GYNE- Family Planning 2017

In The Philipines,Giving birth KILLS Contraceptive Effectiveness

And this fertility rates will raise number of pregnant women. And • Typical Use Effectiveness
unfortuantely, giving birth in our country kills. • Perfect Use Effectiveness
• Contraceptive Failure Rate
• Maternal mortality rates for women age 15 – 49 years • Number of pregnancies per 100 women at 1
old is at 19.8%. year
• Neonatal, infant, child, and under-five mortality rates is • Pearl Index
at 14%, 8%, 22% and 8% respectively.

Family Health Survey, Fertility and Family Planning

Family Health Survey 2011, USAID

According to FHS published in 2011, maternal mortality rates…
FAMILY PLANNING
FEU – NRMF Institute of Medicine
Department of Obstetrics and Gynecology
- Allows individuals and couples to anticipate and attain their
desired number of children and the spacing and timing of their
births
TUE – overall rate of effectiveness in actual use of a particular
contraceptive method taking into consideration human errors
PUE – the rate of effectiveness of a contraceptive when it is
always use correctly and consistently
CFR – pregnancy rates with various types of contraceptions at
different intervals or years. This is the number of pregnancies per
100 women at 1 year.
PI – pregnancy rate computed at # of pregnancies x 1200 over
woman months of use.

OBJECTIVES: Reversible Methods

Discuss different family planning methods as to:
• Types
• Preparations
• Mechanism of actions
• Effectivity
• How to use
• Advantages and disadvantages
• Adverse effects
Family Planning
Key points:
- enables couples and individuals to decide freely and
responsibly the number and spacing of their children
- to have the information and means to do so
- to have access to a full range of safe, affordable,
effective, non-abortifacient modern natural and
artificial methods of planning pregnancy.
Contraception which is the prevention of pregnancy is
sometimes used interchangeably with family planning
The Reproductive Health Bill which was recently passed by the
government defines family planning as a program which…
Spermicides
• Gels, foams, creams, tablets and suppositories
• Active agent : nonoxynol-9
• Coitus- related
• Used with barriers
• No increased risk for congenital malformations or
chromosomal anomalies
spermicides consist of an active agent and a carrier.
The carriers include gels, foams, creams, tablets, films, and
suppositories.
The active agent is a surfactant, usually nonoxynol 9, that
immobilizes or kills sperm on contact by destroying the sperm cell
membrane
Needs to be placed in the vagina before each coital act
Used in combination with barrier method to increase
effectiveness

Types of Family Planning

Reversible Method
- temporary prevention of fertility and includes all the
currently available contraceptive methods

Permanent Method
- terminal

Methods of Contraception
Reversible Methods
• Spermicides
• Barriers
• Oral Contraceptive Pills
• Long Acting Hormonal Contraception
• IUD or IUS

Permanent
• Vasectomy
However, this is not locally available
• Bilateral Tubal Ligation

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BARRIER METHODS
DIAPHRAGM
• Needs fitting for the appropriate size
• Patient Instructions for insertion and removal
• Must cover cervical os totally
• Used with spermicide
• Left in place for 8 hours after last coitus

- Must be carefully fitted. The largest size that does not

cause discomfort or undue pressure should be used.
- A woman should be able to reinsert it herself.
- The diaphragm should be used with a spermicide and
be left in place for at least 8 hours after the last coital
act.
- If repeated intercourse takes place or coitus occurs
more than 8 hours after insertion of the diaphragm,
additional spermicide should be used. Advantages
• Safe and reversible
Advantages • Good continuation rates
• Safe, reversible • Placed longer than diaphragm
• Married, motivated women • More comfortable
• Failure rates decrease with age and duration of use
Adverse effects
Adverse Effects • If left in place > 48 hours:
• Urinary tract infections mucosal ulcerations
• Vaginal epithelial ulcerations unpleasant odor
infection
• Adverse effects on cervical tissue

MALE CONDOM
• Latex, polyurethane, or animal tissue
• Most effective contraceptive method to prevent
transmission of STDs (latex, polyurethane)
• Males with multiple sex partners
• Correct use and careful removal

- Use of the latex male condom by individuals with multiple sex

partners should be encouraged. The latex male condom is the
most effective method of contraception to prevent transmission
of sexually transmitted infections

Male condom: Advantages

• Safe, reversible
• Prevent STD transmission
• Highly effective for motivated user

