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RPD Module – Intake 2023
Flipped Classroom Note - Contraceptives
● Types of contraceptives can be divided into two broad categories as below.
Temporary / Reversible
● Natural methods
Periodic abstinence
Withdrawal
Lactational Amenorrhea
● Barrier methods
⮚ PHYSICAL
Male/ female condoms
⮚ CHEMICAL
Spermicides
● Hormonal contraceptives
Combined Oral Contraceptive pill
Progesterone only pill
Injectable preparations
Subdermal implants
Emergency Contraceptive pill
● Intrauterine devices
IUCD
Permanent
● Female sterilization
Ligation and Resection of
Tubes (LRT)
● Male sterilization
Vasectomy
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●
NATURAL METHODS/Fertility awareness-based methods (FAB)
● Are based on observation of naturally occurring signs and symptoms of the fertile
and infertile phases of the menstrual cycle.
● To avoid pregnancy, it is necessary to abstain from intercourse on potentially fertile
days of the menstrual cycle.
● Use of FAB requires motivation and a regular menstrual cycle, and so cannot be used
for women at extremes of reproductive age. Typical failure rates are high.
● These methods include.
a. Calendar method/ Rhythm method (this will be discussed here)
b. Basal body temperature method
c. Cervical mucus method
d. Sympto thermal method
CALENDAR METHOD
Day 1- 1st day of menstruation
First day of the
fertile period (1st unsafe day) = 27 – 20 = D7
Last day of the
fertile period (last unsafe day) = 30 – 10 =
D20
⮚ A woman must first keep a strict record of her menstrual cycle for at least six
consecutive cycles.
⮚ The cycle is from the first day of her period starts.
⮚ To calculate the fertile time, first, you subtract the number 20 from your shortest
cycle. (DC Dutta's Textbook of Gynecology)
⮚ This gives you the probable first day of your fertile time.
⮚ Then you subtract the number 10 from your longest cycle.
⮚ This gives you the probable last day of the fertile time.
⮚ You need to avoid sexual intercourse during this fertile period.
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⮚ This requires the partner’s cooperation.
⮚ This method is never practiced if the difference between cycle length is more than
10 days, recent pregnancy or abortion, and chronic medical illness.
Fertile period
The fertile period is the period that is optimal for fertilization.
SAFE PERIOD
The part of the menstrual cycle between the previous period and a few days before
ovulation, during which unprotected sexual intercourse is less likely to lead to
fertilization than intercourse at other times. It is the basis for the rhythm method of family
planning, but its safety is only relative. (oxford reference)
● H0RMONAL CONTRACEPTION
❖ ORAL CONTRACEPTIVES
1. Combined oral contraceptives
Combined oral steroidal contraceptives are the most effective reversible method
of contraception. (DC Dutta's Textbook of Gynecology)
This contains estrogen and progesterone combined in one tablet.
Most used COCPs are low doses and contain ethynyl estradiol. (Ten teachers,20th
ed.)
This is given for 21 days followed by hormone-free 7 days during which iron
tablet is given to complete 28 days cycle.
These are taken daily.
Efficacy is about 99% if used correctly.
Mode of action: The probable mechanism of
contraception is:
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1. Inhibition of ovulation — (principal mode) Both hormones
synergistically act on the hypothalamic-pituitary axis. The release of
gonadotropin-releasing hormones from the hypothalamus is prevented
through a negative feedback mechanism. There is thus no peak release of
FSH and LH from the anterior pituitary. So follicular growth is either not
initiated or if initiated, recruitment does not occur.
2. Producing static endometrial hypoplasia.
3. Alteration of the character of the cervical mucus.
2. Progestin-only pills
⮚ These must be taken daily from 1st day of the cycle without pill-free
intervals.
⮚ POP does not contain estrogen and the progestin content is less than the
COC pill.
⮚ Examples: norethisterone (commonly used), Levonorgestrel
⮚ Mechanism of action:
It works mainly by making cervical mucus thick and viscous, thereby
preventing sperm penetration. Also, the endometrium becomes atrophic,
so, implantation is hindered.
❖ INJECTABLE CONTRACEPTIVES
⮚ This is the most popular contraceptive method in Sri Lanka. (DMPA) (prof.
Randeniya’s book)
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⮚ a depot injection of medroxyprogesterone acetate (long-acting progestin).
⮚ It can be administered intramuscularly (buttock, upper arm, lower abdomen)
within 5 days of the cycle) as the formulation Depo-Provera or subcutaneously.
⮚ Administered once in 3 months. From the injection site, steroids are slowly
released into circulation, accounting for the drug's lasting action.
⮚ Mechanism of action:
1. Inhibition of ovulation — by suppressing the mid-cycle LH peak.
2. cervical mucus becomes thick and viscid thereby preventing sperm
penetration.
3. Endometrium is atrophic, thus, preventing implantation.
(DC Dutta)
⮚ No estrogen, therefore ideal method for lactating mothers. (Negative feedback
diminishes on the anterior pituitary during postpartum)
⮚ Efficacy is very high.
❖ SUBDERMAL IMPLANTS
⮚ A less popular method where low-dose progesterone is used as an implant
system.
⮚ A reversible long-acting method is effective for usually 3 - 5 years.
⮚ An ideal method for spacing and limitation of the family.
⮚ The mechanism of action is like the above hormonal contraceptive
methods.
⮚ High efficacy.
⮚ Examples: jadella, Norplant
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❖ EMERGENCY CONTRACEPTIVES
Available as,
• Hormones
• IUD - CU
• Anti-progesterone •Others
HORMONAL EC
⮚ The available products are levenorgestrel and ulipristal acetate.
