rate high for preventing pregnancy compared to other methods
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Contraceptive foam
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* Female method, reversible
* Have to use each time have sex
* Not very good at preventing pregnancy
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* Usually only offered to women near the menopause who have
very low natural fertility
Barrier method
HORMONAL CONTRACEPTION
 Combined
oral contraceptive pills
Mode of action
Acts both centrally and peripherally.
Inhibition of ovulation,suppress the release of FSH
and LH.
Make the endometrium atrophic and hostile.
Alter cervical mucus.
COC

Types of COCP
All contain a synthetic oestrogen (ethinyl estradiol - EE2)
in combination with a progestogen
 Low dose pills contain 35 mg EE2 or less.
 Higher dose pills contain 50 mg EE2, used occasionally.
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Monophasic pills - 21 or 22 identical pills in packet
COC
 Triphasic/biphasic
pills - 21 pills in 2 or 3 dosage
combinations, designed to reduce total hormone
dosage without reducing reliability.
 Every day" (ED) pills - 21 active pills and 7
dummy (or iron) pills.
 Types of progestogen
 "2nd generation" (levonorgestrel, etc)
 "3rd generation" (gestodene, desogestrel)
Hormonal contraceptive
CONTRAIDICATION
 ABSOLUTE CONTRAINDICATIONS
 Circulatory disease
 Ischemic heart disease
 Cerebro vascular disease
 Hypertension
 Arterial or venous thrombosis
 Undiagnosed vaginal bleeding
 pregnancy
COC
•Smoker aged >35
•Impaired liver function
 RELATIVE CONTRAINDICATION
 Migraine
 Long term immobilization
 Irregular vaginal bleeding
 Obesity
 Heavy smoking
 Diabetes
COC
 SIDE
EFFECTS
 Venous thromboembolism
 Myocardial infarction
 Increases LDL,decreases HDL
 Cholelthiasis
 Cancer (breast)
 Hypertension
COC
 MINOR
SIDE EFFECTS
 CNS (depression,headache,loss of libido)
 GIT (nausea,vomiting,weight gain,bloated
ness,gallstones,cholestatic jaundice)
 Genitourinary system(cystitis,irregular
bleeding,growth of fibroids,
 Breast (breast pain)
COC
 BENEFITS
OF COC
 Less dysmenorrhoea
 Less menorrhagia
 Reduced risk of Ca of endometrium and
ovary(50%),PID,benign breast disease
COC
AVAILABLE PREPERATION
 Low dose contain <50ug ethinyl estradiol
 First generation(high dose)
 contain >50 ug ethinyl estradiol
 Second generation;contain levonorgestrel 0.15,0.25mg
and Norethisterone acetate 0.5,1.0 and 1.5 mg and 30 or
35 ug of ethinyl estradiol
 Third generation;contains desogestrel 0.15mg or
gestodene 0.075and Norgestimine 0.25mg with 20 or 30
ug of ethinyl estradiol

COC
Monophasic ;same amount of hormones
 Biphasic and triphasic variable amounts of estrogen and
progestin in each pill.
 DRUG INTERACTIONS
 AVOID OCPs
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Phenobarbital
Carbamazepine
Rifampin
Phenytoin
Primidone
Riboflavin
Progestogen only
contraception
 Progestogen
 Inject
only pills(mini pills)
able
 Sub dermal implants
 Norplant
 IUD
Progestogen only
contraception
 MODE
OF ACTION
 Local effect on cervical mucus making it hostile to
ascending sperm and on endometrium making it
thin and atrophic preventing implantation and
sperm transport.
 Higher dose will act centrally and inhibit
ovulation.
Progestogen only contraception
PROGESTOGEN ONLY PILLS
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Failure rate greater
If POP fails there is slightly higher risk of ectopic pregnancy
Contain second generation progestogens.norethisterone or
norgestrel
Indicated in
Breast feeding
Older women
Presence of cardiovascular risk factors
diabetes
Progestogen only contraception

INJECTABLE PROGESTOGENS


Depot medroxyprogesterone acetate150 mg every 12 weeks, given initially
within first 5 days of menstrual cycle.
Norethisterone enanthate 200mg

SIDE EFFECTS

Menstrual irregularity
Breast cancer
Lipoprotein profile effects uncertain
Delay in conception
Decrease in bone density
Breast tenderness, weight gain, and depression.
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Progestogen only
contraception
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Implants; Norplant :
It consists of 6 matchstick-sized silastic rods which are inserted
(under local anaesthetic) sub-dermally in the inner aspect of the
upper arm, and gives 5 years' contraceptive cover, so some women
still have them in place. The device releases 30 (g levonorgestrel per
24 hours, and is therefore much like the POP.
Differences from the POP are that it is much more effective and
does not have to be taken daily.
Disadvantages
cost (£200)
need for surgical procedure to insert and remove
high incidence of menstrual irregularities > 70%.
implants
POP

Advantages
high safety
 reliability.
 Failure rate
 less than 1 per 100 woman years.
 Implanon:
 This is a new type of implant, a single rod system
releasing a newer progestogen keto-desogestrel which
lasts 3 years

INTRAUTERINE DEVICE
 TYPES
 Copper
containing IUDs with surface areas of
200-375 mm2
 Progesterone releasing IUD
INTRAUTERINE DEVICE
MODE OF ACTION
 Induce an inflammatory response in the endometrium that
prevents implantation
 toxic effect on sperm
 The hormone releasing IUD prevents pregnancy by local
hormone effect on the cervical mucus and endometrium.
 . There is alteration of uterine and tubal fluids to impair
viability of gametes and impede fertilisation.