CERVICAL CAP
• Cup shaped rubber device fitted to the cervix
• Needs fitting (comes in 3 sizes)
• Used with spermicides
• Not left in place beyond 48h
• Failure rates similar to diaphragm
• Normal cervical cytology required
• Pap test three months after

Because of concern about a possible adverse effect of the cap

on cervical tissue, the cervical cap should be used only by
women with normal cervical cytology, and it is recommended
that users have another cervical cytologic examination 3 months
after starting to use this method.
- New condom every sexual contact, check the package for
break and expiration date, condom should be inserted as soon
as erection occurs and before any vaginal, anal or oral contact
with penis.
- The latex male condom should not be applied tightly. The tip
should extend beyond the end of the penis by about half an
inch to collect the ejaculate. Care must be taken upon
withdrawal not to spill the ejaculate.

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FEMALE CONDOM
• Loose fitting soft sheath with two polyurethane rings Calendar
• Inner and outer rings • If shortest cycle is 27 and longest cycle is 32, what is the
• Prelubricated woman’s fertile period?
• Single use only
COMPUTE 
- One ring lies inside the vagina at the closed end of the sheath
and serves as an insertion mechanism and internal anchor. The 27-18=9 and 31-11= 20
outer ring forms the external edge of the device and remains
outside the vagina after insertion, thus providing protection to Fertile period is from days 9 to 20 and couple should abstain or
the labia and the base of the penis during intercourse. use barriers at this time

Basal Body Temperature Method (BBT)

• Daily monitoring of temperature
• Coitus NOT done or a barrier is used from onset of
menses until 3rd consecutive day of elevated
temperature
• No longer used alone

- The temperature method relies on measuring basal body

temperature daily. The woman is required to abstain from inter-
course from the onset of the menses until the third consecu- tive
day of elevated basal temperature. Because abstinence is
required for the entire preovulatory period in ovulatory cycles
and for the entire cycle in anovulatory cycles, the temperature
method alone is no longer commonly used.
Female Condom: Advantages
• Fitting not needed
• Can be inserted before starting sexual contact
• Can be left in place for a longer time after ejaculation
• Additional protection for external genitalia particularly
genital herpes
• Less likely to rupture than male condom
• Also reduces risk for HIV and HPV

Barriers: Advantages
• Reduction of STD transmission especially if used with
spermicides
• Protection against salpingitis and cervical neoplasia

NATURAL FAMILY PLANNING

- Based on the observation of the naturally occurring signs and

symptoms of the fertile and infertile phases of a woman’s
menstrual cycle

Periodic Abstinence
• Avoidance of coitus at the time ovum can be fertilized
• Highly motivated couple
• Four methods:
Calendar/Rhythm
Temperature
Cervical mucus method
Symptothermal

Calendar/Rhythm
• Fertile period based on length of cycles
• Shortest cycle subtract 18 and longest cycle subtract
11
• Couple abstains during the estimated fertile period

Effective for women who have regular menstrual cycle

We should advise the patient to monitor her menses for at least 6

months prior to starting this method

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Cervical Mucus/Billing’s method
• Recognition of changes in cervical mucus consistency
• Abstinence or barrier on the first day of copious slippery
mucus then the couple abstains daily until 4 days after
the last day when the characteristic mucus was
observed.
• “wet” = ABSTAIN
• “dry” = SAFE PERIOD
Combination phasic (multiphasic, biphasic, triphasic)
Symptothermal Method
• Calendar + cervical mucus to establish first day of fertile
period
• Temperature method to establish last day
- Fixed- dose products consist of tablets containing both
an estrogen and progestin. In most formulations they
are given continuously for 3 weeks. No steroids are
given for the next 7 days
- Without estrogenic stimulation the endometrium usually
begins to slough 1 to 3 days after stopping steroid
ingestion.
- 2-3 different dose of E +P
- Tablets of same dose given for 5-11 days in the 21
medication period
- Not found to have advantage over fixed dose

- The rationale given for use of this type of formula-tion is that a

lower total dose of steroid is administered without increasing the
incidence of unscheduled uterine bleeding.