⮚ Mode of action:
The exact mechanism of action remains unclear. The following are the possibilities:
1. Ovulation is either prevented or delayed when the drug is taken at the
beginning of the cycle.
2. Fertilization is interfered with.
3. Interferes with the function of corpus luteum or may cause luteolysis.
(DC Dutta's Textbook of Gynecology)
(But this does not interfere with an established pregnancy. Thus, do not
induce abortion.)
⮚ Postinor 2 - Contains two tablets. The 1st should be taken within 72hr of exposure
and the second 12hr after the intake of 1st.
⮚ postinor 1 - contain only one tablet that should be taken within 72hr of exposure. this
is more convenient than postinor 2 due to single dose.
⮚ COC in higher doses can be used as ECP. The mechanism is the prevention of
ovulation by feedback inhibition on LH, and FSH.
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IUCD EC
★ However, The Cu-IUD is the most effective method of emergency contraception (EC)
available (failure rate 1 in 1,000) and should ideally be offered as first choice to women.
★ Its effect on the endometrium is thought to prevent implantation if fertilization has
occurred.
★ The Cu-IUD can be removed once pregnancy has been excluded or can be left in place
for ongoing contraception.
★ an emergency Cu-IUD can be inserted up to 5 days after the unprotected sex or 5 days
after predicted ovulation.
● IUCD
⮚ This is a device placed in situ and efficient in preventing pregnancy.
⮚ Copper IUCDs prevent fertilization by direct toxicity and causing local inflammation
hostile to sperm, possibly to eggs. They also stimulate a noninflammatory
macrophage reaction on the endometrium causing anti implantation effect.
⮚ These effects are further enhanced by its copper content of it.
⮚ Progesterone-releasing IUCD converts the endometrium unsuitable for implantation.
⮚ Results are,
Inhibit ovum transport
Inhibit sperm transport in the upper female genital tract
Inhibit fertilization
Inhibit implantation
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Advantages and disadvantages of contraceptive methods
Common to all contraceptives:
a) Reduce the incidence of ectopic pregnancy (pregnancy outside the uterine cavity) as
well as a normal pregnancy.
BARRIER
METHODS
Advantages
Disadvantages
Protect from STDs
Just in case of emergency
ALLERGY
No protection from STDs.
HORMONAL
CONTRACEPTION
●
ORAL
CONTRACEPTIV
ES
1. COCP
Contraceptive Benefits
1. Efficacy – about 99% if used
correctly.
2. Sexual intercourse is not
affected by usage.
3. On reversal of the method,
fertility returns rapidly.
Has non-contraceptive
benefits also.
1. Improve menstrual
irregularities,
dysmenorrhea, and
premenstrual syndrome
(pain, vomiting,
discomfort before
menstruation)
2. Reduce the risk of
ovarian and endometrial
carcinoma.
3. 3. Reduce the incidence
of iron deficiency
anemia in menstruating
women.
1. With prolonged use,
women might gain weight.
2. Since taken daily, patient
compliance is the biggest
disadvantage.
.
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POP/PROGESTERONE
ONLY PILLS
Same as above
are MOSTLY the Same as
above.
2.
●
POPs
INJECTABLE
CONTRACEPTIV
ES
(DMPA)
Since there is no estrogen, it is
good for lactating women and
women in their 40s.
Contraceptive Benefits
1. The success rate is more
than 99%. So, this is a
high-efficacy method.
2. As administered once in
3 months, the patient’s
compliance is high.
3. No estrogen, thus an
ideal method for
lactating mothers.
4. Easy to use.
Has non-contraceptive
benefits also.
1. weight gain
2. irregular bleeding
3.
Inability to stop effects
immediately after stopping
usage and delay to return
fertility.
(Average duration is 7 – 12
months)
Therefore, not suitable for shortterm methods.
4. Contraindicated in
pregnancy, >40 years with
DM, HTN, smoking,
severe migraine, and
valvular heart diseases.
1. Reduce the risk of
endometrial carcinoma,
pelvic inflammatory
disease, and fibroids.
2. Symptomatic relief from
endometriosis.
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SUBDERMAL
IMPLANTS
Contraceptive Benefits
1.
Efficacy is very high.
(But slightly reduced in
obese people)
1.
Mostly the Same as above
hormonal contraceptives.
2.
Insertion and removal
require minor surgery.
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2. An ideal method for
spacing and limitation of
the family.
3. Long acting, but
reversible.
4. Easy to use.
5. can be used by breastfeeding
women.
3. Cannot be initiated or
discontinued with the
provider.
Has non-contraceptive
benefits.
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EMERGENCY
CONTRACEPTIV
E PILLS
As COCP
1. Nausea and vomiting are
much more. Intense with
estrogen use.
IUCD form. (An intrauterine
device (IUD) has a lower failure
rate than oral methods of
emergency contraception. Also,
once in place, it can be used on
an ongoing basis)
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IUCD
Contraceptive Benefits
1. Very safe and efficacy is
more than 99% in Cu IUCD.
2. Suitable for spacing and
limitation of the family.
3. Long lasting and reversible.,
thus, rapidly returning to
fertility.
4. No systemic side effects. And
complications are rare.
5. Can be used by breastfeeding
women.
1. Insertion and removal
require a trained provider
as improper insertion may
lead to perforation of the
uterine wall at the time of
insertion.
2. Not suitable for women at
risk of STD s.
3. no HIV/AIDs protection in
CU IUCD too.
4. prolonged or heavy
menstrual bleeding is
possible between
menstrual periods and may
occur as a side effect.
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