INTRAUTERINE DEVICE
INTRAUTERINE DEVICE
SIDE EFFECTS AND COMPLICATIONS
 Vaginal bleeding
 Pain
 Vaginal discharge
 Ectopic pregnancy
 Expulsion
 Uterine perforation 1in 1000 fitting
 Pelvic infection
 Lost threads

INTRAUTERINE DEVICE
CONTRAINDCATION
 absolute
 Pregnancy
 Pelvic malignancy
 Unexplained vaginal bleeding
 Pelvic infection
 Wilson's disease
 Abnormal uterine cavity
 Null parity
 History of ectopic pregnancy

IUD
 RELATIVE
CONTRAINDICATION
Abnormal uterine cavity
 Null parity
 History of ectopic pregnancy
menorrhagia (IUS Mirena better for this)
 * fibroids - distorted cavity
 * valvular heart disease
 * insulin dependent diabetes
 * immunosuppressive therapy
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INTRAUTERINE DEVICE
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FITTING
Fitting after a delivery is either immediately post partum
(uncommon) or at 4-6 weeks postnatal. Fitting after termination of
pregnancy is immediate or at 4-6 weeks. The IUCD can be used as a
post coital contraceptive up to 5 days after unprotected intercourse.
REMOVAL
* At any time if pregnancy is desired.
* After another method is established, if pregnancy is not desired.
* Menopause - removal after 18 months if before 50
* removal after 12 months if after 50
INTRAUTERINE DEVICE
Expulsion
 Relates
to all IUCD types. The risk is greatest in
the first 3 months. Expulsion occurs ore commonly
in nulliparous women. Women should be
encouraged, particularly in the early months, to
check the threads at the cervix after a period to
ensure they cannot feel the device partially
expelled.
INTRAUTERINE DEVICE
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Missing or "lost" threads
The patient should be advised not to rely on the device until its
position has been checked. Missing threads may indicate :
* pregnancy
* expulsion
* threads drawn up into the uterus
* perforation at fitting
Assessment of the patient with examination, ultrasound scans, or Xray if necessary, will be required. Withdrawn threads may be
retrieved and the device left in situ unless it has been disturbed and
partially removed, in which case it must be replaced.
INTRAUTERINE DEVICE
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Pregnancy with device in situ
TOP may be requested. If the pregnancy is to be
continued, removal of the device should be attempted as
soon as possible, while the threads are still visible. Before
12 weeks there is a 50/50 chance of miscarriage whether
the device is removed or not, but early removal prevents
possible midtrimester miscarriage. Removal very early
carries a lower than 50% association with miscarriage.
Intrauterine System (IUS)

The levonorgestrel releasing IUS is marketed as Mirena. It has
many of the properties of an ideal contraceptive in terms of efficacy,
duration of action, safety, ease of administration, lack of
interference with coitus, and reversibility. It can also be used to treat
a variety of gynaecological conditions and thus has a wide spectrum
of possible therapeutic applications.
Intrauterine System (IUS)

This has a plastic T shaped frame, with a steroid reservoir
around its vertical stem. This contains 52 mg of
levonorgestrel/silastic mixture surrounded by a rate
limiting membrane which releases 20 µg per 24 hours into
the uterine cavity. The insertion procedure is the same as
that for a similarly shaped Cu-bearing device. Expulsion
and perforation rates are similar to Cu bearing devices of
similar design. It is currently licensed for 5 years. Plasma
concentrations of progestogen are lower than those with
Depo-Provera, implants, combined oral contraceptive pills
and progestogen only pills.
Intrauterine System (IUS)
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Contraceptive application
Method of action
* changes in cervical mucus
* changes in endometrial morphology
* Suppression of endometrial growth. The atrophic endometrium becomes
unresponsive to oestrogen and undergoes less menstrual shedding.
* changes in ovarian function
* Women may demonstrate normal ovulating cycles, anovulatory cycles and
ovulation with inadequate luteal phase. In long term use, more than 2/3rds of
cycles are ovulatory. The bleeding pattern does not relate to either plasma
levonorgestrel concentrations or to ovarian function.
* foreign body reaction
* effect on sperm migration through genital tract
Intrauterine System (IUS)
 Efficacy
*
Studies up to 7 years show a uniformly low
failure rate among women using this method ( 00.3 Pearl Index).
 * Ectopic pregnancies are rare though not
unreported.
 * No data for its use as emergency contraceptive.
Intrauterine System (IUS)
 Indications
*
long term contraception
 * women dissatisfied with current methods
 * women unwilling or unable to use oral
contraceptive pill
 * women with menorrhagia or menorrhagia and
dysmenorrhoea
 * women with learning or physical disabilities
Intrauterine System (IUS)
 Contraindications
*
pregnancy
 * unexplained bleeding
 * current genital infection
 * severely distorted uterine cavity
Intrauterine System (IUS)
 Side
effects
 PID
 Progestational
 functional
ovarian cysts Uncommon, self-limiting,
managed conservatively.
 menstrual irregularity.
PERMANENT METHODS
 VASECTOMY
 Simple,effective
PERMANENT METHODS
 TUBAL
LIGATION
 Failure rate 2 per 1000
 Emergency
contraception is a safe and effective
way to prevent pregnancy after unprotected
intercourse. There are two kinds of emergency
contraception: Emergency contraception pills,
commonly called the morning-after pill and
intrauterine device
Emergency contraception