Daily progestin/minipill
• low dose progestin
• taken daily at the same time
• no steroid free interval
• ideal for nursing mothers

Estrogen in the OCP

• Ethinyl estradiol
• Mestranol
- All currently marketed formulations are made from syn-thetic
steroids and contain no natural estrogens or progestins.
Enzyme Immunoassay
• Urinary estrogen Progestin in the OCP
• Pregnandiol glucoronide • Levonorgestrel and derivatives (norgestimate,
desogestrel, gestodine)
- Not yet developed and might be costly for couples • Norethindrone, norethindrone acetate,
Norethynodiol,ethinodiol diacetate
Periodic Abstinence: Advantages
• Safe, reversible, affordable OCP: Mechanism of Action
• No pharmacologic side effects • Inhibition of midcycle gonadotropin surge and
prevention of ovulation (more consistent for combined
Periodic Abstinence: Disadvantages than minipill)
• Require highly motivated couple • Progestin action- thick, viscid, scanty cervical mucus ;
• Higher failure and discontinuation rates impaired transport of ovum and sperm; alters
• Long period of abstinence endometrium
• Regular cycles (calendar)
The major effect of the synthetic estrogen is to maintain the
HORMONAL CONTRACEPTIVES endometrium and prevent unscheduled bleeding as well as
inhibit follicular development thus preventing ovulation
Oral Contraceptive Pills (OCPs)
OCPs Progestin also prevents ovulation us well as cause thinning of the
• Most widely used reversible method endometrium, impaired transport of ovum and sperm.
• Estrogen + Progestin
• Progestin only (minipill) OCPs: Adverse Effects
• Currently: low dose formulations • Metabolic
• Cardiovascular
There are three major types of OC formulations: fixed-dose • Reproductive
combination, combination phasic, and daily progestin. • Neoplastic

OCP Formulations Metabolic effects

• Fixed Dose Combination • Estrogen Component
• E + P per tablet • nausea, breast tenderness, fluid retention
• 21 active • minor changes in levels of some vitamins
• 7 inert or pill-free days (Withdrawal bleeding) • melasma
• mood changes and depression
• irregular bleeding
• headaches

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The magnitude of these effects is directly related to the dosage
and potency of the steroids in the formulations.
increased aldosterone synthesis and decreased sodium and fluid
excretion.
produce changes in mood and depression brought about by
diversion of tryptophan metabolism from its minor pathway in the
brain to its major pathway in the liver.
• Progestin Component
• androgenic effects (weight gain, acne,
nervousness)
• adverse mood changes and tiredness
• failure of withdrawal bleeding
• irregular bleeding
• headaches
Progestins are structurally related to testosterone hence can
cause androgenic effects
Protein Metabolism Effects
• Increased hepatic globulin production (estrogen)
factors V,VIII, X, fibrinogen  thrombosis
angiotensinogen  BP elevation
Reproductive Effects
• No permanent infertility
• HPO suppression is temporary and reversible
• Length of delay of return to fertility related to estrogen
dose and user age not duration of use
• Pregnancy immediately after discontinuation not
associated with higher abortion or anomaly rates
Neoplastic Effects
- Breast Cancer
- no significantly higher risk compared to never
users
- Cervical Cancer
- uncertain, conflicting evidences
- Liver adenoma
- high dose mestranol formulations
- OCs have been extensively used for more than 35 years, and
numerous epidemiologic studies of both cohort and case-control
design have been performed to determine the relation between
use of these agents and the development of various types of
neoplasms.

Sex hormone binding globulin (SHBG) reduced by androgens,

including androgenic progestins

CHO Metabolism Effects

• Related to dose, potency, structure of progestin
• Higher dose potencies and dose  greater impairment
of glucose metabolism
• Gonanes (LNG and derivatives) > Estranes
(Norethindrone and derivatives)

Lipid Metabolic Effects

- Estrogen
- Increase
- HDL, total cholesterol,TGs
- Decrease
- LDL
- Progestin The high doses of steroids in the original pill formulations caused
- Increase side effects that frequently led to discontinuation of use and also
- LDL contributed to some serious health risks. Since that time, many
- Decrease other formulations have been developed and marketed with
- HDL, total cholesterol,TGs steadily decreasing dosages of both the estrogen and progestin
- Newer derivatives of LNG- less androgenic, more lipid components.
friendly
All the formulations marketed after 1975 contain less than 50mcg
Coagulation Parameter Effects of ethinyl estradiol (EE) and 3mg or less of one of several
• Estrogen progestins.
- increase: some coagulation factors (e.g.
fibrinogen)  enhances thrombosis Reduction in dose has significantly lowered the incidence of
this is dose dependent severe adverse cardiovascular effects and minor adverse
symptoms without increasing the failure rate.

