Long-Acting Hormonal Methods
1-Vaginal Ring
It is a thin, transparent, flexible ring that is inserted into the vagina, usually around the
cervix. Unlike vaginal barrier methods, such as the diaphragm, exact placement is not
essential. It is left in the vagina for three weeks, slowly releasing estrogen &
progestin into the body.
It is worn continuously for three weeks followed by a week off which triggers
menstruation. Each vaginal ring provides one month of birth control, even during the
week where the ring is not worn.
The first time the vaginal ring is used, it is inserted during the first five days of
menstruation. Use a backup method for the 1st week, because the ring is not effective
until after seven days of continuous use.
A vaginal ring can slip out of the vagina. If this happen; the ring is washed with water
& re-inserted.
The effectiveness of the ring is lowered when taken with certain medications,
including antibiotics, anti seizure, tuberculosis & migraine medications. Common side
effects include yeast infection, vaginal discharge or irritation, weight gain & nausea,
headache, irregular bleeding, breast tenderness, mood changes and the unpleasant
sensation of having foreign body in the vagina. Like the combined oral
contraceptives, the vaginal ring is thought to increase the risk of heart attack and
stroke, especially among smokers. Women with a family history of breast cancer,
diabetes, high BP, high cholesterol, headaches or epilepsy, depression, gallbladder &
kidney disease or breast feeding may not be able to use a vaginal ring. The ring does
not protect against reproductive tract infections, including HIV/AIDS.
2-The Patch
It is a birth control system whereby hormones are delivered directly through the skin
and into the blood stream via a thin patch. It can be weared on one of the following
areas:
The buttocks, abdomen, upper torso (front & back, excluding the breasts),or upper
outer arm.
It is replaced on the same day of the week for three consecutive weeks, and the 4th
week is "patch-free". The patch remains attached & effective while exercising,
bathing or in hot, humid conditions.
It contains the same synthetic hormones as combined oral contraceptive pills
(estrogen and progestin) & is thought to be effective as the pill.
The mechanisms, side effects are also the same as for combined oral contraceptive
pills
.
3-Injectables
It is highly-effective progestin injection given every 3 months, though infertility may
last upto a year.
Side effects include headache, hair loss, nervousness & menstrual irregularities. Other
possible side effects include weight gain, dizziness and allergy. Loss of bone density,
leading to increased risk of osteoporosis is also noted.
4-Implants (Norplant)
Norplant is a progestin implant, consisting of 6 small plastic rods. These are
surgically placed under the skin of the upper arm for upto 5 years, during which time
the rods slowly release progestin into the body. The mechanism of action is the same
as that of progestin pills.
Common side effects include menstrual irregularities,headaches,acne,weight
gain,nausea,anxity,hair loss.
5-Intrauterine Device.
IUD is a small plastic or metal device that is placed inside the uterus.There are 3 types
of IUD available today:
1-Mirena IU system (hormonal)
2-Progestasert IUD (hormonal)
3-Para Guard copper T IUD(hormone-free)
Hormonal IUDs prevent pregnancy by releasing the hormone progestin, which
thickens the cervical mucus, acting as a barrier to prevent sperm from entering the
uterus. They also affect the lining of the uterus to prevent a fertilized egg from being
implanted, should fertilization occur. Because of the hormonal componant, these type
of IUDs must be replaced every 8-24 months, depending on the brand.
For copper IUDs, the metal itself seems to exert a spermicidal effect. The copper also
affects lining of the uterus by not allowing a fertilized egg to implant, and it
stimulates the production of prostaglandins, chemicals that affect the hormones
needed to support pregnancy. ParaGard long-term IUD that may be left in place for 8
years.
The IUD may also cause inflammation of the uterus, preventing implantation of an
embryo and making it more difficult for sperm to enter.
The IUD carries with it a number of serious health risks, which caused many
manufacturers in past to stop distribution, although newer IUDs are thought to be
safer. Health risks include permanent inflammatory diseases, permanent infertility,
ectopic pregnancy, and even death. Common effects include irregular periods as well
as side-effects common to oral contraceptives.
The IUD should never be used by women with multiple sex partners, due to the
increased chance of contracting pelvic-inflammatory disease(PID).IUDs do not offer
any protection against sexually transmitted diseases.
NATURAL BIRTH CONTROL
1-Fertility awareness
Fertility awareness, or natural family planning has been used successfully since the
1930`s.This method is based on the fact that fertilization is most likely to occur
around the time of ovulation. Intercourse is avoided during those times when a
women is fertile, thus preventing conception.
Advantages of this method is that it is very inexpensive, do not require the use of
artificial devices or drugs and have no harmful side effects.
2-Withdrawal
Withdrawal accomplished when, during intercourse, the man pulls out his penis just
before ejaculation.
3-Lactational Amenorrhea method
Among breastfeeding women, menstruation will usually not occur for several
months after the birth of a child. In fact, most breastfeeding women do not ovulate for
4- 24 months after delivery, whereas non-breastfeeding women can ovulate as early as
one or two months after delivery. The hormone that stimulates milk production
(prolactin) decreases the hormone necessary for maintaining the menstrual cycle.
For breastfeeding to act as an effective contraceptive, a women must nurse ten or
more times throughout the day and introduce no other foods into her baby's diet.
Because babies need extra food at about six months, it is not recommended that this
method be used beyond that time.
Although nursing can act as a contraceptive for as long as three years, it will not
postpone menstruation indefinitely.
4-Sympto-Thermal Method
This method requires that a woman take her temperature every morning before she
gets out of bed and record the reading.