CVS Effects Because oral contraceptive steroid formulations with more than
- Venous thromboembolism-risk is greater for higher 50mcg of estrogen were associated with a greater incidence of
doses (>50µg)of estrogen adverse effects without greater efficacy, they are no longer
- Myocardial infarction-no evidence of increased risk of marketed for contraceptive use in the United States, Canada,
MI from atherosclerosis and Great Britain. With the exception of women in whom
- Stroke-conflicting results, No increased risk for past users unusually rapid metabolism of synthetic steroids is anticipated
compared to never users (e.g., women on medications that induce the cytochrome P450
system), use of pills containing 50mcg of estrogen is not
recommended.

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Absolute Contraindications Long Acting Hormonal Contraception

- History of vascular disease
- Systemic diseases affecting vascular system Four types
- Smokers older than 35
- Uncontrolled hypertension
- Existing breast and endometrial cancer
- Undiagnosed uterine bleeding
- Elevated triglycerides
- Pregnancy
- Functional heart disease
- Active liver disease

Relative Contraindications
- Heavy smokers (<35 years old)
- Migraines
- Undiagnosed cause of amenorrhea
- Depression
- Prolactin-secreting macroadenomas

OCPS: Advantages
- Highly effective
- Readily available
- Affordable
Contraceptive Patch
- Easy administration
• 75g ethinyl estradiol + 6.0 mg norelgestromin
- Many non contraceptive health benefits
• One patch per week for three weeks followed by 1
week patch free
OCPS: Non contraceptive health benefits
• MOA similar to OCPs
• Endometrial cancer-protective
• Buttocks, upper outer arm, lower abdomen. Upper
• Ovarian cancer-protective
torso except breast
• Colorectal cancer-protective
Contraceptive Vaginal Ring
• Antiestrogenic effects of progestin
• Steroid delivery through vaginal mucosa directly into
• reduction of menstrual blood loss and less risk
circulation
for iron deficiency anemia
• 2.7 mg ethinyl estradiol and 11.7 mg etonorgestrel
• less incidence of menorrhagia, irregular
• Placed in vagina for 21 days followed by removal for 7
menses and intermenstrual bleeding
days then insertion of new ring
• less likely to develop endometrial adenoCA
• One size, no fitting
• reduction of incidence of benign breast
• MOA like OCPs
diseases
• Expulsion uncommon
• Inhibition of Ovulation
• less dysmenorrhea and premenstrual tension
Injectables
• protection against development of functional
Three formulations
ovarian cysts
1. DMPA
• reduction in size of functional ovarian cyst
2. Norethindrone enanthate
• protection vs ovarian cancer
3. Estrogen + progestin formulations
• Other Benefits
Injectables: DMPA
1. Risk reduction rheumatoid arthritis
• IM or subcutaneous preparations
2. Protection against PID
• Very effective reversible method
3. Reduction in incidence of ectopic pregnancy
• 3 MOAs
4. Reduction of bone loss -perimenopause
1. Inhibition of ovulation
2. Thinning of endometrium
Important Points in Prescribing OCPs
3. Cervical mucus changes
• Adolescent
• Given within the first 5 days of the cycle
• After pregnancy
• Nursing/breastfeeding mothers
Contraceptive implant
• Medical comorbidities (i.e DM, HPN, heart diseases)
• Progestin-only containing contraceptives
• Inserted subdermally under local anesthesia
OCP Users: Follow-up
• MOA same as injectables
• Lab test not necessary for healthy women
• Nondirected history and BP after 3 months
Advantages : DMPA and Implant
• Annual visits: BP, weight, complete PE, cytology
• No daily intake of pills
• Infrequent administration
• Maybe appropriate for those with contraindications to
estrogen

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Benefits: DMPA Levonorgestrel Intrauterine System (LNG IUS): MOA

• Definite risk reduction
• PID and salpingitis
• endometrial cancer
• iron deficiency anemia
• sickle cell problems
• Ovarian cysts
• Dysmenorrhea
• Endometriosis
• Epileptic seizures
• Vaginal candidiasis

Disadvantage and Adverse Effects: Implants

• Unscheduled or irregular uterine bleeding
• Need for minor surgical procedure to insert and remove
device
• Operative site-potential site for infection (uncommon)

Disadvantages and Adverse effects: DMPA

• Unscheduled or irregular bleeding
• Delayed resumption of ovulation
• Weight gain-unclear IUD Insertion
• Depression and mood changes- no clinical trials for • Anyday of the cycle provided the receiver is NOT
evidence PREGNANT
• Headache- not enough studies • No ongoing cervical/vaginal infections

• Metabolic effects- - Preferrably day 1 to 7 of menses wherein the cervical os is

insignificant effects on lipid*, glucose and protein slightly open for the ease of insertion
metabolism
Advantages of IUD
*lowers HDL but DMPA not demonstrated to accelerate
• Highly effective
atherosclerosis.
• Long term (12 years)
• No associated systemic metabolic effects
• Bone loss suggested in some studies but is reversible
• Single act of motivation
• calcium supplementation
The IUD has the highest continuation rate of all reversible
• Neoplastic effects
methods
• Does not affect incidence of breast, cervical
No permanent effects on fertility
and ovarian cancers
Advantages of IUS
Intrauterine Device/ Intrauterine System - The IUD has the highest continuation rate of all
reversible methods
IUD/IUS - No permanent effects on fertility
• Copper containing or progestin-impregnanted device LNG IUS- reduces Menstrual Blood Loss (thinning of the
placed in the endometrial cavity endometrium)
• Two types currently available
- Copper T 380A IUD (12 years) Potential Adverse Effects
- LNG IUS (5 years) • Uterine bleeding (Copper T380A)
• Perforation during insertion
Copper T380A: MOA • Infection
• Spermicide (local sterile inflammation) • Complication relating to pregnancy with IUD-in-utero
• Impedance of sperm transport and viability in the
cervical mucus (Copper) Pregnancy with IUD-in-Utero
• Congenital anomalies - no increased risk
• Spontaneous abortion
• Septic abortion
• Ectopic Pregnancy*
• Prematurity

“IUDs effectively reduces all pregnancies including ectopic ones.

Ectopic pregnancy is reduced by 90% compared to those
without contraception. But if pregnancy does occur with the IUD
in place, the risk of it being ectopic increases threefold.”

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Contraindication to IUD Vasectomy: Disadvantage

• Pregnancy or suspected pregnancy
• Acute PID
• Postpartum endometritis or infected abortion in the last
3 months
• Known or suspected uterine or cervical CA
• Genital bleeding of unknown origin
• Untreated acute cervicitis
• Previously inserted IUD that does not been removed
Sterilization
• Difficult and meticulous reversal or reanastomosis
procedures with success rate only 50%
Bilateral Tubal Ligation
• More complicated
• Transperitoneal incision
• Often under general anesthesia IV, but can be also
under local anesthesia
• Postpartum or interval
• Minilaparotomy or laparoscopy
• Most effective and least destructive type of BTL-
preferred for young women (Modified Pomeroy and
laparoscopic band technique)
• Failure rates increase with duration of time from
procedure (esp. bipolar coagulation and spring clips)

BTL: Complications
• Bleeding
• Infection
• Anesthetic complications
• Bowel injury (laparoscopic electrocoagulation)
• Uterine perforation and device expulsion (microinserts)

• Permanent contraception
• Fallopian tubes, vas deferens
• Reversal are difficult, success rates variable
• Pregnancy rates: extent of damage, surgeon’s
expertise

Vasectomy
• Short outpatient procedure
• Local anesthesia
• Sterility after 14-20 ejaculations
• Two aspermic ejaculates required

- Adviced male to have barrier method or abstinence 3 months

after the procedure

Comparing effectiveness of methods

Vasectomy: Complications
• Hematoma
• Sperm granulomas
• Spontaneous reanastomosis

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The best way to reduce the risk of unintended pregnancy

among women who are sexually active is to use effective birth
control correctly and consistently. Among reversible methods of
birth control, intrauterine contraception and the contraceptive
implant remain highly effective for years once correctly in place.
The effectiveness of the contraceptive shot, pills, patch and ring,
and barrier and fertility awareness-based methods, depends on
correct and consistent use—so these methods have lower
effectiveness with typical use.

This slide will tell us what are the most effective and the least
effective at a glance.

It is of worthy to know that natural family planning such as LAM is

as equally effective provided that we able to educate our client
on how it is done

DISCUSSED:
Discuss different family planning methods as to:
✔ Types
✔ Preparations
✔ Mechanism of actions
✔ Effectivity
✔ How to use
✔ Advantages and disadvantages
✔ Adverse effects