Before ovulation, the temperature is likely to be between 97.2 & 97.40F(36.236.30C).After ovulation, it will rise by at least 0.5 degrees & is often >980F
(>36.70C).When the temperature stays elevated for at least 3 days, a women may
assume she has already ovulated. Intercourse for the rest of the cycle will not result in
pregnancy.
Intercourse during the time before ovulation is less safe than the time after ovulation
because sperm have been known to live up to six days. For this reason, some couples
choose to have sex only after the fertile period. This practice, known as the postovulatory temperature method, is the most effective of all methods of true
contraception, with a failure rate of only 1% among perfect users. However, it is not
recommended because it requires a very long period of abstinence.
5-Ovulation Method ( mucus method)
The ovulation method, or mucus method, requires that a woman be aware of what
is taking place in her body. It is based on the observation that, in the absence of
mucus, no egg is present, and sperm cannot survive long enough to fertilize an egg
which may later be released. During a typical monthly cycle, a woman first has a few
days of menstrual bleeding, followed by a few "dry days" when the vagina seems
quite dry. Then, closer to ovulation she starts to have more wetness or mucus. As
ovulation approaches, the mucus becomes clear and slippery and stretches without
breaking, like a raw egg white. Any time the slippery stretchy mucus is noticed,
intercourse should be avoided until two days after it is all gone-about eight days out
of each cycle.
6-Calendar Method
The calendar method, or rhythm method, is the oldest and most widely practiced
method of fertility awareness. It is based on three assumptions: (1) that ovulation
occurs fourteen days before the beginning of menstruation, plus or minus two days (2)
that sperm remain viable for three days, and (3) that the ovum survives for twentyfour hours. For a woman with very regular cycles, she needs merely to count
backwards from the first day of her period to locate the day on which she ovulated.
Using this information, she can predict when ovulation will occur the following
month and avoid having intercourse around that time.
Most women do not ovulate at the same time each month, and no woman`s cycles are
identical every time. For this reason, the rhythm method is not recommended unless
your cycle is always the same number of days.
7-Electronic Fertility Computers
One newer method of birth control is a small electronic fertility computer which
tells a woman which days she is fertile. With the model shown on the right (Persona)
fertile days are indicated with a red light and infertile days with a green light. If the
light is yellow, the women takes a urine test which changes the light to green or red,
based on the amount of hormone found in the urine. This method is now available in
Europe and Canada, where manufacturers boast a failure rate as low as 6% .
Disadvantages include the expense of the computer and the need to purchase urine
test sticks for use eight days out of each cycle. Additionally, this method is currently
only being recommended for women whose cycles are between 23 and 35 days.
Emergency post coital contraception
This is used to prevent pregnancy after unprotected sexual intercourse .
It is a combination of two hormone regimens, ethinylestradiol (100µg)
and levonorgestrel (0.5mg)(Yuzpe regimen) or high dose of
levonorgestrel (0.75mg ,) given with in 72 hrs of intercourse and repeated
12 hrs later. It is also available as estrogen alone (high dose of
ethinylestradiol and antiprogestin synthetic steroid (mefepristone)
Estrogen and Progesterone proven mechanism of action consist of
inhibiting or delaying ovulation .These hormones will not dislodge an
implanted embryo. However, Mifepristone may be considered
abortifacient as it inhibits ovulation and blocks implantation.
Only mifepristone is effective once implantation has occurred.
Common side effects of post coital include nausea (50%) and vomiting
(20%).Some physicians prescribe antiemetics routinely with the hormone
therapy or repeat the dose if vomiting occurs with in 1-2 hrs of ingestion.
Other theories that if nausea is experienced, the medication must already
be absorbed systemically.
Withdrawal bleeding occurs with in 3 weeks of treatment.The earlier the
pills were used, the more effective they were during the 72 –hrs period
studied .Delaying the first dose 12hrs increased the odds of pregnancy by
almost 50%
Levonorgestrel (0.75mg)
It is given with in 72 hrs of intercourse and repeated 12 hrs later.
It is as effective as the combination of estrogen and progesterone (Yuzpe
reginmen).
As with the combinations of estrogen and progestin, the only absolute
contraindication to the levonorgestrel protocol is pregnancy, because the
medication would be ineffective .it is provided in a two – pill packet.
Mifepristone
It is approved as abortifacent.
It is a synthetic steroid that block progesterone that needed for pregnancy
to continue (compete with progesterone at its receptors).
Each tablet contain 200 mg of mefepristone( needed 600 mg- 3 tablets)
Mifepristone is indicated for the medical termination of intrauterine
pregnancy through 49 days pregnancy.
Patients taking mifepristone must take 400 µg Misoprostol (two tabs of
200mg), two days after taking mefipristone (i.e. on day 3), unless a
complete abortion has already been confirmed before that time.
Patient should be scheduled for and return for a follow –up visit at
approximately 14 days after administration of mefepristone to confirm
that the pregnancy is completely terminated. Lack of bleeding following
treatment usually indicates failure. Medical abortion failures should be
managed with surgical termination.
Although there is no clinical evidence, the effectiveness of mefipristone
may be lower if misoprostol is administered more than two days after
mefepristone administration.
Ketoconazole , Itraconazole , erythromycin and grape fruit juice may
inhibit its metabolism( ↑ serum levels of mefipristone) .Rifampicin ,
dexamethasone and certain anticonvulsants ( phenytoin, Phenobarbital
,CBZ ) may induce mefepristone metabolism (↓ serum levels of
mefepristone)
Side effects of mefipristone
 Vaginal bleeding
 Diarrhea
 Nausea
 Vomiting
 Headache
 dizziness